Commentary

August 2018

 
 Often we envision donating our organs after we are dead, but we can also choose to become an organ donor while we are alive if we share part of our liver or donate one of our kidneys. The proposal to give one of our two kidneys away, though, does raise some ethical and safety concerns. There can be long-term risks for the donor. Donating a kidney, moreover, would not be therapeutic for us — only for someone else — and in fact might slightly increase our own risk for experiencing renal failure in the future.
 
Clearly we have a general duty to respect the integrity of our body. This means we shouldn’t cause injury to it, or damage it, for example, through surgeries or treatments that are not necessary to preserve our health or save our life. In light of these considerations, donating one of our kidneys would seem to run counter to our responsibility to maintain bodily integrity.
 
Yet the notion of integrity can also be understood in a broader sense, namely, as functional integrity, so that if one of our kidneys were removed without imposing undue risk, and without a significant loss of blood filtering function, then we could say that the functional integrity of our renal system was preserved. In that case, the removal of one of our kidneys, as a sacrificial act and for a proportionate reason, such as saving or improving another person’s life, could be justified. This is what the Church affirms.
 
A further ethical concern, however, centers on the fact that the decision to donate must be made freely by the donor, and consent should be given without any undue pressure. This means that offering payments for organs is fundamentally coercive and unethical.
 
We face a serious shortage of available kidneys for transplant in the U.S. Average wait times for a kidney are approaching five years, and about 15-20 people die each day while waiting for an organ — the majority for a kidney. In August of 2018, I participated in a conversation with some of the health policy team at the White House as they considered possible strategies for increasing the supply of live donor kidneys. We discussed the ethical, legal, economic and health implications of some proposed solutions, including the proposal to reward organ donation by providing various non-cash benefits.
 
During the White House meeting, some parties to the discussion offered recommendations that the government provide lifetime guaranteed coverage of all future medical expenses, or lifetime health insurance, to every person who becomes a living kidney donor. I emphasized that we should not be “encouraging” donation by offering “incentives” to donors as a direct benefit at all. Offering lifetime health insurance or similar proposals would, in my view, constitute a form of payment or “valuable consideration” offered to the donor, and would again raise the problem of improperly incentivizing the donation of organs, pressuring someone to consider donating as a way to secure lifetime health insurance coverage.
 
When Congress passed the National Organ Transplant Act in 1984, this concern about incentivizing donations was directly addressed. This law prohibits the purchase of organs or any exchange of “valuable consideration.” This same law, however, clearly permits reimbursement of various expenses associated with the transplant, such as travel costs to get to the hospital in order to have the kidney removed, temporary housing at the time of surgery, lost wages incurred in connection with the donation of the organ, etc.
 
Providing reimbursement of expenses should not be viewed as encouraging or incentivizing the donation itself, but rather as “eliminating disincentives,” or “removing hindrances or roadblocks.”  An organ donor should not have to assume extra personal expense or take on other heavy burdens to be able freely to help out another patient who would benefit from receiving his or her kidney.
 
From the ethical point of view, our ultimate goal should be not so much to “incentivize donation,” as to “support or encourage personal generosity” on the part of those individuals who may desire to donate freely one of their kidneys. The distinction is an important one. At the end of the day, we want people to become organ donors, not organ vendors. Human organs and tissues, because of their close proximity and connection to our human identity, cannot be reduced to commodities to be acquired or sold on an open market.  We must do what we can, legally and otherwise, to safeguard the generosity of the organ donor’s freely chosen act and prevent others, especially the poor and disadvantaged, from being exploited because they need money, health care, or other “incentives.”
 
 
– Rev. Tadeusz Pacholczyk, Ph.D. earned his doctorate in neuroscience from Yale and did post-doctoral work at Harvard. He is a priest of the diocese of Fall River, MA, and serves as the Director of Education at The National Catholic Bioethics Center in Philadelphia. See www.ncbcenter.org
 

Making Sense of Bioethics

By Father Tadeusz Pacholczyk
July 2018

Superheroes attract us. From Greek gods to Superman and Spiderman, our fascination with the awesome deeds of superheroes beckons us to become Masters of our own destiny. Yet even as we enjoy the fantasy of acquiring Promethean powers to combat our enemies and conquer evil, we have legitimate misgivings about mere mortals taking on god-like powers in real life. We are concerned about those who play with fire just like Prometheus did, at the risk of harm and great destruction. Today, as modern medicine tries to rebuff death and control our humanity in ever more sophisticated ways, new temptations arise that challenge us to choose between life and death, between living in reality and living in a fantasy world where we elevate ourselves as “Masters of our own destiny.”

We encounter these Promethean temptations today in the expanding fields of reproductive medicine and infertility. We may be drawn to the idea of “manufacturing” children through in vitro fertilization and related forms of assisted reproductive technologies.  By producing and manipulating our children in laboratory glassware, however, we cross a critical line and sever our obedience to the Giver of life. We assume the role of Masters over, rather than recipients of, our own offspring. We allow our children to be mistreated as so many embryonic tokens — with some being frozen in liquid nitrogen and others being discarded as biomedical waste. We take on the seemingly divine role of creating another human being and reigning supreme over his or her destiny.

We are tempted toward this same type of Promethean mastery at the other end of life. While we recognize that we cannot avoid death, we may be troubled and vexed by the possibility of a protracted and painful dying process. We may decide that the best answer is to “take charge” of the situation and move into the driver’s seat, resolutely calling the final shots ourselves. By ending life “on our own terms” through physician-assisted suicide, we hope to steer around the sufferings and agonies of the dying process. Yet suicide clearly goes against the grain of the kind of creatures we are, creatures intended for life, not death.

The temptation that flashes before us when we consider suicide is the fantasy of becoming “Master” over our destiny by arrogating to ourselves direct power over life and death. We begin to accept the falsehood that we are uniquely in charge of our own destiny, and can remake or destroy ourselves as if we were gods. It is but a short step, then, for us to take further powers unto ourselves, lording it over the fate and destiny of others through activities like euthanasia, direct abortion, and human embryonic stem cell research.

Although we are creatures intended for life, we may not be entirely clear about how we came to possess that life. We sense how we have been cast headlong into existence without asking for it, and we know, with certainty, that we did not create ourselves or have any role in bringing ourselves into being. The fact that we were created entirely apart from our own will means that our existence has been intentionally chosen by Another. The goodness and beauty of our life has been independently conferred on us by One who has radically willed our personal existence. Because that existence is good and beautiful, it ought always to be treated as such, and never directly violated.

The goodness and beauty of the human life we have received is also connected to the gift of our masculinity or femininity. Yet here we also face the temptation of Promethean mastery as we imagine we can become the opposite sex, or that we needn’t be either male or female, but can be any of dozens of different “gender identities.” We engage in the fantasy that our embodied nature is fluid and malleable, and that we can vanquish our birth sex, remaking ourselves through the gender bending powers of medicine and science. But the damage that this fantasy can wreak in a short space of time — the hormones, the surgeries, the irreversible decisions and mutilated bodies — is not trivial. The lives of many thousands of individuals, convinced they have become Masters of their own identities, have already been irretrievably altered or ruined, often with the assistance of other medical or political Masters.

The ever-expanding powers of biomedicine call us to careful ethical reflection and discernment, so we do not fall prey to the temptation of seeing ourselves as Masters, rather than collaborators with God, our inalienable Source of life and being.

Rev. Tadeusz Pacholczyk, Ph.D. earned his doctorate in neuroscience from Yale and did post-doctoral work at Harvard. He is a priest of the diocese of Fall River, MA, and serves as the Director of Education at The National Catholic Bioethics Center in Philadelphia. See www.ncbcenter.org

 

By Father Tadeusz Pacholczyk
June 2018

A comprehensive 2015 scientific review found medical marijuana to be useful only for a small number of medical conditions. Writing in the Journal of the American Medical Association, an international team of researchers found scant evidence to support broad claims for the drug's effectiveness. Although clinical trials showed that chronic neuropathic pain and cancer-related pain could often be treated, other forms of pain, such as those related to rheumatoid arthritis, fibromyalgia, HIV and multiple sclerosis did not show statistically significant improvement. Researchers also found inconclusive data for people with insomnia, anxiety disorders, depression, Tourette syndrome, psychosis, and sleep disorders. They registered concerns about medical marijuana’s significant side effects as well.
 
Yale University researchers, commenting on the review, noted how the approval process for medical marijuana in U.S. states and jurisdictions has often been based on "low-quality scientific evidence, anecdotal reports, individual testimonials, legislative initiatives, and public opinion." They raised concerns around the fact that medical marijuana seems to be receiving “special status” and is being “fast-tracked” for legalization, when it should instead be subject to the standard scientific verifications of the FDA approval process to assure its efficacy and safety. The Yale authors offered this corrective: "Imagine if other drugs were approved through a similar approach… If the goal is to make marijuana available for medical purposes, then it is unclear why the approval process should be different from that used for other medications."
 
In his influential exposé Marijuana Debunked, Dr. Ed Gogek emphasizes how the idea of medical marijuana “didn’t come from doctors, or patient advocacy groups, or public health organizations, or the medical community. The ballot initiatives for medical marijuana laws were sponsored and promoted by pro-legalization groups.” These groups have used the medical marijuana trump card to grease the skids for the acceptance of recreational marijuana. This pincer movement has enabled them to control and reap the windfall from an extensive system of dispensaries that supply and distribute addictive substances. Even if recreational marijuana does not ultimately become legalized in a particular jurisdiction, it is well documented that medical marijuana dispensaries often end up supplying the drug not for rare, valid medical uses, but for substance abuse, similar to the situation with opioid pain medications.
 
Yet the push for marijuana continues unabated. In May 2018, the New York State Comptroller, Scott Stringer, issued a report declaring that legalized marijuana in the Empire State would be a potential $3 billion market, with taxes from its sale generating a potential $436 million annually statewide, and $336 million for New York City. With such sums at play, not only are investors coming out of the woodwork, but towns and municipalities are also issuing ordinances and changing zoning laws to bring in the dispensaries. Indeed, dollar signs beckon, much as they once did for tobacco companies and plantation owners.
  
Besides being addictive and profitable, tobacco and marijuana have other similarities. Marijuana smoke contains harmful chemicals, with ammonia, benzene, toluene, and naphthalene levels in marijuana exceeding those found in tobacco smoke. These chemical components may contribute to emphysema, bronchial irritation and inflammation. Patients with medical conditions treatable by medical marijuana can avoid these toxic chemicals and other side effects by using more purified preparations containing only the active ingredients.
 
In 2003, the Institute of Medicine, a nonprofit, nongovernmental organization that evaluates medical issues, acknowledged that components of marijuana may have medicinal uses, and strongly recommended the development of prescription cannabinoid medicines based on those components: “If there is any future for marijuana as a medicine, it lies in its isolated components, the cannabinoids and their synthetic derivatives.” Several different cannabinoid medications have been developed in recent years, and these medicines work as well as or better than marijuana, have fewer side effects, and are less likely to be abused. These drugs also tend to be effective in the body for longer periods.
 
Dr. Gogek notes the irony of the loud public outcry that would ensue if the FDA were to approve “a drug that had no advantage over safer alternatives, went mostly to substance abuse, increased teenage drug use, and killed people on the highways.” He concludes, “We should not be sidestepping the FDA approval process that was designed to protect us.”
 
In sum, the reality behind medical marijuana is far from the rosy view painted by advocates.  Marijuana is not “just a plant.” It is an addictive drug abused in epidemic proportions, inflicting a serious individual and societal toll. Its use as a medicine needs to be carefully regulated through standard scientific oversight and the FDA approval process, not handed over to recreational enthusiasts and opportunistic businessmen. The current practice of encouraging states and municipalities to legalize medical, and then recreational, marijuana, is, in the final analysis, neither reasonable nor ethical.
 
 
–  Rev. Tadeusz Pacholczyk, Ph.D. earned his doctorate in neuroscience from Yale and did post-doctoral work at Harvard. He is a priest of the diocese of Fall River, MA, and serves as the Director of Education at The National Catholic Bioethics Center in Philadelphia. See www.ncbcenter.org
 

At its core, the idea of a “wrongful birth” claim is unreasonable and ethically incoherent. Parents who bring these lawsuits against obstetricians and hospitals claim that medical professionals should have detected a particular disease or defect in their unborn baby through prenatal testing and informed them about it. Had they been given this information, their argument continues, they would have chosen to abort their baby, rather than spending years of their lives caring for a less-than-perfect, possibly infirm child. Wrongful birth lawsuits enable the parents to seek legal redress, often in the form of multi-million dollar settlements.

In 2013, for example, a jury in Washington state awarded a $50 million payout to a couple who claimed they would have aborted their five-year-old son Oliver if they had known he had an “unbalanced chromosomal translocation.” Because of the mismatched chromosomes he received from his parents, he has an IQ of less than 70 and is unable to walk.

Rachelle Harz, a malpractice lawyer who spearheaded one of these lawsuits in New Jersey in 1999, expressed some of the tortuous thinking that goes into these cases during an interview for 60 Minutes. She noted that although the physician in this case, “didn't cause the child's retardation, what he caused was not giving the proper information to the parents to allow them the choice to abort the child.” She concluded that the doctor “caused the birth of this very, very neurologically impaired child.”

The fundamental flaw in her argument, of course, is the claim that the doctor “caused the birth” of the baby, when, in fact, the birth was caused by an activity that took place nine months prior between the husband and wife. That action of the mom and dad, not an action by the doctor, resulted in the birth.

What the doctor actually “caused” by not discovering and sharing specific medical information with the parents was the preservation of the child’s life. These lawsuits rely on fundamentally flawed logic: first, that it is wrong and illegal for a doctor not to know or to withhold medical information such that a life that would have been ended is saved; second, that a doctor is somehow obligated to facilitate or cooperate in harmful or lethal actions that parents intend to carry out against their own offspring. The medical profession, however, has long professed allegiance to the creed of “do no harm,” so that doctors can serve uniquely as healers, not killers. For obstetricians in particular, the unborn children they track and follow during pregnancy count as that doctor’s patients in the same way that the mothers do.

Whenever a couple sets out with the intention of aborting an imperfect child and requests that prenatal testing be performed for this purpose, the process of testing itself becomes immoral. In the same way, any physician or health care professional who arranges for such tests, if they have prudential certainty that a couple intends to abort an imperfect child, would be guilty of cooperating in evil when that abortion takes place.

To consider a parallel example, if a physician believed that a child arriving to the hospital emergency room had been physically abused or severely beaten by his parents, he would be duty-bound, not to mention legally obligated, to report that abuse to authorities. He would not be permitted to turn a blind eye, or otherwise cooperate in the ongoing harm to that child by his or her parents. Similarly, obstetricians who work with pregnant couples should not be expected to turn a blind eye and provide diagnostic information to parents that will encourage them fatally to assault their unborn child.

None of us is perfect. None of us is born into this world completely free of defects, whether physical or psychological. Those limitations, however, never entitle others to place our lives in the crosshairs and pull the trigger — especially our own parents! In sum, these wrongful birth cases promote catastrophic misunderstandings about parental duties and about the physician’s obligations towards mothers and their children in pre-natal care settings.

Recognizing that some parents will face considerable expense, labor and difficulty in raising a child who requires special care and attention due to disabilities, it seems reasonable to promote a pro-life and supportive response on behalf of these families, rather than encouraging the corrosive practice of wrongful birth lawsuits. That supportive response should include the expectation of everyone chipping in and helping out, whether through insurance, taxes or crowd-funding, or through other forms of civic, societal or ecclesial outreach.

Rev. Tadeusz Pacholczyk, Ph.D. earned his doctorate in neuroscience from Yale and did post-doctoral work at Harvard. He is a priest of the diocese of Fall River, MA, and serves as the Director of Education at The National Catholic Bioethics Center in Philadelphia. See www.ncbcenter.org


 

By Father Tadeusz Pacholczyk  

Each year human immunodeficiency virus (HIV) infects about 50,000 people in the United States, and more than two million worldwide. Reducing the number of infections with this virus, which causes AIDS, is a high priority for public health officials.  Some strategies to reach this goal, however, raise significant moral concerns.
 
These concerns arise when experts seek to reduce infection rates by assuming that men and women lack the freedom to change their sexual behaviors or exercise self control, when they fail to acknowledge that self-restraint is possible and morally required, especially in the face of life-threatening disease.
 
One strategy for trying to control the pandemic includes “pre-exposure prophylaxis,” or PrEP, which involves an uninfected person taking a daily dose of the drug Truvada, an anti-retroviral medication. When someone takes the Truvada pill each day, and is later exposed to HIV through sex or injectable drug use, it can reduce the likelihood that the virus will establish a permanent infection by more than 92 percent. While the drug can have side effects, it is generally well-tolerated.
 
Many activists in the gay movement have argued that PrEP should be widely available and promoted, though other activists strongly disagree. AIDS Healthcare Foundation (AHF) founder Michael Weinstein has stressed, for example, that there are likely to be compliance issues. When someone is required to take a regimen of drugs every day in order to be protected, he argues, it is reasonable to expect that some will fail to do so. A 2014 article in The Advocate, a gay news outlet, notes that, “When asked why so few people have started PrEP, experts give plenty of reasons — cost, worries about long-term effects, and lack of awareness about the regimen itself among both doctors and patients are chief among them. But one top reason is the stigma of using PrEP. Weinstein’s name and the name of his organization, AHF, have become synonymous with the stigma surrounding PrEP use. In an April Associated Press article, Weinstein declared that PrEP is ‘a party drug,’ giving license to gay and bisexual men to have casual, anonymous sex. He’s called it a ‘public health disaster in the making,’ as his oft-repeated argument is that the most at-risk people will not adhere to taking a pill each day.”
 
These compliance concerns have led some researchers and clinicians to look into the possibility of one-time “disco dosing,” where an individual would take the medication, in a high dose, prior to each anticipated “risky weekend.”
 
There are other problems with PrEP as well. Some researchers have noted that once people start on the drug, their risk compensation changes, meaning they engage in more sex with "non-primary partners." Even if PrEP reduces rates of HIV infection, as studies have suggested, the incidence of other sexually transmitted diseases (STDs) may rise due to risk-compensation behaviors. PrEP can provide a false sense of security and encourage the lowering of inhibitions.
 
These kinds of approaches directed toward certain “at-risk populations” clearly raise concerns about sanctioning or supporting immoral behaviors. Medical professionals have raised objections of conscience when it comes to prescribing PrEP to HIV-negative men who indicate they are, or will be, sexually active with other men. They may raise similar objections to providing prescriptions for “disco dosing.” Writing such prescriptions means cooperating in, or facilitating, the evil actions of others.
 
Is pre-exposure prophylaxis always illicit? Not necessarily. For example, if a medical professional were to prescribe Truvada to the wife of a man who was infected through pre- or extramarital sexual activity, it would be for the purposes of protecting the wife from infection during marital relations, and would not involve the problem of promoting or facilitating unethical sexual behaviors.
 
STDs constitute a serious danger in an age where sexual behaviors are becoming ever more indiscriminate. STD outbreaks and pandemics often have their origins in unchaste behaviors and morally disordered forms of sexuality. The Centers for Disease Control notes that “men who have sex with men (MSM) remain the group most heavily affected by HIV in the United States. CDC estimates that MSM represent approximately 4 percent of the male population in the United States but male-to-male sex accounted for more than three- fourths (78 percent) of new HIV infections among men and nearly two-thirds (63 percent) of all new infections in 2010.” We should not be supporting or facilitating behaviors involving multiple sexual partners. These sexual practices, in the final analysis, are not only immoral in themselves, but also reckless and clearly contributory to the spread of STDs.
 
Rev. Tadeusz Pacholczyk, Ph.D. earned his doctorate in neuroscience from Yale and did post-doctoral work at Harvard. He is a priest of the diocese of Fall River, MA, and serves as the Director of Education at The National Catholic Bioethics Center in Philadelphia. See www.ncbcenter.org
 

Making Sense of Bioethics 

By Father Tadeusz Pacholczyk

In recent years we have witnessed a growing tendency to promote suicide as a way of resolving end-stage suffering. Physician-assisted suicide is now legal in a handful of states and a number of other jurisdictions are considering laws to legalize the practice. A few years ago on Nightline, Barbara Walters interviewed an assisted suicide advocate who summed it up this way: “We’re talking about what people want. There are people who, even suffering horribly, want to live out every second of their lives, and that’s their right, of course, and they should do it. Others don’t want that. Others want out!”

Those favoring physician-assisted suicide argue that getting out of our final agony means essentially redeeming a “get out of jail free” card through committing suicide. At first glance, taking this step would indeed appear to end our troubles definitively. But what if this view of things is dead wrong, and we don’t actually end up escaping our sufferings? What if we, instead, end up in a new situation where our trials are still present, and maybe even more intense, on account of the willful decision we made to end our own life?

I was recently reminded of this serious flaw in the “suicide solution” after watching a remarkable video adaptation of Shakespeare’s tragedy Hamlet, with Campbell Scott co-directing and starring in the title role. Listening once again to Hamlet’s timeless soliloquy “to be or not to be,” I was struck by how carefully Shakespeare addresses the vexing question of intense human suffering and the perennial temptation to commit suicide.  

Hamlet muses about whether it is better to put up with the bad things we know about in this life than to step into the strange new land of death's "undiscovered country," a country about which we know very little, and from which no one returns. This leaves us, in Hamlet’s words, “puzzled” and in “dread of something after death.” He wonders aloud about the hidden purposes of suffering when he asks himself, “Whether 'tis nobler in the mind to suffer the slings and arrows of outrageous fortune” than to “take arms against a sea of troubles, and by opposing, end them.” He concludes by asking whether we shouldn’t rather “bear those ills we have than fly to others that we know not of?”

Among those who end up committing suicide, whether physician-assisted or otherwise, many will face extenuating circumstances including severe depression or other forms of extreme mental pain. In such cases, it is clear that their moral responsibility will be greatly diminished, as fear and anguish constrict their ability to think and reason clearly. But this is not always the case, and some people, with clear mind and directed intention, do choose to end their lives, as appears to have been the case for Britney Maynard. She was the young woman in California who in the early stages of her brain cancer carefully arranged and orchestrated her own physician-assisted suicide, establishing months in advance the date and setting, who would be present in the room, what music would be playing as she did it, etc.

Such a decision is always a tragedy, and every life, even when compromised by disease or suffering, remains a great gift to be cared for. When freely chosen, suicide is a form of serious wrongdoing and is, in the words of the Catechism of the Catholic Church, “Gravely contrary to the just love of self. It likewise offends love of neighbor because it unjustly breaks the ties of solidarity with family, nation, and other human societies to which we continue to have obligations.” It leaves behind loved ones to contend with unresolved guilt, shame, and pain.

While ending our life may seem to offer an “escape valve” for the serious pressures and sufferings we face, we do well to consider the real effects of this choice both in this life, and in the life to come. In the next life, a preceding act of suicide may deny us the very relief we were seeking, and may, in fact, lead to harsher purification in a new situation of our own making, or, heaven forbid, lead to a fate far worse than purgatory.

Our Lord and his Church care profoundly for those who commit suicide, and even though this act clearly involves grave matter, the Catechism reminds us that, “We should not despair of the eternal salvation of persons who have taken their own lives. By ways known to him alone, God can provide the opportunity for salutary repentance. The Church prays for persons who have taken their own lives.”

Suicide affects us not only in the here and now, but has significant, even eternal, implications for the journey to that “undiscovered country” that awaits us.

Rev. Tadeusz Pacholczyk, Ph.D. earned his doctorate in neuroscience from Yale and did post-doctoral work at Harvard. He is a priest of the diocese of Fall River, MA, and serves as the Director of Education at The National Catholic Bioethics Center in Philadelphia. See www.ncbcenter.org

 Making Sense Out of Bioethics
       
By Father Tadeusz Pacholczyk                                                 
 
In an August 2015 column in The Washington Post, George F. Will argued in favor of physician-assisted suicide, summing up his perspective this way: “There is nobility in …affirming at the end the distinctive human dignity of autonomous choice.”
 
His conclusion, however, raises several important questions: Shouldn’t death-dealing actions directed against ourselves be seen as a deep repudiation of our autonomy, insofar as suicide eliminates our personal freedom once and for all? If our ability to freely make choices is among the highest of our human faculties, isn’t it a radical contradiction to mount an attack on that autonomy through suicidal acts? Isn’t there a certain absurdity to marshaling our freedom to obliterate our freedom?
 
Autonomy is often described as being able to do what we want, being “self-governing” and “self-directing.” Authentic freedom, though, doesn’t actually mean the ability to do whatever we want; it means the ability to do what we ought, in accord with who we are. To grow in freedom and autonomy means acting in such a way that we attend to, and respect the designs written into our nature. Otherwise, autonomy collapses into a caricature of its real meaning, or worse, into raw violence and forcefulness against ourselves or others.
 
We can consider a simple example: exercising autonomy with respect to our car doesn’t mean doing whatever we want with it, like pouring milk in the gas tank, and orange juice in the oil reservoir. If we intentionally sideswipe other vehicles as we drive along, and strike pedestrians on the sidewalk, these would be acts of violence, not acts of “autonomy” or “free choice.” Authentic freedom with an automobile implies using it in an ordered way to get from A to B, driving safely and legally, and even doing the right maintenance and upkeep on it, maintaining respect for the way the vehicle was designed and intended to be used.
 
Freedom and autonomy regarding what we eat and drink, to consider another example, doesn’t mean we can consume anything at all. We can legitimately choose between apples and oranges, but not between milk and drain cleaner. If, in the name of autonomy, we were to declare that we’re free to do whatever we want with our bodies, and we ingested drain cleaner on purpose to make ourselves ill, we would actually undermine and surrender our personal autonomy. We would no longer be able to do what we might wish to do, as our body rebelled and constrained us to a stretcher on our way to the emergency room or poison control center.
 
Looking at a misguided choice of this kind reminds us how our autonomy is never absolute. This kind of choice would also raise doubts in the minds of those who cared about us regarding our mental and moral sanity. To deem self-inflicted sickness to be desirable would itself be a sickness, a kind of lie, spoken in the name of a perverted sense of being free to do whatever I want, even to the point of self-harm or self-annihilation.
 
The decision to intentionally end our own life by an act of suicide (whether alone or with the assistance of others) pivots our uniquely human power to make sound choices into a seditious power directed against our own good.  To self-inflict death in collusion with a physician would constitute a profoundly disordered decision, and a radically corrosive attack on our autonomy. Rather than something dignified, this abuse of freedom is ethically indefensible.
 
If sane people can recognize that drinking poison to get ourselves sick is wrong, how can we feign that ingesting drugs or using other means to kill ourselves is somehow right and noble? Abusing our own freedom or autonomy isn’t free or autonomous; instead, it enslaves and diminishes us. When medical professionals pivot in their role of healing and curing, and instead become accomplices in terminating the sick and vulnerable, they, too, undermine their own autonomy and corrupt their own professional freedom to genuinely care and “first do no harm.”
 
True autonomy is not limitless or absolute, but is necessarily conditioned by the truth of who we are and the way we function. Properly exercised, our personal freedom manifests a genuine nobility, and a real dignity. We should never will that our final “autonomous choice” be directed against that noble dignity. Rather, we must flee the tyranny of false autonomy if our lives are to be authentically marked by human freedom in its full splendor.
 
        
 
Rev. Tadeusz Pacholczyk, Ph.D. earned his doctorate in neuroscience from Yale and did post-doctoral work at Harvard. He is a priest of the diocese of Fall River, MA, and serves as the Director of Education at The National Catholic Bioethics Center in Philadelphia. See www.ncbcenter.org
 

When Is It a Sin to Make a Referral?
                                                        
 By Father Tadeusz Pacholczyk
 
During World War II, if a contractor had been asked to construct a building knowing that it would serve as a gas chamber in Auschwitz, it goes without saying that he ought not agree to do it. By laying the foundation and supervising the plumbing, electrical and duct work, he would be contributing to, or enabling, the subsequent commission of atrocities against prisoners in the concentration camp.
 
But significant concerns would also arise if he were to reply: “I’m sorry, I have a moral objection to building this structure, but let me put in a call to a colleague who is a contractor, and he will do it for you.” By placing the call, he would still be a part of the causal chain leading to the building of the facility, and to the subsequent evils that would be carried out in it. By making a referral to engage someone else’s services for something immoral, we can still be involved in, and responsible for, the commission of grave evils.
 
Among medical professionals, situations can likewise arise in which they may be tempted to make a referral for an immoral procedure, supposing that because they are not doing the procedure themselves, they are now morally “in the clear.”
 
For example, a pharmacist who lives and works in a state or jurisdiction where physician-assisted suicide has been legalized may be asked to fill a prescription for suicide pills. By declining to fill that prescription, he or she avoids immediately cooperating with a customer’s immoral decision to commit suicide. But it would still raise moral concerns if the pharmacist said to the customer: “Let me pass this prescription to my co-worker, because, although I cannot fill it, he can help you out.” The first pharmacist remains a contributor in the chain of events leading up to the carrying out of the evil act, and he would be cooperating in evil by making the referral to his co-worker.
 
A “referral” in moral terms is when the person who refuses to do the immoral procedure himself or herself directs the requesting person to another individual or institution because the other individual or institution is known or believed to be willing to provide the immoral procedure in question. The decision to offer the referral indicates that the one doing it is choosing, at least implicitly, to help the requester carry out the evil act, and such implicit willing of evil acts can never be morally acceptable.
 
Making a referral can also convey a sense of tacit acceptance and approval of that evil, and therefore the referring provider can also become guilty of wrongdoing by giving scandal. Someone who gives scandal helps to form the immoral will of another. In fact, the term “scandal” in theology refers to any action, word or deed that leads another to sin.
 
Of course, a pharmacist could simply decline to fill a suicide pill prescription. He may have to pay the consequences for his refusal, but it certainly would be a valid and courageous option for him to give witness to the injustice of assisted suicide laws. But that may not be the only way to approach the situation. A conscientious pharmacist could also say to the customer, "There may be other pharmacies around here that can assist you,” or even, “there may be others working at this pharmacy who can assist you," and leave it at that. This would not be a referral, but a simple statement regarding commonly available public knowledge. The pharmacist could then return the prescription to the customer, rather than passing it to a co-worker, and the customer would then have to initiate a new "causal chain" or series of choices as he or she seeks to obtain the immoral medications, looking around and inquiring about who might fill the prescription. This removes the original pharmacist from the causal chain, avoids making a referral to a colleague, and diminishes or eliminates responsibility for any subsequent evils that the customer may end up committing.
 
Regrettably, pharmacists and other health care professionals today are coming under increasing fire from the culture around them as they are being told, as part of their job description, that they have to ignore their well-formed consciences and fill prescriptions for suicide pills, the abortion pill or contraception. Yet a double-standard is clearly at work, for if the prescription were for something a pharmacist knew would be used as a date rape drug to take advantage of a woman at a party, everyone would declare the pharmacist to be a moral hero for refusing.
 
To sum up, then, a great deal of care, vigilance and determination is needed not only for us to avoid committing certain evils, but also to avoid making a referral for those evils to be carried out by others.
        
 
– Rev. Tadeusz Pacholczyk, Ph.D. earned his doctorate in neuroscience from Yale and did post-doctoral work at Harvard. He is a priest of the diocese of Fall River, MA, and serves as the Director of Education at The National Catholic Bioethics Center in Philadelphia. See www.ncbcenter.org