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Dialogue Between Hinduism And Islam : The Unborn Life and Family
Planning
Arvind Sharma1 and Abdallah S. Daar2
For:
International Consultation on Inter-religious Dialogue
Tubingen, October 5-8, 1999.
1. Faculty of Religious Studies
William and Henry building
McGill University, Montreal, Canada
2. Professor of Surgery, Sultan Qaboos University, Sultanate of Oman
Hunterian Professor, Royal College of Surgeons of England
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Introduction
Both Hinduism and Islam* are ethics-based religions. Hinduism is classified amongst the
"Eastern" religions, whereas Islam, together with Judaism and Christianity, are classified as
the major monotheistic religions - the three constituting the "Abrahamic faiths".
The essentially ethical nature of Hinduism and Islam together with their reverence for life,
would lead us to expect many similarities between the two religions in considering the
unborn life and family planning. There are, of course, differences to be expected between the
two "ways of life", but it appears from our first dialogue that some of the apparent differences
are, in terms of practical behaviour, not that large.
We have ended, at this stage, by
identifying a number of issues that need further dialogue.
We have concentrated here on discussing the issues surrounding abortion. Towards the end,
we will touch upon matters related to family planning, where the Muslim position is
presented, pending a more detailed exposition of the equivalent Hindu position.
* The Muslim co-author is a Sunni and tlie comments about Islam pertain mainly to the Sunni tradition of Islam
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General Comparison of Hinduism and Islam
Value Formation
1. Revelation
In Hinduism, the equivalent of the notion of ethics is encompassed in the overarching
concept of "dharma", which is so wide in meaning that it has been defined simply as
"right conduct" The defining elements of dharma are to be found initially in the body of
revealed literature, the Vedas. The Vedas are subdivided into two, three, or four layers.
The threefold division is most convenient for our purpose. These layers are, respectively,
the Samhita (Mantra), the Brahmanas and the Upanisads.
In Islam, "right conduct" is based also fundamentally upon the teaching and values
enshrined in the Holy Qur'an, which is Allah's divine and unaltered Word, as revealed to
the Prophet Muhammed (SAW), recorded in his life time and gathered together within a
few years of his death.
2. Tradition
The second defining element in both religions is received tradition.
Hindu texts
embodying this are called Smrtis, of which Manusmrti is pre-eminent. Although many of
of these deal with caste-conduct, they do have a much wider influence on everyday
behaviour, including the protection of women, which does not seem to be based on caste.
In Islam, the prophet Muhammad provides ideal conduct. There is no divinity about him.
He was a human being, chosen to be the last in a long line of Prophets. His life, sayings
and behaviour were minutely observed and recorded, and constitute the accepted body of
tradition known as the Sunna of the Prophet. Much of the setting and collating of the
traditions was done in the early phases of Islam, and the traditions are thus informed by
the behaviour of the early Muslim communities, based as they were upon their
understanding of the Prophet's tradition.
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3. Conduct
Hinduism is interesting in that it accords a high place to conduct in its value sourcing.
The conduct in question is both the conduct of the elite (sistacara) and that of the masses
(lokakara).
People are expected to do the right thing, and in turn, what they do is
considered the right thing to do, within limits.
In Islam, it is the conduct of the Prophet and early Muslim communities which is
considered exemplary and which informed the early development of Sharia.
It is the
minor differences in interpretation of that tradition/conduct (and to some extent, exegesis
of the Holy Qur'an) that led to the formation of the 4 different schools of Islamic
Jurisprudence, namely Hanbali, Hanafi, Maliki and Shafii (after the jurists who originally
expounded the law). In the modern era, conduct per se as source of value formation plays
no formal role. Nevertheless, Sharia is very capable of adapting to new social and
scientific realities using the fundamental sources of the Qur'an, the Sunna (or Hadith, the
sayings of the Prophet), together with the techniques of Qiyas (analogy) and ijmaa
(consensus).
We have not yet had an opportunity to compare Islamic and Hindu jurisprudence, but
have already noted the common approach to choosing the lesser of 2 evils when evil
cannot be avoided. (See below also on Principles of Islamic Jurisprudence)
4. Conscience
This is a more difficult issue to grapple with.
It tends to be more emphasized in
Hinduism than Islam, and might on the surface appear to be a significant difference. It
warrants further discussion.
In Hinduism it connotes the understanding that each
individual must make his or her own ethical decisions, because each person alone suffers
or enjoys the karmic consequences. In Islam, the very basis of judgement and sin is
predicated upon individual choice, and in that sense is not different from the Hindu
position.
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Conscience as a source of value formation in Hinduism can be seen as mediating between
opposing positions. A pertinent example here would be mediating between the pro-life
and pro-choice camps, affirming "the arguments of each camp while differing from both."
It accepts the pro-life view that the fetus is alive but parts company with it "on the
grounds that the right to life of the fetus ought not to be absolutized. In place of absolute
rights, Hinduism advocates addressing competing rights and values. Ethical dilemmas
arise in case of rape and nicest and when the mother runs the risk of grave injury or death.
Each situation is unique and its own moral tragedy.
The best one can do in such
situations is evil, but then it boils down to a question of degree."
Unless conscience is understood as the use of the individual's own values, even if they
are at variance with fundamental Muslim values, in deciding what is right or wrong then
the Islamic position is little different from the Hindu position. In the specific example
above, Islam also accepts that the fetus has life, but does not absolutize the latter's right to
life. This is more so before "ensoulment" (see below), but even after ensoulment, if the
terrible choice is between the mother's life and that of her fetus. W. Somerset Maugham
has defined conscience as "the guardian in the individual of the rules which the
community has evolved for its own preservation." In that sense, again, there would be
little difference in the positions of Hinduism and Islam.
Destiny of the Human Being: Reincarnation vs. Resurrection
Both Hinduism and Islam hold individuals accountable for their actions, accountability
implying reward or punishment in the future. In Hinduism, repeated reincarnation, with
the individual soul going on the occupy a different body in the next incarnation, provides
opportunity for expression of the individual soul's karma. Thus, good conduct accrues
good karma, and the soul occupies a better body and better circumstances in the next
incarnation. The soul is the vehicle for choice, accountability and propagation through
time.
In Islam, good conduct by an individual person ( body + soul - since the soul will only
occupy that particular body at the time of resurrection) is rewarded with "thawab", which
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is the exact opposite of sin’, which is accrued as a result of bad conduct. In simplified
terms, on the day of judgement thawab is weighed against sin and the person is punished
or rewarded accordingly. Willful, unrepented , unforgiven and unmitigated sin leads to a
period in hell. When good overweighs bad, or after punishment or atonement, the reward
is heaven. [Whether these are physical entities, and how they relate to Hindu concepts of
Nirvana and its opposite, could be another subject for discussion).
Similarities in adjudication
Both Hinduism and Islam, as we have seen, hold individuals accountable for their actions.
When determining a course of action, both religions take into account the context of the
question. With fundamental values informing the analysis, it is possible for the same
action to be correct in one circumstance but not in another. In Islamic jurisprudence, the
following principles are used in adjudication:
•
Need and necessity are equivalent
•
Necessity allows prohibited matters
•
Injurious harm should be removed
•
Prevention of evil has priority over obtaining benefit
•
The greater benefit prevails over a lesser benefit
Both religions are fervently pro-life and pro-morality.
black/white terms.
Ethics is often portrayed in
Islam departs from this in assigning degrees of ethical probity to
individual actions. In Islamic jurisprudence (and everyday life) an act can be.
Haram
Makruh
Mubah
Mustahabb
Fardh
Forbidden
Discouraged
Neutral
Recommended
Obligatory
There are no priests in Islam - only learned people and functionaries. When a new situation
arises, a Mufti (learned, both a legal and theological expert) can be called upon to provide a
ruling (Fatwa). It is quite possible that different Muftis can give different rulings; in most
Islamic countries there would be one Mufti whose ruling would be considered most binding.
(In Shiaism, the Imam's Fatwa has more binding authority).
* As transgression rather than as fault or shortcoming
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The question of abortion: similarities
1. Mother vs. Fetus
In Hinduism, the individual is seen as progressing from a rudimentary state to a more
evolved state. Thus the adult human being, having arrived at a karmic state in which
there is much more at stake for that individual's spiritual destiny, and having acquired
familial and societal obligations, is in a position to be favoured over an equal human
being whose evolution is by comparison rudimentary, and who has not yet established a
social network of relationships and responsiblities. Hence, when it comes to choosing
between the life of the fetus and its mother, Hinduism places greater weight on the
mother's life.
The position in Islam may be predicated on a different set of considerations, but the
conclusion is the same. In fact, it would be correct to save the mother's life and sacrifice
that of the fetus, even after ensoulment. (See below)
2. Abhorrence of Abortion
Both Hinduism and Islam clearly distinguish between miscarriage and abortion, holding
no one accountable for spontaneous miscarriages. Islam, however, has a specific set of
punishments for those who effect an aggression of any sort against the fetus that results in
a miscarriage. These include the payment of a specific amount of "blood money" or
blood ransom.
Both religions view abortion with abhorrence, and wouldfavour contraception for family
planning. There is probably a greater degree of theoretical abhorrence in Hinduism than
in Islam, although a clear dichotomy emerges in actual practice, in the sense that it seems
India has a higher per capita incidence of induced abortions than do Islamic societies.
Even in Hindu society, there are major differences in the rate of abortion: in India
abortion is common, and has been legalized, whereas in Nepal the other major Hindu
country, it is much less prevalent and is illegal.
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In Muslim countries, on the whole, abortion is illegal and can only be performed legally
for very strict, usually medical, reasons.
One possible explanation for the Hindu dichotomy between belief and practice is that,
internally. Hinduism is inherently more diverse than Islam; while an explanation for the
difference between India and Nepal may be that in India, Hinduism has been exposed to
secularizing forces to a much greater extent than in Nepal.
It would be interesting to record the incidence of abortion in more secular Muslim
countries such as Turkey.
3. Permissible abortion/contraception
In both religions, it would be wrong to perform an abortion unless there was good reason.
In Islam, before ensoulment, abortion has been allowed under the following conditions:
•
Danger to the mother's life
•
Danger to the life of an infant totally dependent on the mothers milk
•
(Extreme) social deprivation
•
There is now debate as to whether severe fetal abnormalities could also permit
abortion, but there is no agreement yet. It would be preferable to do genetic tests
for common diseases and avoid marriage in the first place; or failing that, to do
pre-implantation genetic diagnosis and forego implantation (this, too, would
require more discussion that it has had so far in Islamic circles, but then the
technique is in its early stages of development and application).
Once a marriage is entered into, there is a strong leaning towards making it productive of
offspring (even though sex is not seen as only for procreation, its enactment must not
continuously exclude procreation).
As we have noted before, contraception is allowed in both religions; and abortion must not
be used for family planning.
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The question of abortion: differences
1.
Timing of ensoulment
a)
Hindu position
The Hindu position enunciated in the well-known Ayurvedic text Caraka Simhita, is
that the "spirit" is already manifest at conception, and is the causal agent in the
embryo's progressive development. This creative manifestation of the spirit in the
microcosmos is similar to the process of creation in the macrocosmos. On the human
side, the moral character of the individual is also given at conception. Karma is
carried over from one life to the next. Together the spiritual and moral constituents of
the individual make for the production of a person through a continuous process that
is developmental but not disjunctive. It is therefore pointless to discriminate between
different degrees of human potentiality in terms of "ensoulment" "variability" and
"brain waves".
The new life is an intimate, inseparable blending of human and
physical-biological existence.
b)
The Islamic position
The idea of ensoulment is strong and well formed in Islam. It has quite important
implications.
Ensoulment occurs either at about 40 days or at about 120 days,
depending on varying interpretation of sources of authority.
(i)
Ensoulment as watershed
Ensoulment is such a key event that it warrants some exposition to convey just how
much of a watershed it is considered to be. The soul is seen as being breathed into the
developing fetus by Allah. It converts the fetus, until then alive but vegetative, into a
human being, albeit not yet with full legal human rights and obviously not yet with
obligations. Its status is that of "incomplete dhimma" i.e. it has rights but owes no
duties). It is ensoulment with the breath of Allah, the "Ruh" (what Christians call
"Ruah Jahwe"), that converts the fetus into an Insan* that elevates humans above all
other creatures, giving humans enormous powers to exploit the rest of creation. At the
same time, however, ensoulment encumbers Insan with the terrible responsibilities of
stewardship. H. sapiens then becomes Allah's "khalifa" (vicegerent, viceroy) on earth.
* H. sapiens is called Insan in tlie Qur'an. Tliis is closer to the Latin "Homo" and tlie German "Mensch" than to
the English "Man."
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(ii)
Ensoidment, volition and neuromuscular coordination
That ensoulment imparts an element of volition is well described by Ibn al Qaim thus
"If il is asked: does the embryo, before the breathing of the sou! into it, have
perception and movement? It is answered that the movement it possesses is like that
()fCl growing plant. Its movement and perceptions are not voluntary. When the soul
is breathed to the body, the movements and perceptions become voluntary and are
added to the vegetative type of life it had prior to the breathing of the soul"
When seen as occurring at about 120 days, it corresponds approximately to the time
when the fetus begins to make purposive movements, i.e. developing neuromuscular
coordination. The fetus soon begins to "quicken", confirming the pregnancy to the
mother and to the world.
(Hi)
Resonance with Our'anic embryology'
Islam does not bestow high regard to miracles. About the only miracle emphasized in
Islam is the miracle of the Qur'an. There is only one version of the Qur'an, the Holy
Book of all Muslims.
The language of the Qur'an itself is considered miraculous - it is said that no human is
capable of creating such beautiful language.
Another miracle is its contents, and
germane here is the amount of intricate detail of embryological development scattered
in various parts of the Qur'an. Muslims consider it miraculous that such microanatomical (and conceptual) accuracy preceded the microscope by a millennium. The
emphasis on embryology in the Qur'an resonates in the Muslim's view with the
emphasis on ensoulment, and the two subjects are often discussed together.
(iv)
Abortion
Since ensoulment imparts proper "humanness" to the fetus, it imparts with it a
demand for a higher level of moral regard, leading to specific aspects of
jurisprudence. Abortion before ensoulment can be permitted for a number of reasons,
as noted above. After ensoulment, however, abortion is allowed only under extreme
circumstances, usually to save the life of the mother.
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(v) Iddah
In Islamic law (Shariah) when a woman is widowed, she cannot remarry if she is
pregnant. She is required to wait (Iddah) for 4 months and 10 days*. If she is in the
early stages of pregnancy, at the end of that period (which would also coincide with
ensoulment at about 120 days) there would be quickening, the fetus will be felt, and
the woman would have to wait for parturition. If not, she can proceed to another
marriage.
(vi) Fela! rights
After ensoulment the fetus has a right to inherit if the father dies; if miscarried, and
shows signs of life (eg movement) then there is the right to be inherited if the fetus
will have owned property at its birth. The punishment for aggression against the fetus
is more after ensoulment, and if the fetus is killed or aborted through this aggression,
the perpetrator has to pay a blood ransom to the family.
Ritual prayers and forms of burial are also different for the aborted fetus before and
after ensoulment.
->
Pre-delermination
In Hinduism a question that a determined predeterminist may pose is this: if everything
happens according to Karma, why should abortion be a sin? Islam would not be so predeterministic. Insan has been given (limited) free choice — indeed, with intelligence, this is
probably humankind's greatest gift.
However, these rather different perspectives on pre-determination certainly warrant further
elaboration.
3.
Other reasons for abhorrence of abortion
Hinduism is aversion to abortion is in the first instance based on the fact that the spirit is
inherent at conception (and guides subsequent development of the embryo and fetus). Wide
social context, solicitude for the mother "in general" and the implications of birth for human
destiny are additonal considerations of why there is such abhorrence to abortion in classical
* 3 months or 3 consecutive menstrual cycles, if for a divorce.
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Hinduism . In Islam the abhorrence is primarily due to the solicitude for the life of the fetus the other considerations play a much lesser role.
Additional factors to consider are that:
•
A son is needed to perform the last rites for the parents. Abortion could lead
to the loss of an only son.
•
The "holistic" conception in Hinduism requires that the fetus not be interfered
with.
•
Human rights have a special implication for human destiny, and this renders
abortion particularly heinous. [We need to explore further whether there is a
similar idea in Islam],
Glorification of the yvomh
Another aspects of abhorrence of abortion in Hinduism is the expression of the value of life
in the Samhit portions of the Vedas, which glorify the womb itself, and elsewhere in charms
to protect the embryo. We are unaware of such an attitude to the womb in Islam. Charms are
used by Muslims in many countries, but they are often considered "superstitious."
Intentionality
A very important consideration in Islam is that an act may be judged to be right or wrong
depending on the intention of the agent. Committing a crime with good intentions may be
punishable in this life when humans apply the Shariah, but may well be judged differently
and be forgiven by Allah. This kind of analysis finds reflection in the (western) philosophical
ethical concept of the Law of Double Effect.
Re-calibrating the Hindu and Muslim positions
In reality the positions regarding ensoulment/abortion may not be that far apart either. While
Caraka's Samhita gives the impression that at no time within embryonic/fetal development is
there a state of pure matter in which the termination of that life is morally justified, the
Sasruta* Simhita recommends abortion in difficult cases where the fetus is irreparably
damaged or defective and the chances for a normal birth are nil. In such circumstances, the
’ Sasruta is regarded as one of the greatest surgeons in history, and the father of plastic surgery.
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surgeon should not wait for nature to take its course but should intervene by performing
craniotomy and remove the fetus.
We have also already noted that in both religions, perhaps for different reasons, the mother's
life takes precedence over the fetus. Perhaps the key to understanding that there may not be
much difference between the two is to ask what is meant by "life." Both hold that life is
present at conception; but whereas Hinduism would hold that life is equally "human" at all
stages of development, Islam would add that ensouled human life is different and special.
The two religions certainly agree that no abortion is better than any abortion, and that the
earlier it is the less of a moral issue it is in degree, and that both traditions value life as such.
Areas requiring further dialogue
I. Embryo as symbolising life
There is in Hinduism a rather strong symbolism attached to the embryo as representing
life in general. We are not aware of this role of the embryo in Islamic discourse. Perhaps
the bigger question is in the whole area of symbols and the roles they play in the two
religions. This will require greater expertise than is available to the current Islamic co
author of this paper.
2. Harmonization with nature
An insight we share is that Islam sees the rest of creation and the environment in term of
stewardship responsibilities, while Hinduism, in the sense that it is meant to "empathise
and harmonize with natural forces and processes rather than to exploit or dominate them",
is more holistic.
Muslims in general will say that the more harmonious they are with nature and the
environment, the better. They would add, however, that the following need to be taken
into account:
•
The saving of human life takes precedence over almost anything else. Islam is
fervently pro-life, as enshrined in the famous Qur'anic verse:
(It was ordained for the Children of Israel)
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"that if anyone slew a person...it would be as if he slew the whole people
(mankind); and if anyone saved a life, it would be as if he saved the life of the
whole people. " (Qur'an, Al Maida, 32)
•
Insan is Allah's vicegerent on earth, and is elevated above the rest of creation.
Humankind, therefore, has the right to exploit the rest of creation and the
environment ((counterbalanced by stewardship responsibilities and obligations,
which call for respect and preservation).
This difference, and its implied differences in Weltenschaaung, may also not be all that
real in the practical unfolding of the two traditions. We would need to assess this in a
much more rigorous and scientific way to see whether there is a real difference in how
other species and the environment are treated by adherents of the two traditions.
3. Caste status of the embryo
It has been held in classical Hinduism that the embryo of a caste Hindu (especially a
Brahmin) is more deserving of protection than that of a slave. However, deeper analysis
indicates that caste seems to play a lesser role. Why this is so is an interesting point
worthy of further study.
Family planning, embryo experimentation, assisted reproduction, genetic engineering
etc.
We did not have the opportunity to go into the details of these issues. Below is a summary of
the understanding of the Islamic co-author of this paper, presented as an opening to further
dialogue between these two ethical world religions.
1. Family Planning
This has a long history of acceptance and has been permitted for health and socio-economic
reasons; and sometimes for lesser reasons.
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a) Coitus interruptus is well known, and acceptable, in Islam.
All the schools of
jurisprudence, however, insist that this must be with the specific consent of the wife, as she
has the right to bear children, and fully to enjoy sex.
b) Family Spacing through prolonged breast feeding. In recent years this has been
encouraged in societies with high fertility rates. The Quran mentions 2 years as being the
appropriate length of breast-feeding. Breast feeding has a specific and special status in Islam,
especially in relation to "suckling motherhood" whereby a child suckled by a woman who is
not that child's biological mother becomes a sibling of the woman's children, who therefore
cannot get married to each other, as this would be tantamount to incest.
c) Other Methods, e.g. the pill. While opinions vary, on the whole this is seen as acceptable,
provided account is taken of the fact that the key (though not the only) purpose of the sexual
act is procreation. Contraception must give way to procreation at some stage.
d) Intrauterine contraceptive devices (IUD's) and the preimplantation embryoz IUD's, work
by stopping implantation; the fact that their use is permitted would imply that the embryo
before implantation (or as some would prefer, the "pre-embryo"), is not yet considered as
having much moral consideration. This needs to be reconciled with Al Ghazali's conception
of the phase of "imperceptible life" before quickening.
e) Abortion cis afamily planning method is unacceptable.
f) Sterilization - is frowned upon, but may be allowed when both partners agree, provided it is
temporary; i.e. permanent methods are not allowed unless in a woman with a reasonable
number of children and coming to the end of her reproductive life; or for strict medical
indications.
2. The beginning of life; preimplantation genetic diagnosis and chorionic villous
sampling.
subsequent developmental stages of life as we know them.
1.
It must contain the full genetic endowment of a human being as a species
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We have previously noted that the 5 criteria for the beginning of life imply that a zygote, after
fertilization of the ovum by the sperm, would be considered alive.
However, the use of IUD's has been permitted, and in some Muslim countries, so has of pre-
implantation genetic diagnosis with a view to not implanting the embryo when, say,
thalassemia major is diagnosed.
Even chorionic villous sampling and abortion has been
practised in some Muslim countries. What this implies is that although the pre-implanted
embryo has moral worth and is considered to have a form of life, the moral consideration
extended to it is much less than that extended to the established fetus especially after
ensoulment; it is not considered a full person yet, and has fewer legal rights accorded to it.
(See above re "ensoulment')
3. Experimentation on the embryo or fetus.
Islam encourages research and learning. In principle, research would be allowed on aborted
fetuses, provided the pregnancy was not planned specifically for this purpose, and the
abortion occurred spontaneously or was otherwise permitted. Creating embryos specifically
for the purpose of research would likely not be permitted in Islam.
4. Assisted Reproduction.
The pursuit, by a couple, of the wife's pregnancy is legitimate. IVF is allowed and widely
practised - one of the busiest clinics in the world is in Saudi Arabia. Proviso: the gametes
(sperm and ova) must be from a couple who are currently married. Sperm or ova donation
from third parties is strictly forbidden. Thus, AIH (artificial insemination by husband) would
be perfectly legitimate, but AID (by donor) is forbidden.
5. Surrogacy:
Islam sees genetic and biologic motherhood as one, and that it should be kept that way.
Surrogacy has therefore been ruled impermissible.
6.
Genetic Engineering,
Genetic Engineering per se, is not forbidden; as in most things in Islam, it all depends on
what the intention is, and what the science is applied for.
In this context, the important
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consideration would be that much is still unknown, and the consequences for future
generations must be taken into account.
Thus, while diagnostic applications and safety
ensured therapeutic interventions would be permitted, germ-line interventions would not;
creating transgenic micro-organisms to manufacture therapeutic products would be permitted,
but producing dangerous micro-organisms for germ warfare would not.
7. Genealogy.
Islam is very concerned with genealogy, and so anything that might confuse genealogy would
not be permitted.
Thus, testicular or ovarian implants that would continue competent
gametogenesis would not be allowed; the same, but without gametogenetic capability would
theoretically (say for hormonal needs, although it is difficult to see a medical need) be
perfectly acceptable.
8. Organ transplantation: the anencephalic.
Brain death as constituting death of the person has been accepted, and is practised extensively
in Saudi Arabia, for example, but there are significant opinions to the contrary. In relation to
our topic here, the main issue would be that of the anencephalic fetus who is born alive. It
boils down to this: it must not be killed, but if it dies naturally (as they always do quite soon
after binh), it would be permissible to use its organ for transplantation.
Life must be saved; it is the prolongation of life, and not the prolongation of the process of
dying, that is called for. In other words, when medical intervention will only prolong death
and has no possibility of saving life, a point of futility' has been reached, and it is then
permissible to withhold further intervention; however, normal life's requirements, like food
and water must not be withheld. When there is the possibility that analgesics may also hasten
death, it is the intention of the intervention that is given moral consideration. Euthanasia is
not permitted.
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Further reading:
Hinduism
Julius J. Lipner, "The Classical Hindu View on Abortion and the Moral Status of the
Unborn", in Harold G. Coward, Julius J. Lipner and Katherine K. Young, Hindu
Ethics: Purity, Abortion and Euthanasia (Albany, NY: State University of New York
Press, 1989) p.42-43. Also see p. 65 note 32.
Louis Renou, Religions ofAncient India (London: The Athlone Press, 1953) p. 48.
S. Cromwell Crawford, Dilemmas ofLife and Death. Worldviews and Contemporary Issues
(Albany, NY: State University of New York, 1995) p. 21.
William A. Young, The World's Religions: Worldviews and Contemporary Issues
(Englewood Cliffs, New jersey: Prentice Hall, 1995) p. 127.
Islam
Albar, Mohammed A. Human Development as revealed in the Holy Qur'an and Hadith (The
Creation of Man between Medicine and the Qur'an) Jeddah. Saudi Publishing and
Distributing House. 1986.
Bucaille, Maurice: The Bible, The Qur'an and Science. The Holy Scriptures examined in the
light of modern knowledge. Translated from French by Alastair D. Pannell and the
author. Indianapolis North American Trust Publication. 1979. (Library of Congress
Catalog Card No. 77-90336).
Daar AS. 1994. Xenotransplantation and religion: the major monotheistic
religions. Xeno 2(4), 61-64.
Daar A.S (1997). A survey of religious attitudes towards donation and transplantation. In:
Procurement and Preservation and Allocation of Vascularized Organs. Eds. G.M.
Collins, J.M. Dubernard, W. Land and G.G. Persijn. Kluwer Academic Publishers,
Dordecht . Pp.333-338.
Glasse, Cyrille. The concise encyclopedia of Islam. San Francisco. HarperCollins. 1991.
(ISBN 0-06-063126-0).
Ibrahim, Abdulfadl Mohsin. Abortion, Birth Control and Surrogate Parenting. An Islamic
Perspective. American Trust Publications. 1989. (ISBN 0-89259.081-5).
18
Draft
1
Islamic Code for Med. Ethics. The Kuwait Document.International Organization of Islamic »
medicine,1st. Edition. Kuwait.X Copies in English and arabic can be obtained from the
author). 1981.
kamali, M H (1991) Principles ofIslamic Jurisprudence^ Islamic Texts Society,
Cambridge
.4-
19
THE STATUS OF UNBORN LIFE IN HINDUISM
Arvind Shanna
McGill University
i
I
The question just posed - regarding the status of unborn life in Hinduism - is a question
which is ethical or moral in nature, or a question which pertains to what Hindus call
dharma. This is a key Hindu term which “includes not only religion but all the ethical,
social and legal principles associated with religion and which together constitute the real
meaning of life for the Hindu. The word is so wide in meaning that Radhakrsnan can only
define it as right conduct”’.1 In addressing issues which pertain to dharma one is advised
in Hinduism to consult what in Hinduism are called the roots or principles, or the defining
elements of dharma. These are four according to one standard fisting and may be broadly
described as (1) revelation; (2) tradition; (3) conduct and (4) conscience. In other words.
these foui constitute our sources of value. Therefore in dealing with, or even wrestling with
issues pertaining to dharma. one should take four factors into account: (1) what do revealed
scriptuies have to say on the point; (2) what light does received tradition shed on the point;
(3) how have people in general, and specially those more estimable among them in
particular, conducted themselves in relation to the issue and (4) what does your own
conscience say in the matter. The status of the unborn life should therefore be assessed
from these four points of view.
Arvind Shanna: The Status Of Unborn Life In Hinduism
-2•
n
REVELATION
The body of revealed literature in Hinduism is collectively called the Veda in the
singular or Vedas in the plural, on account of they being four in number. Another word for
it is □rw/z, or what was divinely seen or heard. The Vedas are again subdivided into two, or
three, or four layers. The threefold division is most convenient for our purpose. These
layers are respectively called (1) the Samhita (or Mantra), (2) the Brahmanas and (3) the
Upamsads.
References to unborn life in these three sections clearly establish the point that.
according to the revealed texts of Hinduism, anything with a human DNA constitutes
human life. Unborn life, in this sense, has the status of life. This is expressed indirectly in
the SamhitU portions of the Vedas in the glorification of the womb2 itself and elsewhere in
charms to protect the embryo.3 In one famous Brahmana text, in the Satapatha Brahmana.
“abortion is used as a criminal yardstick to illustrate the despicable character of ritualistic
sins and their punitive consequences”.4 In one of the Upanisads, the Kausitaki Upanisad,
the killing of embryo is classed along with the most reprehensible crimes, which include
patricide and matricide. A passage with a similar implication is also found in the better
known and larger Brhadaranyaka Upanisad. Both the Upanisads “assume that abortion is
among the most deplorable evils, subject to consequences that karmically affect both this
life and the next, and that only through enlightenment is one delivered from its malevolent
force”.5
An’ind Sharma: The Status Of Unborn Life In Hinduism
-3-
Normally a reference to the relevant material in the scriptural texts suffices on points
of dharma. However, the question of the status of unborn life has a medical dimension to it
also. The texts which deal with medicine in Hinduism are called Ayurueda (or the Veda of
longevity) and belong to the category of Upavedas, i.e., Secondary’ Vedas. They do not
possess revelatory stature but are worth consulting given the nature of our inquiry.
One well-known text of Ayurueda is the Caraka Samhita. .An examination of the text
shows that it too is opposed to
abortion as morally evil. It does so on the assumption that spirit is present in matter
from the moment of conception, and is the causal agent in its progressive
development. This creative manifestation of the spirit in the microcosmos is similar to
the process of creation in the macrocosmos. On the human side, the moral character
of the individual is also given in conception. Karma is carried over from one life to
the next. Together, the spiritual and moral constituents of the individual make for the
production of a person through a continuous process that is developmental but not
disjunctive. It is therefore pointless to discriminate between different degrees of
human potentiality in terms of “ensoulment/ ‘liability,” and “brain waves.*’ The new
life is an intimate, inseparable blending of human and physical-biological existence.
The upshot of Caraka's view is that at no time withing embryonic development
is there a state of pure matter in which the termination of that life is morally justified.6
.Another medical text, the Su^ruta Samhita
recommends abortion in difficult cases where the fetus is irreparably damaged or
defective and the chances for a normal birth are nil. In such instances the surgeon
should not wait for nature to take its course but should intervene by performing
craniotomic operation for the surgical removal of the fetus.7
TRADITION
Texts which embody tradition are called Smrtis, of which no less than twenty texts
are known. .Among these the Manusmrti is considered preeminent. Although many of these
deal with rules of caste-conduct they all emphasize the protection of women and strikingly
Arvind Sharma: The Status Of Unborn Life In Hinduism
-4-
such “female protection docs not seem to be based on caste. Life is at stake, and hence all
women have the right to protection”,8 as is “the birthright of that most vulnerable form of
all existence - a child in the womb”.9
CONDUCT
Hinduism as a religion is interesting in that it accords a high place to conduct in its
scheme of sources of value. Normally, within a religion, the sacred revelation and tradition
lay down the norms and one is supposed to adjust one’s conduct to it. In Hinduism,
however, the conduct of the elite (sistacara), or even widespread practice (lokacara), can
itself be treated as a source of value-formation. Not only should people do the right tiling;
what the people do can also be regarded as the right thing to do; within Emits, of course,
which raises the question of who sets the limits.
This principle of Hinduism comes into hill play, both positively and negatively, in
dealing with the status of unborn life. First what, from a modem liberal perspective, we
would consider thejrositive side: despite the fact that both Hindu revelation and tradition
are opposed to abortion:
In the late 1980s 3.9 million induced abortions were reported annually in India.
Abortion has been legal in India since 1971, when the Medical Termination of
Pregnancy Act was passed. It allows for abortions when “the continuance of the
piegnancy would involve a risk to tire life of tire pregnant woman or of grave injury to
her physical or mental health” or when “there is substantial risk that, if the child were
bom, it would suffer such physical or mental abnormalities as to be seriously
handicapped.” Two appendices state that when a pregnancy is caused by rape of the
failure of a birth control device, “grave injury” will be assumed.10
It must be noted at the same time that “many Hindus are disturbed by the use of
elective abortion as birth control”.11
.Arvind Shanna: The Status Of Unborn Life In Hinduism
-5-
negative side is represented by the phenomenon of gender-bias in abortion.
“Between 1978 to 1983, 78,000 female fetuses were aborted”.12 It is also worth noting that
Hindu leaders “consider the use of abortion for sex selection, usually used to secure male
children, to be immoral. It is considered infanticide”.13
We are obviously dealing here with a matter of some complexity within the category
of conduct, particularly in relation to its twofold character as (1) Sistacara or the conduct
of the elite and (2) lokacara or the conduct of the people. The first question is: who
constitures the elite ? By normative criterion, Hindu leaders should constitute tire elite. As a
practical matter, however, the Westernized elite in India could constitute the elite, an elite
which may or may not overlap with the Hindu elite. There could be leaders of society who
are not Hindu leadens, specially in a secular country like India. Then there is the question of
relationship
leianonsmp of
or this elite to the masses. To what extent iin a democracy, for instance, must
the leadersjpllmy their electorate in order to lead it! These issues must be left unresolved
here, to be addiessed later.
CONSCIENCE
Illis is important in both a general and a particular way. “Hinduism is a religion
which recognizes that each person must make his or her own ethical decisions, because
each person alone suffers or enjoys the karmic consequences”.14
It is also important because it is through this source of value formation that Hinduism
mediates its position between the pro-life and pro-choice camps, affirming “the arguments
of each camp while differing from both”.15 It accepts the pro-life view that the fetus is alive
but parts company with it “on tlie grounds that die riglit to life of the fetus
Arvind Sharma: The Status Of Unborn Life In Hinduism
-6-
ought not to be absolutized. In place of absolute rights, Hinduism advocates addressing
competing rights and values. Ethical dilemmas arise in case of rape and incest and when
the mother runs the risk of grave in jury or death. Each situation is unique and its own moral
tragedy. The best on can do in such situations is evil, but then it boils down to a question of
degree’1.16 To that extent Hinduism is pro-choice, or rather pro 'moral1 choice.
m
RECALIBRATING THE ISSUE
The specific position of Hindu revelation and tradition is pro-life but an overall
exploration of the argument in terms of all the sources of dharma reveals the
complexity of the issue, specially at three levels:
(1) at the level of the acara or conduct vis-a-vis other sources;
(2) within acara, or conduct, in terms of sistacara and lokacara and within them in
terms of what constitues the elite and the people;
(3) at the level of the individual between his karma or what he does and his dharma
or what she should do.
The following points need to be taken into account in terms of the contemporary
specificity of Hinduism, so that we can remain on guard against false specificity and
false abstraction.
(1) Within the category of revelation, the secondary forms of it turn out to be more
significant than the primary. Moreover, in terms of revelation, contraception is
acceptable but not abortion.17
Arvind Shanna: The Status Of Unborn Life In Hinduism
-7-
(2) There is hardly any moral resistance within modem Hinduism, its rcvalational and
traditional teaching notwithstanding, against abortion per se, but abortion as a
means of birth control and as a means of sex-selection arouses genuine moral
indignation.
(3) The relevant elite in India today turns out to be the legislative elite, which has
taken over the role of the Qistas or moral exemplars; and it is the electorate which
now constitutes the people (or loka). Hence the bonding between the two is
political and legal in form, though still moral in content. However, it does create
the possibility that the legislators may say one thing in public life and act
differently in private. Is what they say, thereby compromised.
(4) Within the legal framework, the individual may then take his or her own moral
vision, by using karma and dharma as its two eyes, as indicated in the following
passage.
In a pregnancy where the mother’s life is in a balance, Hindu ethics places
greater weight on maternal right than of fetal rights. The adult human being,
having arrived at a karmic state in which there is much more at stake for her
spiritual destiny, and in which there are existing obligations to be performed for
family and society, is in a position to be favored over an equal human being
whose evolution in this life is by comparison rudimentary, and who has not yet
established a social network of relationships and responsibilities.18
Arvind Sharma: The Status Of Unbom Life In Hinduism
-8-
POINTS FOR DISCUSSION
(1)
Classical Hinduism distinguishes abortion from miscarriage.19 Is a similar
distinction drawn within Islam?
(2)
Classical Hinduism distinguishes between kinds of miscarriage in terms of periods
of pregnancy, but does not seem to distinguish between kinds of abortion in relation
to fetal development.20 What is the situation within Islam?
(3)
According to the majority view in classical Hinduism, ensoulment occurs at the
time of conception.21 When does ensoulment occur according to Islam?
(4)
In classical Hinduism, the attitude against abortion reflects an element of solicitude
for the mother in general.22 Is such the case in Islam?
(5)
'
•
•
•
73
In classical Hinduism, abortion is considered particularly heinous/ What is the
position on this point in Islam?
(6)
In classical Hinduism, the “embiyo of a caste Hindu (especially a Brahmin) is more
deserving of protection than the embryo of a slave...”.24 Is there a comparable
provision in Islam?
(7)
There is an important social dimension to the Hindu attitude towards abortion, in
addition to the moral.25 Is such the case in Islam?
(8)
According to classical Hinduism, abortion violates the integrity of both the victim
and the abortionist as a human person/6 Is such the case in Islam?
(9)
If the live fetus cannot be safely delivered, maternal life takes precedence over fetal
life/7 What is the position within Islam on this point?
Arvind Sharma: fhe Status Of Unborn Life In Hinduism
-9-
■a
(10)
In classical Hinduism, the status of the unborn child is not affected if it is the
product of an adulterous union.28 Can a position on this point be identified within
Islam?
(H)
It has been argued that the distinction made in Western thought between a human
be*ng and a human person does not apply to classical Hinduism.29 Is it applicable in
Islam?
(12)
Human birth has a special implication for human destiny, which renders abortion
particularly heinous?0 Is human birth also considered special in Islam?
(13)
If eveiylhing happens according to Karma, why should abortion be a sin? - This is
a question which could be posed by a determined predeterminist within Hinduism.31
Is a comparable position possible within Islam?
(14)
Abortion can be considered unHindu.32 Can it also be considered unlslamic?
(15)
The embryo is symbolic of life in Hinduism. 33 Is it so in Islam?
(16)
The aversion to abortion within Hinduism may in part be attributed to its tendency
to “empathise and harmonise with natural forces and processes rather than to
exploit or dominate them”.34 Is this the case in Ishim?
(17)
There are strong ritualistic reasons underlying the Hindu attitude to abortion.35 Is
such the case in Islam?
(18)
Hindu ethics does not confine itself to consideration of timeless rational factors but
also involves context.36 Does ethical discussion in Islam provide a point of
convergence or divergence in this context?
(19)
India, although predominantly Hindu, has legalised abortion.37 What is the situation
in Islamic countries?
Arvind Sharma: The Status Of Unborn Life In Hinduism
-10-
(20)
Classical Hinduism treats of abortion in a context of “wider social and moral
obligations7’ rather than as “a matter of exclusively individual rights (especially of
the mother)”.38 What is the Islamic position in this regard?
(21)
In some cases, in classical Hinduism, an abortionist has been identified as a
murderer.39 Is this ever the case in Islam?
(22)
Some aspects in classical Hinduism in relation to abortion are very striking. To
mention only three: (1) killing 4lhe embryo (even) of a stranger...is tantamount to
killing a Brahmin”40; (2) one suffers ritual-deprivation upon harming ‘The embryo
t
or its mother”41 and (3) ’’...the Smrti of KOtyDyana allows the execution of a
•
•
BrOhman for procuring abortion”.
42
»i
•
•
•
(The inviolability of the Brahmin is the gold
standard of conservative orthodoxy; the treatment of women that of modem
liberalism. The bracketing of these in the above-mentioned provision is striking.
Are similar examples identifiable within Islam?
Arvind Sharma: The Status Of Unborn Life In Hinduism
- 11 -
NOTES
1. Louis Renou, Religions ofAncient India (London: The Athlone Press. 1953) p. 48.
2. S. Cromwell Crawford. Dilemmas of Life and Death: Worldviews and Contemporary
Issues (.Albany, NT? State University of New York Press, 1995) p. 21.
3. Ibid., p. 22.
4. Ibid., p. 23.
5. Ibid., p. 24.
6. Ibid., p. 30-31.
7. Ibid., p. 32.
8. Ibid., p. 27.
9. Ibid., p. 28.
10. William A. Young, The World's Religions: Worldviews and Contemporary Issues
(Englewood Cliffs, New Jersey: Prentice Hall, 1995) p. 127.
U.Jbid., p. 128.
12. S. Cromwell Crawford, op.cit., p. 34.
13. William A. Young op. ciL. p. 128.
14. Ibid.
15. S. Cromwell Crawford, op. cit., p. 31.
16. Ibid.
17. Ibid., p. 196.
18. Ibid., p. 32.
19. Julius J. Lipnen ’’The Classical Hindu View on Abortion and the Moral Status of the
Unborn”, in Harold G. Coward, Julius J. Lipner and Katherine K. Young, Hindu Ethics:
Purity, Abortion and Euthanasia (Albany, NY: State University of New York Press, 1989)
p. 42-43. Also see p. 65 note 32.
Arvind Sharma: The Status Of Unborn Life In Hinduism
- 12-
_ ^--3
Introduction
International Consultation on Interreligious Dialogue in Bioethics
Christoph Benn
Dear collegues and friends,
it is a great pleasure for me to give the introduction to our consultation. For a long time my
collegues and me have been planning this event and it is difficult to express the amount of
gratitude I feel that you have followed our invitation and are about to engage in two days of
intensive dialogue and delibarations.
I would also like to remember those who have been part of the planning process and can not
be with us today. Dr. Michael Akerman from the Institute of Judaism and Medicine in New
York and Dr. Arvind Sharma of McGill Univiversity in Montreal, Canada had given their
energy and thoughtfulness to the preparatory process but can not be with us today. Dr. Simon
Mphuka from Zambia had to cancel his flight just one day before his anticipated arrival
because his wife got ill. We include them in our prayers and hope that we will meet all of
them at a different occassion.
Let me express another concern. If we look around we clearly miss a proper gender bias. All
of us gathered here are men. I think this fact certainly requires some further thoughts. Of
course, we could explain why there are no ladies present. We had invited some distinguished
female scientists and ethicists as well as representatives of international organizations. But
unfortunately, all of them could not accept our invitation for various reasons some just
recently on a short notice. But probably it would be too easy to accept this explanation - we
tried, but we failed. We are not satisfied with this answer because the virtual absence of
women in interreligious dialogue has been complained about before. It has to do with the fact
that in all organized religions women are not represented appropriately in the leadership. They
are not represented according to their proportion in scientific and policy making institutions
either. Therefore I really regret that we were not able to reverse this trend for our consultation
and we should certainly pay attention to this issue when we plan future initiatives.
So what is the specific purpose of this consultation? I see mainly two purposes: We want to
contribute to find answers to some of the most vital issues in international health and we want
1
to contribute to a deeper understanding between different faith communities and traditions so
that peaceful relationships in a pluralistic world can be achieved and maintained.
We will try to approach some of the burning ethical issues in international health. There are
many appropriate ways to deal with ethical questions and dilemmas. There are rational
arguments, guidelines by international organisations and specific laws in individual countries.
But without any doubt religions and faith communities do play a major role in the building of
ethical opinion or what others have called moral formation.
Let me briefly introduce the subjects we will cover within the next two days.
1.
The value of life and the cost-effectiveness considerations in international health. In
recent years at least since the publication of the World Bank Report 1993: Investing in Health
and the WHO publications on the Global Burden of Disease there is an intense debate whether
this approach is ethically justified. The answer to this question has very important
implications as currently many decisions on resource allocation in health are based on the
assumptions that the value of life in general and healthy life in particular can be measured and
interventions prioritized accordingly. Religions have always shaped the perception of the
value of life in their cultural context. Therefore this issue has to be explored more intensively.
2.
Demographic developments and reproductive health are very high on the agenda of
international organisations. The World Development Report 1999 has just been published
with alarming figures concerning the lack of access to appropriate services particularly for
women and the future projections for the relation between resources and population size on
this globe. At least since the International Conference on Population and Development in
Cairo in 1994 we know that the reactions and opinions of religions play a major role in the
formulation of internationally accepted guidlines. There is a great need for a constructive
dialogue with and among religions on these issues.
2
In many countries and regions some of the most burning ethical issues relate to the
questions of death and dying and euthanasia. An ageing world population, the increase in
chronic diseases, progress in medical technology and the lack of resources provide the
background for an ethical discussion about the autonomy of individuals, the dignity of
persons at the end of their lives and the role of health professionals in providing guidance for
patients who cannot hope to recover from their illnesses. Ethicists like Peter Singer who
advocate ethanasia under certain conditions have highlighted the need for intensive debate to
which religions can contribute many valuable insights.
4.
Everybody is aware of the devastating effect of HIV/AIDS in many regions of the
world. It is by now the No. 1 cause of death in Africa and the NO. 4 worldwide. Many
2
countries are trying to implement effective prevention programmes. Unfortunately quite often
organized religion has contributed to fear and blame and has sometimes hampered badly
needed prevention methods including condoms, sex education for youth or needle exchange
programmes for drug addicts. There is an urgent need that religions come to an agreement on
what is appropriate and what is not acceptable so that people will be encouraged to protect
themselves from HIV/AIDS by all scientifically proven methods.
5.
There is hardly any other problem affecting health on a global scale as the dramatic
inequalities and inequites between the different regions of the world. There are good reasons
to conclude that the current inequities in the allocation of resources for health are the most
devastating problem in global health requiring our urgent attention. Millions of deaths could
be prevented each year if people had affordable access to basic quality health services and
preventive measures. Therefore ethically it is one of the most important tasks to analyze the
current inequities and to consider ways how these might be overcome. The religious
communities can provide valuable insights for these considerations.
These are the issues we are going to address within the next few days and we hope that this
consultation will come to conclusions and statements that will help the work of many people
active in the different areas of public and international health.
Let me turn to the second purpose: promote a deeper understanding and peaceful relationships
between religious communities. The eminent theologian Wesley Ariarajah who for many
years had been leading the interreligious dialogue programme of WCC once borrowed an
analogy from the health sciences when he was asked what his dialogue program was all about.
He said:
"Dialogue is not an ambulance service; it is a public health programme." That is true. You
cannot start with a dialogue programme when there is already ethnic or religious conflict.
Rather interreligious dialogue is a preventive measure. It is supposed to build relationships,
common understanding and peaceful cooperation so that tensions are reduced in advance and
escalation is prevented.
Ariarajah continued:
"Dialogue is not so much about attempting to resolve immediate conflicts, but about building
a community of conversation, a community of heart and mind across racial, ethnic and
religious barriers where people learn to see differences among them not as threatening but as
natural and normal. Dialogue thus is an attempt to help people to understand and accept the
other in their otherness. It seeks to make people at home with plurality, to develop an
3
l
appreciation of diversity, and to make those links that may just help them to hold together
when the whole community is threatened by forces of separation and anarchy." (Ariarajah:
Not without my neighbour - Issues in Interfaith Relations. WCC 1999, p. 13)
1 think this phrase captures very well what we are about to do here. We are not here to deny
our diversity, to neglect differences of background or opinion, but we are here to feel at home
in our plurality. We are here to express our deeply felt convictions and our perception of
religious truths. But we can do so in mutual trust, sympathy and respect so that everybody
should feel free to share with the others what he feels is important to him. We hope to come
closer together, to find common grounds on important issues in international health and by
doing this we sincerely hope that we will contribute to a public health programme in
interreligious dialogue that will help us and others to reduce tension to to build peaceful
relationships in the different communities and countries from which we come.
4
Sexual Ethics in the Context of HIV/AIDS - A Christian Perspectives
Consultative Group on HIV/AIDS
World Council of Churches, Geneva
Moderator: Christoph Benn
Ethics is the systematic study of moral reasoning in theory and practice. It clarifies questions about
right and wrong, but also demonstrates their complexity: most ethical theories and many moral
judgements are contestable. Some norms, values or principles are sufficiently widely agreed for codes
of professional practice or laws to be based on them. But no ethical theory or decision-making method
yields unequivocal conclusions which convince everybody: too many different beliefs, philosophies,
cultural backgrounds and life experiences influence our views of right and wrong. Meaningful and
constructive frameworks developed by ethics over the ages are used to examine the facts and values
in question. Such discussions can lead to a degree of consensus or at least a mutual understanding of
divergent views.
This approach is akin to that adopted by the early Church in relation to Graeco-Roman philosophical
concepts (without which much Christian theology is literally unthinkable). In health care ethics today,
the conceptual framework most widely used in analyzing bioethical questions is some variation on the
'Principles of Bioethics’: respect for persons, beneficence and non-maleficence, and justice. Each
principle represents a prima-facie duty - that is, it is morally binding unless it conflicts with one of the
others. The framework does not provide a method for choosing between the principles when they do
conflict, or for determining the scope of their application (for example, who counts as a person?).
However, in medical ethics in general and in ethics related to HIV/AIDS in particular we often
encounter problems which arc characterized by the fact that there are extremely complex issues which
are intrinsically ambiguous. There has to be a choice between alternative decisions on right or wrong
for all of which one can find conclusive arguments supporting one or the other opinion.
-1
The theories or principles alone cannot solve these problems as there might be mutually exclusive
decisions which all violate certain principles while they might be supported by others. This is what is
called an ethical dilemma. We arc often not faced with the question whether or not to violate a certain
theory or principle, but which possible alternative violates them more or less. Therefore ethical
principles arc not in themselves sufficient to reach a conclusion in the case of ethical dilemmas, but
they add an accessible ethical dimension to the international scientific vocabulary', and a common
language in which to address, analyze and discuss medico-moral questions of cross-cultural concern.
-2
'The final outcome may be that reasonable people will disagree, but the process ofdebate and
scrutiny of these perspectives is likely to produce the kind ofthoughtful judgement that is always more
valuable than simplistic conclusions reached without the benefit of careful, sustained reflection and
discourse. ' (Reamer: AIDS and Ethics)
This framework of principles has an additional advantage: It can be employed by either deontologists
or utilitarians. Broadly speaking, these are the two main schools of thought in philosophical ethics. It
can also be accepted by the adherents of many religions. Even when those with different philosophical
or religious views qualify- the principles or their scope, the common core language remains
ecumenical. These particular principles, moreover, were originally identified by examining ethical
codes and standards (especially of the health care professions) which in turn had been deeply
influenced by Christian history.
-4
In the context of the HIV/AIDS pandemic the development of an ethical response to a variety of issues
is crucial. Such a response bvjthe Church, while inspired by the Gospel, will no doubt commend itself
to reasonable people of good will in modern pluralistic and secularized societies.
-5
There arc high expectations by people in all societies to get answers to their burning questions through
ethical considerations. The churches in particular are faced with expectations to exercise their role in
1
providing moral guidance. It is an unique opportunity to convey to the world a relevant message in a
time of moral and political crisis. This message should be a contribution to a peaceful and just co
existence of people and nations. At the same time there is considerable disagreement among Christians
themselves on ethical issues threatening the spirit of unity in diversity which is characteristic for the
ecumenical movement. This is clearly expressed in a joint document of the World Council of
Churches and the Roman Catholic Church:
-6
'At the same time, renewed expectations rise in and beyond the churches that religious communities
can and should offer moral guidance in the public arena...Pressing personal and social moral issues,
however, are prompting discord among Christians themselves and even threatening new divisions
within and between churches...In a prayerful, non-threatening atmosphere, dialogue can locate more
precisely where occur the agreements, disagreements and contradictions. And dialogue can affirm
those shared convictions to which the churches should bear common witness to the world at large.
Furthermore, the dialogue can discern how ethical beliefs and practices relate to that unity' in moral
life which is Christ's will. '
-7
Entry’ into ethical dialogue requires a comprehensive knowledge of the basic ethical principles, the
facts of the situations in question and clear technical information related to it. These elements should
enable a well informed, transparent and verifiable discussion and decision making process.
A.1.a Two Approaches to Ethical Reflection
-1
Ethical reflection asks about the "rightness" of particular actions. Traditionally such reflection has
proceeded from one of two starting points: either from the norms which arc understood to govern
human behaviour, or from the consequences which follow from that behaviour. A brief review of these
two broad approaches, known as "deontology" and "consequentialism" (or "utilitarianism")
respectively, will serve to introduce our discussion of specific forms of ethical reflection.
A.I.a.i
Deontology
-1
Deontology is the doctrine of duty and incorporates some of the oldest ethical systems in all cultures.
It focuses on the intrinsic duties and values which determine our actions. These values formulated as
commandments and rules for human behaviour are a matter of principle and have their own
undeniable justification in themselves. The formulation and justification of these deontological values
can originate from different perspectives.
-2
The ‘Ten Commandments' found in the Old Testament (Ex. 20, 1-17) are an ethical code based on
divine revelation. The Golden Rule ‘Do to others as you would have them do to you' (Luke 6. 31)
which is found in the New Testament and similarly in many world religions serves as a general
guideline for the assessment of human behaviour. Deontological philosophical reasoning like
Immanuel Kant's „ Supreme moral law“: ‘Act only on that maxim through which you can at the same
time will that it should become a universal law' are intended to convince all reasonable people by the
force of this argument. Therefore there are moral rules and values which can be regarded universal
and forming the basis for principles and ideals which have to be translated into concrete moral actions.
A. 1 .a.ii
Consequentialism (Utilitarianism)
-1
Consequentialism claims that the question of right or wrong action is decided by the consequences of
these actions. The moral quality does not depend on the action itself but on its utility for the benefit of
people which might be defined as happiness or greatest good. This theory is based on only one moral
principle: the principle of utility. Therefore potentially there can be no conflicts between conflicting
principles. To arrive at conclusions on right or wrong it is necessary to calculate net benefits and to
balance alternative solutions taking into consideration resources and the needs of people concerned.
-2
The fact that utility is the supreme principle does not mean that utilitarians would justify any txpe of
action as long as it results in a greater benefit for a person or a group of persons. A particular version
2
of this theory' is called rule utilitarianism. They regard moral rules such as truthtelling, respect for life,
keeping promises etc. as essential elements of our fabric of life. These rules are to be observed
because the overall benefit of keeping these rules is greater than their neglect. Even if in single cases
there might be situations where disregard of these rules could produce some benefit, the long term
results would be negative. Therefore these rules are to be kept. The principle of utility . however,
would still be regarded as supreme principle in case that some of the moral rules got into conflict with
each other.
A.1.b Principles of Medical Ethics
-1
Apart from the two main perspectives on ethics there are the ethical principles which are widelyreferred to in ethical studies noyvadays and can be applied to various ethical problems. The four most
important principles are respect for persons, beneficence, non-maleficence and justice.
A.1 .b.i
Respect for Persons
-1
Notwithstanding common agreement that ‘a person’ cannot, or should not, be considered as a distinct
entity outside of relationships or community, the term here refers to a human being yvho is capable of
exercising a degree of autonomy, hoyvever limited. Autonomy is literally ‘self-rule’, or the capacity to
think, to make decisions and to act for oneself. It may be limited - by immaturity, by lack of relevant
information, or by physical constraint; the capacity- for autonomy is a matter of degree, greater or less
in different people at different times. Special skills (listening, enabling or political) may be required to
ensure maximum respect for the autonomy of people yvho are inarticulate, impaired or constrained.
-2
To exercise their autonomy people need access to relevant information on which to base their
autonomous decisions and a certain degree of liberty so that decisions can be made without undue
coercion or manipulation.
A.I.b.ii
- 1
Bneficence and Non-Maleficence
Beneficence is literally ‘doing good’ and non-maleficence, ‘not doing harm’. These principles express
the duty to enhance the yvelfare of other people if one is in a position to do so. and to avoid doing
harm wherever possible. The latter has been considered the most important moral principle of
physicians since the times of Hippocrates: ‘Above all, do not harm’, and the two duties together
require physicians to produce net medical benefit yvith minimal harm. Here the skills, not just of
evidence-based medicine, but also of other carers and friends, may be required to determine yvhat is in
the best interests of people temporarily or permanently unable to express their oyym autonomy.
A. I.b.iii
Justice
- 1
The principle of justice or fairness is more wide-ranging than the others mentioned and may be
appealed to if they are in conflict. It is especially concerned with the distribution of goods, services
and resources: in this it presupposes that all human beings are of equal worth, and that attributes such
as status, gender, wealth or merit do not justify inequalities. Not all inequalities are unfair: people have
very- different needs, and yvhile those yvith equal needs should be treated equally, those yvith unequal
needs should be treated unequally.
-2
Justice is concerned yvith the formulation of criteria for solving potential conflicts between people
yvhich necessarily arise as the conception of yvhat people deserve or do not deserve differs widelydepending not only on convictions, but also on positions in the local, national or global community. In
the context of HIV/AIDS justice is related both to bioethical questions of the distribution of scarce
resources in health care as yvell as to the larger issues of poverty and economic constraints as
contributing factors to the spread of HIV.
While the principles of respect for persons and beneficence are more, though not exclusively,
concerned with individual ethics justice is more concerned with social ethics, with the treatment of
3
I
persons in communities or even with the question of right and wrong actions within and between
communities, societies or nations.
A.2
Further Approaches and Christian Ethics
- 1
These principles are acceptable to the two main schools of thought in philosophical ethics. Respect for
persons reflects both Kant’s (deontological) imperative to treat people always as ends and not means,
and Mill’s (utilitarian) requirement that everyone should be free to determine their own actions if these
do not infringe on the autonomy of others. Both schools also accept beneficence and non-maleficence,
although they may disagree on the scope of these principles, on how to work out their implications,
and on whether beneficence is a praise-worthy virtue or an obligation to everyone. Justice, too, is an
agreed goal, but maybe pursued by different strategies: Libertarian ethics leaves distributive justice
largely to market forces, while egalitarian ethics demands that all people get the same share. Some
theories restrict liberty, to achieve a greater degree of justice; others, for example Rawls’ contract
theory', give liberty priority over equality, but only if allowing inequalities is to the benefit of the least
advantaged.
-2
Most other contemporary theories or approaches to medical ethics are compatible with and
complementary' to the four principles approach. Case-based methods, for example (which attempt to
revive the best methods of traditional casuistry') relate concrete examples to agreed principles; while
narrative or story-telling ethics (which is not unlike the Christian method of telling parables) can also
relate constructively to the principles.
Virtue ethics (which emphasize that the right choices are most likely to be made by good people)
focuses on other aspects of the moral spectrum which need to be taken into account, as do care
approaches (which emphasize context, relationships, the particular and compassion rather than
dispassion). The only approach which seriously seeks to replace the principles is the ‘common
morality' approach, which offers a deductive method which ‘it is claimed', can find the correct
answers to specific ethical questions. But the main difficulties with this approach as an alternative to
the principles in relation to practical medical ethics arc:
a) that its exclusive claims for its own interpretations of‘rationality’ and ‘common morality’ are
contestable: and
b) that the proposed deductive system of decision-making is not only very complicated but also
depends on getting people to agree about a series of more or less abstract value judgements before
they can reach the correct concrete judgement about the ethical question in hand.
-4
Another approach to Christian ethics, which would also have meaning for general ethical behaviour,
has been described by H. Richard Niebuhr in The Responsible Self. This has the advantage of
describing ethics-in-a-relationship, which Niebuhr pictures as a dialogue of responsibility. The two
ethical questions he discerns are: 1. 'What is going on in this situation?' (i.e. one must be wellinformed), and 2. What is the fitting thing to do, the thing that fits the dialogue best here, and allows it
to continue. The fitting action can never be specified in advance, because it will depend on particular
circumstances, and thus requires responsibility.
-5
Christian ethics on the other hand derives from theological reflection on Scripture and the churches'
response to revelation. It owns no single comprehensive ethical theory', but embraces principles and
values drawn from historical and personal Christian experience and. for some, from natural law
theory. It is deontological in seeing obedience to God's living Word as the supreme rule for
conscience and community. But its incamational and eschatological orientation regards human
freedom to respond to the complexity and ambiguities of ordinary moral experience as God-given - an
opportunity to grow, through mutual forgiveness, in grace and understanding.
-6
The joint WCC - Roman Catholic working group on moral issues mentions also other Christian
resources for moral reflection such as: liturgy and moral traditions, catechisms and sermons, sustained
4
I
pastoral practices, the wisdom distilled from the past and present experiences, and the arts of reflection
and spriritual discernment. How ever, there was a general agreement that:
'The biblical vision by itselfdoes not provide Christians with all the clear moral principles and
practical norms they need. Nor do the Scriptures resolve every ethical conflict. Nevertheless, there is
a general consensus that by prayerfully studying the Scriptures and the developing traditions of
biblical interpretations, by reflecting on human experiences, and by sharing our insights in
community. Christians can reach reasonable judgements and decisions in many cases of ethical
conduct. '
-7
These judgments and decisions of Christian ethics are in harmony with the principles of modem
bioethics as described above, but they also go beyond them, since they derive from notions of
relationship. God relates to all creation, human and non-human, and they are in relation with each
other. Thus a principle like the autonomy of persons may be found in e.g. the unconditional value of
creatures (Matt. 10.30), or in Paul's respect for the conscience of the gentile (Rom.2.4). Yet as God not
only respected the freedom of the world, but loved it (Jn 3.16), so Christians not only respect the
others' autonomy, but love their neighbours.
For Christians, beneficence is a basic duty; and because it comes under the command Jove your
neighbour as yourself, beneficence wherever possible includes benevolence (or goodwill). Christian
ethics goes beyond the moral rule of beneficence which is required by anyone at all times. Jesus
taught not only to do what is required by law , but to do more out of love, to go the extra mile (Matt. 5,
41) as a characteristic feature of the values of the Kingdom of God.
-9
While we may not find a comprehensive theory of distributive justice in the Bible, Justice' is an
important and frequently used biblical concept. The scriptural concept of justice is a relational one
which asserts the inescapable intcr-rclatcdncss of all things. Equality is again supported by the story of
creation itself, and repeatedly the Bible reminds us that our first and foremost concern have to be
those who are in greatest need. In Old Testament terms those in greatest need were the widows,
orphans and strangers to whom all Israelites had special obligations. In the New Testament the poor,
despised and marginalized people arc those who understand first the message of the Kingdom of God,
and Jesus Christ meets us in the least of His brothers and sisters. Let us be reminded that all these
groups arc exactly those who arc nowadays most affected by HIV/AIDS.
A.3
Ethics Applied to Some Issues Raised by HIV/AIDS
The biocthical problems raised by HIV/AIDS arc often complex and ambiguous, with no conclusive
arguments on either side, yet practical decision-making is urgently needed. Those involved in
decision-making moreover, arc of all faiths or none, and to differentiate between alternative solutions
sound facts and technical information are required. To be more than rhetorical therefore, a Christian
ethics must be translated into a language that can be shared with all informed people of good will; and
thence translated into meaningful action. The application of the principles outlined above to the
particular problems and questions posed by HIV/AIDS can be regarded as a touchstone for the validity
and the soundness of the arguments.
A.3.a Discrimination
- 1
Discrimination against people living with HIV/AIDS unfortunately occurs in all societies and
communities and has become an important factor preventing effective means against the further spread
of the pandemic. Discrimination makes the whole community more vulnerable to the spread of HIV
including the discriminators themselves and those who are discriminated. In a situation of
stigmatization, prejudice and gossip both groups are less likely to accept the presence of HIV in the
community and to cooperate in the prevention of the factors leading to the spread of the pandemic.
-2
Therefore possibly for the first time in histoiy the pevention of discrimination against people affected
by an infectious disease is an integral part of the strategy to control the pandemic.
5
At the same time all ethical principles require that nobody is dicrimnated against because of attributes
such as race, gender, religion or being affected by a particular disease. The respect for persons
unequivocally demands that all people are respected in the same way and nobody can be ostracised
because of a natural event such as a disease.
-4
The principles of beneficence and non-maleficence are clearly violated in the case of discrimination as
it causes considerable harm to those who are discriminated and as was shown above in the end also to
those who arc discriminating. Justice again demands that people are treated equally and fairly so that
they receive the care and attention which is attributed to all people.
A.3.b Confidentiality
- 1
Confidentiality requires that information which persons wish to keep to themselves or to a person
whom they trust (doctor, counsellor) is kept secretly and is not disclosed to anyone outside this
relationship of mutual trust which is protected by special obligations. Confidentiality of personal
health information is required both by the respect for persons and by traditional medical ethics. Lack
of privacy inhibits responsible decision-making. This is particular!}’ important in relation to sensitive
information like HIV serostatus, ways of infection or symptoms of AIDS. By maintaining
confidentiality and trust, doctors or counsellors are in a unique position to influence behaviour,
thereby reducing the risk of HIV infection being transmitted to others. On the other hand disrespect for
the principle of confidentiality might drive people infected with HIV underground, if they have
reasons to doubt whether their status could be disclosed to others. This would impair the positive
opportunities of the doctor-patient relationship.
-2
However, there might be situations of conflict when one person discloses his/lier HIV serostatus to a
counsellor, but refuses to reveal this status to others at risk through mutual relationships. We have a
situation of two conflicting principles. The doctor's or counsellor's dilemma (heightened if caring for
both partners) is whether to respect the first client's autonomy or, in order to avoid potentially fatal
harm to the partner, to breach confidentiality. The principle of autonomy demands strict
confidentiality and prohibits the disclosure of this information to a third party.
On the other hand the principle of bcncficcncc/non-malcficcncc demands that the life of persons is
protected by providing the necessary information enabling that person to avoid a serious infection. But
that may make it less likely that such information will be confined to doctors or counsellors in the
future. So respecting the duty of non-maleficence in this case may have long-term consequences
which arc medically more harmful than beneficial.
-4
Both principles have to be balanced and each particular case has to be treated with extreme carefulness
of ethical judgement. What these tensions between the principles make clear is the need to treat each
case of this kind with great sensitivity. Every attempt has to be made to help the client to disclose the
information to his/her partner voluntarily. Only when this utterly fails may the doctor/counsellor
consider to override the principle of confidentiality, on a strict "need to know' basis.
-5
Decisions of this kind are experienced as absolutely agonizing by those who have to make them. They
are also rarely needed since normally a trustful doctor/counsellor-patient relationship should almost
always be able to avoid steps which might violate the confidentiality. Much more common is the need
to ensure that confidentiality is not breeched inadvertendly or carelessly.
A.3.c Sex, AIDS and health education
- 1
In some cultural environments, people refuse to talk about sex, AIDS and aspects of sexual health.
Many people of good will fear that greater talk of sex or sex education will result in a corresponding
increase in promiscuous behaviour. Clearly the Church also has a moral responsibility to minimise
communal and personal vulnerability to conditions in which sexually transmitted disease might
spread.
6
-2
In spite of understandable reservations, reliable research has revealed that education about sex, AIDS
and health in general, particularly with children and young people, does not result in increased sexual
activity. On the contrary, trends indicate a delay or reduction in sexual activity due to education.
Given this background, the responsibility of the Church in facilitating sound, well-resourced education
is plain.
Stories ofsituations in which lack of'bad education resulted in or exacerbated bad moral behaviour...
'The highest incidence ofHIV/AIDS is among young people in the productive age group of 20-40
years. In some areas, young girls are sold to pay the debts ofparents and to augment the income of
the family. We have received reports that men are looking for younger women and even children as
marriage or sex partners on the assumption that they don't have HIV or that they could cure them
from HIV. '
2
Equipping people, particularly children and youth, with the ability to make sound moral decisions is
the most effective way of achieving responsible moral behaviour. Education, however, is more than
knowledge. Increasing the number of facts known by a person will not necessarily result in well
equipped decision-makers. Effective education is responsive to the cultural context into which
information is introduced, and involves the mutual participation of educators and students in the
education process.
A.3.d Condoms
-1
The condom is a simple technical device to prevent the exchange of body fluids during sexual
intercousc. While its efficiency raises technical problems, the condom itself poses no specifically
ethical problem. Concerning the efficency of the condom in regard to the prevention of Sexually
Transmitted Diseases (STD) there is clear scientific evidence to prove that the condom is a safe and
effective means of protection.
The World Health Organization is referring to a carefully designed study on:
‘A Response to Recent Questions about Latex Condom Effectiveness in Preventing Sexual
Transmission of the AIDS Virus" prepared by the Program for Appropriate Technology’ in Health
(PATH), Seattle. USA in January 1994:
"Condom breakage and slippage has been analyzed, both through studies in which participants have
been surveyed about their condom use and through studies in which participants have keen given
condoms and asked to report on various aspects of their use. One U.S. consumer survey ofalmost
3300 people reported condom breakage rates ofless than one percent.
Laboratory studies have also been carried out to assess leakage ofa variety of microorganisms,
including HIV. These studies have demonstrated the ability of intact latex membranes to prevent the
passing of HIV, herpes and hepatitis B viruses, cytomegalovirus and chlamydia trachomatis, even
after mechanical stimulation. Even worst-case condom barrier effectiveness had been shown to
provide 10.000 times more protection than no condom at all.
Conclusion of the study:
Condoms, when used consistently and correctly, are highly effective at reducing the risk of infection
from HIV and other sexually transmitted diseases. Therefore, efforts focused on improving condom
quality, availability and use represent a critical aspect ofpublic health strategies to contain these
diseases."
-2
The ethical questions which might arise concern the effects of the use and the promotion of condoms
on behaviour. Some would argue that the promotion of the use of condoms might have the effect of
increased promiscuous sexual behaviour, while others argue that sexual behaviour is largely
7
determined by other factors and condoms do not effect the frequency of sexual intercourse but only the
unwanted consequences of this behaviour, e.g. the transmission of Sexually Transmitted Diseases
(STD). This is a question to be answered by social anthropologists or sociologists who study the
effects of various factors on human behaviour. Up to now there are no conclusive studies showing that
the promotion of condoms increases or discreases promiscuous sexual behaviour.
But the implications of the conflicting arguments on the use and promotion of condoms will be
influenced by the ethical principles applied. There might be a conflict between the desire to protect
people’s moral integrity by reducing incentives for sexual promiscuity and the desire to protect
human life by averting a potentially lethal infection.
-4
Respect for persons would favour the self-determination of persons which requires to promote access
to information on the means of protection from an infection and to the protective device itself.
According to this view even if condoms had also negative effects, it would be paternalistic to withhold
the necessary information so that people could decide for themselves. On the other hand if studies
showed that the promotion of condoms could increase the risk of HIV transmission, then the principle
of beneficence and non-maleficence would clearly require restricting the access to condoms.
-5
But again, if studies showed that the promotion of condoms could reduce the risk of HIV
transmission, the same principles would consequently lead to a moral obligation to save lives by
enabling people to protect themselves. In addition justice would demand that all those who arc in need
of a protective method get access to it and not only those who live in societies where these methods
arc freely available or who have the ability to pay.
-6
Because of these arguments many Christian health professionals and counsellors have decided on the
grounds of pastoral responsibility and after careful considerations to provide their clients with the
protective device on demand without claiming that this is or should be the only answer or solution for
the problem of HIV prevention.
-7
It should be kept in mind, therefore, that condoms arc only one of the different methods to prevent
HIV transmission. The primary aim will be to change behaviour and social conditions in a way which
puts people at a lower risk to get into contact with the virus. All choices have to be presented to the
people concerned and all efforts have to be made to empower them to make responsible decisions for
their lives based on the options available according to current knowledge and experience.
-8
After careful consideration of the ethical questions and of the technical details the following conclusion
was drawn:
Without blessing or encouraging promiscuity, we recognize the reality of human sexual
relationships and practice, and of the existence of HIV in the world. Statistical evidence
demonstrates that education on positive measures of prevention and the provision and use of
condoms help to prevent transmission of the virus and the consequent suffering and death for many
of those infected.
-10
Should not the churches, in the light of these facts, recognize the promotion of condoms as a method
of prevention of HIV?
A.3.e Needle Exchange
- 1
The sharing of needles and syringes between people addicted to injectable drugs is one of the principle
ways of HIV transmission in this group. Therefore the provision of clean needles and syringes to those
who need these devices is a method to prevent unintended HIV transmission caused by unsterile
instruments. As a technique, this again does not pose any ethical problem. But since the use of drugs
such as heroin is illegal in many countries and since societies try to discourage their use, the provision
of the means for injecting these drugs might be questioned ethically.
8
-2
Answering this question again depends on the results of reliable studies. It is beyond doubt that the
provision of clean needles can eliminate the risk of HIV transmission with i.v. drug users via this
route. There are also studies on programmes having introduced needle exchange schemes which have
clearly shown that the introduction of these schemes has not increased the use of these drugs
(Amsterdam). If the availability of needles does not influence the drug using behaviour significantly
then there would be a strong moral obligation (based on all of the principles) to provide these devices
as it has the potential to save lives.
Again it should be remembered that needle exchange programmes are only one method to reduce one
of the many risks and threats to human life posed by the use of narcotic drugs. The best way of
reducing HIV transmission through infected needles would be the primary or secondary prevention of
drug use itself. Therefore the needle exchange programmes will come as a complement to the
educational campaigns. All programmes should be culturally acceptable, accessible and based on
voluntary participation.
-4
After careful consideration of the ethical questions and of the technical details the following conclusion
was drawn:
-5
Without blessing or encouraging the use of narcotic, intravenously applied drugs, we recognize the
reality of human addiction to these drugs and the practice of sharing needles for the application of
these drugs which carries a high risk of HIV transmission.
-6
Well designed studies demonstrate the evidence that education and the provision of clean needles in
exchange for used ones help to reduce the risk of viral transmission and the consequent suffering
and death for many of those infected by this way.
-7
Should not the Churches, in the light of these facts, promote free education for all those addicted to
drugs and the provision of clean needles as long as the addiction is not avoided?
A.3.f HIV Testing
- 1
Respect for persons requires that nobod}- is forced to undergo diagnostic or therapeutic procedures
affecting his or her future life without proper information enabling them to make independent and
informed decisions on whether or not these procedures should be performed. Explicit consent is not
required for all laboratory' tests: for routine investigations w’hich carry no particular risk and arc
necessary for treatment, a patient’s general consent or evident wish to be treated is sufficient. The HIV
test is different from routine investigations, not only because the condition diagnosed is still incurable,
but also because of its personal, social and economic consequences for the people concerned in form
of discrimination and stigmatization once their infection is made public.
-2
Therefore HIV testing should only be done if informed consent of the person concerned has been
obtained without any form of coercion or persuasion and if appropriate pre- and post-test counselling
sendees are provided. This implies that compulsory testing for whatever purpose is to be regarded as
unethical, including testing for admission to jobs, education, entry' into countries, medical treatment
etc. Also testing before marriage if recommended must be voluntary for both partners.
2
Potentially there could be a conflict between the individual rights of a person infected with HIV and
the rights of a society wishing to protect a large number of its members by control mechanisms
restricting those individual rights. As in some epidemics of the past arguments of utility could be used
to justify overriding the individual’s rights to informed consent, or to confidentiality, in favour of the
rights of the majority. In practice however, these extreme measures are neither necessary nor useful in
the case of HIV infection: reliable studies have shown that the best way of prevention is providing
information and seeking voluntary cooperation, but not coercion or compulsory' testing.
9
A.3.g Research
-1
There are several ethical problems posed by research related to HIV/AIDS. These concern e.g.
research on human subjects in the development of new drugs, the access to experimental drugs by
desperately ill patients and ethical guidelines for the conduct of vaccine development and trials.
-2
For all research studies involving human subjects there are international codes and guidelines
regulating the ethical preconditions for these studies. The Nuremberg Code 1947, the Declaration of
Helsinki of the World Medical Association 1975 and the International Guidelines for Ethics and
Epidemiology of the Council for International Organisations of Medical Sciences (CIOMS) 1990 all
protect the rights of those who take part in any form of trial in the search for new treatments or
vaccines. These codes clearly state that persons should only be invited to participate voluntarily and
after informed consent in trials which are scientifically worthwhile and in which the risks to subjects
have been minimised.
Trials related to HIV/AIDS are no exception to this, but problems arise when taking part is the only
way in which dcsperatly ill patients can hope to receive any potentially effective treatment. Nonmalcficence obliges researchers to increase the numbers receiving an experimental therapy only
slowly and in careful stages, as evidence of its effectiveness and lack of harmful side-effects
accumulates. This can conflict with the autonomy of patients who wish to decide for themselves
whether or not to risk the side-effects of a potentially beneficial therapy. Yet if the wishes of too
many such patients arc granted, the trial may be invalidated, an unproven or even harmful drug
promoted, and research on promising alternatives delayed, to the detriment of future patients. Such
conflicts can be overcome only by the ethical sensitivity, forbearance and mutual understanding of
researchers and patients alike.
-4
Research on experimental therapies may require that some subjects receive, for comparison, not the
therapy itself, but a placebo (something harmless which looks similar). The ethical problems of this
arc intensified in HIV vaccine trials. When research into the effectiveness of an experimental vaccine
requires the subjects to be at continuing risk if the trials arc to demonstrate efficacy, the ethical
problem is compounded by the possibility that participation may create a false sense of security, and
also that the risk could be reduced by health education. In addition to these non-malcficencc concerns
there are those of justice, arising when those recruited arc too poor or too ill-informed to decline to
participate. At the very leastjustice requires that risks and benefits in the development, production
and distribution of potential therapies and vaccines arc shared globally, without placing vulnerable
groups or countries at a disadvantage.
A.3.h Allocation of Resources
- 1
The just allocation of resources is a major presupposition for an adequate care of people living with
HIV/AIDS and for an effective prevention of the spread of the infection. This applies to the different
levels of social and economic structures. On a community level personal , financial, emotional and
spiritual resources have to be mobilized to achieve the full participation of PWAs in the communal life
and to give them the care which is required for their physical and emotional well-being.
-2
On a national level HIV/AIDS has to receive the attention, the support of the leaders and the
mobilization of resources corresponding to the significance of the problem in terms of the human
suffering involved and the social and economic consequences of the pandemic on the national level
2
-4
At a global level, the international community has to ensure that adequate measures are taken for the
fight against a global pandemic affecting all regions and continents on the globe. Up to now resources
for the treatment and care of AIDS patients and for the prevention of HIV transmission are distributed
extremely unequally. Although more than 80% of all HIV infections occur in less-affluent
countries.they receive only a small portion of the international resources spent on HIV/AIDS.
This raises serious questions about distributive justice. Justice requires the most care for those in
greatest need. This means, in practice, that available resources should be redistributed, giving each
10
country' a fair share and enabling them to establish programmes adapted to their local situation. This
aim may seem unrealistic in a short-term politico-economic perspective. But its aim - to reduce both
the burden on those directly affected, and the further spread of the infection - is consonant with the
common good, at a time when, economically as well as epidemiologically, world populations are
becoming increasingly interdependent.
A.3.i The Duties of Health Professionals to treat PWAs
-1
Unfortunately there are reports about people living with HIV/AIDS being refused the entn* to health
care institutions (including those of the churches) and of being refused by individual health care
professionals whom they have approached for treatment, help or advice. Ethically and historically
these attitudes are not justified. Access to health care is a right for all persons including those who are
infected with HIV. There are no medical or ethical reasons for any restriction of this right.
-2
Some health professionals have referred to the increased risk of contracting HIV by treating PWAs.
This is not justified by the studies which have been conducted on the occupational risks of health
professionals so far. In fact up to now there are very few health professionals who are HIV-positive
and who could be proven to have contracted the infection though actions related to their professional
duties. In general health professionals are not considered to be at greater risk than the general
population.
Given proper observation of normal precautions, the risk to aquire the infection occupationally is very
small. Statistically a needle prick with HIV infected blood will lead to an infection in 0.3% of all
cases. Therefore so far the international bodies regulating professional conduct have demanded that
people infected with HIV should be treated in the same way as other patients and the refusal of
treatment would be considered as gross violation of the rules of professional conduct. This view would
be supported by all three biocthical principles.
11
I
To Save or Let Go: An Ethical Dilemma for Thai Buddliists
Pinit Ratanakui. Mahidol University
Introduction
In few areas have the advances in scientific knowledge and the new medical
technologies raised more basic questions about the very nature, meaning and value of
human life than in the whole area of death and dying. That health care professionals find
themselves in conflict over ethical dilemmas in this area is not surprising, since there is
a lack of public consensus on what is morally acceptable. Already in the West, there has
begun a groundswell of cultural change in which traditional attitudes and ideas about
death and the dying process are being modified or rejected by many and the same
development is occurring now in Thai society. In this society, undergirded by the
teachings of Theravada Buddhism, the replacement of traditional medicine with high
technological medicine has raised new ethical issues that traditional Thai morality and
accepted practices cannot adequately deal with. The new life^support technologies have
blurred the line between prolongation of life and prolongation of the dying process, and
have raised questions about the adequacy of the traditional definition of death as the
cessation of all vital signs. At what moment in the dying process should we declare that
“death’’ has occurred? Shall we continue the traditional definition of “death’’ or declare
“death’’, when the new measuring devices detect the cessation of higher brain activity, or
when both the higher and lower brain activities cease to function spontaneously,
unassisted by machines or procedures like hyperalimentation.? There are also other
questions such as: Is the refusal of life-preserving treatment by artificial means a morally
acceptable option or does it constitute a kind of suicide prohibited by Buddhist
teachings? Is it morally wrong for doctors, nurses and families to withdraw life
preserving treatments or to stop such treatment, once these have begun? Are such
actions the same as “killing’’ patients or are there important ethical distinctions to be
made between “lerting-go-of-Iife’’ by withholding or stopping treatment, and actual
“killing7’ or causing death? The lack of public and professional consensus on these
questions creates the possibility for emotionally laden moral conflicts within the general
public, between families and their doctors and even among medical professionals
themselves. Therefore it is necessary for Thai Buddhists to make systematic reviews of
Buddhist morality and traditionally accepted practices concerning death and dying, and
to rethink or reinterpret Buddhist ethics in its application to these new issues that are no.
so far clearly defined in Juddhism. Such a need and moral conflicts were brought to the
attention of Thai Buddhists by the case of 86 year-old Venerable Buddhadasa. a leading
Buddhist scholar-monk and teacher of this century.
Venerable Buddhadasa Bhikku was a highly revered religious figure in Thailand
and one of contemporary Buddhism’s most respected scholars. For many years, he had
lived at a forest monaster/, Wat Suan Mokkha. in Chaiya in southern Thailand, teaching
faithful disciples, educating visitors from around the world and writing books that
spread his wisdom far beyond his forest hemitage. He had an international reputation as
a modem Buddhist saint.
2
In his early 80s, Venerable Buddhadasa suffered a series of small strokes. He
declined to enter hospital. Although he permitted physicians to visit him at his
monastery, he made clear to them that he did not want them to use the technologies of
modem medicine on nim. His belief in the healing power of Dhamma or Nature had
convinced him that attempts to heal the body by chemical or mechanical means interfere
with the body's own self-healing power. After each of these episodes, meditation, herbal
medication, diet and simple living according to Dhamma seemed to restore his vitality.
Also, one short visit to a hospital tor another illness had convinced him that the
atmosphere of the modem hospital was not conducive to humane care and was certainly
not a place suited to have a good death. On his return from that hospitalization, he took
the unusual step of writing a ^living yvill/’ stating that in case of irreversible coma he did
not wish his lire sustained by such devices as ventilators and intravenous feeding. He
spoke clearly and forcefully to his disciples about his wishes to die naturally.
On May 29, 1993, the Venerable Buddhadasa. now in his 86,h year, suffered a
major stroke. His monk disciples began to care for him at the monastery in accordance
with his wishes. However, a lay disciple, who was a leading neurologist at
technologically equipped Siriraj Hospital in Bangkok, was eager to save the life of his
master and persuaded the monks to allow the venerable monk to be flown to Bangkok,
promising that he would not be intubated. The doctor stated that if no improvement was
seen within seven days, the venerable patient would be returned to Wat Suan Mokkha.
The monks agreed and the patient was admitted on May 29, at 1 a.m. He was in a deep
coma. During the next few days, the intensity of technological medicine accelerated,
each step justified by an appropriate medical rationale, until Venerable Buddhadasa was
on a ventilator and being parenterally fed and hydrated. The monks who had
accompanied him to Bangkok protested; the physicians responded that they had a duty to
continue once they had begun treatment. This duty was enhanced by the reputation of
their patient. The physicians prevailed. But realizing finally that their life-support
treatment could not restore health or a meaningful human existence for the Venerable
Buddhadasa, the attending doctors were willing to let their patient be taken back to his
own temple where he passed away on July 8, 1993, still with the medical technologies
he had repudiated.
Moral Conilicts. How do they arise?
The case involving Venerable Buddhadasa has raised many moral issues
concerning death and dying. Foremost among them is the question of how to decide who
is right in the event of moral conflicts. The case at hand is the conflict of values and
moral perceptions between the attending physicians who have faith in the healing power
of modem technological medicine and, as part of their professional ethics, have the
obligation to save life of the patient in their care when there is some sparks of hope, on
the one hand, and on the other hand, the belief of Venerable Buddhadasa and his monk
disciples in the limitation of modem medicine particularly in its interference with the
natural process of dying. As evident in his ‘‘living will” the venerable monk wanted to
set an example of facing death without fear or anxiety, in keeping with the teachings of
Buddhism. This religion places death at the heart of the human predicament while also
recognizing it as the primary solution to this predicament. Liberation from death can be
found not by denying its inevitability but only by confronting it with equanimity and
3
understanding. Such liberation is possible through the practices of meditation
particularly that with concentration on the idea of death (morancmusati) and on
decomposing corpses (asubhd) which will prepare us to face the fact of death in a
realistic and intelligent manner and also free us from the clutch of the egoistic ego, and
ultimately to attain nibbana, the final liberation from the endless cycle of life and death
{samsara)1
Over sixty years Venerable Buddhadasa had devoted his life to the propagation
of these teachings, and through his meditation practices had prepared himself to be
faithful to them, so that the egoistic self would not be in command of either his life or
his dying but be dissolved. The model for him was that of the Buddha’s dying, a
peaceful letting go of life in the presence of his disciples. The image of the Buddha
hooked to machines or sustained at a meaningless level of human existence could have
given an entirely different meaning and impact on Buddhist adherents. This was what
inspired the well-know monk to write a “living will,” to request that no extraordinary
means, no hi-tech equipments be used on him when the state of irreversible coma
occurred. At age of 86 he accepted the natural deterioration of his body and the decline
of its functions, and was ready to let go of life to accept timely death {kalamorana'). He
did not want people to cling to him nor to his physical life as refuge, but wanted them to
practice Dhamma, the Buddhist teaching, to which he had dedicated his life.
Venerable Budehadasa did not object to the use of modem high-tech medicine
when it could clearly save lives and was the only available resource. But he rejected its
use to prolong the dying process because, for him and for all Buddhists, the last
conscious moments of life are precious. For some Buddhists these dying moments could
be the occasion for final liberation from rebirths in samsara existence. For others these
are occasions to fill the minds with remembrance of their good deeds (kusala kammci)
and thus ensure a better rebirth. According to Buddhism, even a recollection, with true
remorse, of previous bad deeds (akusala kammd) can mitigate bad consequences in the
next life. Thus special care should be given to dying persons to help them to die a “good
death” meaning death with the best possible rebirth or without rebirth.
In his writings Venerable Buddhadas underlined the Buddhist belief in the
preciousness of human life3. But he made a distinction between a life that is truly viable
in which the individual has full command of his faculties, is responsive, responsible and
interrelated, and a life merely existing on the biological level without human awareness
and human interactions. This is another important reason why he wrote a living will
requesting that he must not be kept artificially alive on a solely biological plane. This,
however, does not mean that Venerable Buddhadasa, or Buddhism in general, supports
euthanasia, that is the taking of life either by the self or others. He only wanted to be
allowed to die naturally i.e. to let nature take its course, and not to be put on artificial
means to prolong the dying process.
4
Can Reason Dissolve Moral Conflicts?
What we encounter in this case is a conflict between two sets of values and
obligations. The problem is how to decide which if these sets in this circumstance is
right. Both the physicians and the disciples wanted to do what was best for Venerable
Buddhadasa, their ajarn, spiritual teacher.4 The physicians wanted to save his life by
using whatever means were necessary, even against his expressed wish in the “living
will”, while the disciples wanted to respect the “will” and allow him to die naturally.
The physicians believed that they were morally bound to preserve and prolong their
patient’s life at all costs and that such obligation accords with the Buddhist teaching of
the preciousness of human life. These were the underlying reasons why they did not
want to cease the life-saving treatments on the monk. In the eyes of the disciples the
continuation of the futile treatment showed the lack of respect for their ajarn whom was
treated only as a body to be mechanically controlled, and not as the embodiment of
Dhamma for which he had lived.
Given the fact that sufficient ethical thinking has not been done on this issue by
Buddhist ethicists nor by physicians, and given their different beliefs and values the
conflicting claims of the physicians and the disciples regarding what was right could not
be mediated through arguments alone. At this juncture, both parties practiced
compassion, patience and tolerance as Buddhists and searched for a compromise.
Finally, realizing the futility of their treatment the physicians were willing to let the
hopelessly terminally patient be taken back to his temple but still on the respirator and
with feeding tubes in place. Neither the physicians nor the disciples wanted to take the
devices out for fear of causing the death of such a saintly monk as such action would
yield grave kammic effects for the perpetrator.5
Living Wills: Should They Be Recognized?
The concept of a “living will” is new in Thai society. Its underlying premise is
individual autonomy, namely that a competent patient has the right to select or reject
medical treatments. In Thai society the concept of the autonomy of the individual to
choose or refuse medical treatment has not been a focal issue.6 How a patient is to be
treated is the physician’s decision alone and patients’ rights are not recognized. The case
of Venerable Buddhadasa has raised the issue concerning the right to refuse life
preserving treatment and the obligation of the physician to honor such right. Though a
“living will” is not a usual practice in Thai society, when it was made by an 86 year old
monk, who had dedicated his life to understanding, practicing and disseminating
Buddhist teachings, and who was ready to let go of life, should his expressed wish be
respected? Particularly his case is different from the case of the “living will” written by
a person is still young, healthy and unaware of possible future medical development and
cures. This young person may change his mind when he is actually facing death and, if
he could, might express the desire that everything possible be done to sustain and
prolong life.
By tradition it has been recognized by families, patients and physicians that a
physician’s role is to do any or everything to preserve and prolong his patient’s life in all
cases. Consequently physicians are looked upon as healers, dedicated to preserving and
5
prolonging life of all patients under their care. This primary image of the medical
professionals should not called into question. But does this mean keeping the hopelessly
terminal patients alive at any cost? Are physicians morally bound to preserve life in all
cases and under all circumstances? And as the country strives towards more democratic
principles and individual rights, should the patients’ right to die in the nanner of their
own choosing be honored? These moral issues need to be analyzed and discussed in the
Thai public and among physicians to find possible solution and consensus. The
traditional responses are no longer adequate. New circumstances make necessary a
review of traditional ideas, attitudes and accepted practices to cope with the reality’ of
life in contemporary Thai society.
Does Euthanasia Interfere with the Law of Kamma?
The case of Venerable Buddhadasa has also raised the issue of euthanasia in
Buddhism. A Buddhist solution to the complex issue of euthanasia has to be found
within the framework of the doctrine of kamma, Buddhist psychology and the teaching
of compassion. According to the doctrine of kamma a patient’s disease may have
physical cause such as bacterial infection and/or kammic cause namely the result of his
*7
past bad kamma. When the suffering has kammic cause it will have to run its course
until the kammic potency is exhausted. Even if the patient seeks to end his suffering by
taking his own life he is only interrupting the course of kamma, the suffering will arise
again in his life until that bad kamma is completely expended. Within this framework
the physician ought not to interfere with the working of kamma either by actively taking
the patient’s life or by withdrawing life-support systems. If the bad kamma is allowed to
run its full course here and now, the patient might be reborn into a higher state when the
present life has come to its end. But that could not happen if the patient’s life were to be
cut short while the bad kamma is still to be undergone.
The Buddhist understanding of health and disease in terms of kamma does not
lead to a fatalistic attitude of not seeking any care at all or giving up treatments out of
despair. Buddhism advises us that for practical purposes we have to look upon all
diseases as though they are produced by mere physical causes since no ordinary person
can definitely know which disease is caused by kamma. But even if the disease has a
kammic cause it should be treated. As no condition is permanent and as the causal
relation between deed and its correlated consequence is more conditional than
deterministic, there is the possibility for the disease to be cured so long as life continues.
On the other hand, we need to take advantage of whatever means of curing and
treatment are available. Such treatment, even if it cannot produce the cure, is still useful
because appropriate physical and psychological conditions are needed for the kammic
effect to take place. The presence of the predisposition to certain disease through past
kamma and the physical condition to produce the disease will provide the opportunity
for the disease to arise. Medical treatments will improve the patient’s physical condition
and thereby prevents bad kammic results to manifest fully. At the same time the
treatments do not interfere with the working of the individual’s kamma but may reduce
its severity. The usual advice of Buddhism given to a person with incurable disease is to
be patient and to perform good deeds to mitigate the effects of the past bad kamma. For
the law of kamma does not entail complete determinism. It only stresses the causal
relation between the preceding “cause” and the following “effect” understood in terms
6
of mutually conditioning factors. The emphasis on the kammic cause of health and
disease implies individual responsibility for health and disease. It, however, does not
mean that Buddhism assigns personal responsibility for all illness. In Buddhist thinking
kamma has both the individual and social dimensions. This latter component may be
termed social kamma which, for example, refers to the environmental factors that could
aggravate or mitigate an individual kamma.
Is Mercy-Killing really Merciful?
In Buddhist psychology hatred or ill-will (dosa), delusion or spiritual ignorance
(moha') and greed (lobha) are the three defilements conductive to bad kamma. With
regard to mercy-killing or active euthanasia in the context of Buddhist psychology this
act cannot be carried out without the ill-will or felling of repugnance on the part of the
pepertrator towards patient’s suffering. The motivation behind this action may be good
i.e. to prevent further suffering of the patient, but as soon as such thought becomes
action to terminate life it becomes an act of aversion. So when a physician performs
what he believes is “mercy-killing”, actually it is due to his repugnance of the patient’s
pain and suffering which disturb his mind. The physician experiences negative emotions
toward this disturbance and projects it on the suffering of the patient. But he disguises
his real feeling (i.e. repugnance) as a morally praiseworthy deed to justify to himself for
“mercy-killing”. If he understands this psychological process he would recognize the
hidden hatred that arises in his mind at the time of performing the lethal deed, and
would not deceive himself with the belief that this deed was motivated by benevolence
alone. Therefore from the view of Buddhist psychology “mercy-killing” is not really a
benevolent act. It is done from ill-will i.e. the felt desire to end the patient’s suffering is
actually derived from self-deceptionviz the physician’s own repugnance in watching the
patient’s suffering. Actually he wants to save himself from further suffering, and not the
patient. This self-deception has bad kammic consequences both for the physician and the
patient.
The Buddhist ethical ideal of compassion does not complicate the issue of
mercy-killing for the practice of compassion has its limits which prohibit killing of
humans and animals regardless of the conditions of their lives. In the case of dying
persons compassionate help is limited to giving drugs in sufficient quantities to relieve
intense pain as a last resort and helping them to face the inevitable calmly and to have a
“good death”. Beyond this point the precept against the taking of life is violated. The
Buddhist compassion cannot be associated with killing in any form.9
What Criteria Should Influence Euthanasia Decisions?
In Thai society the problem surrounding the euthanasia issue is complex. It
involves many factors such as the use of modem medical technologies medical costs and
Buddhist teachings. It is true that life-saving and life-preserving technologies could keep
more of us alive for longer periods than formerly. But this success has raised questions
about the worth of the life saved. Venerable Buddhadasa’s “living will” represents the
demand that people be allowed to die. This response to the success of modem medicine
is shared by many people including medical personnel who witnessed the results of these
new procedures. It is also true that medical expenditures for keeping alive weighs
7
differently between the rich and the poor. Because of these facts lay Thai Buddhists,
who consider euthanasia a violation of the Buddhist precept of taking life, realize that
there are circumstances in which euthanasia is not a clear cut case of an immoral act.
Through the newspapers they have become aware of cases such as that of a 94 year old
woman kept alive by artificial means for over a year at the cost of bankruptcy of her
family. Another case was that of an 11 year old girl in irreversible coma for years, again
at high cost to the family. In such cases questions are raised to these Buddhists whether
economic factor, the age of the patient and the quality of life should make any different
in their decisions on the use of life-support systems. None could give a definite Buddhist
answer. Some say yes and some no, for they are not certain about the Buddhist position
regarding this issue, an which there has not been ethical reflection.
The reality is that, although euthanasia is not legalized in Thai society some
forms of it are being currently practiced by some physicians who sometimes make life
and death decisions alone, and sometimes with families. Should physicians be deciding
which patients are better off dead and thus directly act to cause their death? Should
families make the decisions? What criteria should be used to make such decisions?
What about the possible abuses that would arise then? All these questions need careful
analysis to find resolution and consensus. The lack of public and professional consensus
on these questions and regulations of these practices of euthanasia will create a general
climate of suspicions and mistrust of modern medical practice in Thailand and the intent
and motivation of medical personnel. At stake will be the primary social role and image
of physician, who have traditionally been conceived of as “preservers of life”. What
would happen to the public when the physicians become “death advocates”?
Is Lctting-go-of-life a form of Killing?
The practices of passive euthanasia particularly the withdrawal of life-support
systems or stopping treatments that simply prolong the dying process are known to exist
in Thai hospitals. The position of “passive euthanasia” is more difficult to resolve in
Buddhist context. In this case the ethical waters become more muddy. Despite their
belief in the law of kamma a certain number of lay Buddhists who are aware of the
problems arisen from sustaining life at all costs and under all circumstances consider
withdrawing life-support systems morally acceptable particularly in a case when, by the
best medical wisdom and through rigid testing, there has occurred in the patient total
birch death, i.e. irreversible coma and no hope for recovery. They recognize that there is
a real moral distinction between “leting-go-of-life” or “allowing to die” and “directly
and intentionally killing”. For them, in such case letting an irreversible comatose die
does not violate the precept against killing. It is not outright killing and such an act of
omission is motivated by good intention e.g. for the best interests of patients, or their
families, or society, given the expense of maintaining these patients and the scarcity of
medical resources?0
In Buddhist ethics, intention is crucial in determining actions as right or wrong,
and kamma is defined in terms of intention. But with regard to passive euthanasia there
can be mixed motivations behind the intention to act in seemingly good ways. The intent
of family members and the physician to let the patient die may be motivated by selfish as
well as altruistic desires. For example, for family members there may be the desire to
8
relieve the suffering of a patient and the desire to inherit his fortune. The physician may
desire to end the pain and suffering of one patient and at the some time desire to have a
viable organ for transplantation in another patient. A hospital can have a policy
accepting passive euthanasia motivated both by the desire to relieve the suffering of the
patients and families and to contain medical costs. For these reasons lay Thai Buddhists
are cautious about extending the grounds for “letting-go-of-life” by withdrawing
medical technologies beyond the strict and narrow grounds mentioned above. It is true
that sometimes “letting-go” is just as immoral as killing directly. If parents passively
allowed children to die by not giving them food available we would hold it to be as
horrendous an act as strangling them. Since many factors entering into decisions about
withdrawing life-support treatments these Buddhists want such decisions to be made on
a case to case basis. They also recognize that sometimes human choices are only
between two evils. Even in this tragic life situation one still has responsibility to choose
the lesser evil.
For such agonizing decisions there has been little guidance culled so far from
Buddhist sources to help Buddhists and to ease their conscience. As generally known
Buddhism encourages each person to face the troubles by relying on oneself alone,
without expecting any divine power to intercede and help. Choosing among evils
requires wisdom (pannd) or insight arising from the regulated mind (samadhi), right
understanding (sammadhithi) of the real nature of existence characterized by
conditionality (paticcasamuppda), impermanence (anicca), suffering (dukkha) and
unsubstantiality (anatta), and from continuing learning (sikkha). With samadhi and
sammadithi, one is able to make a realistic evaluation of a given situation and to act
thoughtfully and unselfishly. Sikka enriches panna, diminishing the number of mistakes
made. Since there have been cases especially with younger people where remarkable
recoveries have occurred even after doctors pronounced them terminaly ill or as being in
irreversible coma, these lay Buddhists also are unwilling to see general policies adopted
accepting passive euthanasia for fear of possible abuses that are detrimental to patients
and existing moral norms of society. As there are always risks and uncertainties, they
would incline to favor life.
Is there a Buddhist Principle for Euthanasia Decisions?
As mentioned above Buddhism upholds the preciousness of human life and is
against euthanasia or mercy-killing. With regard to the debate on “the right to die” the
Buddhist principle of mutual dependency and inter-relatedness (paticcasamuppada) may
be added to the basis of ethical reflection on this issue. This concept affirms the
interdependence of all beings. When all beings depend an other beings, name of them is
primary, and concern for others, co-operation and harmony are crucial human values in
social relationship. Suicide or assisted suicide as a “right to die” cannot be absolute
because people do not live a^one but a re members of communities who might be injured
by their death or by a social policy that encourages such death. With regard to life and
death decisions this principle could also be applied to the case. Accordingly physicians
should not deer
citfe and act by themselves but in partnership with patients, their families
or surrogates^When making decisions about treatment, including the use of life-saving,
life-preserving technologies. When conflicts arise, some form of structure of mediation
is needed. In the case of Venerable Buddhadasa such mediation means was lacking
9
leaving resolution to the good will of the two parties. But such good will or possible
compromise may not always be present and a law might be enacted to regulate decision
making in case of conflict. But law is a blunt instrument, unable to deal with the
individual differences and nuances that mark human interactions especially in matters of
life and death the public then must be more educated about what is involved in such
decisions. Similarly physicians and nurses must be educated to change their roles to be
more of a partner and facilitator in helping patients and surrogates make decisions. Apart
from this, while keeping their primary image as healers, dedicated to preserving and
prolonging the life of all patients under their care, physicians have to develop a new
approach to death and dying, so that when death becomes imminent they would become
graceful acceptors of the inevitable, not seeing the hopeless condition of the dying
patient as the failure of their skills and knowledge. They should turn their full attention
now to the compassionate care of the dying. Their main concern is to relieve the
suffering of the patients and families and to ensure a “good death” for the patients.
Is Hospice Care a Buddhist Alternative?
There are grounds in Buddhism for hospice care. In Buddhist tradition death is
accepted as the natural end of life and one is not encouraged to either hasten it or to save
it all costs. Buddhism is also known for its holistic approach to health care, focussing on
the entire person, and for its emphasis on the last stage of life as being of great
importance and on the practice of compassion on the part of physicians and nurses to
provide a special care for the dying. The ideal is to help them to die in a calm, conscious
state, so that possible good rebirth is obtained. Hospice care provides humane treatment,
comfort, consolation and companionship to the dying either in their own homes or in
special units at hospitals staffed by specialists specially trained to deal with the physical,
mental, emotional, moral and spiritual suffering that people and families endure at the
end of life.
In Thailand this hospice-like work has been carried on by numerous monks. Out
of their compassion these monks make use of their temples as refuge for full-blown
AIDS sufferers, who, shunned by friends and families and rejected by society, came to
the temples as the last resort. At Wat Prabat Namphu, a temple in Lopburi Province, for
example, twenty AIDS sufferers are being cared for by the abbot and 5 monk-assistants
without any charge. Though they are not specially trained to deal with dying persons
these monks could help them to have meaningful lives in their last days. This
compassionate care includes herbal treatments to relieve the patients’ pain, the provision
of consolation and companionship to alleviate their suffering caused by depression and
lonliness, the teaching of meditation practices and the encouragement of observing the
precepts and merit-making to prepare them for the last days of their lives to ensure
“good death”. Apart from these they are also encouraged to enjoy life through playing
and working together however short it may be. The work of this temple indicates that
compassionate care for the dying is a Buddhist alternative to euthanasia. We can only
hope that such care will continue in the days to come, especially when people are
touched by the selfless work of the monks and by the manifested fruits of their work.
10
Conclusion
Euthanasia is an agonizing problem in Thai society as more and more hi-tech
treatments are being used by physicians to save the lives of their patients. It has raised
many unresolved ethical problems as witnessed by the case of Venerable Buddhadasa.
It is clear that active euthanasia including assisted suicide is morally
unacceptable in Buddhism. But passive euthanasia presents a complex ethical challenge
to Buddhist morality. Physicians cannot prolong the use of life-support systems
indefinitely because of many complicated factors involved such as medical cost for
family members, scarce medical resources, medical uncertainty, and the resulting quality
of patients’ lives saved or sustained. While some lay Buddhists draw a moral distinction
between “directly killing” and “allowing to die” or “letting-go-of-life” to avoid the
breach of the Buddhist precept against the taking of life, the majority do not share the
view. Passive euthanasia therefore remains problematic for the general public. It is even
more problematic for the physicians who strongly believe that sustaining the lives of
their patients is their primary duty and obligation. The question of to save or “let-go-oflife” is therefore a continuing ethical issue for the majority of Thai Buddhists as they
grapple with the reality of existence in the modem world and the need to be faithful to
Buddhist teachings. Like Venerable Buddhadasa more and more elderly Buddhists,
monks and lay people alike, express their wishes to be allowed to die in case of
irreversible coma accepting death as a natural end as taught by Buddhism. But whether
the physicians and the families will help to fulfill their wish is still a mooted point.
11
Note
1. There are various meanings of nibbana (or Nirvana in Sanskrit) found in different
contexts in Buddhist texts. In the paper the term is used to mean the unconditioned
state of consciousness in which there is the ceasing of the “I” (Ego), lust, hatred and
delusion, the three principal forms of evil in Buddhism. This state is not caused, not
originated. It simply makes itself known when all that is opposite (ego-absorption,
lust, hatred and delusion) is removed. There are two kinds of nibbana’, i.e. saupatisesa nibbana-nibbana without the disintegration of all the five aggregates of
existence, and anu-patisesanibbana-nibbana without any element of life remaining.
It is believed that with this state of consciousness completely void of any defilement a
person is released from the round of existence.
2. In this endless cycle the whole range of sentient beings, from the tiniest insect to
man, is believed to exist. Only the human being, however, has the potential to
terminate this cycle. The term sansara is usually presented in Buddhist art as the to
Wheel of Life (bhavacakra). For a detailed discussion of this concept, see The Three
Jewels by Sangharakskita (London: Ryder 8 Company. 1967), pp. 68-82.
3. Many of his work were translated into English, French, and German. Some of
English/French books and articles on his life and work are Donald Swearer, Thai
Buddhism: Two Responses.
Leiden: E.J. Brill, 1973; Louis Gabaude, Une
Hermeneutique Buddhique Contemporaine de Thailande: Buddhadasa Bikkhu. Paris:
Ecole Francaise d’Extreme Orient, 1988; Peter A. Jackson, Buddhadasa: A Buddhist
Thinker for the Modem World. Bangkok: Siam Society, 1988; Grant A. Alson,
“From Buddhadasa Bhikkhu to Phra Debvedi: Two Monks of Wisdom, and Donald
Swearer, “Buddha, Buddhism and Bhikkhu Buddhadasa”, in S. Sivaraksa (ed),
Radical Conservatism: Buddhism in the Contemporary World. Bangkok: Thai Inter
Religious Commission for Development, 1990.
4. Data concerning the last days of Venerable Buddhadasa at Siriraj Hospital was
compiled from the author’s interviews with some attending doctors and his disciples.
5. In Buddhism, kcimma (or karma) means volitional actions, good or bad, has
consequences (yipaka) according to its nature. One reaps what one sow. In regard to
killing a human the gravity of the action depends on the quality of the one killed. To
kill a virtuous person such as a saintly monk is worse than killing others.
6. I have discussed the concept of individual autonomy in thai culture in an article
entitled “Community and Compassion: A Theravada Buddhist Look at Principlism”
in Edwin R. Du Bose et al (eds), A Matter of Principles: Ferments in U.S. Bioethics
(Pennsylvania: Trinity Press International, 1994), pp. 121-130.
12
7. In Buddhist perspectives, life and death are an integral part of samsara existence, and
each rebird is conditioned by the nature of the previous lives. In samsara existence
each person weaves his own web of fate through his deeds (kamma). The individual
is both the cause and the effect, the entries deed on the one hand, and, on the other
hand, the effect of the deed. As an effect of his past deeds he is the product of the
past. But as a cause he is a field of possibilities i.e. he has the ability to gradually free
himself from the past to become whatever he wants to be.
8. For further discussion on this issue, see Pinit Ratanakul and Kyaw Than (eds),
Health, Healing and Religion (Bangkok; Mahidol University, 1997), pp. 29-33.
9. For a discussion on different Buddhist perspectives on euthanasia, see Damien
Keown, Buddhism & Bioethics, (London: St. Martin’s Press, Inc.), pp. 168-173.
JS-
1
Equity and Resource Allocation in Health:
The Islamic Perspective
Adnan A. Hyder, MD MPHPhD, Johns Hopkins University, USA
Introduction
This paper will begin with explaining a working definition of equity and its relationship
to health resource allocation. Following this is an exploration of the Islamic perspective
of populations and their welfare with specific reference to health and health care. The
meaning of equity within such an Islamic state would then be defined together with
implications for resource allocation decisions. Throughout the paper the stress would be
to attempt to link Islamic literature, jurisprudence and sources with the issues in the
distribution of benefits - in this case health benefits. At the end is a summary of those
features that may help define such an "Islamic perspective".
Part I: Equity and Health
The Meaning of Equity in Health
The search for equity in health is essentially a struggle to reduce inequities in health
status between people. The reduction of inequities requires the capacity to recognize and
label such inequities. The definition of these inequities rests on the identification of
inequalities in health, which can be measured by some qualitative or quantitative
parameter. The presence of an inequality in health status between two persons or group of
people (howsoever defined) does not necessarily mean the presence of an inequity.
Rather an inequality is a necessary but not sufficient criteria for defining inequity.
The mere presence of "unequal age" or "unequal physical strength" is an inequality that
may not be avoidable or necessarily harmful. However, if the inequality has attributes
that can define it as avoidable and harmful (Bryant et al 1997) then it can be considered
an inequity. The latter would include groups of people with unequal infant mortality rates
or individuals with different access to health care. Thus an avoidable and harmful (to
health) inequality is an inequity.
The concept of being avoidable and harmfill though seemingly easy to fathom is also
complex. Traits that affect health and are controlled by genetic factors are in general
currently unavoidable (though medical technology may change that premise); while poor
access to health care is certainly avoidable. For example, the color of hair may be
unavoidable but not harmful to health; while poor access to health care is avoidable and
harmful to health.
Equity and Resource Allocation in Health
1
Inequalities in health are often influenced by individual and societal responses to health
issues. One of the main features of such a response, especially in organized societies, is
the distribution of resources to improve health and the health status of people.
Historically speaking, such responses unfortunately have also been responsible for the
creation of inequities. Unequal, targeted and unjust distribution of benefits such that some
gain and others do not, has allowed the creation inequalities. It is therefore quite logical,
that an attempt at redistribution of current financial and economic resources would be
attempted to redress some of these issues.
Resources denote a wide spectrum of societal goods and services that can be
redistributed. These funds and in addition those controlled through money such as
manpower, infrastmeture and technology. At the same time, an analysis of the status quo
in most developing countries will show that current distributions are not helping reduce
inequities - rather the redistribution of funds needs to be augmented and focused. Thus
there are several ways of reallocating resources, all of which will not help reduce
inequity. It therefore becomes imperative to be able to identify the specific pattern of
resource flows that is most likely to help with health equity in a population.
There have been several developments in health policy and planning that aim to assist in
the identification of resource flow patterns that maximize output for the investment. Such
criteria of cost effectiveness (greatest bang for the buck) will stress the total output
compared to the total input for any potential resource allocation. It is a useful and
pragmatic criteria but for equity purposes, it is necessary though not sufficient since it is
essential to know Aoir and to whom benefits will be distributed. An equity analysis will
therefore cany cost effectiveness analysis further to map the location of benefits received
and their subsequent impact on health status differentials.
The Moral Argument for Equity
The moral argument for equity in health is a derivative of the overall moral case for
egalitarian distribution of benefits. Justice or fairness is the basic moral premise within
which elements of both social and distributive justice are embedded. This moral premise
seeks that to ecich is his ot her due and like be treated as like. Equity then becomes an
operational element for this principle of justice to implement a sense of fairness in
distribution of benefits.
Part II: Islamic References
Defining the Sources
There are well recognized sources of information within Islamic knowledge:
-the Quran
-the life and teachings of the prophet (sunnah).
2
In addition two other means of decision making have been allowed:
-consensus (ijmaa)
-analogy (qiyas).
Together the above comprise the Shariah and have lead to the formation of two major
sects within Islam: Sunni and Shia. And within the Sunni sect there are four schools of
thought (jurisprudence).
The Quran (Koran) is the book of God, the last of the revealed books, delivered through
His chosen messenger Prophet Muhammad (PBUH).
The teaching and sayings of the prophet represent another source of information. There
exists a complex science of tracing the alleged sayings to the sources and references and
verifying them. The most verified of sayings (hadith qudsi) are highly valued for their
guidance.
The Welfare Society in Islam
The attributes of an Islamic society are ensconced by the following principles of Justice
(adal or insaaf), brother hood (unity) and a dynamic equilibrium of rights and obligations.
Justice has been quoted in the Quran more within the context of just decision-making and
fair judgements for differences amongst people. Brotherhood is used to promote the
concept of inter-dependency between each person within an Islamic society. Such that
either by being a relative, dependent, neighbor, poor or other each individual has some
linkage with each other. Thus the Islamic society is to be seen as unitary entity
comprising individual parts, rather than the reverse. It is important to note that this
concept of the Islamic society does not have geographical boundaries and may be used to
illustrate local, regional, national or supra-national entities.
The interplay of rights and obligations in an Islamic society is what maintains a live link
within the concept of an organic whole. Each individual has rights which define their
expectations within the social dynamics of the family and society. At the same time there
are distinct responsibilities that come with each role that have to be carried out. In
addition there are obligations towards God that each individual and the society as a whole
needs to fulfill.
Islam and the Distribution of Benefits
An exploration of the distribution of benefits in Islam is important for defining conditions
that will assist thinking through the concept of health distribution. Material goods and
wealth are one form of "benefits" that may be obtained and distributed under rules that
have been clearly defined.
Distribution of property taken from the enemy has been mentioned explicitly in the
Quran. If it has been obtained in battle then.
3
"And know that out of all the booty that ye may acquire (in war) a fifth share is
assigned to God - and to the Apostle, and to near relatives, orphans, the needy,
and the wayfarer,-"
(S. VIII, 41)'
In conditions where property and wealth is obtained without battle, then:
"What God has bestowed on His Apostle (and taken away) from the people of the
townships, - belongs to God, - to His Apostle and to kindred and orphans, the
needy and the wayfarer, in order that it may not (merely) make a circuit between
the wealthy among you
(some part is due) to the indigent
muhajirs (immigrants), those who were expelled from their homes and their
property
"
(S. LIX, 7-8)
In both the situations above the rights of the disadvantaged parts of the population have
been protected. In the case of newly acquired wealth through war a specific amount
(20%) has been specifically set aside for this group. It is also important to note the use of
the phrase "...that it may not (merely) make a circuit between the wealthy among you..."
which is specific indication of the circulation of wealth between a limited few in a
society. This danger of wealth being restricted to a small proportion of people is disliked
and by analogy, any benefit (such as health) that would augment human life should
therefore not be restricted to a few in any society.
Another form of benefits is that which is given away by people for others. Thus the
injunctions for the distribution of charity are similar:
"To spend of your subsistence , out of love for Him, for your kin, for orphans, for
the needy, for the wayfarer, for those who ask, and for the ransom of slaves"
(S.II, 177)
This verse stresses the active re-allocation of personally owned wealth and property to
others less advantaged for the love of God. The descriptions of the disadvantaged are
common to other scriptures.
Islam and the Value of Health
Islam respects the value and humanity of man; it’s outlook is holistic and comprehensive.
This needs to be emphasized and the role of religion in the protection of human life and
health all over the world needs to be promoted.
In verified teachings of the prophet Muhammad it is said that God would ask <My
servant, why have you not visited Me?>. The person would reply: <How can I visit You,
and You are the Lord of all mankind>. God would say: <Did you not know that so and so
1 These are references to the Holy Quran in the following order: S=Surah or Chapter number; #=verse
niunber.
4
has fallen ill, and that if you were to visit him you would have found Me there?>. Thus
God is to be found with the sick and helping them is being close to Him. This
consideration of the sick must be viewed as a serious injunction of not only helping the
sick cope with sickness but also making them less sick. Thus the healer is always with the
sick, always with those who are close to God and making them healthier makes the healer
special in the eyes of God.
Part III: Islam, Health and Equity
Implications of Islamic Perspectives on Equity
Islam does not recognize any differences between individuals to be of substance to their
destiny except for their closeness to God. All other differentials are for worldly purposes,
and the only one that matters is how pious (taqwa) is the individual. Therefore, for all
intents and purposes all are equal.
Differences of gender, age, color and others are seen as a tribute to the powers of creation
of God, such that no one individual is exactly similar to the other. They are to be
considered as morally irrelevant. Therefore the distribution of benefits based on these
features should also be egalitarian unless it is for the benefit of the under privileged. This
is the one category of persons that has been grouped separately on the basis of the
challenges that God has put them in - for which they will emerge successful. This group
of people may have different types of worldly disadvantage (not moral) such as lack of
money, power and social status. Moreover they can be in such a state for a long time
(mimicking permanence) or for a temporary period of time. These are the poor, the
orphans, the wayfarers and the needy. A difference in their health status is therefore
unacceptable based on these attributes. This is therefore a case for the active reduction of
inequities between groups of people.
Though the word equity does not appear in the Quran, words denoting egalitarian society,
universal brotherhood and inter-dependence of people have been clearly expressed. These
concepts denote an active movement for the recognition and demonstration of unity
within the larger Islamic community (ummah). Thus a case for the active search for
equity is also made.
Implications of Islamic Perspectives on Resource Allocations
The active notions of seeking equity and reducing inequity in health in Islam have to be
operationalized within the context of provision of resources and opportunities. These
principles mandate the distribution of resources to the advantage of the poor and other
vulnerable groups.
However, allocations of state funds are not the only means of reliance on achieving such
equity. Social and financial safety nets have been actively promoted in Islam as defined
by functions of the Islamic state and the individual. Zakat or income-based charity is
5
mandatory on those individuals who qualify (based on annual wealth holdings). This
represents 2.5% of the annual wealth and is to be either given directly to the poor in the
absence of state mechanisms or through a state controlled means.
There is an integral and interactive relationship between poverty and health. Poor people
are much more likely to be unhealthy, and when they fall ill are more likely to stay ill and
recover to less than optimal levels. Unhealthy people are also more likely (in the long
run) to face economic consequences, especially if they are living on subsistence levels, as
happens in most developing countries. This relationship is difficult to tease out and is
complex even in the interventions taken to-date. However, if people are prevented from
falling into poverty, assisted in improving their incomes and helped with catastrophic life
events then there is a higher chance that they will not fall in the poverty-ill-health crisis.
A true re-distribution of funds in an Islamic society will therefore achieve this purpose
thus favoring a better health status for all and specifically those who are more unwell.
6
ACKNOWLEDGEMENTS
With thanks to Irfan Ali Hyder for his guidance in writing this paper.
REFERENCES
Bryant JB, Khan SK, Hyder AA. Ethics, equity and WHO's health-for-all. World Health
Forum 1997, 18:11-.
Morrow RH, Bryant JB. Health policy approaches to. American Journal of Public Health
1995,
Benn C, Hyder AA. Equity. International Journal of Health Services, 1999 (submitted)
Hyder AA. Equity as a goal for health, an operational inquiry. Journal of Pakistan
Medical Association 1999, .- (in press)
Murray, Lopez. The Global Burden of Disease 1990. Boston, MA: Harvard University
Press, 1996
The Holy Quran. Translation and interpretation by Ashraf Ali. Lahore, Pakistan
Hyder A A. Abortion in Islam: the 120 day Question. Karachi, Pakistan: Aga Khan
University, 1989
Summary report from the working group on Islam. In: Theological perspectives on other
faiths. Geneva: Lutheran World Foundation, 1997
Christianity and other faiths in Europe. Geneva: Lutheran World Foundation, 1995
Global ethic: a guideline for economy and politics. International Conference for Students.
Parliament of the world's religions. Declaration toward a global ethic. Chicago, USA:
Foundation Global Ethic, 1994.
Islamic Organization for Medical Science. Islamic Vision for social problems of AIDS.
Kuwait, 1OMS, 1995.
Summary of presentations of religious perspectives relating to research involving human
embryonic stem cells. 30lh meeting of the National Bioethics Advisory Commission.
Riggs Library, Georgetown University, Washington, DC.
Fazal-ur-Rahman. The Quranic Foundations and Structure of Islamic Society. Volumes
I and II. Pakistan: Publishers, 1989.
7
I
Equity and Resource Allocation in Health - The Christian Perspective
Christoph Benn
DIFAM, Tubingen
I. Current inequities in health
When we look at the status of global health at the beginning of a new millenium we can see
unprecedented opportunities and challenges. But even a cursory investigation of health
indicators shows us that there are dramatic variations between the different regions of the
world. There are good reasons to conclude that the current inequities in the allocation of
resources for health are the most devastating problem in global health requiring our urgent
attention. Millions of deaths could be prevented each year if people had affordable access to
basic quality health services and preventive measures. Therefore ethically it is one of the most
important tasks to analyze the current inequities and to consider ways how these might be
overcome. The religious communities can provide valuable insights for these considerations.
There is no universal agreement about a working definition of the term equity and the
methods to achieve equity. Of course, the term equity has to be differentiated from the term
equality. It is impossible to achieve complete equality in terms of health status or allocated
health care resources because people have very different needs and are living under very
different conditions. Equity can be understood in relation to different variables: one could
measure the resources spent on health per capita (input), the coverage of or access to health
services (output) or the outcome in terms of levels of morbidity and mortality. In this paper
the main concern is equity in terms of allocated resources on national and international levels
keeping in mind that the reduction of inequity will lead to measurable differences in health
outcome. The following definition will be used: equity is fairness in the distribution of
resources enabling people to achieve the highest attainable level of health and reducing
disparities in health status as far as possible. Equity has to be achieved independ from the
wealth of the individual or the country of birth and residence and irrespective of criteria such
as gender, ethnic origin, religion or social class.
The national level
1
i
There are striking inequalities in health in many countries. The inequalities can be
demonstrated in terms of health expenditure per capita for different parts of a population as
well as in terms of health indicators for different ethnic and social groups in a given society.
These difference exist in countries with a strong private sector like the USA (Andrulis 1998)
and the Republic of South Africa (Bloom 1998) as well as in countries with a more socialized
national health system like the UK (Townsend 1982) and Sri Lanka (Jayasinghe 1998).
The international level
Just considering the most commonly used indicators for the status of health we can discern
enormous differences between the most affluent and the poorest nations.
Life expectancy is a very crude measurement not only for the quality of available health
services but also for the general living conditions influencing health. There is a gap of 35
years in life expectancy at birth between the least developed countries (43 years) and the most
developed countries (78 years). (WHO 1995, p.l)
A very sensitive marker for health and development is child mortality. In some highly
developed countries infant mortality is as low as 4.8 per 1000 live births whereas it may be as
high as 161 per 1000 live births in some least developed countries. There is a strikingly high
33-fold difference between these countries. (WHO 1995, p.5)
One of the most tragic and yet largely preventable event is the death of a young woman
during childbirth. Here the gap is even more drastic. Although this problem has become very
rare in countries with a good infrastructure in health (1:1400), more than 580.000 women die
from the complrcations of childbirth in low-income countries every year (1:16). The mortality
rate is more than 50 times higher in those poorest countries than in high-income countries
(WHO 1999, p.97).
Unfortunate and unjust inequalities
Some inequalities in health might be unavoidable. There are conditions affecting human
health like genetic disorders, disabilities, natural disasters etc. that are unfortunate but not
unjust events. Neither individuals nor societies can be held responsible forthem. Therefore
there might be a moral claim to help persons affected by these unfortunate events as much as
possible but it is not necessarily a demand of justice.
2
v
Other events affecting health like infection with a pathogen at a given point in time might be
called unfortunate as well. But there is overwhelming empirical evidence that infectious and
other diseases are to a large extend determined by social factors like housing conditions,
access to clean water, access to information and education, access to health care etc. These
factors are influenced by individuals and societies so that inequities in these regards might be
called not only unfortunate but unjust.
This differentiation between unfortunate and unjust events has consequences for the
conclusions we draw about what has to be done to change unjust conditions.
IL What can be done to overcome these inequities
The methods to prevent premature and avoidable deaths are commonly available in the more
affluent parts of the world but are not sufficiently available in low-income countries because
of the extremely uneven distribution of resources on this globe.
It is impossible to outline a complete strategy of how to reduce current inequities in health in
this short paper. There is a wealth of knowledge and concepts about this question and the
author wishes to refer to a practical evaluative framework for decision makers that has been
developed to implement the concept of equity once its basic assumptions and philosophical
justification have been accepted (Benn, Hyder 1999).
III. The Christian understanding of justice
1. The Old Testament
The basis of any consideration of justice in the Holy Scriptures is the equality of status before
God which is shared by all men and women. Every human being has been created in the
image of God (Bible: Genesis 1,27) and this quality belongs to all, independent of any other
differences.
The Hebrew word for justice sdq describes good and harmonious relationships between God
and man and between different human beings. God is the one who is just. He has given
mankind his good order and a just man is the one who follows this order. The main source for
the good order can be found in the law of Moses (tora).
3
The word sdq describes in a positive way all the actions that are preserving harmonious
relationships within a community, be it between family members, the working relationship
between a landowner and his servants or the relationship between the king and his subjects.
But obviously the term was used for the relations as they were established in the ancient
society of Israel. It was not a tool to critisize or change the social order of that time. Therefore
we have to be careful with a translation of sdq into the modern word justice because it might
cause false associations and implications. Some scholars prefer to translate sdq with loyal or
faithful relationships rather than the perhaps misleading term justice for which there is no
exact equivalent in the Old Testament (Koch 1976).
However, sdq requires people to pay particular attention to the weak, the poor and the
vulnerable who were under the special protection of God's law. In particular the orphans,
widows and strangers were regarded as being socially disadvantaged. Doing justice meant to
protect them. And doing justice in this sense was certainly one of the most important and
noble things man was expected to do.
"He has showed you, O man, what is good. And what does the Lord require of you? To act
justly and to love mercy and to walk humbly with your God." (Bible: Micah 6:8)
However, the Old Testament is quite realistic about man's ability to fulfill the requirements of
justice. The prophets remind the people of Israel again and again that they have failed to do
justice and that the true service of God is the pursuit of justice.
2. The New Testament
The book the Christians call the New Testament (NT) is a collection of writings of different
authors reporting about the life of Jesus and his teachings as well as giving theological
interpretations of it.
The Greek term used most frequently for justice is biKoctocnjvri (dikaiosyne). It means justice
as well as justification. Overall the term justice appears relatively frequently in the NT and
different greek words are being used for the term we call justice or righteousness apart from
dikaiosyne. Given the structure of the NT it is not surprising that experts agree that in the NT
Hiere is no uniform understanding of the term justice (Hagglund 1984, p. 419).
4
Rather there are different concepts that need to be interpreted:
a. Justice as an attribute of God
Justice is primarily related to God. It is not an abstract principle relating to the political or
social order but a religious term describing what is demanded for man to do. Human justice is
a response to God's justice that human beings can experience.
b. Justice as justification
God's justice is evident in the undeserved justification of man. The justification provided for
man by God himself as a gift out of grace. The freedom from sin and guilt achieved through
justification by God leads not so much to justice but to a responding love.
c. Justice and the law
Justice as understood in the New Testament does not replace the law of Moses. Jesus was a
Jew. He acknowledged the validity of the Jewish law and ordered his disciples to practice
strict adherence to this law. However, in several of his sermons he asked his disciples to go
beyond the strict requirement of the law. This is sometimes called the "new justice" in the
New Testament (Luz 1989).
Justice is not denied as an important value but love goes beyond justice demanded by law.
"Do not think that I have come to abolish the Law or the Prophets; I have not come to abolish
them but to fulfill them." (Bible: Matthew 5:17)
d. Justice in relationships
Justice in relationships is understood as the actual deeds of one person toward the other.
Justice is something you do and not so much the abstract order regulating the relationship of
an individual toward the community in which he or she lives. An example is the story of the
Good Samaritan who helps a person who was wounded by robbers. He shows compassion and
mercy although it is not his duty and although he is from a different ethnic background than
5
the victim (Bible: Luke 10, 25-37). This story is the answer to the question: Who is my
neighbour? The answer is that anybody is your neighbour who is in need of your help.
The requirement to do justice is certainly not confined to the own religious or ethnic group.
God's love is extended to all human beings who are created by him and those following his
commandments are required to offer all fellow human beings their love and concern. Jesus
was dealing very often and, one could even argue in a special way, with persons not
belonging to the Jewish community. When taking examples of outstanding faith and
exemplary behaviour he pointed at people of different ethnic or religious origin like the Good
Samaritan, Roman soldiers or women from neighbouring ethnic groups. Therefore ethical
demands transcent national and religious boundaries.
IV. The Christian understanding of distributive justice or equity
Distributive justice or equity is even less a theoretical concept in the Bible than justice as such
and there is no specific term for equity (Bowlby 1983). But certain aspects of the law of
Moses, of the sermons of the prophets as well as of the parables and teaching of Jesus can
provide us with valuable insights.
The law of Moses contains regulations about the distribution of goods and wealth. One
example is the so called Sabbath Year (Bible: Leviticus 25). It demands that after seven times
seven years the Israelites should take a rest for themselves, their animals and their land. It is a
time to recreate, to forgive all debts, to release captives, to make a fresh start. This law is
certainly about the redistribution of wealth and property rights. The purpose is to provide
everybody with a new and fair chance in life recognizing that in the usual pursuit of human
work, of power, greed and war inequalities and inequities will grow and perpetuate
themselves if there is no mechanism of redistribution.
The concept of the Sabbath year has been used extensively in the worldwide campaign of debt
cancellation for highly indebted poor countries. It is questionable whether historically this
concept has ever been put into practice but it certainly reminds Jews and Christians of the
kind of order God intended for man to live in. It is an order that tries to provide human beings
with a fair chance in life, not allowing inequities to rise to unacceptably high levels.
6
The call for a Sabbath or Jubilee year was reconfirmed by the great prophets like Isaiah
(Bible: Isaiah 61, 1-2) and directly referred to by Jesus when he announced his understanding
of the Kingdom of God in a synagogue at the beginning of his public ministry.
"He [the Lord] has sent me to proclaim freedom for the prisoners and recovery of sight for the
blind, to release the oppressed, and to proclaim the year of the Lord's favor." (Bible: Luke 4,
18-19)
Throughout his ministry Jesus taught about love to one's neighbor which was for him closely
related to the love of God. He warned about the dangers of accumulating material wealth and
asked people to give up their riches in favour of the poor. The motivation for this demand was
not so much social change and an egalitarian society but the drive for spiritual perfection.
Therefore Jesus was certainly not a social reformer fighting for justice in a modern sense of
this term but a religious reformer who expected radical change in the personal lives of his
disciples. In general Jesus‘ teaching was more about love and compassion than about equity.
Love is about face-to-face relations between different persons. Love involves not only a
particular action but the whole person. It goes beyond what might be rationally expected of a
benevolent person. Love never contradicts or obstructs justice but goes beyond the demands
of justice. After justice has been fulfilled love will do even more.
"True love is always more than justice; love fulfills first the law of objective justice. There
can be no love at the cost of justice or circumventing justice, but always beyond justice and
working through justice." (Brunner 1981)
The question is: what is the relationship between love and justice? The influential 20th century
American theologian and ethicist Reinhold Niebuhr puts it very well:
"A rational ethic aims at justice, and a religious ethic makes love the ideal. A rational ethic
seeks to bring the needs of others into equal consideration with those of the self. The religious
ethic, ... insists that the needs of the neighbor shall be met, without a careful computation of
relative needs. ..(Since it [the principle of love] is more difficult to apply to a complex society
it need not for that reason be socially more valuable than the rational principle of justice.)"
(Niebuhr 1960, p.57)
7
Niebuhr captures the essential difference between the principles of love and justice. The
principle of justice is more limited. It gives a person its due, it tries to calculate carefully
claims and gratifications to come to a just solution. But love goes beyond that. It does not go
against the principle of justice, it rather presupposes its implimentation. But it will allocate to
a particular person more than what pure justice demands. It gives out of true love and
compassion not calculating the cost and not comparing the consequences of a certain action to
persons who are not directly involved. Therefore love is not necessarily the best advisor for
policy decisions. On the other hand love prevents the development of justice into a
mechanical dehumanizing tool. Forrester is right in his warning that "without love justice
always degenerates into something less than justice." (Forrester 1997, p. 218)
There are certain stories and parables in the New Testament that illustrate Jesus' attitude
toward distributive justice and its relation to love.
When Jesus was annointed with a very precious oil by a woman his disciples criticized this
behaviour saying that the money should have been spent for the poor. But Jesus objects to this
saying: "The poor you will always have with you, and you can help them any time you want.
But you will not always have me." (Bible: Mark 14, 7) He acknowledged the apparent waste
of the oil as an act of love that had a value in itself This value was higher than a strict
application of a principle of justice demanding redistribution of any available resources for
the poor.
In a parable Jesus tells the story of the owner of a vineyard who hires workers for a day. Some
are hired in the morning, some at lunchtime and some one hour before dawn. At the end of the
day they all receive the same wages. Of course, those who were hired in the morning
complain about unfair treatment, but the landowner asks them: "Are you envious because I
am generous?" (Bible: Matthew 20, 1-16) Jesus compares this situation to the kingdom of
God indicating that we do not receive our dues because of our own efforts and work but we
receive what we need. Translated into modern ethics we might conclude that Jesus favours
distribution according to need and not distribution according to merit or status.
Again we should not take these stories and parables as ethical principles and theories because
this would lead to misinterpretations. They are fragments and indicators in our search for the
meaning of distributive justice.
8
In the New Testament we find another illustration in one of the earliest form of donations for
international aid. St. Paul asks the richer congregations in the Greek town of Corinth to collect
money for the poorer congregations in Jerusalem (Bible: 1. Corinthians 16). It is to be
transferred to Israel to help their brothers who are in severe material need. But there is no
question of achieving equity or redistributing income from a richer nation to a poorer one. It is
to be done out of love and charity to satisfy an immediate demand.
But there are also good arguments to state that love and compassion can be less than justice. If
somebody shows compassion toward his/her neighbour and offers temporary help without
paying any interest in the social condition leading to the situation causing this particular need,
this kind of love is lacking an essential component. Justice but also love understood in a
comprehensive way demands that help is offered that has the potential to change the
conditions leading to need. These conditions can be caused by social, economic, physical, or
spiritual factors. Certainly any kind of cheap compassion is far from the concept of love in the
New Testament. When Jesus was demonstrating the meaning of love in concrete deeds he was
not only addressing the particular need of a person but the whole life including the physical,
mental and spiritual dimension. The aim was not to give alms but to help the person to
experience the fullness of life. This attitude is illustrated in the many stories presenting Jesus
as a healer. He is healing the whole person helping him or her not only to overcome physical
illness but also social isolation and spiritual exclusion.
Further considerations by Christian philosophers/theologians
Christian theology and ethics has not only reflected on the understanding of justice in the
Holy Scriptures but has also been influenced extensively by philosophy and secular thinking.
In particular Greek philosophy as the dominating school of thought in the mediterranian
culture of that time provided crucial insights to Christian theologians throughout the centuries.
The most influential school of thought for Christian theology was that of Aristotle. He regards
justice as the most complete virtue and taught that justice means to give everybody one's due.
Equals should be treated equally and unequals unequally in proportion to the relevant
inequalities. In Aristotle's sense justice means fair or proportionate treatment (Gillon 1985,
p.87). This is the basis for the just distribution of goods, rights and other things in society. It is
also called arithmetic justice as the correct measure of distributed goods can be calculated
almost mathematically. One of the problems with Aristotle's ethics was that equality was not a
9
principle applied to all human beings. In ancient Greece only free male citizens were regarded
as full human beings and slaves, women and foreigners were certainly not included in the rule
that goods and rights should be distributed equally.
Many Christian theologians throughout the centuries have written about justice and
interpretated its consequences for moral behaviour. The formulation of their theories was
always done in close dialogue with the dominant philosophers of their time who presented
their particular views. The most influencial theories apart from Aristotle were those of Kant,
Hegel, Mill, Marx and in this century Rawls, Nozick, McIntyre and others. It is impossible to
review all these theories here. In recent years most theologians writing about justice/equity
would refer to the major schools of thought such as libertarian ethics, utilitarian ethics, Rawls'
justice as fairness or Marxist interpretations in a theology of liberation.
Summary
In summary we have to conclude that there is no commonly accepted Christian theory of
justice. There are a number of concepts often leading to totally different conclusions. The
Scottish theologian Duncan Forrester in his book "Christian Justice and Social Policy"
published only two years ago came to the discouraging conclusion that "nobody knows what
justice is" (Forrester 1997, p.2). What we do have are insights and fragments. These are based
on central texts in the Holy Scriptures indicating how justice was understood in the context of
the Old and New Testament. Therefore the lack of agreement among ethicists does not mean
that the exercise to search for the meaning of justice in health is futile. Even thoughful
insights can be convincing not only for scientists but also for policy makers who put ideas
into practice.
Keeping in mind these limitations the following insights can be derived from a careful study
of Christian and biblical ethics:
1. All human beings have an equal status before God and deserve fair opportunities in life.
2. In the Holy Scriptures there is a special concern for the poor, the sick, and those needing
special protection.
3. Measures have to be taken to counterbalance the effects of human greed and the misuse of
power.
10
4. The main criterium for assistance is need.
5. The rules of justice are defined in the law of God revealed to man. The law has to be
fulfilled.
6. Love goes beyond justice in doing more than is required by law.
7. Justice and love apply to everybody irrespective of national boundaries or ethnic
backgrounds.
V. What are the consequences of our understanding of equity and resource allocation?
The following conclusions are a possible interpretation of the aforementioned Christian
understanding of distributive justice. They are by no means statements of any kind of
authoritative body of Christian churches or theological schools. There are probably as many
variants of practical conclusions for the distribution of resources in health care as there are
theories of justice and political systems. Basically the question of resource allocation is a
political one and can only be resolved by political means. But religion and morality are part of
a process leading to widely supported opinions and political decision making. The following
remarks can only be an attempt to explore the potential of ethical thinking based on religious
values.
Consequences for resource allocation on a national level
The principles would lead the author to conclude that Christian ethics would support the
allocation of resources in health so that equal access to health care for all people according to
need would be achieved. Justice would demand that conditions are established enabling
people to live healthy lifes and develop their full human potential. The primary responsibility
to ensure access to health and healthy living conditions falls upon governments as the elected
bodies looking after the well being of all people.
Of course, it has to be realized that resources are by necessity limited and any amount of
resources for health is competing with other vital concerns. Therefore Christian ethics would
not necessarily support equal access to maximum health care. Justice would demand fairness
in the distribution meaning that people with equal needs have equal claims on public
resources to provide them with the quality health care covering the most essential needs.
11
Beyond this optimum care the principle of love would oblige Christians to make additional
resources available out of compassion and concern for the sick to provide the highest level of
available health care. But this level does not necessarily have to be funded by public means.
Consequences for resource allocation on the international level
Resources are required to reduce the most glaring inequities in global health. Due to the
present global economic system many countries cannot mobilise sufficient resources to enable
its citizens to achieve a decent level of health. The international community and citizens of
wealthy nations in particular have to supplement the locally available resources. There are
basically two ways to argue for this kind of international development aid. It can be done out
of charity or compassion. Rich nations or individuals might feel that morality demands to help
people in desperate situations. These poor people have no legitimate claim on the resources of
the rich. They can only hope for voluntary contributions out of abundance others comand.
Some might come to the conclusion that no more is required out of the Christian
understanding of love and compassion.
The other alternative is to say that most differences in health status are avoidable and
therefore unjust. It would be first and foremost a matter of justice to correct these inequities.
Poor people need not wait for generous donations but they have a moral claim for assistance.
This concept is certainly supported by the Human Rights Declarations stating that health and
health care is a basic human right (Jamar 1994). Therefore providing necessary resources to
achieve this goal is not only a charitable action but a legally required policy. As we are
talking about Universal Human Rights all people commanding sufficient resources either
privately or through their governments are obliged to make the resources available to
implement the basic human rights if the respective governments in poor countries are not in a
position to do it. Justice and human rights do not respect national boundaries but extend to all
human beings wherever they live.
What might be the appropriate Christian response to these two different lines of arguments?
Looking at the concepts of justice and love it seems to me that first the fulfilment of the law
of justice is required. Justice in this case means that all human beings should have access to
resources in health permitting them to lead healthy and productive lives facilitated by a
defined level of basic quality health services. Beyond that Christians according to their
12
understanding of love should feel obliged to do even more than that and share resources freely
so that more than a basic level of health and health care can be provided.
Bibliography:
Andrulis DP 1998 Access to care is the centerpiece in the elimination of socioeconomic
disparities in health. Ann. Int. Med. 129, No.5: 419-420
Benn C, Hyder AA 1999 Towards equity in global health: an evaluative framework for
decision makers. Health Policy and Planning. In press
Bloom G, McIntyre D 1998 Towards Equity in Health in an unequal Society. Soc.Sci.Med.
47, No. 10: 1529-1538
Bowlby R 1983 Is there a Theology of equality? The Modern Churchman 26, No. 1: 3-15
Brunner E 1981 Gerechtigkeit [justice], 3rd ed., Zurich, p. 153 (own translation)
Forrester D 1997 Christian Justice and Public Policy. Cambridge: Cambridge University
Press
Gillon R 1985 Philosophical Medical Ethics. Chichester: Wiley
Hagglund B 1984 Article Gerechtigkeit [justice] in: Thelogische Realenzyklopadie, Vol. 12,
Berlin: de Gruyter
Holy Bible - New International Version 1978 East Brunswick: International Bible Society
Jamar SD 1994 The International Human Right to Health. Southern University Law Review
22: 1-68
Jayasinghe K, et al. 1998 Ethics of Resource Allocation in Developing Countries: The Case
of Sri Lanka. Soc.Sci.Med. 47, No. 10: 1619-1625
13
Koch K 1976 Article sdq [justice] in: Theologisches Handworterbuch zum Alten Testament
(eds.: Jenni E, Westermann C). Vol. 2, Munchen: Kaiser, 507-530
Luz U 1989 Article Gerechtigkeit [justice] in: EKL - Internationale Theologische
Enzyklopadie. Vol. 2, Gottingen: Vandenhoek, 87-91
Niebuhr R 1960 Moral Man and Immoral Society. New York: Scribner's
Townsend P, Davidson N (eds.) 1982 Inequalities in Health - The Black Report.
Harmondsworth: Penguin
World Health Organisation (WHO) 1995 The World Health Report 1995 - Bridging the Gap.
Geneva: WHO
World Health Organisation (WHO) 1998 The World Health Report 1998- Life in the 21st
Century. Geneva: WHO
14
I
Buddhist Sexual Ethics and AIDS
Pitak Chaicharoen, Mahidol University
Sex and AIDS are issues widely discussed today. Buddhism has been known
for its spirit of renunciation and its ideal of compassion. There are many people who
are puzzled to know what the Buddhist attitude towards sex, the basic fact of life, is,
and what kind of response Buddhist monks make to the issues AIDS epidemic. The
purpose of the paper is to discuss the Buddhist view on the nature of sexuality, love
and marriage, its attitude towards AIDS sufferers and the compassionate work of
some Buddhist monks in Thailand to alleviate the suffering of these people.
Sex and Sin
Buddhism recognizes the power of sexual desire in man and realizes that this
primal force can create problems unless it is properly managed. Many people are
proned to much suffering because of the lack of knowledge and understanding of the
nature of their sexuality and the way to be related to the opposite sex. In keeping with
its “middle way” philosophy Buddhism does not advocate the two extreme position of
rigid puritanism and total permissiveness with regard to sex. In Buddhist
understanding sex in neither “sinful” nor “virtuous”. Sexual act becomes good or bad
only when it is benefitial or harmful to all the parties involved.
Buddhism accepts that sexual pleasure is very much part of the worldly life,
but it considers the craving for or the attachment to sexual pleasure as unconductive to
ultimate peace and purity of the mind. In this respect the observance of celibacy is
neccassary if one wants to gain spiritual development and perfection at the highest
level. Though Buddhism advocates celibacy for Buddhist monks it does not urge the
average lay people for total abstinence. To these people it teaches them how to
regulate and control sex to solve their personal problems and particularly not to act
irresponsibly and recklessly to make the other suffer.
Love and Marriage.
In Buddhist sexual ethics love between a man and women should not be based
entirely on carnality. Love is an expression of human concern for another being. This,
however, does not mean that Buddhism does not recognize the physical aspect of love
which is expressed in sexual union between a man and a woman. Buddhism wants
this physical side of love to contribute to the well-being of the couples and be
consummated selflessly and with compassion.
Marriage is viewed as important part in the strong web of relationships of
giving support and protection. It is a partnership of two individuals based on trust,
sharing, equality, generosity and dedication. In such relationship duties and
obligations the two parties have to each other and to the children born through the
pleasure of sex are emphasized. These duties and obligations are self-imposed
because marriage, in Buddhist view, is a matter of personal choice and is a civil affair,
not a “sacrament”. There is no specific Buddhist marriage ceremony. Buddhist monks
usually attend the wedding ceremonies as guests to give blessings to the married
couples and not to saeri the wedding. Since marriage is a secular affair the‘married
2
couples are free to choose the kind of life they want to have. It they want to practice
contraception it is entirely their own business and Buddhist monks have no part in it.
Abortion is a different matter it because involves the taking of life and thus violates
the Buddhist precept against killing. This, however, in the view of the majority of lay
Buddhists, can be condoned in cases of serious health hazards where it may represent
the lesser evil.
As in the case of contraception Buddhism does not lay down any religious
rules with regard to the number of wives a man should have or should not which
people are forced to follow. Marriage to more than one person is an option for
Buddhists. However, monogamous marriage seems to be the most benefitial to the
two parties than polygamy which may be more an expression of mon’s lust.
Post marriage blues and Divorce
As mentioned before, in Buddhist view, marriage is a secular affair and the
bond is not insolvable. If the husband and the wife cannot live together, instead of
leading a miserable life with anger and hatred, they should have the liberty to separate
and live peacefully. However, the separation must be done in an atmosphere of
understanding by adopting reasonable solution and not by creating more hated. If they
have children, they should try to make the divorce less traumatic for the children and
help them to adjust to the new situation. It is unacceptable in Buddhism to neglect the
children and made them suffer as the consequence of divorce.
Sexual Misconduct and Adultery
With its emphasis on sex with responsibility Buddhism prohibits sexual
misconduct. Adultery or extra-marital sexual relation is a form of sexual misconduct
because it undermines the stability of marriage, based on trust and loyalty, by the
selfishness of one or the other party. Thus adultery is something to be avoided. It is an
inauspicious action which will bring harmful consequence to all people involved.
Pre-marital Sex and Homosexuality
Buddhism does not regard sex before marriage between consenting
heterosexual adult couples as sexual misconduct if there is love and agreement
between them. However, since the mind is always in constant change any illicit action
or indiscretion may cause undue harm to either party if legal marriage does not
happen as expected. Buddhism, therefore, urges young couples to exercise self
restraint on sexual desire or to get married. Though early marriage may “work” or
may not “work” it is preferable.
Unlike pre-marital sex homosexuality is not a clear cut case. For the Buddhist
monks complete abstinence is essential for spiritual envelopment. Sexual intercourse
whether of hereosettual or homosexual nature is considered a parajike (offence) that
involves irrevocable expulsion from the Order. But for lay people there is no Buddhist
discourse on homosexuality. Whether on not this sexual activity is a form of sexual
misconduct needs careful investigation. However, it is clear that neither sexual
indulgence nor sex without love is acceptable in Buddhist sexual ethics.
2
3
Buddhist Method of Sexual Control
The importance and the power of sexual drive in man is well recognized in
Buddhism. In order to prevent problems caused by sexual indulgence Buddhism urges
people to behave themselves sexually to the best of their ability. Instead of
emphasizing rigid suppression of this primal force Buddhism recommends the
practice of mindfulness as an important means of gaining control of human sexuality
by avoiding repressed sex. This practice involves the four foundations of mindfulness
i.e. the body, feelings, mental states and mind-contents, Mindfulness of the mental
states will enable us to know, for example, how lust arises and how it ceases, and
therefore, how to bring about its cessation. Knowing is therefore victory. Thus there is
no forcing. It may take time and need much perseverance, but it does not do violence
to one’s nature.
Sexuality and AIDS
As mentioned before, in Buddhist view, there is nothing “sinful” about sex.
Since people have both strengths and weakness it is easy for the average lay people to
make mistakes in their lives partially in regard to sexuality. With such realization
Buddhism does not want those who made such mistakes to develop a guilty-complex.
Instead it encourages them to avoid repeating these mistakes, and to look forwards to
the future. A the same time Buddhism wants us to exercise compassion towards these
people who are less fortunate by being sympathetic to them and by alleviating their
sufferpeopleing.
It is this compassionate attitude that is the basis of the Buddhist monks’ work
for AIDS sufferers in Thailand. AIDS has been a deadly disease in the countries since
the eighties. In 1998 the Ministry of Public Health estimated that the number of Thai
infected with the HIV virus were between 700,000 - 900,000. The main problem
AIDS patients have been facing in the country is lack of adequate care provided by
the government. At present there are 204 non-gonvermnent organizations, which are
helping these sufferers in various ways ranging from consultation to treatment and
care. Among these there are 44 organizations that provide AIDS sufferers with
lodging and care. There are also 10 organizations specifically geared to children born
from HIV positive mothers. Besides these organizations there are some Buddhist
monks who acting on their own initiatives turn the temples into lodging for AIDS
sufferers who usually turn to the temples as the last resort.
AIDS Sufferers and Buddhist Monks
One of these monks is Phra Pcecha of Wat Tern Sriwilai in Saraburi nears
Bangkok who uses special herbal concoctions to boost up the patient’s immune
system to resist the virus. The herbs—numbering thirty and used in these
concoctions—cannot be bought from the indigenous drug stores but have to be
collected in the deep jungle. Along with herbal treatments, the monk prescribes a
vegetarian diet, merit-making (such as helping others and boservace of the precepts),
and the practice of meditation. Merit-making and meditation are components of the
healing process because the monk believes that healing has something to do with the
spirit. Through merit-making the patient develops an ability to “give” while
3
4
meditation enables him/her to develop self-control and to let go of stresses caused by
anger and anxiety. Though this particular treatment is still experimental there are at
least two specific cases out of one hundred AIDS patients in the earlier stages who
have been declared by hospital physicians to be completely cured. Other patients
remain a symptomatic and ethics stabilize or increase their T-cells. Consequently, a
large number of patients have come to the temple to seek help from the monk who, in
the absence of any government support, is quite over-burdened (particularly when the
resources of the temple are very limited). The monk has only two assistants and he
himself has not enough time to rest, having to teat the patients from dawn to dusk.
This raises the question of the limits of compassion. ‘7 am very tired, " he said, lland
my health is in deterioration. "At times while treating patients 1 have to rush to my
lodging to throw up because of over-work and exhaustion. But have grest sympathy
for these sufferers who have no other place to go. Of course I treat them free of
charge. But some of their relatives like to donate money to the temple. This enables
me to buy one herbs from villagers and to help more patients. The temple has very
limited space. 1 like to advise people to take the medicine home and to come back only
if there is no improvement. If theyfollow my advice on diet, merit-making and
meditation while taking the prescribed herbal concoctions, I expect the cure to be
effected in one year and a half. Apartfrom treatment J encourage all patients to have
hipe instead of despair, otherwise their conditionswill become worse. It is not
important for me at all to know how they got AIDS and whether they are good people
or not. All 1 know is that they are in great suffering and I have to help to relieve their
suffering. "
Wat Tam Sriwilai treats only AIDS patients in the earlier, curable, stages.
There is another temple which takes care of those in the full blown stages where no
cure is possible. This temple is Wat Prabat Namphu in Lopvuri, another province near
Bangkok, and the monk is Phra Alogkul. Moved by compassion for those AIDS
sufferers, who have nowhere to go for needed care, the monk has transformed his
small temple into a hospice. Without professional knowledge about AIDS, he wears
no protective clothes when treating these patients. When AIDS patients were initially
accepted into the temple, other monks fled and villagers threatened to stop supporting
the temple because of their fear of AIDS. Lacking proper knowledge about this deadly
disease the villagers believed (wrongly) that the disease could be spread easily (e.g.
though mosquito bites), and, as a preventive measure, demanded the monk to keep the
patients under mosquito nets at all times. During this period, Phra Alongkot had to
deal with the hostile attitudes of the villagers as well as procure adequated resources
in order to provide proper health care for the AIDS patients. After three years of hard
work hemanged to persuade the villagers to develop compassion for these patients and
to support the temple’s humanitarian work. Gradually the villagers began to follow
him even visiting the patients and helping to treat them. The treatment consisted
mostly of traditional herbs, diet, and meditation. Apart from the medical treatment,
patients are encouraged to form a support group and to enjoy life (however short it
may be). At present the temple has five volunteers from the villages. The monk is
now receiving, increa-sing assistance, including financial support from NGO’s and
the general public. Government agendee are also encouraging other temples to follow
the example of Wat Phrabat Namphu. Even though they cannot cure the patients, the
temple is a refuge for patients in their final days. At the temple they are with
supported and cared for (without any charge), and often livelonger. When they do
pass away they let go of their lives peacefully. The provision of free health care adds
4
5
a burden for the temple however. Few relatives visit the temple and when the patients
die their bodies are cremated and their bones kept at the temple because relatives will
not receive them for fear of contracting the HIV virus. The Ministry of Public Health
and some NGO’s are assisting the temple to initiate a home care project for AIDS
sufferers which will have a supportive community for them. To implement this
project, Phra Alongkat has to work harder to persuade people in different villages to
take care of AIDS patients in their own areas and not to bring them to the temple. It is
not important whether he succeeds or not, for the has already set an example of
translating the high ideal of Buddhism into practice, and has contributed, though in a
limited way, towards the alleviation of suffering in contemporary Thai society. When
divorced from action this moral ideal of compassion is nothing at all.
These two monks are examples of Buddhist monks who have been working to
provide proper care to AIDS sufferers. This is a way of translating compassion into
action to alleviate human suffering and to help these suffering people to lead
meaningful lives to the end. Through this means AIDS sufferers are not neglected and
left to their own destiny by themselves.
Conclusion
Buddhist sexual ethics does not regard sex “holy” nor “unholy” it is an
expression of craving which sparks life but is not conductive to spiritual development.
Thus celibacy is an option for those who want to attain perfection and purity of the
mind. For the average lay person Buddhist sexual ethics affirms the importance of
love and marriage and particularly monogamy. At the same time it discourages sexual
misconduct such as adultery or extra marital sexual relations. Though pre-marital sex
between two consenting adult couples is acceptable it is less preferable to marriage.
As a means of gaining control of human sexuality Buddhism recommends the practice
of mindfulness which will enable us to know our sexual desire and the way to bring it
to cessation. This practice is not any form of suppression nor does it lead to repressed
sex with harmful physical and emotional consequences.
Equally emphasized in Buddhist sexual ethics is compassion. It is incumbent
on us at all time to act responsible with regard to our sexual behavior so that the
sexual act will not bring suffering to people involved. This compassion is also called
upon us particularly in cases of sexual lapses. While it is possible to restraint or to
transcend the sexual impulse not many people are able to reach this stage. In such
case we should not condemn those who violated the precepts but should be sympathic
and help to alleviate their suffering as much as we can. This compassionate attitude is
witnessed in the selfless work of Buddhist monks for the well-being of AIDS
sufferers in Thailand.
5
C|
The Jewish Approach
to
Living and Dying
Shimon Glick MD
The Gussie Krupp Professor of Internal Medicine
Jakobovits Center for Jewish Medical Ethics
Center for Medical Education
Faculty of Health Sciences
Ben-Gurion University of the Negev
Beer-Sheva, Israel
When presenting “Jewish attitudes” to any subject it is appropriate to
specify in advance what specific position is represented within the
spectrum of extant Jewish positions. Israeli governments have fallen
over the definition of “Who is a Jew”. Various Israeli supreme court
justices have, in their published decisions, defined Judaism’s core values
in diametrically opposing ways. Jews everywhere today live in pluralistic
societies, and many different voices claim to speak for Judaism.
The “Jewish attitude” in the present paper does not refer to the results of
a poll among bagel-eating individuals with a name identifiable as being of
middle European Jewish origin. Rather it refers to those individuals who
consciously govern their lives by the tenets of their faith and who actively
seek out Jewish values to guide their actions. These individuals, while
clearly a minority among ethnic Jews, to my mind compose the group
whose voice can be appropriately said to represent the “Jewish attitude”.
The majority of these Jews are what are commonly referred to as
Orthodox, and therefore I feel no need to apologize, or be defensive,
about using these values as representative of Judaism. Furthermore
even those who do not identify as Orthodox, if they are serious about
using Judaism’s values to guide their decisions, must ultimately fall back
on the classic Jewish sources, no matter how differently they are
interpreted - and there is certainly room for various interpretations. These
sources represent probably the longest unbroken tradition in bioethics
which is still followed by its adherents. Former Israeli supreme court
justice and talmudic scholar Menahem Elon estimates that there are over
300,000 halakhic responsa, a veritable treasure of casuistic literature on
which all Jewish scholars of whatever their persuasion are dependent.
But before referring to actual Jewish texts I want to comment about
Jewish culture, with regard to attitudes towards life and death.
The task of defining Jewish culture is no less difficult. Russian Jewish
culture differs from Moroccan Jewish culture, which in turn differs from
American or Yemenite Jewish culture. But each of these, in turn, differs
from the specific non-Jewish culture that surrounds it. In Israel we have a
blend of multiple Jewish cultures - mixed, but not homogenized, into a
unique Israeli blend of Jewish culture, which includes, perhaps very
importantly for bioethics, the post-Holocaust impact. There is I believe a
commonality - a Jewish ethos that can be extracted from these diverse
Jewish cultural expressions.
I remember distinctly a visit of mine as a lecturer at the University of
Manitoba School of Medicine in the 1960’s when the chairman of the
department of medicine there asked me whether I had an explanation for
an his observation among the physicians in his department. He had
noted that the Jewish physicians tried much harder in treating their
patients and gave up much later in the struggle for saving lives than did
their Christian counterparts. At that time I had no answer for him, nor
1
could I confirm the validity of his observation. But I now believe that this
perceptive clinician and educator did identify correctly an essential
element of the Jewish ethos - a strong emphasis on life. This life ethos is
reflected also in a number of other manifestations, including perhaps the
impressive overrepresentation of Jews in the medical profession in
almost all societies and eras. Other expressions of this culture include
the relatively high percentage of Israeli patients on dialysis as compared
to wealthier countries, the Israeli policy of placing physicians virtually on
the front line in the battle field in order to enhance the chances of saving
the lives of wounded soldiers, and the overrepresentation of Israeli
patients in transplantation centers around the world. Finally there is a
myriad of jokes confirming the perhaps exaggerated emphasis on life in
the Jewish value system.
The Jewish culture is strongly pro-life, probably more so than its
daughter religions, Christianity and Islam. This culture, even among
avowedly secular Jews, is rooted in several thousand years of Jewish
tradition, and is religious in origin.
It is best expressed by the Mishnah in Sanhedrin (1): “Therefore was
Adam created as a single individual - to teach us that one who destroys
a single life is as if he destroys an entire world. And he who saves a
single life is as if he saved an entire world. And so that one man should
not say to his fellow man ‘My father is greater than yours’”.
This statement in the Mishnah is responsible for what I call the
“mythology” of the infinite value of human life; that is that every life is of
equal and infinite value, that even a moment of life is equivalent to longer
periods of life, and that no value whatever is placed on the quality of life.
I do not use the word “mythology” in a pejorative sense, nor do I wish to
denigrate this principle which does bear a powerful and important
message. But clearly no recognized halakhic authority prescribes a
course of action in full accord with that phrase. Otherwise we would not
permit anyone to die without an attempt at resuscitation and without
attachment to a respirator, even if only for a few minutes. But the
message, nevertheless, is clear and unequivocal. Life is of enormous
significance. We dare not deliberatly extinguish even a brief moment of
life, even if this life is of poor quality. This is a valid and valuable myth
which characterizes Jewish tradition.
But there is a dialectic here. On the one hand life has intrinsic value,
independent of what can be accomplished, and we are cautioned not to
trifle with even tiny quanta of life, even if to our mortal perception this life
serves no obvious purpose. Life is a precious divine gift of great intrinsic
value - but it is also of instrumental value. Man is placed on Earth to
serve his Creator. The Jewish religion is one in which deeds are
emphasized more so than merely beliefs. In the words of the Talmud (2)
“One Hour of good deeds is worth more than all of the world to come.”
2
One may exploit even the shortest life opportunity to utter another amen,
to say a prayer, to give a coin to a poor man, or to say a kind word to a
distressed neighbor. Thus even in the area of the duty to save another’s
life, on the one hand some sages give a pragmatic rationale for the
mandate to violate the Sabbath (3). “Violate a single sabbath so that he
may be enabled to keep many subsequent Sabbaths.” But on the other
hand the duty to violate the Sabbath takes precedence even if the patient
is comatose and does not stand a chance to live beyond the moment,
and certainly he will not be able to keep subsequent Sabbaths.
Yet in spite of this unequivocal premium placed on human life, it is
important to emphasize that life itself is not an absolute, nor even the
ultimate highest value in Jewish tradition. The Torah commands us at
times to sacrifice our own lives for higher values. For example, when one
is faced with the forced violation of one of three cardinal sins (idol
worship, murder, forbidden sexual relations) or at times when sacrifice of
one’s life is a matter of kiddush hashem (sanctification of God’s name).
The Torah also mandates the taking of human life, capital punishment,
although only under ceratin clearly specified conditions. The command
„lo tirzahk” in the Ten Commandments is not generally translated in
Jewish sources as „do not murder”. There are times when taking a life is
not just permitted, but even required.
There are several other aspects of the Jewish tradition that bear on the
subject which should be mentioned. The Jewish physician-patient
relationship, unlike that in the United States and some other Western
countries, is not what Baruch Brody calls the contract type (4) - i.e. a
totally voluntary relationship under which the physician agrees to
undertake the care of a patient and the patient may or may not seek
medical attention. The physician has a duty to help any patient who
needs his assistance. This obligation is derived variously from several
Biblical ordinances, such as „Do not stand idly by your friend’s blood” (5)
- and - „You shall return it to him” (6), the latter referring to the obligation
to return a person’s lost object, and extended to include lost health.
The characteristic American slogan „mind your own business”
expressing a laissez-faire, individualistic attitude towards ones neighbour
is not part of the Jewish tradition. The Jewish attitude may justifiably be
termed paternalism, if you will, but in its positive, rather than in its
commonly used, pejorative, connotation. Just as I would care deeply if
one of my own children were sick and was headed for a disasterous
decision, so too am I concerned about my patient, and I am obligated to
help him/her in distress. Autonomy, the virtually unlimited right of a
person to dispose of one’s body as he/she sees fit, with no restrictions, is
foreign to our tradition. Man is a but a custodian of his body - bound by
the ground rules imposed upon him by the Creator and ultimate owner of
the body - the Almighty. In the West the last few decades have
3
witnessed the rise of autonomy to the top of the list of ethical values, to
the point that it often takes precedence over almost all other values. In
our tradition, while there is more recognition of autonomy than is
commonly believed, it certainly is far more limited than in the secular
West. There is relative unanimity in the recent Jewish tradition that it is
mandatory for a person to seek medical attention for any major illness,
and that is equally mandatory to follow expert medical advice particularly if a potential danger to life exists.
Suicide is unequivocally condemned in the Jewish halakhic literature,
and the strictures prescribed in the halakha about the burial, the
treatment of the bodies, and the rules of mourning for those who have
committed suicide are quite harsh and even seemingly cruel particularly when one takes into account that those who suffer from this
stance are the surviving family, who obviously have already suffered
severely.
Yet side by side with the unequivocal condemnation of those who
commit suicide, one can find another thread throughout history, from the
Tanach to our own day. There are repeated attempts to find extenuating
circumstances to mitigate the harsh attitudes towards suicide. In contrast
with the strict uncompromising theory, the practice, as guided by the
rabbis in dealing with individual cases in their community, was usually
much more understanding and forgiving. Rabbis went out of their way to
unearth the most tenuous extenuating circumstances to permit the
suicide’s body to be treated respectfully and not ostracized. This is a
fascinating and illuminating insight into the nuanced application of
rabbinic law to meet the needs of the individual and of the
circumstances. Interestingly enough with the dramatic increase in
societal approval of suicide and the rise in the rate of suicide in the West,
Rabbi Ovadiah Yoseph, the former Sefaradic Chief Rabbi of Israel, has
suggested that, in reaction to this shift in societal norms, rabbis might
once again revert to treating suicides according to the strict letter of the
law.
I would now like to turn our attention to euthanasia itself. It is important to
point out that the definition of the term and the aim of the practice is a
„good death11, and only one person is dying - the patient. In this
discussion the focus should be primarily on the individual, not on the
family, not on the physician, not on the hospital administrator, not on the
minister of health, nor on the budget director.
In this sensitive and difficult area there are significant differences of
opinion, even among accepted Orthodox halakhic authorities, because
the interpretation of the basic texts and their degree of relevance to
modern dilemmas is not easy, and rarely straightforward. Therefore
indivicuals of great erudition, scholarship, and conscience may interpret
the same texts differently.
4
The spectrum of possibilities for euthanasia begins with active
euthanasia, (which, of course, may be involuntary, i.e. against the wishes
of the patient, non-voluntary, or voluntary). None of these are sanctioned
by the Torah, no matter how difficult the circumstances. The command
not to take human life continues to be valid, and there is unanimity on
this point. With respect to active euthanasia it makes little difference
whether the patient has only a few minutes or a few years to live active, purposeful, taking of life is a capital crime in Judaism.
The Shulkhan Arukh goes so far as to forbid the mofing, or even the
touching, of the person who is in the death throes, for fear of hastening
his death, even by a few moments. The picturesque example given
compares the dying person to a flickering candle - any movement may
extinguish the flame. Similarly and untoward movement of the patient
may be the final push from life over to death - a forbidden act.
Is our tradition callous to the suffering of the patient? Do our rabbis really
feel that there are no situations perhaps even worse than death? No,
indeed we do recognize that in certain situations continued suffering may
be a fate worse than death. There is little glorification of suffering in the
Jewish tradition. And there are several sources which may be interpreted
to permit, and even perhaps encourage, prayer to the Almighty for the
death of a suffering patient.
One of the most moving and dramatic stories describes the terminal
illness and death of Rabbi Yehudah the Prince (7). His rabbinic
colleagues and students decreed a public fast and prayed for his
recovery, as did his maid, known for her wisdom. But when she observed
the degree of her master’s suffering and the indignity to which he was
subjected by his unrelenting diarrhea, she decided that it was more
appropriate to pray for his death. But her prayers stood no chance
against those of the great rabbis, who continued in their pleas for his
recovery.
The Talmud describes graphically and movingly a dramatic heavenly
struggle between those on earth who wanted Rabbi Judah’s recovery
and the angels in Heaven who were beckoning him to heaven. In
desperation, and with great ingenuity, it is told that Rabbi Judah’s maid
threw a jar from the roof. The noise distracted the rabbis from their
prayer and, with this impediment to death removed, the tide turned in
favor of the maid’s prayers, and Rabbi Judah’s soul departed in peace.
The Talmud seems to have approved of this simple woman’s act,
although some authorities note that the rabbinical contemporaries of
Rabbi Judah acted differently than the maid, and perhaps it is their view
that should prevail. There are several other references in Jewish sources
which seem to legitimize the prayer for death.
But the permission to pray for the death of a suffering patient was limited
by an extraordinarily perceptive, and currently most relevant, insight by a
5
19th century Turkish rabbi, Haim Palache (8). He was approached by a
pious member of his community who was in a serious ethical quandary.
His wife had.been seriously ill and suffering for many years with an
incurable illness. Her suffering had now reached a point where she no
longer could tolerate her distress. Euthanasia was clearly out of the
question for this pious Jew and his wife. But he asked the rabbi whether
or not he was permitted to pray for his wife’s death, since recovery was
essentially impossible.
Rabbi Palache, in a sensitive and meticulous review of the relevant
Jewish sources, concluded that indeed there were grounds to permit
such prayer when suffering is so great that death may properly be seen
as a deliverance much to be desired. But he added a critical limitation,
that only those who have no involvement in the care of the patient may
pray for the patient’s death, because only they can do so objectively. But
family members, or members of the health-care team, who are burdened
in any way by the responsibility of the care of the patient, may not pray
for the patient’s death, since their prayer may be tainted with a degree of
self-interest. The Jewish tradition is extraordinarily sensitive to the subtle
biases that may influence life and death decisions, even in the bestmotivated and pious individuals. The relevance of this insight in our era
of managed care and ..bottom line" considerations is obvious.
What about what has been referred to as passive euthanasia, i.e.
witholding theapy which may be life prolonging in order to shorten life?
There are philosophers who contend that there is no ethical difference
between passive and active euthanasia. In general, these philosophers
are not contending that just as one forbids active euthanasia so too one
should forbid passive euthanasia. On the contrary almost invariably they
are trying to convince those who do not treat everyone maximally, that by
the same logic they should not hesitate to perform active euthanasia.
I find it fascinating to note that physicians, nurses and other individuals
who personally deliver care for the patients, and who are the ones whose
actions determine whether a patient shall live or die, as well as when and
how the individual will die, often reject the philosopher’s equation of
active and passive euthanasia. Their intuitive response is that there is a
difference between active killing and merely witholding a therapeutic act.
And I believe that ethicists and philosophers would do well not to reject
such intuitive responses out of hand. The halakhah too backs this
intuitive response and posits an unequivocal difference between an act
of omission and one of commission, with respect to culpability.
Having made this point, I prefer to avoid altogether the use of the term
passive euthanasia, even for those acts of omission which the halakhah
might sanction. The goal should not be the death of the patient. The goal
should be the avoidance of suffering and the elimination of barriers to the
6
natural process of death; not the hastening of death. One may argue that
this represents quibbling ofer semantics, but I believe that terminology is
important medically, philosophically and emotionally.
The Jewish tradition recognizes the permissibility of removing a factor
that prevents the death of a dying patient. There are two unusual
examples cited in the Shulkhan Arukh which describe a patient in the
throes of death (poses) whose imminent death seems delayed by one of
two stimuli; one was noise created by a woodchopper near the patient, or
salt on the tongue of the patient. Either of these phenomena, perceived
as impediments to the death of the patient, may be removed, because
such removal is not considered active termination of life, but merely
removal of obstacles to the departure of the soul.
Another example cited in support of the permissibility of removal of
impediments to death, is the moving description of the martyrology of
Rabbi Hanina ben Tradyon (9). When he was immolated by the Romans
they placed layers of wet wool on his chest to prolong his suffering.
When the rabbi’s students witnessed the suffering of their rabbi, they
suggested that he inhale the flames to hasten his death, to which he
replied: „Better that the Lord who gave me my life take it from me rather
than that I should contribute to my demise". While the Roman
executioner witnessed the scene, he too apparently was moved, and he
asked the rabbi whether he might attain a place in Heaven if he hastened
the rabbi’s death. The rabbi replied in the affirmative, whereupon the
executioner raised the flames, removed the wool, and then in a final act
of personal repentance leaped into the flames and perished together with
Rabbi Hanina. At this point, a heavenly voice proclaimed that both Rabbi
Hanina and the executioner entered Heaven.
It is not easy to translate any of these examples into modern idiom. What
are the modern analogies of the woodchopper, the salt or the removal of
the wet wool? There are significant differences of opinion between
established halakhic experts on each of these points.
Individual, seemingly similar, cases may be different enough in subtle,
but important ways, so as to yield different condlusions. It is therefore not
easy to derive generalizable rules. For example: How does one define a
dying patient, a poses? The classic definition is that of a patient expected
to die within 72 hours, but there is considerable controversy as to the
exact definition. Some experts have even stated that we simply do not
know. Prediction of death is at best a very inexact science, even by the
experts in intensive care whose professional life is spent treating critically
ill patients, as Dr. Joann Lynn and her.colleagues have so convincingly
shown over the past few years (10).
7
When dealing with a patient who has been judged to be incurable, that is
the basic illness is no longer amenable to specific treatment and who is
suffering, most Jewish authorities agree that the patient may refuse
obtrusive, complex, and distressing treatments, which may be regarded
not as life-saving, but rather as merely prolonging the death process.
Those treatments, which many feel that may be refused, include dialysis,
attachment to a respirator, resuscitation, surgery, chemotherapy and the
like. On the other hand straightforward, safe, simple treatments, such as
antibiotics for an intercurrent infection or a blood transfusion for severe
anemia, should be given. Feeding and fluids by mouth should certainly
not be witheld, nor should simple intravenous fluids to prevent
dehydration. Most authorities would also not permit withdrawal of tube
feeding, although if a patient would have to be restrained in order to
insert a feeding tube, such force-feeding would not be mandated by all
authorities.
It cannot be overemphasized that pain relief muts be offered in quantities
sufficient to relieve suffering, even if such treatment shortens life.
Actually more and more data are accumulating suggesting that adequate
and humane pain relief may not only not shorten life, but may prolong
life. The treatment of pain, even in 1996, still leaves much to be desired
in even the best Western hospitals, because of ignorance and/or
callousness.
What roles do the patient’s wishes have in these decisions? Here indeed
there seems to be a clear acceptance of, and respect for, the patients1
desires by most halakhic authoroties. While theoretically a Jewish court
(bet din) may compel therapy on an unwilling patient, in the real world
today no such authority exists. In practice most authorities do not favor
actual physical coercion to treatment. When one is dealing with a dying
patient who is suffering, one should accept the patient’s refusal of those
treatments which he/she regards as without adequate benefit/cost ratio
for himself/herself.
Most halakhic authorities do differentiate between withdrawal of therapy
already begun and withholding of therapy, although many philosophers
and physicians regard the two processes as ethically identical. The
halakha is particularly strict when withdrawal of a therapy, such as
disconnection of a respirator, is followed immediately by death. But there
are valid halakhic ways in special circumstances for terminating therapy
without a direct causation of death.
I would caution again that it is difficult to give precise guidelines for
individual cases. There are often subtle differences between seemingly
identical cases which may result in opposite halakhic rulings.
There is also as yet no unanimity of opinion in each situation. The field is
dynamic; new and difficult dilemmas are being posed daily, and new
8
specific decisions often carve out new ground and new precedents. We
are, after all, dealing with life and death matters.
It is critical to emphasize that a great deal of objectivity is essential in
these decisions. The only concern of the halakha is the welfare of the
patient under discussion, it is clear when one reads much of the general
literature on the subject that all too often it is the interests of the family,
the staff, and/or the society that may influence the decision, usually in a
direction of terminating the patient’s life. These considerations are totally
unacceptable by our tradition.
One of the unfortunate effects of the almost universal transfer of the
locale of death to the hospital and even more so into the intensive care
unit is the conversion of a natural process into a battlefield environment.
And just like modern warfare is dominated by technology, so too is
today’s dying scene. Some of the undesirable consequences of this
change are:
1) the fostering of the illusion that death is conquerable - if but we make
the effort,
2) the loss of the critical emotional and social support by family and
friends in the death process, and
3) the deprivation of the ultimate equanimity and resolution of life issues
on the part of the patient.
In times gone by the confession (vidui) by the dying person was an
integral part of the Jewish dying process. While not a sine qua non for
status in the world to come, as last rites may be for the Roman Catholic,
the confession nevertheless was an important, and standard procedure,
for a seriously ill person. With what I call the Americanization of the
death process even among pious Jews, there has been a marked
reduction in the undertaking of this religiously and psychologically
therapeutic step of squaring accounts with one’s maker and one's family
before death, and then being able to accept death’s inevitability as a
natural finale to a life well lived.
I would like to close with a bit of a digression from the Jewish view on life
and death, to the Jewish view on another subject which bears on the
present discussion.
A few months ago, I received a letter from a prominent secular
philosopher ethicist who is doing some research on the slippery slope
concept; and he asked me whether there are traditional Jewish sources
that address the issue. Indeed there are. There is a clear
acknowledgement of human nature in its ability to rationalize and to blur
distinctions, if it so suits the individual and the society’s purpose. I
believe that in the field of treatment of the terminally ill and euthanasia
the rapidly changing societal attitudinal changes that have taken place
over the past two decades are clear evidence that the slopes are indeed
9
slippery. While unquestionally the overuse of life sustaining technologies
and the arrogant paternalism of physicians have contributed in a major
way to changing attitudes, it is hard to escape the condlusion that these
objective realities do not explain fully the or of events.
The Dutch experience is particularly troubling. Although only a few short
years ago we were repeatedly and emphatically assured that the
safeguards, as originally proposed, would prevent any abuses, the reality
has proven otherwise. Thousands of cases of non-voluntary euthanasia
of adults and children have taken place, and further erosions are on the
horizon. As one Dutch physician told me recently when he was asked
how it felt to actively kill a patient. „The first time was difficult".
Subsequent cases were much easier for him. So too, it seems that each
step along the path towards societally encouraged active euthanasia is a
natural progression from the previous one.
I believe firmly that it would be a tragic mistake to join the stampede
toward changing our Jewish medical tradition, which has been a beacon
of humanity and sensitivity towards human life and human suffering.
10
■V
p<j-s
THE VALUE OF HUMAN LIFE
IN THE JEWISH TRADITION
Implications for the DALY approach
SHIMON M. GLICK MD
Center for Medical Education;
Faculty of Health Sciences
Ben-Gurion University
Beer-Sheva
ISRAEL
Telefax: 972-7-6477633
E,Mail: Gshimon @bgumail.bgu.ac.il
Adress:
Ben-Gurion University
ROB 653
Beer-Sheva, Israel
August 1 999
-1-
Judaism is appropriately regarded as a religion and a culture, in which
life in general, and human life in particular, is granted an extraordinarily
high value probably well beyond that in most other cultures . The Lord Rabbi
Immanuel Jakobovits, the creator of the term "Jewish medical ethics" has
popularized the view that the value of human life in Judaism is "infinite
and beyond measure". This concept has been repeatedly quoted subsequently
and it carries with it important practical consequences, as pointed out in
the original text (1) by Jakobovits "a hundred years and a single second are
equally precious: one may not normally deliberately take a single life even
to save multiple lives".
I have since pointed out on multiple occasions that the infinity concept
is a myth, albeit a most useful one. In the real world, while Judaism
assigns comparatively great importance to human life, it does not act
invariably in consonance with the infinity concept. Otherwise, for example,
we would attach every dying patient to a respirator, even if we could
thereby add just a few minutes of additional " life". There is no responsible
Jewish authority who suggests such a policy.
The importance of human life in the Jewish tradition is divinely
ordained. It is not because of life's instrumental value, but is intrinsic. Man
is a creation of God in his "image". Man's body and soul are not his exclusive
possession to dispose of them at will, but are the creation and possession
of the divine Creator who has given them over to man as a caretaker, to use,
but not to abuse, in the service of the Creator and of fellow man.
Thus not only is murder prohibited as a cardinal sin, as it is in many
other religions, but suicide is regarded as no less serious an offense. In
fact some regard suicide as a more serious offense.
A twentieth century scholar Rabbi Tukachinsky, in a classic work on end
of life guidance, (2) writes:
"The sin of one who murders himself is greater than that
of one who murders someone else for several reasons: First,
through this murder he has left no possibility for any
remorse and repentance. Second, death
(according to
Babylonian Talmud Yoma 86, etc.) is the greatest form of
-2-
repentance, but he, on the contrary, has committed through
his death the greatest sin, namely, murder. Third, through
his act he has made clear his repudiation of his Creator's
ownership of his life, his body, and his soul; he has denied
the simple idea that he did not participate in his creation
at all, but rather [maintains that] his entire identity is
exclusively [within] his power to sustain, to reproduce his
existence, or to destroy it. He is like one who actively [and
intentionally] burns a scroll of the Torah, for our Sages,
may their memory be blessed, compared the creation of the
soul to a scroll of the Torah that [now] has been burned and
he must therefore face judgment in the future for this as
well.
He is also among the unequivocal deniers of the continued
existence of the soul and of the existence of the Creator,
may His name be blessed, and of the future judgment after
the departure of the soul [from the body]...."
While this comment may represent perhaps an extreme exposition of the
traditional view of suicide it does reflect a generally unequivocally
negative view towards suicide.
Indeed the strictures prescribed in the halakhah about the burial, the
treatment of the bodies, and the rules of mourning for those who have
committed suicide are quite harsh and even seemingly cruel - particularly
when one takes into account that those who suffer from this stance are the
surviving family, who obviously have already been traumatized severely.
Yet, side by side with the seemingly unquivocal condemnation of those
who commit suicide, one can find another thread throughout history, from
the Bible to our own day. Baruch Brody, (3) and more recently Noam Zohar,
(4) have attempted to present a more balanced view of suicide, pointing out
the particular incidents in traditional texts in which suicide under unique
situations
was
apparently
at
least
understood,
and
even
condoned.
Furthermore, in contrast with the strict uncompromising theory, the
practice, as guided by the rabbis in dealing with individual cases in their
-3-
communities was often much more understanding and forgiving. Rabbis
went
out
of
their
way
to
unearth
the
most
tenuous
extenuating
circumstances to permit the suicide's body to be treated respectfully and
not ostracized. This is a fascinating and illuminating insight into the
nuanced application of rabbinic law to meet the needs of the individual and
of the circumstances. Interestingly enough with the recent dramatic
increase in societal approval of suicide and the rise in the rate of suicide
in the West, Rabbi Ovadiah Yoseph, the former Sefardic Chief Rabbi of
Israel, has suggested that, in reaction to this shift in societal norms,
rabbis might once again revert to treating suicides according to the strict
letter of the law.
The deliberate taking of a human life is one of the worst possible
offenses in Judaism. Witnesses in capital cases are forewarned to exert
every effort to be absolutely truthful because human life is at stake. The
Talmud (5) prescribes the formula for this instruction:
"For this reason Adam was created as a single person, to
teach you that anyone who destroys a single soul is
regarded by Scripture as if he destroyed an entire world,
and anyone who rescues a single soul is regarded by
Scripture as if he saved an entire world; and so a man may
not say to his fellow man "my father is greater than yours".
Virtually all of the precepts and commands of the Jewish faith are
waived if there is even a question of risk to human life. Such suspension is
invoked even if the life to be saved is fleeting, even if the life is of poor
quality and even if the chance for saving life is minimal. Similarly the
taking of a human life, no matter how close to death, or however
compromised, is nevertheless a capital offense. Perhaps the most dramatic
example given is that of child falling to a certain death from great heights;
if someone kills him by a sword while falling, the perpetrator is guilty and
punishable for shortening life even by seconds. So too one who kills a dying
person is guilty of a capital offense.
Capital punishment is clearly mandated in the Jewish tradition, and one
cannot help£>ut get the impression from reading the biblical text itself that
-4-
!
such punishment seemed to have been meted out with relative ease. But the
halakhah and codes of Jewish law which regulated practice throughout
history made the meting out of capital punishment, a difficult, if not
almost impossible, task. The requirements of evidence for conviction are so
stringent , circumstantial evidence is ruled out; so that capital punishment
was rendered almost impossible in practice. Indeed one Talmudic comment
referred to a court that handed down a death sentence once in seventy years
as a "murderous court".
But it is fair to point out that there is also a dialectic here. On the one
hand life has intrinsic value, independent of what can be accomplished, and
we are cautioned not to trifle with even tiny quanta of life, even if to our
mortal perception this life serves no obvious purpose. Life is a precious
divine gift of great intrinsic value - but it is also of instrumental value.
Man is placed on Earth to serve his Creator. The Jewish religion is one in
which deeds are emphasized more so than merely beliefs. In the words of
the Talmud "One hour of good deeds is worth more than all of the world to
come". One may exploit even the shortest life opportunity to utter another
amen, to to say a prayer, to give a coin to a poor man, or to say a kind word
to a distressed neighbor. Thus even in the area of the duty to save another's
life, on the one hand some sages give a pragmatic rationale for the mandate
to violate the Sabbath. "Violate a single sabbath so that he may be enabled
to keep many subsequent Sabbaths". But on the other hand the duty to
violate the Sabbath takes precedence even if the patient is comatose and
does not stand a chance to live beyond the moment, and certainly he will
not be able to keep subsequent Sabbaths.
The life orientation of the Jewish faith is expressed also in other ways.
Ascetism has been frowned upon by mainstream Judaism throughout the
ages. Man's role is to enjoy the world in which he lives, to exploit it, to be a
partner in creativity, all within fairly carefully prescribed civilized limits,
all in the service of the Creator.
Holiness in Judaism is not the withdrawal from the world but the
injection of holiness into the mundane daily activities of eating, drinking,
working and sexual activity. One is bidden to marry, to have children, as a
-5-
partner with God in creation, within the boundaries prescribed for a holy
nation.
Celibacy
is
not
an
acceptable
option,
no
matter
what
the
circumstance. Indeed the scholars and rabbis, the intellectual and religious
elite, were most likely to marry early and have many children, in contrast
to a number of other religions. The demographic and eugenic consequences
of this practice are of considerable interest and impact.
Because of the importance attached to life in this tradition, the role of
a physician assumes major proportions. It is no accident that Jews have
been attracted to the healing professions for centuries, that the proportion
of Jewish physicians in almost every culture was extraordinarily high and
that many leading rabbis in the Middle Ages were also physicians. Healing
was regarded as part of imitatio dei - for God said "I am the Lord your
healer". In addition, the permission, and indeed the obligation, to heal
another is derived variously from several verses in the Torah:
1) The verse regarding the obligation of an assailant to
ensure that the victim is "thoroughly healed" (Exodus 21:
19-20).
2) "Love your neighbor as yourself (Leviticus 19:1 8).
3) "Do not stand idly by the blood of your neighbor II
(Leviticus 1 9:1 6).
The value attached to human life, the concept that the body is not ones
own possession to do with it as one pleases, the obligation not to stand by
idly while another's life is in danger, create a milieu quite different from
the classic American "mind your own business", laissez faire, attitude
towards one neighbor and his/her illness. A positive kind of communitarian
paternalism is engendered and encouraged, even at times to the point of
imposing treatment on an unwilling patient - an idea anathema to the
current Western ideology which emphases autonomy. This paternalistic
involvement is incumbent on the individual and on the community.
The Talmud advises scholars not to take up residence in a city without
physicians, safe water and sewage services as part of ones religious
obligations. The community is obliged to provide health care for its
citizens as one of the basic services rendered.
-6-
Judaism respects not only human life, but al! life, and indeed all of
creation, living or not. But there is, in the Jewish tradition, a clear
hierarchy in nature, rising progressively from the inanimate through the
plant and animal, to the human and the divine. In a purposeful universe,
those in the lower category serve the higher forms. Thus, unlike some
modern philosophers who decry the discrimination between man and animal
as "speciesism , a concept akin to "racism", our tradition regards such
blurring of the boundary between animal and man as more likely to lower
man to the level of the animal than the reverse.
The Jewish legal and aggadic traditions are replete with references to
the importance of kindness and sensitivity to the suffering and needs of
animals. Moses was chosen to lead his nation in part because of the
kindness he showed to the lambs while a shepherd; Rabbi Judah the Prince
was punished with years of illness and suffering merely because of a
callous remark about an animal being led to slaughter; we are obliged to
feed our domestic animals before sitting down to our own meals; etc.
But whereas Judaism pioneered legislation against any cruelty to
animals,
long
before such
concepts
were
accepted in the West,
it
unhesitatingly gives man the right to dominion over animals, to kill them
for any nonfrivolous human use. This privilege was given to man, for man
was created in "God's image", a concept subject to multiple interpretations,
but with important implications. This permission carries with it a clear
responsibility for man to act at a moral and ethical level higher than the
animal - otherwise there is little rationale for his priority over the animal.
The use of animals for medical research is regarded as laudable and
mandatory, when indicated, provided such activity is carried out with
sensitivity and minimalization of animal suffering. But, the license to
exploit animals specifically excludes killing and paining of animals for
trivial purposes such as hunting, cockfighting and the like which have
traditionally been totally alien to Jewish culture. Indeed, Albert Einstein is
quoted as once defining a Jew as one who derives no pleasure from hunting.
While the dichotomy between body and soul is perhaps not as clearly
marked as in Christianity, and the body-soul unit is regarded more as an
-7-
integrated unit than as conglomerate of the holy and the base, death
reduces the body to a source of ritual "uncleanness". Yet the body must be
treated with utmost respect, as the former repository of the soul, and it
must be buried rapidly.
The life ethos of Judaism and the strong emphasis on the individual has
pervaded Jewish culture, even the secular variants thereof, to this day. In
modern Israel one can find such manifestations in the relatively high rates
of dialysis, in the sending of physicians to the front-lines of the battle
field, and in the innumerable Israelis for whom money is raised to send
them to leading transplant centers the world over.
Even much of Jewish humor reflects the strong emphasis on human life
that pervades the culture.
The reverence for life, both for its instrumental value, but also for its
intrinsic worth, affect the attitude towards equitable distribution of
health care services.
Learned discussions about equity in distribution of health care services
and the various formulas that are proposed have invariably lead me to
serious uneasiness. The comparative advantages of various economic and
ethical theories for the most equitable division of the resources are dealt
with in a commendably scholarly manner, but one which seems to ignore the
most glaring existing injustices inherent in our world.
The almost axiomatic thesis of inadequate resources for health care and
fl
tragic choices" that must be made, while indisputable on the whole,
nevertheless has hypocritical and misleading aspects, when one compares
the expenditures on health care to those on military purposes. It was once
estimated that for the money the world spends just on several hours of
military expenditures, one could completely eliminate eight infectious
diseases throughout the world by immunization. The Western world also
spends absolutely incredible sums of money on gambling, smoking, alcoholic
beverages, pets and entertainment. The diversion of even a small fraction
of these expenditures towards properly chosen health care outlays could
make a dramatic contribution to world health.
If one looks within the health care field itself the disparities between
-8-
nations often dwarf those within countries. According the World Bank
figures for 1990 (6) the high income countries spent 90% of the world's
annual total of 1,700 billion dollars of health expenditures, about 1,500
dollars per person. The developing countries spent about 10% of the world's
total for an average of $41 per person. The pathophysiology of a such
glaring discrepancies, their ethical implications and the steps to rectify
the inequities are unfortunately discussed all too rarely, for obvious
reasons.
Another basic point that merits reemphasizing in any discussion of
distribution of health care resources is the Inverse Care Law. (7)
This law, which is probably no less powerful than some of nature's laws
of thermodynamics, was described by Dr Julian Tudor-Hart. Tudor-Hart is
an anachronism, a Marxist true believer, in the best idealistic sense of the
term; a family physician who has devoted his professional life to caring for
underprivileged and improverished Welsh miners. He stated that even in
societies that are allegedly egalitarian, the best health care is generally
given to those individuals who need it least, and the worst to those who
need it most. Enormous gaps remain between "the haves" and the "have nots"
even in relatively egalitarian societies. While the existence of these gaps
is an almost inevitable consequence of the human condition, awareness of
this "law" and conscious efforts to redress these unfair situations can help
to narrow them.
A closely related and most relevant point is that perhaps the major
contributory factor to ill health, even if we define it in a purely biomedical
sense, is poverty. This is neither the time not the place to examine the
pathophysiology of this relationship, but it is universal in all societies in
which it has been examined. The morbidity and mortality in the poor sectors
of towns and countries is much greater than that among the well-to-do. Of
course, poor health, in turn, is a major contributing factor to poverty, and
the poor sick are often trapped into a vicious reciprocal cycle. The
consequences of this relationship are most relevant to health policy issues.
The poor have much less free money to spend on healthcare after the non-
optional expenses for food, housing, clothing and education have been taken
-9-
care of.
Overrepresented among the poor in most societies are the aged and the
disabled, the groups that would be most affected by a blanket application of
DALY (disability adjusted life year) or QALY (quality adjusted life year)
calculation to the determination of the manner of distribution of health
care resources.
The discussions on the ethics of distribution of health care are a
relatively recent phenomenon, for several reasons. It is only modern
medicine that has provided us with effective treatments, and therefore
with choices. It was not until almost the mid-twentieth century that
specific treatments for many medical illnesses become available at all,
that
selection
technologic
of options
advancement
became
the
relevant.
costs
of
Shortly
medical
thereafter, with
care
began
to
rise
incessantly. Now the choices became more and more painful and the experts
were called in to assist in these decisions.
Economists, of course, quite appropriately were consulted since fiscal
responsibility in decision-making falls into their area of expertise. And
quite in keeping with their experiences and outlook they analyzed the
choices through their perspectives - how to get the most for the dollar
spent - a logical, rational and seemingly non-disputable thesis.
Simultaneously with these developments, another evolution, or perhaps
a revolution, was occurring in Western medicine. Medicine was changing
from being strictly physician-centered to becoming more and more patient
centered.
This meant that individual health care decisions were being made not
just according to the needs of the patients, but now also taking into
account the patient’s desires. While the former might possibly be best
assessed by the physician, the relevant desires are purely the patient's.
The weight now appropriably being assigned to the patients' desires
creates a much greater variability in health care decisions as compared to
when the physician decided unilaterally on choice of therapy.
When a patient is faced with a personal decision in which he/she has to
choose between two alternate treatments in a rational way, economists
-10-
have suggested a helpful conceptual tool, the QALY or DALY. (8) If we can
accurately assess and factor in the patient's preferences, we can, by this
analysis, help the patient choose intelligently between two alternate forms
of therapy. We can ascertain and calculate the degree of tolerance a patient
has for a particular disability, and the ultimate choice can then be
individualized for that patient. One would hope that in practice physicians
might actually take the trouble to learn about the unique preferences and
foibles of their specific patients, that they would expend the effort to
determine as best they could the risks and benefits of each form of
treatment available,
that they would present all the data to the patient,
and together they would arrive at a reasoned, balanced decisions. This
process would permit autonomous patient choices that would reflect and
grant status to the unique individuality of each human being, his/her
tolerance of suffering, and the values that are of greater and lesser
importance for him or her.
But DALY's and QUALY's, while perhaps ideally suited for such individual
decision-making have not achieved their fame (or notoriety) for individual
decision-making. They have been proposed for the most part to help
societies which have limited resources for their "infinite" health needs, in
their decision-making as to which services to finance, and to whom to
provide care. (8)
The assumptions behind such use are several: (9)
1. The "quality" of life can be quantified reliably - and should be factored
in to the decision making process. I believe that while the quantitation
will inevitably be difficult, there is general agreement that the effort to
evaluate and quantify quality is a useful exercise. The thought processes
inherent in the exercise probably improve the quality of care.
2. The ethical theory best suited for the societal decision making is a form
of utilitarianism, "the greatest benefit for the most people". This
superficially attractive slogan is quite problematic, even if society had
a way of determining what is the "greatest good" for each member of
society. Unfortunately the present century has experienced the distorted
and criminal application of pure utilitarianism by the Nazi regime.
-11-
Elementary school books in Nazi Germany presented children with
mathematics exercises such as: "How many apartments for young couples
could be constructed with the money that it costs to maintain a mentally
retarded person in an institution for a year?" The consequences are well
known, and could and should be reflected in our decision-making.
The application of utilitarian ethic clearly gives priority to community
preferences over those of the individual patients in apportioning
resources.
This kind of reasoning can also readily lead to a deprivation of care for a
less numerical and usually weaker segment of a community irrespective
of the magnitude of its needs.
3 By definition, older patients, those with multiple illnesses and the
disabled will inevitably and invariably receive a lower priority than the
young and the otherwise healthy individuals afflicted with identical
illnesses. A 70 year old with pneumococcal pneumonia stands no chance
in the competition with a 30 year old suffering from the identical
disease even if the prgnosis for cure is identical. It is no wonder that
the major public opposition to the use of QALYs and DALYs comes from
the elderly and the disabled. While it is true that both these groups have
traditionally been discriminated against in treatment, the application of
DALYs has given this discrimination a legal and ethical force, and a
respectability, against which it is difficult to argue.
The Jewish tradition cannot accept the DALY concept as the overriding
guiding principle in societal health care decisions, for several reasons. The
emphasis on the uniqueness and importance of each individual does not
permit us to deny care to an individual on the basis of an arbitrary
assessement that saving that person's life or reducing his suffering is less
important than that of another.
Research data have shown repeatedly that discrimination against the
aged is already widespread in the Western world. The elderly person even
when his/her physiologic state is identical with a younger person, is likely
to receive less ideal care. (10) This discrimination is probably rooted in
part in the current societal emphasis in on instant gratification, youth and
-12-
achievement, but this approach is not compatible with the Jewish tradition.
When discussing priorities for scarce organs with medical students, I
often ask the students whether they would accept age as a criterion. There
are usually two groups in each class, those who are opposed to age
discrimination and those who are willing to accept such discrimination. But
the assumption is invariably whether or not to favor the younger person.
Just to be devil's advocate I often shock the group by vocally and
deliberately advocating discrimination against the young, arguing that the
older person who has contributed so much to society deserves his/her
reward whereas the younger person has not yet proved himself nor has he
merited a reward from society.
Aside from the importance of the individual and the unwillingness of our
Jewish value system to begin rating one person's life over that of another,
there are several other considerations in rejecting the DALY approach to
societal decision making about health care priorities between individuals.
The older person is venerated in the Jewish tradition, is granted respect by
both family and society. Society, and particularly offspring, acknowledge a
debt of gratitude to parents and elders for their years of contributions in
raising, and sustaining and educating them. This in itself mitigates against
overt discrimination because of increased age.
But there is another factor that militates against discrimination
against the aged and the disabled. The Jewish tradition, in many ways,
expects of its adherents to give special attention to the needs of the
underprivileged and disadvantaged members of society. Again the idea of
imitatio del is invoked. The Almighty is described as healer of the sick,
clother of the naked, liberator of the captive, raiser of the fallen, paragon
of hesed, (giving loving-kindness). Particularly are we admonished to give
special attention to the underprivileged, the disadvantaged in society.
Specifically mentioned repeatedly in our sources are the stranger, the
orphan, the widow and the poor. The admonitions about mistreatment of the
stranger are mentioned 35 times in the Bible, with the reminder "you too
were Stangers in Egypt". The specific groups mentioned in the Torah are
paradigmatically the weakest elements in society, those in greatest need
-13-
of succor. While the elderly and the disabled are not specifically cited as
such among those singled out for special attention, all the previously
invoked principles apply to them in today's society, for they are today's
vulnerable. Thus it is inconceivable that an already disabled person, or an
elderly person who has serious existential problems, and who is already
devalued in an achievement-oriented society should be doubly discriminated
against by going the bottom of the priority list in obtaining health care by a
DALY system.
Does this mean that health care rationing should be done haphazardly
emotionally, irrationally and without careful evaluation of the costs and
benefits? On the contrary, since there are in all societies resources which
are significantly less than needed to meet the reasonable health needs of
each society, rational calculations must be made. These calculations are
not just optional but are an inherent part of the responsibility of
community leadership. Community leaders have an obligation to take into
consideration all community needs, and they must divide the resources
equitably and wisely, balancing immediate needs with future investments.
While a premium is placed on human life in Jewish thinking and therefore
life-saving will have a relatively high status, it is recognized that it would
be foolhardy and irresponsible to spend all of the community's resources
only, or largely, on health merely because "life is of infinite value". In a
classic Talmudic case discussion, a legal precedent of sorts with obvious
ramifications for health care rationing, communities are forbidden to
ransom captives at exorbitant rates - for fear of "impoverishing the
community" and in order to discourage even more exorbitant demands in the
future. Thus while failure to ransom a captive would probably lead to
almost certain death, it is recognized that saving lives cannot be done
regardless of cost, because communities have other needs as well. And
rational decision making does not permit a community to budget its limited
resources irresponsibly. An individual on the other hand is generally
granted full authority (if he has the means) to ransom a family member of
his at any expense.
Thus a calculation of what the particular yield in life and health for
-14-
.
each
dollar
is
a
legitimate,
and
even
mandatory,
exercise
for
any
community. Quality of life, and not merely existence, is also a legitimate
community concern on the macro level. It is here that DALYs and QUALYs
provide excellent means of calculation of the burden of disease versus the
benefits from its prevention and treatment. QALYs provide useful data on
the return for an investment. But even the most ardent advocates of QALYs
have not proposed them as exclusive determinants for spending. Indeed in
the
World Bank's discussion of DALY's they state explicitly that
»«_
an
important source of guidance for achieving value for money in health
spending, is a measure of the
cost-effectiveness of different health
interventions and medical procedures". They point out explicitly however
that "just because a particular intervention is cost-effective does not
nean that public funds should be spent on it". And the reverse is equally
true, in that at times for a variety of reasons, funds may need to be spent
for a non-cost-effective intervention, which may provide other values.
In considering DALY's or any quantitative measure of cost effectiveness
we must, in a system based on a Jewish tradition, build in particular
safeguards to protect the underprivileged, the relatively voiceless, the
disenfranchised, if we are to preserve our humanity - even at the expense
of greater cost.
There is one way of utilizing cost-effectiveness calculations and yet
avoid discrimination against the elderly or disabled. The key to all rational
. decision making using formulas are the specific values attached to the
various outcomes.
If one decides to place a very high value on the
preservation and enhancement of a society's ethical level, it may assign an
added premium to the life of the weak and the disadvantaged - a sort of
reverse Darwinism. Then the treatment of such individuals may yield a high
enough priority to merit their receiving treatment, even in a purely cost
effectiveness calculation..
It has been said that the ethical level of a society is best assessed by
the humane way it treats its elderly, its weak and vulnerable populations.
There is much to be said for specifically factoring in such values in any
health care system.
Articles-human life
-15-
BIBLIOGRAPHY
*
1.
Jakobovits, I. (1959) - Jewish Medical Ethics - New York Bloch
2.
Tukachinsky, T.M. (1960) - Gesher Hahayim 2nd ed., Jerusalem: Solomon
(Hebrew)
3.
Brody, B.A. (1989) - A historical introduction to Jewish casuistry on
suicide and euthanasia, in Suicide and Euthanasia - Brody B.A. ed.
Kluwer Academic Publishers
4.
Zohar, N.J. - Jewish deliberations on suicide in Physician assisted
suicide: expanding the debate by Battin, N.B.; Rhodes, R.; Silvers, A. -
Routledge NY and London (1998)
5.
Mishna, Babylonian Talmud Sanhedrin 4: 5
6.
World Bank - World Development Report (1993) - Investing in health;
world development indicators - New York
7.
Tudor-Hart, J. (1 978) - The inverse care law, 1,405-41 2
8.
Williams, A. - Economics of coronary artey bypass grafting -
BMJ (1985); 291: 326-329
9.
La Puma, J.; Lawlor, E.F. (1990) - Quality-adjusted life-years-ethical
implications for physicians and policy makers - JAMA 263: 291 7-2921
10. Samet, J. et al (1986) - Choice of cancer therapy varies with age of
patient - JAMA 225, 24: 3385-3390
-16-
International Consultation on
Inter-religious Dialogue on Bioethics\
October 5-8, 1999
Purpose, goals and objectives
Adnan A. Hyder MD MPH PhD, Johns Hopkins University, USA
"Tell me what your God is like and Til tell you what your society looks like. ”
[T. Sundermeier. The Meaning of Tribal Religions for the History of Religion]
Part I: The Rationale for Discourse
This world is defined in specific though related ways by the many religions existing
today. It is only through an interactive process of communication that a common vision
of a just world can be developed by all peoples from all religions. The basic principles
which define such an inter-religious dialogue include:
•
•
•
•
a pressing need to aid those people in distress, globally
a commitment to inter-religious discourse for humankind
a common engagement to alleviate ill health
promotion of deeper understanding of each religion.
The Challenge
The need for such a dialogue is based on the fact that there are a set of challenges that
face each religion.
•
•
•
•
We are of a religion, and as such we live with a mission for change; how do we live
out this mission in the 21st century?
We live in a multireligous and multicultural society as a global reality; how does each
religion respond to this reality?
Everybody wants to live in peace and yet religions have been abused and used to
incite tensions and war; how can we make religion contribute to peace and tolerance?
How can this inter-religious dialogue contribute to such efforts (as described above)?
The Response
Responses to these challenges can vary though we argue that there is only one response
which will be mutually fulfilling.
One form of response to the global reality has been defined as the "patchwork".
Individually we each create our own "patchwork faith" that has elements of our choice
from each religion. This response expresses freedom of choice to mix and match; and yet
denies the essential notion of the claim to the truth as expressed by each religion. It
therefore indicates that there are many religious truths and the individual is accepting
many at the same time.
Another response is to dialogue with faiths - to gain more knowledge of our own religion
and to gain more knowledge of other religions. This assumes that we have a conviction
that our religion is the truth but we also affirm that other religions have the right to exist
and prosper. This response generates tolerance and promotes healthy communication.
In fact, dialogue is a part of the "mission" of each religion. It can be defined as an
interaction where people speak 'with humility and listen with respect.
The Action:
Opportunities for inter-religious dialogue today are manifold and occur in many different
places and formats. Direct face-to-face discussions, exchanges via traditional media such
as phones and faxes, and interactions through the Internet and email are all available and
need to be seen as an opportunity. In addition, the opportunities for discourse are pressing
for world peace.
Such interactions need to be held accountable to some "guidelines" for a dialogue such as
an exploration of the following issues.
•
•
•
•
•
What is the nature of the relationship between the religions?
What is the religious tradition on each side?
What are the perceived obstacles to common ground?
What are the areas for engagement?
Suggestions and recommendations for practical application.
Finally we all need to make sure that we conduct a reality test of a global perspective
This entails recognition that:
•
•
•
all religions will continue to exist;
they all seek the common good of humanity; and
they all need to take each other seriously.
This will help and facilitate meaningful inter-religious exchange.
Part II: International Dialogue in Tubingen
We are privileged that the Inter-religious Dialogue on Bioethics in Tubingen will
contribute to efforts for world peace. We are honored that people, such as yourselves,
have taken time out of your busy scheduled to come and share your thoughts and listen to
others. We are thankful to the people who facilitated this event and have made it possible
for us to meet in this wonderful town of Tubingen.
The overarching goal of this meeting is to demonstrate the intrinsic beauty and need for a
deeper understanding between religions and their positions on important health issues.
The next two days are meant for open discussion - this is the central theme of this
dialogue. We all have an interest and a stake in these issues, and yet we need time and
opportunity to explore the possibilities. Each session of this meeting will do exactly that define a set of possibilities, which will open intellectual, and we hope, practical prospects
for a better understanding between religions.
The specific objectives of this meeting are therefore to:
•
•
•
•
•
pursue an inter-religious dialogue on specific issues of bioethics
produce documentation to demonstrate the intersection of religious thoughts on thise
issues
identify areas where further dialogue is required for a common understanding
recognize that such explorations need to be encouraged and stimulated more
frequently
emerge with a set of practical recommendations for further research and action.
The conduct of this meeting is simple. Each session has a central topic, which will be
introduced by 1 or 2 speakers that come from specific religious backgrounds. This will
lead into a general and interactive session where we can all join to explore the specific
health issue from an ethical and religious perspective. There is no fixed, standard format
for any session - you are free to innovate to the advantage of the whole group. The
meeting will cover the following themes:
•
•
•
•
•
Value of life
Status of unborn life and family planning
Sexual ethics and HIV/AIDS
Patient autonomy and euthanasia
Equity and resource allocation
The final session will discuss the result of the meeting and future steps to be taken. It is
important to note that this meeting is not a one-time, stand-alone event. Rather it is the
beginning of a process where dialogue, research and action will merge for a common
goal. It must be seen as the predecessor of a set of activities, such as:
•
•
•
More dialogues with different stake holders
More research on the attitudes and opinions of people on Bioethics
More case studies on inter-religious action in health
This stream will require your support and continuing efforts, and the support of others
who are not present here today.
We hope that these common objectives, together with your own personal objectives will
be fulfilled over the next 48 hours.
■
■
DIFAM
German Institute
for Medical Mission
Paul-Lechler-StraBe 24
D - 72076 Tubingen
Tel. ++7071/206-512
Fax ++7071/27125
Consultancy
Dr. Rainward Bastian, Dr. Jutta Pehle,
Sr. Dorothea Harms. Dr. Helmut Scherbaum,
Hr. Albert Petersen, Fr. Helga Fiillner
206-512
Information Tel.:.
Seminars
Community Based Health Care
Sr. Dorothea Harms
Theological Seminars
Dr. Christoph Benn,
Dr. Helmut Scherbaum
Wiirrburg
Heilbronn
Karlsruhe
rk
206-520
.206-520
... by railway and bus:
Rail connection Stuttgart-Tubingen.
From the bus terminal 'Europaplatz'
(next to the railway station) take bus
no. 4 (direction 'Waldhauser-Ost')
and get off at the bus stop "CorrensstraBe/Tropenklinik'. Then follow the
sign 'Tropenklinik'.
... by car:
Coming from Stuttgart on B27,
take the exit 'Kliniken/Kunsthalle'.
From here (as from any other di
rection) continue in direction Tubingen-Zentrum and follow the
signs ‘Tropenklinik’.
•
206-531
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.........
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DIFAM
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Tubingen Project
DIFAM
German Institute for Medical Mission
.206-111
Information Tel.:
Paul-Lechler-StraBe 24
D - 72076 Tubingen
Tel. ++7071/206-512
Fax ++7071/27125
Bank account:
Ev. Kreditgenossenschaft Stuttgart (BLZ 600 606 06)
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Bi
Layout: Petra Kriegeskorte/DIFAM
Production: Hepper Verlag, Tubingen-Hagelloch
January 1996
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Information Tel.:
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Pharmaceutical Department
Hr. Albert Petersen
Ml
STUTTGART
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Study Department
Dr. Helmut Scherbaum
How to get there...
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DIFAM- »,•Health in a sick world"
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DIFAM
DIFAM - Consultancy:
DIFAM - Pharmaceutical Department:
DIFAM, a national church office for health care, advises and
supports churches, mission societies, church-related development
agencies and other Christian institutions worldwide.
It offers professional services and practical assistance to nurses,
physicians and other medical staff working in health care services
overseas. The DIFAM Pharmaceutical Department advises health
care institutions overseas in the selection of essential drugs and in
questions relating to appropriate technology.
The DIFAM Pharmaceutical Department supports Christian hospi
tals and health care institutions in more than 80 countries with
essential drugs as recommended by the World Health Orga
nization (WHO), and with medical equipment. It is an official
purchasing office for the EKD Social Service Agency
(Diakonisches Werk) and other organizations.
\
DIFAM - Seminars:
DIFAM regulary offers courses and seminars on ‘Community
Based Health Care’ and ‘Tropical Medicine'.
Furthermore, it organizes interdisciplinary seminars for theo
logians as well as for people working in social or health care
services. Important issues are the exchange of experiences, the
training in practical skills and the discussion on the Christian
healing ministry.
I DIFAM
DIFAM - Library:
\
The ecumenically based German Institute for
Medical Mission (DIFAM) in Tubingen was foun
ded in 1906 and is the institution responsible for
the hospital
‘Tropenklinik
Paul-LechlerKrankenhaus’.
It is a member of the Association of Protestant
Churches and Missions in Germany and of the
Baden-Wurttemberg Diaconical Service (Diakonisches Werk).
DIFAM - Study Department:
|
In close cooperation with the CMC - Churches' Action for I
Health of the World Council of Churches, the DIFAM Study I
Department works on the Christian understanding of I
health, healing and disease and on principles of health I
care.
/
DIFAM cooperates with Protestant and Catholic
missions and German church-related develop
ment agencies as consultants for the realization
and support of health care programmes world
wide. DIFAM is in close contact with churches
overseas and with CMC - Churches' Action for
Health of the World Council of Churches (WCC).
DIFAM activities are mainly financed by dona
tions.
worldwide
SSpendenrat
o
cn
The German Institute for
Medical Mission tasks and objectives:
The DIFAM Library offers a wide range of international
publications on health care (books, periodicals, teaching
materials, posters etc.) with a special emphasis on the tro
pics and subtropics.
DIFAM - German Institute £or
Medical Mission:
DIFAM. a national church
office for health care
activities, promotes Chri
stian health care pro
grammes worldwide and
helps people to help
themselves.
DIFAM - Hospital:
I
The hospital Tropenklinik Paul-Lechler-Krankenhaus' in Tu
bingen offers medical care to patients with tropical diseases, exa
minations before and after a stay in the tropics and vaccinations as
well as general health care counselling for people who plan to tra
vel to the tropics. Another important scope of work of the hospital is
the medical care and treatment of elderly and chronically sick pati
ents from Tubingen region.
DIFAM - Public Relations:
DIFAM - Tubingen Project:
DIFAM wants to inform the public about ist various activities in
health care with publications and the organization of many activi
ties for young and old (e.g. visits in congregations, confirmation
classes, presentations in schools, exhibitions, fairs, contributions to
church services and congregational festivities). Important issues
are the activities of the Pharmaceutical Department and questions
concerning the global HIV/AIDS pandemic.
The Tubingen Project aims to provide home care servi
ces for seriously ill and dying persons in the Tubingen
region. In cooperation with local health and social services
centres, the project tries to provide nursing care and ade
quate pain control so that long admissions to hospitals can
be avoided.
DIFAM - Campaign:
The special campaign ‘All people:
Children of God!' wants to support
people with AIDS, leprosy or tubercu
losis as well as the differently abled.
It promotes the integration of these
programmes into general health care
services overseas.
\
Q
A Muslim - Christian Dialogue on Equity and Resource Allocation
in Health
Adnan A. Hyder and Christoph Benn
1.
Define the specific position of one’s faith concerning the topic in question
The Christian Position
♦
All human beings have an equal status before God and deserve fair opportunities in life.
♦
In the Holy Scriptures there is a special concern for the poor, the sick, and those needing
special protection.
♦
Measures have to be taken to counterbalance the effects of human greed and the misuse of
power.
♦
The main criterium for assistance is need.
♦
The Riles of justice are defined in the law of God revealed to man. The law has to be
fulfilled.
♦
Love goes beyond justice in doing more than is required by law.
♦
Justice and love apply to everybody irrespective of national boundaries or ethnic
backgrounds.
The Islamic Position
•
The only morally relevant difference between people is "closeness to God".
•
The vulnerable defined in any way - the poor, the sick, the aged, the infirm - have special
status such that their needs need to be looked after
•
The distribution of benefits - of any type - needs to be monitored both by the individual
and the society
•
This distribution needs to be towards the favor of the disadvantaged and for the reduction
of morally irrelevant inequalities.
•
The application of this justice is for the Muslim ummah globally, and to include the non
Muslim people of the world.
1
2.
Explore the main ethical/philosophical arguments for this position
The Christian Arguments
The consideration of the Christian meaning of justice and equity has been based mainly on the
Holy Scriptures consisting of the Old Testament and the New Testament. It is a search for
insights gained from the most accepted texts of Christianity. However, no attempt was made
to do an analysis of how these concepts were applied historically by Christians nor were the
differences in interpretation between different Christian denominations or churches taken into
consideration. These differences do exist and to put principles into practice they have to be
applied to concrete political and socioeconomic contexts. Although desirable this kind of
comprehensive analysis was beyond the scope of this background paper. It was also decided
by the authors that a comparison of the foundations and ideals of a particular religion is more
appropriate for a first step in interreligious dialogue than the more divisive issues of the
historical context including cultural, ethnic and political aspects.
The basis of any consideration of justice in the Holy Scriptures is the equality of status before
God which is shared by all men and women. Every human being has been created in the
image of God (Bible: Genesis 1,27) and this quality belongs to all, independent of any other
differences.
The Hebrew word for justice sdq describes good and harmonious relationships between God
and man and between different human beings. God is the one who is just. He has given
mankind his good order and a just man is the one who follows this order. The main source for
the good order can be found in the law of Moses (tora).
In the New Testament we find four different concepts of justice:
a. Justice as an attribute of God
Justice is primarily related to God. It is not an abstract principle relating to the political or
social order but a religious term describing what is demanded for man to do. Human justice is
a response to God's justice that human beings can experience.
2
b. Justice as justification
God's justice is evident in the undeserved justification of man. The justification provided for
man by God himself as a gift out of grace. The freedom from sin and guilt achieved through
justification by God leads not so much to justice but to a responding love.
c. Justice and the law
Justice as understood in the New Testament does not replace the law of Moses. Jesus was a
Jew. He acknowledged the validity of the Jewish law and ordered his disciples to practice
strict adherence to this law. However, in several of his sermons he asked his disciples to go
beyond the strict requirement of the law. This is sometimes called the "new justice" in the
New Testament (Luz 1989).
Justice is not denied as an important value but love goes beyond justice demanded by law.
d. Justice in relationships
Justice in relationships is understood as the actual deeds of one person toward the other.
Justice is something you do and not so much the abstract order regulating the relationship of
an individual toward the community in which he or she lives. An example is the story of the
Good Samaritan who helps a person who was wounded by robbers. He shows compassion and
mercy although it is not his duty and although he is from a different ethnic background than
the victim (Bible: Luke 10, 25-37). This story is the answer to the question: Who is my
neighbour? The answer is that anybody is your neighbour who is in need of your help.
Distributive justice or equity is even less a theoretical concept in the Bible than justice as such
and there is no specific term for equity. But certain aspects of the law of Moses, of the
sermons of the prophets as well as of the parables and teaching of Jesus can provide us with
valuable insights.
Throughout his ministry Jesus taught about love to one's neighbor which was for him closely
related to the love of God. He warned about the dangers of accumulating material wealth and
asked people to give up their riches in favour of the poor. The motivation for this demand was
3
not so much social change and an egalitarian society but the drive for spiritual perfection.
Therefore Jesus was certainly not a social reformer fighting for justice in a modern sense of
this term but a religious reformer who expected radical change in the personal lives of his
disciples. In general Jesus‘ teaching was more about love and compassion than about equity.
Love is about face-to-face relations between different persons. Love involves not only a
particular action but the whole person. It goes beyond what might be rationally expected of a
benevolent person. Love never contradicts or obstructs justice but goes beyond the demands
of justice. After justice has been fulfilled love will do even more.
Christian theology and ethics has not only reflected on the understanding of justice in the
Holy Scriptures but has also been influenced extensively by philosophy and secular thinking.
In particular Greek philosophy as the dominating school of thought in the mediterranian
culture of that time provided crucial insights to Christian theologians throughout the centuries.
The most influential school of thought for Christian theology was that of Aristotle. He regards
justice as the most complete virtue and taught that justice means to give everybody one's due.
Equals should be treated equally and unequals unequally in proportion to the relevant
inequalities.
The Islamic Perspective
The attributes of an Islamic society are ensconced by following the principles of Justice (adal
or insaaf), brother hood (unity) and a dynamic equilibrium of rights and obligations. Justice
has been quoted in the Quran more within the context of just decision-making and fair
judgements for differences amongst people. Brotherhood is used to promote the concept of
inter-dependency between each person within an Islamic society. Such that either by being a
relative, dependent, neighbor, poor or other, each individual has some linkage with others.
Thus the Islamic society is to be seen as unitary entity comprising individual parts, rather than
the reverse. It is important to note that this concept of the Islamic society does not have
geographical boundaries and may be used to illustrate local, regional, national or supra
national entities.
The interplay of rights and obligations in an Islamic society is what maintains a live link
within the concept of an organic whole. Each individual has rights which define their
4
expectations within the social dynamics of the family and society. At the same time there are
distinct responsibilities that come with each role that have to be carried out. In addition there
are obligations towards God that each individual and the society as a whole needs to fulfill.
Islam does not recognize any differences between individuals to be of substance to their
destiny except for their closeness to God. All other differentials are for worldly purposes, and
the only one that matters is how pious (taqwa) is the individual. Therefore, for all intents and
purposes, all are equal. Differences of gender, age, color and others are seen as a tribute to the
powers of creation of God, such that no one individual is exactly similar to the other.
Therefore, the distribution of benefits based on these features should also be egalitarian unless
it is for the benefit of the under privileged. This is the one category of persons that has been
grouped separately on the basis of the challenges that God has put them in - for which they
will emerge successful. This group of people may have different types of worldly
disadvantage (not moral) such as lack of money, power and social status. Moreover they can
be in such a state for a long time (mimicking permanence) or for a temporary period of time.
These are the poor, the orphans, the wayfarers and the needy. A difference in their health
status is therefore unacceptable based on these attributes. This is therefore a case for the
active reduction of inequities between groups of people.
Though the word equity does not appear in the Quran, words denoting egalitarian society,
universal brotherhood and inter-dependence of people have been clearly expressed. These
concepts denote an active movement for the recognition and demonstration of unity within the
larger Islamic community (ummah). Thus a case for the active search for equity is also made
and the active notions of seeking equity and reducing inequity in health in Islam have to be
operationalized within the context of provision of resources and opportunities. These
principles mandate the distribution of resources to the advantage of the poor and other
vulnerable groups.
However, allocations of state funds are not the only means of reliance on achieving such
equity. Social and financial safety nets have been actively promoted in Islam as defined by
functions of the Islamic state and the individual. Zakat or income-based charity is mandatory
on those individuals who qualify (based on annual wealth holdings). This represents 2.5% of
the annual wealth and is to be either given directly to the poor in the absence of state
mechanisms or through a state controlled means.
5
There is an integral and interactive relationship between poverty and health. Poor people are
much more likely to be unhealthy, and when they fall ill are more likely to stay ill and recover
to less than optimal levels. Unhealthy people are also more likely (in the long run) to face
economic consequences, especially if they are living on subsistence levels, as happens in most
developing countries. This relationship is difficult to tease out and is complex even in the
interventions taken to-date. However, if people are prevented from falling into poverty,
assisted in improving their incomes and helped with catastrophic life events then there is a
higher chance that they will not fall in the poverty-ill-health crisis. A true re-distribution of
funds in an Islamic society will therefore achieve this purpose thus favoring a better health
status for all and specifically those who are more unwell.
3.
Specify the areas of agreement with the discussion partner from a different faith
There is broad agreement on the understanding of equity and the need for a more just global
allocation of resources in health. There is also agreement that Islam and Christianity share
some important roots, e.g. both are based on Holy Scriptures and have originated in closely
related geographical and cultural contexts. Both religions recognize the teachings of Moses
and Jesus is recognized by Muslims as an important prophet. These historical connections
need to be strengthened in the real discourse between peoples of both religions.
Statements agreed upon by Muslims and Christians:
♦
Man is created by God
♦
All human beings share the same value and status which constitutes the basis for an
egalitarian distribution of rights and benefits
♦
There is a special provision for the orphans, needy and wayfarer
♦
We meet God by caring for the sick
♦
The modern term equity is not a specific concept in our Holy Scriptures
♦
We can however get insights and inferences from stories and teachings
♦
We both refer to arithmetic justice "to each his or her due" although it is a philsophical
concept not directly derived from the Holy Scriptures but from philosophical
interpretations
6
4.
Specify the areas of disagreement with the discussion partner
It is challenging to identify any areas of clear disagreements but there are some concepts
which require further clarification.
The concept of individual and community.
In the early Christian tradition there has been a strong emphasis on the person that is in
relation to others - in particular the extended family system and the membership in the Jewish
faith community. Later on through the reformation and the period of enlightenment there was
a stronger emphasis on the individual in his/her direct relationship with God. A person is
justified by God through his or her individual faith in Jesus Christ. Community in the form of
a Christian congregation is still important but the individual is a sufficient entity with rights
and responsibilities. This more individualistic approach has helped to come to terms with the
concept of human rights which is not a Christian idea but presupposes an understanding of a
person having intrinsic rights over against governmental and religious authorities.
Two important points for the Islamic position. The individual has distinct roles and
responsibilities that define the equilibrium between that individual and the society. There is a
dynamic interface between the responsibilities towards others and the rights that define each
person. The latter lead to the expectation that others have obligations towards the individual
as well. These "rights" have been as explicitly defined to make each interaction a bilateral
give and take situation.
The relationship of the individual with God is direct - in some ways more than in Christianity
as there is no interceding by Christ even in prayers. Rather, man is directly responsible to God
and must take individual responsibility for all actions irrespective of the role of society. This
is true for most of the roles that are defined by personal action. In addition there are some
specific roles which are societal in nature and are directed to the group rather than the
individual. For example, funeral prayers in a neighborhood (for a resident) may be attended
by some people to fulfill the obligations of all the people in a neighborhood. Thus, there are
two different kinds of spheres of human existence in Islam - one which can only be defined by
individual human action, and the other where collective action defines the roles.
7
People outside the "brotherhood”: are. there obligations towards those?
The responsibility of those in the religion towards those of other faiths is emphasized in Islam
in many ways. Protection and provision of civil services for those living in the community
(irrespective of faith) is mandatory. In an Islamic state, the state must protect all while those
of other faith may or may not contribute (indicating that it is not necessary for them to
contribute to the protection). Similarly, helping those in need is not related to their faith - it is
defined by need.
The Christian teaching emphasizes that God's love extends to all people irrespective of their
own religious or ethnic background. There are even quite a lot of stories in the New
Testament showing that people from a different background are in many ways closer to the
"Kingdom of God" and are portrayed as good examples for Jesus' disciples, e.g. The Good
Samaritan, the Roman soldier, the Syrophoenician woman. Therefore the ideal is that the
Christian should respond to God's universal love and extend his love and concern to all fellow
human beings and help those in need irrespective of their background.
To pursue a hypothetical case where resources are very scarce (such that you can help only
one person of two) and there are two people to help - one of your faith and the other not.
Would preference be give to the one of one's faith over the other, or would there be a case for
seeing who is more "needy" and then helping that person irrespective of faith? Such an
exploration would be worthwhile.
5.
Identify the common ground for further discussion and continued dialogue
To explore further the understanding of love andjustice and the relationship of love going
beyond the demands of the law (ofjustice).
Three related points pursuing the Islamic perspective:
•
Laws in Islam are only to be enforced within the presence of an Islamic welfare state.
Scholars (Fazal-ur-Rahman) have indicated that punishments can only be applied if all
persons can eat and live at an acceptable minimum. A starving persons cannot be held
responsible for stealing food - it is the fault of the state to have conditions such that
persons are starving.
8
•
Islamic injunctions define the minimum standard that either must be done or is acceptable.
The maximum is never defined but always stated as being left to the state and actions of
people. Thus the minimum requirement for giving charity and alms have been clearly
defined while love of those in suffering and love for God will define how much more a
person or people will do. Examples from the behavior of the companions of the prophet
indicate that the desire to help, to love God and love the prophet made it easy for these
persons to give away their entire households in the way of God.
•
The concept of love in Islam extends to all humans and to all forms of life in earth. They
are to be regarded as the creation of God and man is the "highest form" of this creation.
Thus animals and insects should not be destroyed unless there is need for human survival
or danger to mankind. Glimpses into the life of the prophet indicate his concern for the
welfare of animals and active efforts to ensure that they are treated with love and
kindness. Similarly, the main characteristic of his dealings with all mankind (those in the
faith and those not) was kindness and compassion. It is these types of behaviors that
defined the universality of mankind in the eyes of God.
How does the concept of giving alms relate to the principle of doingjustice and changing the
conditions leading to poverty and ill health?
Islam and Christianity would agree to such a case. In addition, poverty and ill-health can be
the main weave that can help us see the common purpose of all religions on this earth. We
need the love of God as expressed through the love of all mankind to help suffering people.
6.
Highlight areas that need further research and/or reflection
We need further reflections on the consequences of our religious convictions for the
distribution of resources in health. Could we find a religious consensus, with other religions,
to demand a more egalitarian distribution of resources in national and international health
leading to more equity?
Looking at the concepts of justice and love in Islam and Christianity advocate an allocation of
resources at community, national, and international level that provide an adequate level of
health care and reduce current inequities at all these levels. This can only be achieved by
giving preferential treatment to the most disadvanteged groups in any given society. All
9 .
X
human beings should have access to resources in health permitting them to lead healthy and
productive lives facilitated by a defined level of basic quality health services. On an
international level resources have to be shared according to ability to help and to need. The
obligations of people and nations commanding a aufficient level of resources extend beyond
their own ethnic, religious or political communities.
Christianity and Islam share great truths - they need to be shared more effectively.
New forms of engagement are required to break historical suspicions between religions.
Health is an avenue where this can be attempted.
In the Muslim tradition there is an impetus for believers to set aside theological disputes and
meet on the common grounds of ethics:
"If God had willed. He would have made you one single community, but He wanted to
test you. So vie one with another in good deeds. To God you will return, and He will
decide wherein you differed".
(S V:48)
In view of current global reality, it is most important to identify and reaffirm the set of
"common goods" of priority. These include integrity and the dignity of humankind and thus
aniy act against this is to be seen by both as an act against God. Therefore, this can define the
common struggle for human rights, against poverty and for justice.
Human rights
Our discussion of equity and justice in health is closely related to the discussion of human
rights. Nowadays we are talking about three generations of human rights. The first, are the
civil or political rights as embodied in the universal declaration of 1948. They are aiming at
the protection of the individual over against the state and its executing authorities. It is
defending the liberty of the individual person to exercise his or her right to freedom and right
to non-interference by the state.
10
•t
The second generation are the social and economic rights as embodied in the International
Covenant on Economic, Social and Cultural Rights of 1966. It includes rights to certain
sendees and condition as e.g. the right to health in a broad sense and to health services in
particular.
The third generation are usually interpreted as the rights of communities or societies e.g. the
right to development. These are collective rights extending not to individuals but to societies
or nations.
Could there be a consensus among major world religions concerning the justification and
implementation of these rights? Can we come closer to a common understanding of a
definition of the right to health? Can we agree on the rights of disadvantaged communities or
nations to a broad definition of social and economic development9 Do only societies have a
legal claim to developmental progress or can individuals hold their governments and
authorities responsible for failed developmental progress and violations of social human
rights?
Reality and practice
Despite the theological perspectives a review of current reality will demonstrate that countries
that have one or the other faiths as dominant have different practices.
11
Interreligious Dialogue on Bioethics 5. - 8. Oktober 1999
Participants
Name_________
Rainward Bastian
Institution__________________ ___
German Institute for Medical Mission
e-mail_______________
Difacni@cilyinfonclz.de
Christoph Bciui
German Institute for Medical Mission
Difacin.bcnn r/cllxiiifonci/.d c
John Bryant
CIOMS
JbryantJiioscow'aworldnct. att.net
Pitak Cliaicharocn
Mahidol University', Center of
Religious Studies
shpit@maliidol.ac. th
Abdallah Daar
Sultan Qaboos University of Oman
Asdoc//;^.l.o..jj.cLpin
Shimon Glick
University of the Negev
University Center for Health Sciences
GSHlMON@bgumail.bgu.ac.il
Adnan Hyder
Global Health Forum, Geneva
adnanliyder@hotmail.com
Manoj Kurian,
World Council of Churches
fvlku@xvcc-coe.org
Jeremy Lauer
World Health Organisation
Lauerj@who.int
Pi nit Ratanakul
Mahidol Universit}', Center of
Religious Studies
shprt@mahidol.ac.th
Dietrich Roessler
University of Tubingen
H. Sudarshan
Community Health Cell. Bangalore
Vgkk@vsnl.com
Urban Wiesing
University of Tubingen
Urban.wiesing@uni-tuebingen.de
Address' •______________
Paul-Lcchler-Str.24
D-72076 Tubingen________
Paul-Lcchlcr-Slr.24
D-72076 Tubingen________
P.O.Box 177
Moscow, Vermont 05662
USA___________________
45/3 Ladplirao 92, Bangkapi.
Bangkok 10310
Ben-Gurion University of the Negev
POB 653
Be'er Sheva 84105
ISRAEL
"14936 HABERSHAM CIRCLE
SILVER SPRING. MD 20906
150. Route de Ferney
1211 Geneva 20
Switzerland
_______________
20. avenue Appia
1211 Geneva 27
Switzerland
________________
45/3 Ladplirao 92, Bangkapi,
Bangkok 10310
Kcplcrslr. 15
D-72076 Tubingen________
C/o H Udayakumar 377
3d' Cross. First Block.
Jayanagar. Bangalore 560011
Kcplcrslr. 15
D-72076 Tubingen
1
I
THE ROLE OF THE CHURCH IN DELIVERY OF SUSTAINABLE HEALTH CARE:
REFLECTION ON BASIC THEOLOGY AND ETHICAL PRINCIPLES
Peter J. Henriot, S.J.
Jesuit Centre for Theological Reflection
Lusaka, Zambia
Paper presented to Workshop on Sustainable Health Care
Sponsored by CIDSE and Caritas Internationalis
Leeuwenhorst, The Netherlands
25-30 September 1995
[DRAFT]
I
THE ROLE OF THE CHURCH IN DELIVERY OF SUSTAINABLE HEALTH CARE:
REFLECTION ON BASIC THEOLOGY AND ETHICAL PRINCIPLES
Health care has long been associated with the mission of the church to evangelise, to
bring the Good News to all nations. In Mark’s account of the missioning of the first disciples
after the Resurrection, Jesus promises that believers would "place their hands on sick people,
who will get well." (Mark 16:18) This ministry of healing is a continuation of Jesus' healing
activity. Throughout the Gospels, we have examples of the cure of the sick as a integral part
of the preaching of the coming of the Kingdom of God (e.g., Luke 10:9). In its missionary
activity worldwide, the church has always had a role in the delivery of health care.
Will that delivery of health care be sustainable? This question that we struggle with
during this workshop takes on a particularly urgent character when we reflect on the reality
confronting the countries that serve as the focus of our attention, the "countries with limited
resources." (Is this the politically-correct language for the "poor countries"?)
My own reflections come from the stance neither of a theologian nor a health-care
professional. My training is in the political economy of development and my immediate
experience is in a very poor African country. Therefore in preparing the topic assigned to me,
I was particularly touched by the message of the World Health Organisation's publication
earlier this year, The World Health Report 1995: Bridging the Gaps. I am sure that many of
you also have read this and have equally been touched by the power of its opening
paragraphs:
The world's most ruthless killer and the greatest cause of suffering on earth is
extreme poverty.
Poverty is the main reason why babies are not vaccinated, clean water and sanitation
not provided, and curative drugs and other treatments are unavailable and why mothers die
in childbirth. Poverty is the main cause of reduced life expectancy, of handicap and
disability, and of starvation. Poverty is a major contributor to mental illness stress suicide
family disintegration and substance abuse.
Poverty wields its destructive influence at every stage of human life from the moment
of conception to the grave It conspires with the most deadly and painful diseases to bring a
wretched existence to all who suffer from it. During the second half of the 1980s, the number
of people in the world living in extreme poverty increased, and was estimated at over 1.1
billion in 1990 - more than one-fifth of humanity.1
Our discussions here go on in the face of this recognition that poverty is the number
one health problem in today's world. What we say about the church's role in the delivery of
sustainable health care must of course address that sad fact. My contribution in this
presentation is to provide some contextual theology and macro-ethical principles for us to
reflect on as we look at this topic.
A CHANGING CONTEXT
Today the delivery of health care by church-related institutions and organisations
continues to go on around the world as it has for many centuries. But within many of the
countries with limited resources, there is a new context for the church's role. This new context
is marked by two significant movements, two important transitions. These are the movements
toward (1) political democratisation and (2) economic liberalisation.2 The first provides a new
2
context for church-state relations, and the second a new context for meeting the economics of
health care. Because this topic is so broad, let me narrow it to the continent of my own
experience, Africa, and be very specific with examples from the country of my own mission,
Zambia.
Political democratisation is the transition from authoritarian regimes to forms of
government that allow greater popular participation under a constitutional rule of law that
respects basic human rights. The 1960's in Africa was the period of "First Independence,"
when freedom from colonial rule was achieved and national identity secured. Hopes were
high, as majority rule governments took control and parliaments with multi-party organisation
were put in place. But the experience of full freedom and dignity was short-lived in many if not
most of the new African states. For a variety of reasons, internal and external, the hopes of the
First Independence gave way to the rise of one-person and one-party totalitarian rule, and, in
many instances, the oppression of military dictatorship. By the end of the 1980's, out of the
44 sub-Saharan African states, some 38 were governed by authoritarian regimes.
Then a new experience of "Second Independence" began in the 1990's-throughout
Africa. Again for a variety of internal and external reasons, there has occurred a move toward
political democracy, the rise of or return to a system of multi-party competition, the respect for
a free press, and the hope of protection and promotion of basic human rights. In Zambia, for
example, we ended a period of 27 years of one-person, one-party rule with a peaceful
transition in 1991 to multi-party democracy. Other African countries have experienced similar
transitions. South Africa, of course, is the most dramatic instance of transition to democratic
majority rule and offers the greatest hope even amidst extremely difficult circumstances
But the political democratisation movement is still too young to make evaluations of its
success or predictions of its sustainability. In many parts of Africa there have been setbacks
- most notably in Nigeria with the retention in power of a cruel military dictatorship. But what
is important for our discussions here is that the movement for political democratisation
provides a new context for the church's mission of health care. Another paper of this
Workshop will specifically address church and state relations. Here it is sufficient to point to
two questions that arise: (1) is a democratic context more conducive to the orientation of
health care under church sponsorship? and (2) does sustainable health care itself require
today a more democratic style?
Economic libera/isation is the transition from a centrally-planned, state-controlled
economy (socialism) to a free-market, privatised economy (capitalism). For a variety of
reasons, internal and external, African economies declined in the period after Independence.
Deteriorating terms of trade, increasing debt burdens, mistakes and misplaced priorities
meant a fall in production and a decline in standards of living. Basic services and
infrastructures deteriorated. Social indicators of health and education that had risen after
Independence took a turn downward. By the end of the 1980's, of the poorest forty nations in
the world, 27 were in sub-Saharan Africa.
In an effort to turn around the economic decline of Africa and address the serious
problems of widespread poverty, the international donors began pressuring governments to
change significantly the direction of their economies. The model of change adopted was that
formulated by Northern economists associated with the International Monetary Fund and the
World Bank. The "Structural Adjustment Programme" (SAP) is an effort to bring short-term
stabilisation (e g., through devaluation, budget constraints, credit restrictions, etc.) and long
term restructuring (e.g., through removal of price controls, privatisation, trade liberalisation,
3
etc.). Faithful adherence to this economic liberalisation is now a condition for any further aid
and assistance.3
The experience of a country like Zambia is illustrative of the problems created by SAP.
First, there is widespread suffering of the people. The elements of SAP such as the
withdrawal of subsidies, imposition of fees in health and education, and retrenchment of
workers impose especially hash burdens on those who are already suffering. This is a point
strongly made by the Zambian Bishops in their 1993 Pastoral Letter, Hear the Cry of the
Poor. Second, there is serious questioning of the long-term development consequences of
SAP, since it does not address questions such as employment generation, agricultural
production to feed the nation, the informal sector, regional cooperation, and the environment.
This is not the place to go into detailed analysis of the economic liberalisation
movement. Other workshop papers will take up questions of resources, financial aspects, etc.
But it is possible to point to two questions arising in this new context for the church's health
care mission: (1) What is the impact of increased poverty and suffering of the people on
demands made on the church's health mission? and (2) Will governments make increased
efforts to put health care back into private hands of groups like the church?
The context for the church's health care mission is of course affected by other important
events on the continent of Africa, all deserving much more analysis than is possible here.
These events include:
•
The rise in internal conflicts such as that experienced in Somalia, Liberia, Rwanda and
Burundi, and the danger of regionalisation of these conflicts
•
Increased numbers of refugees and internally displaced people, caused by these conflicts
and also by natural disasters such as droughts and pestilence
•
The HIV/AIDS pandemic with consequences not only for health care but for economic
development and political stability
THEOLOGICAL REFLECTION
Theological reflection is necessarily contextual. For this reason, this paper has begun
with an analysis of the changing context. To discuss the role of the church in the delivery of
sustainable health care it can help to provide a theological model that addresses the challenge
posed by the two movements of political democratisation and economic liberalisation. Such a
model will by no means provide specific answers for the difficult practical questions of day-today health care but can provide a framework for evaluation of what is currently going on and
for stimulation for our thinking and planning about new directions for the future.
I want to suggest as a theological model the three-fold action of the Good Samaritan
that we find in the well-known Lucan parable (Luke 10:30-37). The Samaritan's response to
the health care needs of the person beaten by robbers and left for dead along the JerusalemJericho road included these elements:
•
compassionate awareness: not ignoring the needs despite pressures to do so
•
effective immediate response, providing personal care even at great expense
4
•
long-term structural response: providing institutionalised care in cooperation with others
To begin with, the church's sustainable health care must be compassionate. One
writer describes compassion as "that divine quality which, when present in human beings,
enables them to share deeply in the sufferings and needs of others and enables them to move
from one world to the other; from the world of helper to the one needing help; from the world of
the innocent to that of sinner."4 Jesus in his ministry is certainly the model of compassion, as
again and again we are told in the Gospels that he is moved with compassion to take some
healing, comforting, uplifting action (e g., raising the widow's son, Luke 7:13; feeding the
5000, Mark 8:2; teaching the crowds, Mark 6:34) ; healing the sick, Matthew 14:14).
Coming along the road to Jericho after the priest and Levite, the Samaritan sees what
they also had seen: a man lying badly injured in the road. But the Samaritan sees with the
eyes of compassion and enters into the suffering man's world. His awareness is not blocked
by the pressures of going off for other important business, of fearing what involvement might
bring, of revulsion toward such pain and anguish. He does not ignore the needs of the man
precisely because he has been moved by compassion; his is a compassionate awareness,
much deeper and much more compelling than the superficial and selfish awareness of priest
and Levite.
In today's context of economic reductionism, there is little place in government and
business policy circles for compassion. The neo-liberal economics that guides structural
adjustment programmes creates pressures to ignore and marginalise the poor and the
suffering. Compassionate awareness is blocked by systemic emphases on budgetary
constrains, competition, efficiencies, bottom-line exigencies, etc. Furthermore, the sheer
magnitude of human suffering in much of the world has given rise to the frightening
phenomenon described as "compassion fatigue": people are simply exhausted, worn-out and
wearied by stories of and contact with those who are suffering. "Don't tell us any more! We've
done our part!" (Who knows, possibly the priest and the Levite had just come from tending to
the needs of many others who had been beaten up on the road to Jericho?!)
This theological model tells us, therefore, that sustainable health care in today's context
must be motivated by a compassionate awareness that may be pressured and may be
wearied but is never blinded.
The second thing to note in the Good Samaritan model is the immediate personal
response. The Samaritan takes time to become personally involved, providing what help he
can at the moment: "he poured oil and wine on his wounds and bandaged them; then he put
the man on his own animal and took him to an inn, where he took care of him." (Luke 10:34)
Throughout the Gospels, we have stories of how Jesus reached out and touched someone in
need, a sign of his personal involvement (e.g., curing a leper, Luke 5:13; straightening a
crippled women, Luke 12:13; healing a deaf-mute, Mark 7:33; comforting Peter's mother-inlaw. Matthew 8:15; feeding his own disciples, John 21.13). His was not a distant, aloof,
detached ministry. He became personally involved and shared whatever he could, most
especially his loving presence and personal touch.
What does this personal involvement shown in the Good Samaritan model say to our
efforts for sustainable health care in today’s context? As I will explain in greater detail later in
this paper, there is a serious tension in health care in the industrialised world between two
competing models of health care: health care ministry and health care industry. In the former
5
model, there is more personal, hands-on emphasis; in the latter, a technical, specialised
approach means greater de-personalisation. But as you know so very well, personal
involvement, the personal touch, is a medicine that no amount of technological sophistication
can replace.
■>
Our theological model thus points to the fact that sustainable health care must
emphasise personal involvement of health-care givers.
Finally, we need to take note of the long-term structural response present in the Good
Samaritan model. Not only was the Samaritan compassionately aware and immediately
involved; he was also committed to further assistance through arrangements that involved
planning, financing, and cooperative efforts. "The next day he took out two silver coins and
gave them to the innkeeper. 'Take care of him,' he told the innkeeper, 'and when I come back
this way, I will pay you whatever else you spend on him.'" (Luke 10:35) The Samaritan took
steps to institutionalise the care given so that it would be effective. As important as his own
immediate and personal care was for the injured person, it was not enough.
This "institutionalisation" of loving care has been a mark of church-related health care
over the years, in the best sense of the word. Hospitals, clinics, hospices, homes, etc., are all
ways of assuring that the loving care can go on. Indeed, the establishment of these
institutions by the church was a significant step toward “sustainability" of health care before
that phrase ever became popular. In the tight economic situations of today in countries with
limited resources, commitments to institutions may be more difficult but also more necessary.
The control over these institutions - not simply in financial terms but also, and more
importantly, in terms of values — is also a serious challenge in the new political environment.
Thus, sustainable health care in today's context must, according to our theological
model of the Good Samaritan, find ways of effective institutionalisation of the compassionate
and personal response of the church.
ETHICAL PRINCIPLES
In looking at ethical principles that would guide the church in the delivery of sustainable
health care, I want to make an initial distinction between the macro-ethical and the microethical.
•
Macro-ethical principles guide societal and institutional response and refer to topics in
social policy areas such as access of the poor to facilities, priorities for the future, etc.
•
Micro-ethical principles guide individual response and refer to topics in personal choice
areas such as contraception, maintenance of life-support systems, etc.
Because my own training and experience is in the field of the political economy of
development, my focus here will necessarily be on the macro-ethical principles. Someone
with more specialised medical ethic background would have to address the micro-ethical
principles. But I will say this. From my involvement in consultancy with church-related health
care systems in the United States in the 1980's, my impression is that considerably more
attention has been spent on the micro-ethical issues that on the macro-ethical issues. That
has meant in practice that some very significant points regarding institutional practices have
not been subjected to as critical an ethical evaluation process as have been individual
6
practices of medical personnel. An obvious point is that the ethical demand of concern for the
poor - the implementation of the church's mandatory "option of the poor" - has significant
consequences that should affect institutional decisions and policies.5
For provoke our discussion here this morning, to stimulate questions in our discussion
groups today, and to focus our potential resolutions in the days ahead, let me suggest a set of
four macro-ethical principles that should guide the role of the church in the delivery of
sustainable health care. These principles are related and all can be rooted in the theological
model of the Good Samaritan that I have presented. As you hear the principles, I ask you to
apply them to your own specific experiences and test their validity and relevancy.
Sustainable health care in today's context should be primarily:
1. Ministerial (not industrial)
"Sustainable health care should follow a ministerial model and not an industrial model."
This first and indeed foundational principle states very simply that providing health care
is a form of service in and for the community before it is a form of economic activity, a
commodity exchanged for profit. Care is to be provided for whoever needs it. Who pays for
that care is an important consideration, but it definitely is a secondary consideration. This at
least has been the traditional ethic guiding health care over the years.
Now this principle may be simple to state, but it is increasingly difficult to implement.
Of late, particularly in the rich countries, health care has followed more of an industrial model
than a ministerial model.6 This is understandable given the pressures arising when health
care assumes the economic proportion it does. For example, in the Untied States of America
health care currently accounts for more than 14% of the annual GNP. The fastest-growing
sector of health care activity is the for-profit sector.
The ministerial model of health care emphasises:
•
•
•
•
the service of persons with respect for equal dignity of all
a holistic approach relating to the whole person in the whole community
a focus on the spiritual dimension of the person
a preference for the poor, the so-called "option for the poor"
The industrial model of health care emphasises:
•
•
•
•
the pursuit of profit for a return on investment
specialisation for efficiency with attention to individual parts
technological effectiveness
competition in order to survive economically
Although these models can be complementary - one must survive in order to serve! they also can be conflicting in the values, directions, standards and ethos of an institution. For
example, the option for the poor may be pressured to give way in the face of stiff competition
and budgetary constraints. Sustainable health care in a church-related institution in today's
political and economic context must be guided by this macro-ethical principle of ministerial
service if it is to maintain the religious character, the link to Jesus' ministry of evangelisation,
that was the mark of its founding.
7
2. Holistic (not isolationist)
"Sustainable health care treats the whole person in the whole community, not isolating
personal parts from the rest of the body or individuals from the rest of the community."
This ethical principle recognises that a human person is not a unique organism with
isolated problems, but a whole. Not just a whole individual person either, but a part of that
whole that is the web of relationships to the wider community, to the person's family, to their
work, to their social situation.
Sustainable health care is guided by this principle when it avoids a hyper-specialised
approach to taking care of a sick person or to preventing illness. I am more than my inflamed
appendix, more than my malaria-caused fever. There is a spiritual dimension to my existence,
in the sense of my beliefs, my hopes, my loves. This dimension too must be taken into
account when I am seeking health care. For example, other professionals in society must be
recognised besides simply the physician or the nurse. Religious personnel are not simply for
offering "spiritual consolation" but have a significant role in the preventive and curative
processes.
Moreover, I am not alone, a lone individual. There is a societal dimension to my
existence, a dimension that cannot be ignored in diagnosing needs and in prescribing
remedies. Families, support groups, work places, all come into consideration in an holistic
approach. And the cultural aspects of my existence are likewise seen as important. This is
especially true where explicit cultural emphases are significant factors in holding a society
together and in giving it its identity.
One consequence for sustainable health care guided by this holistic principle: the role
of the traditional healer and of traditional medicine assumes a much more important role. This
is certainly true in Africa. Recently I was speaking with some African friends who told me of
the significance of advice from traditional healers and of the use of herbs, special diets, etc.,
that followed traditional patterns. They were not speaking of consulting the ng'anga (witch
doctor) for medicines to seek revenge or enhance domination. Rather, they sought to be in
touch with the wisdom of a community that knew health remedies before the chemistry,
technology and "scientific rationalism" of Western medicine came to control so much of health
care activities. There is greater interest today in this traditional wisdom. It is certainly in line
with the holistic ethical principle we have been speaking of here.
3. Structural (not symptomatic)
"Sustainable health care should take account of the structural causes of sicknesses
and not deal only with the symptoms."
It is certainly clear from our earlier discussion of the changing political and economic
context that sustainable health care is profoundly affected by what is occurring today in
countries with limited resources, such as African countries. The structures of political
participation and of economic distribution touch the life and the livelihood of every individual.
Institutions and services of health care are themselves involved in the transitions taking place
around them.
8
It is for this reason that church-related sustainable health care must be guided by an
ethical principle that recognises the deeper causes of sickness in society, especially
sicknesses that affect the poor. Dr. Paul Farmer, a physician and anthropologist at Harvard
Medical School who has worked in rural Haiti, has argued that health care is ineffective in poor
societies unless it addresses the deeper, poverty-related forces that are the root causes of
many of the serious diseases on the increase, such as tuberculosis.7 If TB, for example, is ,
viewed as an exclusively biological phenomenon, then available resources will be devoted to
pharmaceutical and immunological research. If the problem is viewed primarily as one of
patient compliance (e.g., whether or not medicine is taken, diet is followed, etc.), then plans
will be made to change the patient's behaviour. But if a more serious structural analysis is
done, and the poverty-related forces are identified (e.g., overcrowding, hunger, lack of
education, inability to pay for drugs, etc.), then effective sustainable health care must also
necessarily address these forces.
What strikes me about Dr. Farmer’s analysis is that it is remarkably substantiated by
the World Health Report 1995 that I referred to at the opening of my remarks. According to
WHO, "The world's biggest killer and the greatest cause of ill-health and suffering across the
globe is ... extreme poverty." And this poverty affects people in a variety of ways. Let me give
an example that I know of from personal experience in Zambia. The UNICEF efforts to
promote universal immunisation have been very successful in our country - a rate of 88% for
tuberculosis, for instance. But this rate has been falling off in the past year or two, as very
poor parents have stayed away from clinics that now are charging user fees (because of SAP).
Although the immunisations are free, they are associated in people's minds with clinics that
charge fees for other services - and are avoided!
Health care cannot, of course, solve problems of poverty. The point I am making is that
sustainable health care must be guided by a macro-ethical principle that recognises that
sicknesses and ill health are in many instances caused by the deeper societal structures of
poverty, inequity and injustice. It does not help to address only the symptoms; the structures
must also be addressed.
4. Liberative (not dependency-building)
"Sustainable health care should be liberating to all those involved, health-care givers
as well as receivers, and not build dependencies."
In countries with limited resources, one of the most serious challenges in the
development process today is to avoid building bonds of dependency. A major critique
offered in recent decades of "developmentalism" - the political-economic ideology espoused
by many Northern countries and donor institutions - has been that it ignored the structural
dependency existing in North-South relationships. Structures of trade, aid, investments, and
monetary arrangements have all maintained the dominant influence of the rich countries.
These dependency relationships can, of course, also go on within and between
organisations and between individuals. It is thus a challenge to design and implement
relationships that are liberative and not dependency-building. This is true in the efforts of
sustainable health care. On the level of individual interactions, it is important that the style of
exchange between the health-care giver and receiver be such that people are empowered to
build on their own ideas, to make new discoveries for themselves. The people must become
actively responsible for their own and the community^ health. To use the expression of Paulo
J
9
Freire, people become subjects of their own development, not objects of someone else's
efforts to develop them.
In Zambia, we make use of a popular development education approach called "Training
for Transformation" that is based on Freirean methodology.8 (It is also used in several other
countries in eastern, southern and western Africa.) I myself have participated in programmes
with health care workers in which the emphasis has been in the liberative direction. Local
communities build their own clinics; local health workers involve people in education, nutrition,
sanitation, and environmental programmes. The well-known handbook for village health care,
Where There Is No Doctor, is another excellent example of promotion of a liberative health
care approach.9
There is also the sensitive issue of the dependency on outside funding of churchrelated health care efforts in countries of limited resources. This is surely an issue of
importance for the members of this audience and for the CIDSE/Caritas Internationalis
sponsors. The dilemma is that without some outside assistance, much health care would be
curtailed. Yet the question arises: does outside assistance build dependencies and also
absolve local governments, groups and individuals from their political and personal
responsibilities? (This is not an academic question for me in Zambia, since I personally
arrange for donations of much-needed medicines to be shipped from the United States to our
mission hospitals that experience the constraints of severe national poverty.) The African
Synod message of last year made the point in general terms in a paragraph significantly
entitled, "Examination of Conscience of the Churches in Africa," when it stated: "Our dignity
demands that we do everything to bring about our financial self-reliance."10
CONCLUSION
What "sustainable health care" demands in the situation of countries with limited
resources will become more clear over the remaining days of this workshop. What I have
attempted to do in this presentation is to provide an analysis of the context of political and
economic transition; to offer a model of contextual theology based upon the compassion,
personal involvement and institutional commitment shown by the Good Samaritan; and to
suggest a set of macro-ethical guiding principles that emphasise a ministerial, holistic,
structural and liberative approach.
I close where I opened, by repeating the message of the World Health Organisation:
"The world's most ruthless killer and the greatest cause of suffering on earth is ... extreme
poverty." Can we of the church find a role in the delivery of sustainable health care in such a
world? Faithful to following the way of Jesus who said, "I have come that they may have life
and have that life more abundantly" (John 10:10), we must seek our role humbly, wisely,
courageously.
DRAFT: 20 September 1995
Peter J. Henriot, S.J.
Jesuit Centre for Theological Reflection
P.O. Box 37774 10101 Lusaka, Zambia
tel: 260-1-250-603: fax: 260-1-250-156
e-mail: phenriot@zamnet.zm
10
ENDNOTES
World Health Organisation, The World Health Report 1995. Bridging the Gaps (Geneva: World
Health Organisation. 1995). p. 1
2For a more complete treatment of these topics, see Peter J. Henriot, S.J., "The Social Context of the
AMECEA Countries on the Eve of the African Synod," AFER (African Ecciesial Review}, Vol 34, No. 6,
December 1992, pp 340-363
3For further explanation of SAP, see Peter J Henriot. S. J., "Effect of Structural Adjustment Programmes on
African Families, in African Christian Studies (Journal of the Catholic University of Eastern Artica), forthcoming
1995.
4From a privately circulated paper by Howard Gray, S J ; "Moving Ahead "
5See Peter J. Henriot, S.J., "Service of the Poor The Foundation of Judeo-Christian Response," in James E
Hug, S.J., ed., Dimensions of the Healing Ministry (St. Louis: Catholic Health Association, 1989), Pp. 66-85.
6See Peter J Henriot, S.J., "Catholic Healthcare: Competing and Complementary Models." in Hug, op. cit., pp
19-19-35.
' Paul Farmer "Medicine and Social Justice", America, July 15 1995, pp 13-17
8Anne Hope and Sally Timmel, Training for Transformation. A Handbook for Community Workers, 3 vols
(Harare, Zimbabwe. Mambo Press, 1984).
9David Werner, Where There Is Mo Doctor A Village Health Care Handbook for Africa (London Macmillan
Publishers, 1987).
‘^"Message of the Synod," #44, in The African Synod (Nairobi: Paulines Publications Africa, 1994), p 26
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