Hospice Patients Alliance: Patient Advocates




Man in the World




(Part of the Ethics of Life Series)



by Ron Panzer

April 17, 2013

Part Six of Ten



The Law of Double Effect


The humble and honorable man rejects the ways of the culture of death and seeks to find the right way. Yet, even when we are motivated to act mercifully, justly and faithfully, there are still situations where we may not be sure what we should do. There are different possibilities, choices we can make, and there are often other, even undesirable, consequences arising from any of our possible actions.

In other words, for many actions in the world, there is more than one effect or consequence — there is a "double effect." This is not really as complicated as it might appear, and the process of considering those other consequences is something that is done all the time, even by children. Children may consider, "If I steal this candy, I will be able to eat and enjoy it (the primary intended goal)." Yet, "if I get caught, I will be punished (the second unintended effect)." They will then choose whether to steal the candy or not.

Of course, this is just an illustration. In many cases, we can get right to the heart of the matter by using the Moral Imperative: "Do good. Avoid evil." In those cases, we already know what act is moral. The Law of Double Effect should only be used when it is unclear what act is really good to do, and what act is wrong to do.

Physicians often face difficult decisions in the real-life healthcare setting. They may consider whether to act one way or the other, and to accept an undesirable consequence or not. When there are such other consequences that arise from a contemplated action in healthcare or elsewhere in society, the law of double effect (or "principle of double effect") is a helpful tool to analyze the situation and to provide guidance. It states that:

  • "The act to be done must be good in itself or at least, neither good or bad."
  • "The evil effect must not be intended for itself but only permitted as an accidental by-product of the act performed."
  • "The good [or goal of what is] intended must not be obtained by means of the evil effect."
  • "There must be a reasonably grave reason for permitting the evil effect."1
  • Briefly, the first part of the principle of double effect reminds us that the moral imperative must be followed. "Do good. Avoid evil." The second and third parts again remind us of the moral imperative with regard to the effect of our action: we can't willingly intend that a harmful effect occur and we must not achieve our goal (the good) by doing something we know to be wrong. This has been popularized in the maxim: "The ends" do not justify the "means!" Even then, sometimes a truly unintended consequence occurs.

    It should be pointed out that the law of double effect is not, as some suggest, "maximizing the good"2 while "minimizing the harmful," as if we are weighing proportionate "goods" and "evils." There are some actions that are always wrong that must not be done, ever. We must always consider what kind of action we intend to do — that it is good and not evil.

    In the case of the child contemplating the theft of candy, the moral imperative immediately shows us that the act is not to be done. The act of stealing is itself wrong to do, i.e., immoral, and as a means to the end of obtaining candy is not permitted to achieve that good. Another example: In order to save their child, parents may choose to send a drug-addicted teenage son to a rehabilitation center. The temporary deprivation of family life might be considered an acceptable unintended consequence, a double effect.

    In the case of abortion, the moral law shows us that we may never directly and intentionally kill an innocent unborn child for any reason, under any circumstances. We already know that to kill is wrong, but what if we're thinking about ourselves only?

    We may think, "I can't have a child! It will ruin my plans and my life!" and consider medically-killing our unborn child in order to assure our idea of a perfect future. We intend the good: the lifestyle we had planned with no child at this time. The means used to secure that goal is wrong — we have to kill our child to achieve it! The law of double effect shows us that we cannot morally do it.

    Also, we need to consider that we don't know that it will ruin our lives. God may have another plan for us, a wonderful plan that includes keeping the child and making a life together, or, having the child and allowing those who desperately want a child to have him to love through adoption. Here, a great good comes out of a much better choice!

    If we keep the child, we must remember that we never know what will come in this life, but God does! We need to trust in Him rather than taking things into our own hands in a way that harms others or ourselves, or actually kills another human being.

    A common example demonstrates how the principle of double effect is applied in a healthcare setting: a surgeon, for example, can perform surgery on a mother to remove a cancerous lesion, even though there is some chance that the unborn child would suffer death as an unintended consequence (the second or "double" effect). The first effect is to save the life of the mother.

    The act of performing an abortion is in itself evil and can never morally be directly willed; the act of performing surgery to save the life of the mother is not. Here we can see that following the natural moral law and acting to care for the mother leads to fulfillment of the ethics of life and maintains reverence for life.

    What about artificially cloning humans3 or creating them from artificially-formed sperm and oocytes derived from other cells? Parents may have lost a child or be unable to have another child for some reason, and scientists could offer them a child.

    We might be tempted to condone cloning or other artificial reproductive techniques out of compassion for the parents. We might conclude that having another child or curing a disease through human cloning is "good." Yet, the moral imperative tells us that an evil can never be chosen so that a good consequence might result. Human cloning is an intrinsic evil that can never be directly willed.

    The procreation of children is intended by God to occur through the sexual union of husband and wife within the marriage covenant, not through a surrogate, and not through a genetically-manipulated clone inserted into the womb of the mother, another woman, or even an artificial womb possibly developed in the future. What happens when a clone is "created?"

    The sanctity of marriage and the sexual union of husband and wife are separated from their intended purpose: the creation of new unique life, the strengthening of the marriage bond, the expression of love between husband and wife, the strengthening of the family bond, the promotion of the culture of life and the cultivation of faith in God.

    With cloning and artificial techniques for creating sperm and oocytes used to create human beings, marriage is likely to eventually become a dispensable institution, since man as scientist can manipulate already living cells and genetic material to "create" life however he chooses.

    The artificially-created lives, first known as embryonic humans, are disposable, and are certain in many cases to be discarded and thereby killed. We can therefore justly argue that the act of cloning is intrinsically evil. Even if we were to argue that the intended consequence is good, i.e., the intention is "good," the kind of act performed is evil and thus can never be done.

    Why evil? The act itself violates the divine and the natural moral law, and diminishes the sanctity of marriage and family. The means are not good as well: as a means to accomplish cloning, it is certain that innocent human beings in embryonic form will be created and some killed, which is always evil. As we are reminded in the law of double effect: according to the moral imperative, we cannot use evil means to achieve a good end: it is never morally justifiable to intentionally kill one innocent human to save another.

    In addition, research cloning will inevitably lead to the cloning of humans for actual life in this world. Would such clones be patentable and "owned" by those who "created" them? We know that corporations whose scientists created genetically-modified seeds and organisms have patented their creations and fought in court to preserve those patents. Any corporation that spent millions of dollars to clone humans would certainly patent their creations.

    What rights would such clones have as patented humans? Would they have any rights at all? Would they be used as victim-slaves used to produce medicines or for involuntary research as clone-children or clone-adults? Would they be subject to execution any time the corporate leaders decided they were no longer useful? Would they be used in human trafficking for forced prostitution or for slave labor?

    The answer is very likely,"Yes!" as some of these types of terrible situations are already being reported as happening to people in various parts of the world. Would cloned humans be forced into military service as soldiers in the military? Would they be allowed to grow into children or adults in laboratory prisons and then have their organs harvested for transplant, thereby killing them? Many scientists who have no respect for the divine and the natural moral law today would ask, "Why not?"

    Utilitarians attempt to "justify" it by suggesting "it is for the greater good of society." Hitler and the National Socialists ("Nazis") "justified" what they did in exactly the same way! No matter how much they assert their misconceptions, the evil of what they do remains. We know that using and exploiting human lives as a means to achieve other ends is wrong.

    It is obviously wrong to anyone who recognizes the natural moral law and thinks about it carefully. The basic human right to freedom demands that we not do these things. The principle of justice demands that such human beings not be so horrifically mistreated. The divine and the natural moral law always address what is just for the individual as well as for society as a whole.

    For these and so many other reasons, many have urged the banning of human cloning on the basis that it is intrinsically evil. Even if we were to put aside these objections to cloning and artificially-creating human life, the principle of justice demands that we not do these things. Children have a human right to have a mother and father and to be raised in a family. This is the natural order of things.

    We already know that those children who are deprived of a mother or father or family are scarred and wounded in a way that affects them for the rest of their lives. We can readily foresee that artificially-created humans would, in many scenarios that may arise, be deprived of mother and father as well as family.

    While we recognize that scientific advancement is wonderful and admirable, certain acts simply should never be done. In the case of those humans created in these artificial ways, we can ask, "Who are the parents?" "Who will raise them?" "Will they be raised in state facilities or labs?" "Will the newly produced humans be educated in the way of life, introduced to the divine and the natural moral law, to God, or to the Holy Scriptures?" The answer is almost certainly, "No, they will not."

    What about those original "justifications" for artificially creating life? Men and women want children, but may not be able to procreate naturally. There are an estimated 143 million orphaned children in the world today!4 Should anyone desire to experience a family and parenthood, yet be unable to procreate? Adopt, serve, love!

    Out of the suffering of both those who seek children to establish family life and those who have no parents, in God's way of doing things, arises joy and love. What a blessing those who seek to have a family can bring to those who are all alone! The act is good, the means are good, and there are no evil effects. This is the way of life.

    What about the tainting of vaccines? The cascade of evil arising from evil is already demonstrated with abortion: legal abortion allowed for the availability of the fetal tissue used in research and in vaccine production. Those dead babies provided fetal tissue cell-lines being used today as media to grow the viruses used in vaccines today. It is possible that tiny amounts of genetic material from the fetal cell lines used may be part of the vaccines eventually injected into your body or your children's bodies, without your knowledge!

    It may surprise many that media developed from aborted human or animal fetal cells has been and is being used in vaccines5 manufactured to combat various diseases. As of 2011, the most widely-used Polio, MMR, Varicella and Chickenpox, Hepatitis A, Rabies, and Shingles vaccines are developed using media from aborted fetal cell lines.

    Applying the principle that the end does not justify the means, again we can see that preventing terrible illnesses is a lofty goal, but using tissue from aborted fetuses to accomplish that goal is immoral, as abortion itself is intrinsically evil: "you shall not murder." The use of aborted fetal cells in the media to grow vaccines is not only prohibited under the divine and the natural moral law, but is unnecessary to accomplish the goal, as other materials are available to be used as media for the vaccines.

    Some smaller vaccine manufacturers are not using tissue from aborted fetal human beings or animals in their vaccines, and they were not used decades earlier. Why manufacturers are using media derived from fetal cells is understandable when we recognize that these cells contain genetic material that is certain to affect those vaccinated. What their intent is, is not yet known to the general public. Although harmful effects are being reported, there is an ongoing effort to suppress this data.6

    What about those who seek to "improve mankind" through genetic-engineering? We might be tempted to think this is good. However, even though the intent may sound good, the means used are immoral. As is the case in cloning, innumerable embryos will be used, experimented upon, and then will certainly be killed as scientists try and try again to find just the "right" genetic mutation to introduce in their quest to "create" the perfect "man" (as they define "perfect").

    The moral law clearly shows that to knowingly commit evil and murder a human being in order to achieve a good, however lofty, is immoral. We must be honest with ourselves and accept long-established scientific facts. We must remember that whether sexually or asexually created, the tiniest embryo at the earliest stage of life is a human life, a human being, just the same as you and I once were when we first began to exist.

    All human embryos produce "specifically human7 enzymes and proteins ...specifically human tissues and organ systems," and therefore are clearly human life! The embryo that you and I once were had the unique nature of a human being, developing as no other living animal develops!

    In the case of those transhumanists and futurists who seek to remake man using biotechnology, nanotechnology, supercomputers and genetic engineering, we can understand that what they are doing is completely immoral and wrong. The assumption that man, as God physically created him, is what needs changing is completely mistaken. Secondly, there is no understanding that man needs to change inside and is already equipped with what he needs to change inside: his power of reason, his mind, his heart, and his free will.

    In addition, the transhumanist initiatives will be used by those whose intentions themselves are not moral. Scientists are already experimenting in altering the genetic makeup of animals and man, and have done so. Creating the "perfect soldier" or killing machine is one suggested goal: a man or woman with little hesitation to kill, with heightened physical and mental abilities, speed, strength, endurance, and a diminished sense of conscience to allow them to coldly obey possibly evil orders from military superiors.

    In some cases, the goal may be evil; the means may be evil and the result evil! When man is no longer "man" as God created him, when man no longer has a God-given conscience, then he becomes something else, something other than "man." What will such individual humanoid creatures do then? How would they interact with actual human beings? Could they co-exist peacefully with mankind or would strife break out between actual human beings and the new genetically-engineered humanoids?

    In addition, all laws that speak to protecting "human" rights become null and void with respect to those individual humanoids that are no longer truly part of the human species. Cloned or genetically-engineered and altered "humans" may fall into this class of human-like creatures that are no longer protected by law and are used and exploited for evil purposes. This alone would preclude moral and prudent individuals from pursuing this research and technology. However, those who are pursuing it have no respect for the divine and the natural moral law.

    In those situations where there is more than one effect of a particular act, the application of the law of double effect does clarify which act is good and which is to be avoided. However, it only clarifies these for those who are intellectually honest in their pursuit of actual good. Those who are bent upon a culture of death agenda, who choose to do harm for one purpose or another, whether or not it is found to be "ethical," will misuse the law of double effect to "justify" doing harm. In so doing, they attempt to make themselves appear to be acting morally. They ignore the precautionary principle and plunge ahead recklessly to achieve their utopia, or profit, endangering all in their path.

    The consciously active participants in the culture of death who willingly do evil hide behind the pretense of seeking to do the good, while intending harm all along, either in the means used or the end goal sought, or both. They will say that they find "complexity" in a situation when there is no complexity. They will say that they find confusion when there is none, and mislead others so that they also go astray and harm others (John 8:42-44; 1 Corinthians 14:33).

    In the culture of death form of end-of-life care, those who seek to impose death without openly admitting what they are doing are known to misuse the law of double effect:

    • They say that "the patient had terrible pain," that "relieving pain is good,"
    • Or that "increasing the dose of pain medication is therefore good."
    • They state that they "only intend to relieve pain" when they drastically increase
      the dose of opioid medications like morphine and fentanyl, but the patient without fail
      dies shortly thereafter supposedly as "an unintended consequence."
    • They say, "We are letting the patient go. It was his time."
    • They pretend that they "only intend to do good."

    Really? The reality is that they routinely lie.

    That lie is exposed when it is observed that in many cases, the patient had no clinical need for a drastic increase in pain medications or that the dose of opioids was recklessly increased beyond the guidelines for safely adjusting that dose (standards of care for titration). When those who seek to impose death misuse the law of double effect, they only use it to deceive others and hide what they have done. Therefore, their actions that impose death are called stealth euthanasia. They actually intend to impose death.

    The law of double effect requires honest deliberation and the actual intent to do no harm in order to assure the ethical choice. In pro-life hospice and palliative care, medications are carefully administered and adjusted within the standards of care for titration of that dosage, as actually needed for the patient's individual and unique clinical condition. If dosages are increased, it is because the patient truly needs more medication to control a symptom.

    The actions in a pro-life facility are right because they honor the life of the patient and respect the sanctity of life. The means used are right, and death is never imposed artificially. The intent is good, because it remains true to the original pro-life mission of hospice and palliative care: to relieve suffering while making the best effort to avoid harm to the patient!

    The Precautionary Principle


    There are times when we really do not know what the results of our actions may be, and in many instances, in healthcare especially, there are risks that sometimes must be taken. We may believe we are acting for the good, hoping that good arises from our actions. The moral law shows us that we may not intentionally, knowingly do evil or a harmful act, and we may not do an evil in order to achieve a good.

    What if we intend good and the acts we do are not directly causing harm now and we don't know what the results may be in the future? Can we do them? The "Precautionary Principle" would guide us to avoid performing acts that are likely to cause great harm, or that we have good reason to believe might cause great harm.

    For example, in cooler areas of the world, a child running onto the ice in winter to play might simply have a great time playing with others on that ice. On the other hand, if it is early or late in the winter season, the ice may be quite thin, and the child may fall into the ice and possibly die. Like a mother advises her children, "Don't go asking for trouble!" "Use common sense!" The authorities might issue safety guidelines advising, "Don't go onto the ice unless it is at least 4 inches thick!" Even then, it may not be safe.

    In medicine and healthcare, these guidelines for safe practice are called standards of care. They are the regulations that govern how healthcare is delivered. Standards of care may be set forth in state administrative law, in professional standards from the respective healthcare professional boards, or as internal standards of care in each agency and facility.

    Laws are created in various ways: through a legislative body, as a decree from a monarch (or dictator), as case law arising from a court's ruling, and as administrative law issued by those in the executive branch of government. The standards of care issued by a healthcare professional board have the effect of law because law governing licensed professionals require them to adhere to their respective professions' standards of care. The standards of care serve to prevent harmful action and promote helpful actions that are likely to protect the health and well-being of the patients, as well as all who serve.

    In medicine, we must follow the standards of care to assure safe treatment for our patients. If we wish to experiment to find a cure for a disease, again, we must follow the standards based upon ethical principles that reflect the divine law, the natural moral law and avoid harm.

    Can we, as the National Socialists ("Nazis") did8 so long ago, inject individuals with any number of medications simply to see if any one of them cures that disease? If we have no reason to believe the medication is helpful, if there has been no prior experience with that medication, we cannot, because it is quite reasonable to believe the medication might actually harm the patient.

    Even though we seek a good, a cure for a disease, we cannot do something that might be harmful and is likely to be harmful. When they are unwilling, we absolutely cannot! Can we, as the Nazis did, inject innocent civilians with various diseases or even harmful substances to study what happens in their condition? Certainly not.

    "The precautionary principle9 asserts that the burden of proof for potentially harmful actions ... rests on the assurance of safety and that when there are threats of serious damage, scientific uncertainty must be resolved in favor of prevention."

    The need for the precautionary principle is portrayed in the ancient Greek story of Pandora's Box (or "jar"). There are some actions that are so likely to cause harm, we must never do them. The box given to Pandora, though entrancingly mysterious and beautiful, and promised to contain "gifts from the gods," contained something that was still not known by man. It was decreed by "the gods" that it was never to be opened!

    Imagine having been given a beautiful gift that you would never open. Some could withstand the force of their curiosity and leave the box alone. However, being imperfect, some man would eventually succumb to his pride and curiosity and, like Pandora, open the box. We would then have released what it actually contained: all the evils of the world such as disease, famine, and all forms of suffering that spread across the world.

    Man does many forbidden things that he knows are likely to or might bring harm. He might as a child go out onto the ice to see what happens. As a teenager, he might drive 100 mph to see how the car handles or just to have fun, only to land in a ditch. As a physician, he might try a new drug or treatment on a patient without adequate research.

    The Holy Bible contains the story of Adam and Eve who were told they could eat of so many fruits in the garden, but were told not to do one thing: eat of the tree of the knowledge of "good and evil," the Tree of Death. However, they could not resist the possibility of "becoming like God." They wanted to see what happened. They disobeyed and did the one thing, the only thing, they were told not to do.

    Sumatra Tiger - courtesy of Wikimedia Commons photo by Dick Mudde
                "Sumatra Tiger - courtesy Wikimedia Commons

    We recklessly disregard all the warnings and court danger like a hungry tiger that seduces us with its beauty and apparent harmlessness. We open the gate releasing that danger and only too late do we recognize it for what it is: death. But if we meditate upon and follow His law, we are enabled to find a way to resist and through grace vanquish that danger (Psalm 119).

    Yes, some acts are simply not to be done, ever! Even though we are curious and hopeful that good will arise from these actions, some acts are to be avoided, and we are to actually restrain ourselves and others from doing them. This is the intent of law and the standards within our field: to promote and preserve the good.

    Yet, all sorts of experimentation under the guise of "progress" are being conducted that is quite harmful. Scientists are experimenting upon the public without their permission or knowledge.

    The precautionary principle demands that for the safety of the people, i.e., to prevent harm, all experiments should be contained in a controlled environment while the principle of informed consent demands that such experiments only involve those who know the risks involved and voluntarily agree to participate.

    With the quest for immense profit guiding decision-making in the pharmaceutical industry, some corporate leaders have placed medications on the market without adequate testing10 (or after suppressing the release of research that concluded the medications were not safe). The medications are marketed to the physicians who prescribe them, and the effects on the patients are observed, sometimes resulting in the deaths of thousands.11

    In other words, some medications' efficacy and safety are only known after the public is unwittingly experimented upon, or after the pharmaceutical industry has reaped billions in profit, resulting in the recall and removal from the market of those medications that prove to be unsafe at any dose.

    Ethical principles set forth in the standards for each industry and profession, demand that any potential, even unknown effects of the experiment must be likewise containable and capable of being controlled, and any harmful products destroyed, so that no harm is done to the public. Disgracefully, these most basic ethical principles, part of the Precautionary Principle, are not being followed at all in many modern scientific, medical and technological experiments and initiatives.

    As a consequence, terrible harm is being done to people, animals and the environment. For example, many experimental, genetically-engineered organisms and food crops have been released into the world at large by the manufacturers such as Monsanto, Dow, DuPont, Bayer and BASF, with sometimes even lethal effects.12

    What is clear to anyone who understands the basics of biology and ecology is the impossibility of testing for all the actually possible consequences of changing the basic genetic makeup of a living organism: plant, animal, or even human. Up till this time, God and the Nature He created have worked out the genetic makeup of each living being, arriving at a perfect ecological balance with all other living things.

    When different types of individuals within one species (like different types of dogs) mate and reproduce, the results are still within the natural order of things — time-tested and safe. When different types of plants within one species are cross-pollinated to get a better type of plant, for food, for example, that again is time-tested and safe.

    However, when man changes a gene in a living being as he is doing today, often having no idea what the result will be, there is no way to know what effect that will have under an infinite variety of varying conditions in this world. Any one gene, or part of a gene, has multiple functions, many of which are not yet known. When he inserts genetic material from other species into a living organism, as is being done today, he creates "chimeras," beings that share characteristics of more than one species, that have never existed before!13

    Changing one or more genes or portions of a gene to make an animal taller, stronger, to produce more milk or even to produce a vaccine in its milk,14 may seem to be worthy goals, and man is doing all of these today. Yet, the precautionary principle tells us that there is potentially terrible harm that may arise, and that once released into the world, is not containable or predictable.

    Man is "playing with fire," as many scientists are warning that we really do not know the consequences of these experiments in the world at large. Although proud man laughs at such warnings, man is sure to be "burned" eventually when he continues on an unethical and reckless path.

    In ethical scientific investigations and research, the precautionary principle and others guide ethical and safe progress. In the fields of service, the standards of care spell out how ethical action is to be accomplished in the missions we serve, whether in patient care or any other praiseworthy setting.

    Just as the divine law exists within God's infinite being, true ethics, the ethics of life, are meant to live within man, serving as an actual restraint to doing harm.

    If they do not live within man, but are merely written down and not adhered to, they have no effect on man's conduct. Man becomes a lawless savage, capable of much greater harm than any beast of the fields! Violation of the ethics of life is the basis for the culture of death, and in healthcare, it is the basis for the exploitation and medical killing of the vulnerable.

    Prudence


    The Precautionary Principle is, upon reflection, a part of a timeless concept, "prudence," a virtue that has been to a great extent disregarded for decades in society and particularly in the realms of scientific, technological and even medical circles. Prudence implies practical wisdom in how we conduct ourselves in life. It implies that man has the habitual knowledge of how to act rightly. Prudence perfects our reasoning ability.15

    Other cardinal virtues such as justice, fortitude and temperance arise out of prudence — in knowing how we may rightly conduct different aspects of our lives. Without prudence, right action in the world is impossible, because without prudence there is no right reason to govern our actions in this world (Proverbs 2:1-11).

    Having prudence16 implies that, in our assessment of a situation, we accurately perceive the reality of the situation confronting us, that our mental image of it is "true to being." It implies that we actually seek to properly understand it without jumping to inaccurate conclusions through bias, preconceptions, or our desires, that would distort our understanding. It implies that we are then able to quickly and rightly respond to the unexpected situations that necessarily arise in life.

    A champion chess player is able to foresee, to anticipate, the moves of his opponent in response to his own moves, even several moves ahead, and to then choose the moves that lead to victory. Prudence enables us in just this same way to have the foresight to know which of various available courses of action will likely lead to good or to harm, even years later. It guides us to rightly arrange our actions so that we successfully achieve our purpose in acting, and more essentially, in living.

    Prudence implies caution when confronted with possible or likely harm, but is not cowardice that would prevent us from acting. Prudence allows man to see the long-range consequences of his actions and how those actions would affect the ultimate good he seeks. It is what guides a general to carefully make his battle plans and then courageously enter into a battle to defend his people. Prudence is what guides a fire chief to make sure all firemen are properly trained and equipped with the necessary equipment to stay safe during a rescue.

    In health care, prudence guides health care professionals to act wisely and properly, sometimes immediately, in order to heal and save. Prudence helps them to take calculated yet reasonable risks at the patient's request to achieve the goal. Prudence guides the physician to double-check his evidence, consider all the possibilities, consult with other physicians as needed to be sure before pronouncing a diagnosis and determining a treatment plan.

    Prudence in medicine implies that physicians and all healthcare professionals follow accepted standards of care based upon sound medical science, acting in a timely and effective manner, without, on the one hand, being reckless, or on the other hand, being incapable of acting. Prudence encourages man to act with precision and care so that scientific or medical research is accurate and its results true.

    However, man is imperfect and certain to make mistakes unintentionally. How can we assure perfect action in an imperfect world, especially when lives depend upon it? We cannot assure perfection, but we can strive to achieve higher compliance with the standards of care. Prudence on the part of every participant in the healthcare system promotes that compliance, and therefore, promotes the safety of the patient and the healthcare workers.

    Prudence guides a nurse administering a medication to check, double-check, and then check once more that the correct medication is given to the right patient, in the right dose, at the right time, through the correct route or method (oral, intravenous, topical, or other). Prudence is what makes a physician great among seemingly more intelligent but reckless and arrogant peers.

    Imprudence in action is to do what should not be done. In healthcare, this is dangerous and sometimes lethal. When it occurs, we fail to give careful attention to the details of our work or completely fail to do what is needed to be done; this is negligence.

    Whether it is diligently paying attention to details in how we care for a patient, or in making sure a car is properly repaired so that it is safe, or in manufacturing materials that people will trust their lives to when they use them in this world, acting with prudence makes the difference between life and death, safety and danger, and being worthy of our trust, or not.

    When we consider that many patients are either partially or completely dependent upon the healthcare professionals serving them, completely neglecting to do what needs to be done harms our patients. Negligence in serving those in need is a betrayal of the trust patients place in the healthcare professional. They trust that all acts will be done rightly, i.e., prudently.

    It is clear that to be prudent, one must be humble enough to recognize one's own human limitations, receive feedback from those who would correct, and then strive to overcome them through patience, study, education and training. In other words, healthcare professionals cannot afford to be offended when they are corrected by those training them or giving them feedback. In healthcare, there is no place for an arrogance that prevents us from listening sincerely to others and improving what we are doing.

    To be prudent, one must persevere in the face of obstacles to success, and yes, pray. Whether acting in service to others or with regard to one's own personal life and family, prudence is essential. Prudence gives rise to purity in action, cleanliness in technique, and innocence and sincerity in motivation.

    In 1847, Hungarian physician, Ignaz Semmelweis,17 worked to reduce the rate of puerperal (childbirth) fever and death, and prudently introduced new antiseptic procedures requiring cleanliness on the part of all healthcare workers, especially the physicians who were not properly washing their hands. He reduced the rate of mortality from between 10-35% down to less than 1%, saving many women's lives. However, narrow-minded physicians of his time did not accept his conclusions, ignored his work and ridiculed him.

    Florence Nightingale, working with patients during the Crimean War in 1854, also observed that many patients were dying from infection (rather than battle wounds in this case), and prudently instituted improvements in sanitation, nutrition, hygiene, and even ventilation, saving thousands. Her insights and innovations have been applied in hospitals and clinics throughout the world.

    Her use of statistical analysis for quality improvement in health care is another major contribution to modern medicine, health care and applied statistics used in many fields. She created visual graphics (now known as "pie charts") to make vital statistics more comprehensible which helped to assure her recommendations were followed.

    Nightingale began the first modern school of nursing, wrote Notes on Nursing, What It Is and What It Is Not,18 a manual of nursing, created standards of professional care, and contributed in many other invaluable ways to the well-being of society. She was a brilliant thinker, statistician19 and societal leader. When it is so clear that a great heroine like Nightingale cherished life and made her innovations in order to protect life, why do modern-day nurses and physicians think it acceptable to impose death upon the vulnerable and those in need?

    In her Notes on Nursing, she emphasized several reforms that the male physicians of her time had completely ignored, yet she proved they were vital to the patient's survival. This is an example where a professional nurse with a "woman's insightful perspective" made all the difference. Her innovations demonstrating prudence in action, the right way of managing healthcare settings and the patients, have saved millions of lives!

    Following the earlier work of Semmelweis, Nightingale and others, Joseph Lister,20 a British surgeon, introduced the idea of antiseptic surgical technique in 1867, reforming the standards of care so that cleanliness, and the washing of wounds with dilute solution of carbolic acid to disinfect them drastically reduced the rate of infection. Because of the work of Louis Pasteur demonstrating the link between the presence of microscopic bacteria and disease, physicians and scientists were finally able to accept the reforms and implement them.

    Physicians who ignored Ignaz Semmelweis and Nightingale were wrong. Where she was placed in charge of the wards, the infection rates dropped. Yet, even today, more than one hundred years after Nightingale and Lister, with "more than 1.5 million nosocomial [hospital-acquired] infections" each year, "studies show that less than 50% of health care employees wash their hands as frequently and thoroughly as they should."21

    Surgery, medications, and other treatments are needed, but the entire environment and management of the patient matter just as much, for the patient will die if either is not provided. Physicians without nurses cannot maintain a hospital or promote the healing of patients, and nurses without physicians cannot do so either.

    Just as absolute purity in the chemicals used and how all of them are combined in any intended chemical reaction is essential to assure the desired and accurate results, a medication's absolute purity is required for a medication to be safely administered to a patient and to assure its efficacy. Purity in technique, cleanliness, even sterile technique in many procedures, is also essential within the healthcare setting.

    Prudence guides man to be precise in what he does, to act lovingly, skillfully, and to use technique that achieves the goal of his work. Prudence makes man succeed in doing the best he can do, whatever work he sets himself to accomplish.

    Nightingale instituted prudent improvements to assure proper ventilation and housing temperature control, assessed and reformed the complete facility physical environment, the administrative management of the facilities, the reduction of disturbing noises, the provision of a variety of pleasant sights and input to the patient to improve the patients' psychological mood.

    She made sure that attention was given to assure the provision of healthy nutritional meals, proper bed and bedding, the provision of light (rather than keeping patients in dark rooms), cleanliness of rooms, walls and hygiene of patients as well as health care professionals. She initiated an understanding of rehabilitative work undertaken by patients as their abilities allowed, to encourage their progress.

    She began the modern quality improvement efforts in health care by emphasizing the need for very careful observation and assessment of the patient's condition, as well as the use of statistical analysis to understand what methods are most effective in all niches of healthcare. In other words, Nightingale looked at the whole person, the whole environment, arranging everything, ordering everything so that it contributed to the healing of the patient. That is the practical application of the moral law to the health care setting!

    All who serve the public need to take a moment and remember great leaders like Florence Nightingale and others, who brought great enthusiasm and dedication to the mission, and perseverance in the face of difficulty. She, as we all must, safeguarded the lives of the patients in the hospitals and healthcare facilities of her time, yet her suggestions have led to innumerable standards of care still being applied today.

    Those who have served the public for many years need to remember what it was like to graduate from school and newly enter the field of service. Like Nightingale, we need to remember the enthusiasm and dedication that motivates those who are called to serve. What a healthy pride we may know after having worked so hard and well to accomplish our goal, and prepare ourselves to know how to rightly act in our field and to begin the wonderful mission we are called to serve! It is prudence that impels our will to carry out the right so that good is actually done.

    Prudence may be considered the mother of the other virtues since it impels man to do all things in the right way according to the natural moral law. Prudence gives man the ability to see what will truly result from his actions, and allows him to see the harm that always does, and will, arise from acting contrary to the divine and the natural moral law.

    According to Plato, Socrates taught that whoever knows what is good, will also do what is right. Yet, Aristotle correctly replied to that assertion and said that due to "moral weakness," a man may do "what he knows to be wrong."22 Clearly, we see this all the time in our own lives as well as in the lives of others all around us. St. Thomas Aquinas pointed out that through grace, the virtues are infused into man, and then such a sanctified soul is enabled to more completely do what is right (Matthew 5:48, John 17).

    True prudence, as a grace from God, makes man so extremely aware of the price to be paid for violating the divine and the natural moral law, and shows him the consequences of such actions like a huge sign that warns him, "Danger ahead!" "Wrong way!" "Turn around!" A sane and prudent individual will not knowingly and willingly do the horrific and drive his car into a brick wall, jump off a cliff, or drink poison.

    In exactly the same way, the man who possesses prudence would never knowingly violate the divine and the natural moral law, because for him, the consequences are even more serious than those that endanger his physical life. He has more than a merely mental understanding of right and wrong. He has a strong drive to do the right, finds joy in doing the right, and has a strong sense of horror at doing the wrong. He will fight to not do the wrong as strongly as a man will fight to stop himself from being pushed off a cliff.

    For those who are lost into the culture of death, quite the opposite condition exists: doing the wrong brings them a perverse delight, and exploiting or killing the vulnerable becomes an entertainment. They enjoy horror-themed entertainments that depict terrible evils in a positive light and mock those who strive to please God. As many family members whose loved ones have been medically-killed have told me, those who impose death in health care settings often display a perverse thrill in not only having the power to kill, but in actually killing!

    They consider the evil of medically-killing human embryos or fetuses (human babies in the womb) sacred and good, but they are incensed that anyone would place restrictions on their immoral activities — restrictions that the divine and the natural moral law would place on them. They want to be able to kill their babies as they want to, to be able to kill the vulnerable if they deem them unworthy of life. They want to do whatever they want to do, however they wish to do it. "Don't tell me what to do!" they shout, and they try to intimidate any who challenge them.

    On the other hand, the prudent man of faith knows that God blesses those who follow obediently and remain faithful to Him. He knows that those who willfully and consciously rebel against Him cast aside such blessings and stand to lose the grace they may have been granted (Matthew 16:26). He knows they stand to lose fellowship with God and to lose all that is good here as well as hereafter.

    Prudence23 is "right reason applied to" the acts of man, what true wisdom would advise man to do. It is prudence that helps us see what we ought to will to do and then enables us to actually do it.

    Without prudence there is no ethical activity, no virtue, no restraint from doing harm to oneself or others, and no culture of life. Without prudence, there is no safe place for patients within the healthcare system; healthcare becomes a business rather than a mission of sacrificial love.





    Next:    "Man in the World" (Part Seven)



    Endnotes:

      1.    Fagothey, Austin, S.J., "Principle of Double Effect," Chapter 9: "Moral Determinants,"
                Right and Reason, p. 107-108, (2nd or 3rd editions only)
                (St. Louis: The C.V. Mosby Company, 1963). Back

      2.    Anthony Zimmerman, "How Proportionalism Corrupts Moral Theology," LifeIssues.net, Nov 1990. Back

      3.    Dave Weldon MD, "Why Human Cloning Must Be Banned Now,"
                The Center for Bioethics and Human Dignity, April 2002.
             Dr. C Ward Kischer, "Cloning, Stem Cell Research and Some Historic Parallels, American Bioethics
                Advisory Commission, a div of American Life League, 2002.
             Rebecca Taylor, "Cloning 101, 2005.
             Dianne N Irving, MA, PhD, "So You Think That "Reproductive Cloning" Isn't Done Yet? Guess Again,
                LifeIssues.net, July 2008.
                "'Pluripotent' Stem Cell (iPS) Research is Not the Usual 'Adult' Stem Cell Research,
                LifeIssues.net, April 2009. Back

      4.    Orphan's Hope, " Our Vision,"
             All God's Children International, "Adoption," Back

      5.    Children of God For Life, " USA & Canada - Aborted Fetal Cell Line Products,"
                and Ethical Alternatives (Nov 2012), Am J Public Health. 2001 September;
               91(9): 13581361. Back

      6.    Natural News, " Dr. Andrew Wakefield reveals real story behind vaccines, autism and more,"
               April 10, 2012. Back

      7.    Diane N Irving, MA, PhD: "Scientific and Philosophical Expertise an evaluation of the arguments
                on "Personhood"," LifeIssues.net, Sept 20, 1996, originally Linacre Quarterly,
                February 1993, 60:1:18-46;
                When do human beings (normally) begin? "scientific" myths and scientific facts," LifeIssues.net, Feb 1999.
                Definitions of a "Human Organism" and a "Cell"," LifeIssues.net, Oct 2004. Back

      8.    Robert Jay Lifton, MD, "The Nazi Doctors: Medical Killing And The Psychology Of Genocide,
                Basic Books, 2000. Back

      9.    Bernard D. Goldstein, MD, "The Precautionary Principle Also Applies to Public Health Actions,"
                Am J Public Health. 2001 September; 91(9): 13581361. Back

    10.    Peter Juni, MD, et. al., Risk of cardiovascular events and rofecoxib: cumulative meta-analysis,"
                The Lancet, Volume 364, Issue 9450, pp 2021 - 2029, 4 December 2004;
                doi:10.1016/S0140-6736(04)17514-4. Back

    11.    Hurriyet Daily News, 893 Turks die in major drug companies' experiments," Hurriyet Daily News,
                Nov 15, 2011, also see:
             National Council of Negro Women, Non-Consensual Research in Africa: The Outsourcing of Tuskegee,"
                The Rebecca Project for Human Rights United Africans for Women & Children Rights Back

    12.    Dr Sagari R Ramdas, "Bt cotton and livestock: health impacts," GMwatch.com, Jan 28, 2010; also see:
             Craig Slater, Marin Voice: Prop. 37 -- GMO corporations and Whole Foods dumb down California,
                Nov 29, 2012. Back

    13.    Adam Rutherford, "Synthetic biology and the rise of the 'spider-goats',"
                The Observer, January 14, 2012. Back

    14.    Lana Berkowitz, "Goat milk vaccine could save lives,
                MySanAntonio.com, March 3, 2012. Back

    15.    St. Thomas Aquinas, "Of Prudence," "Treatise on the Cardinal Virtues"
                Summa Theologica SS, Questions 47. Back

    16.    Josef Pieper, "Prudence," The Four Cardinal Virtues - Prudence, Justice, Fortitude, Temperance,
                Univ of Notre Dame Press, 1966; also see for a brief description:
             Doug McManaman, "Prudence," LifeIssues.net, Jan 2006. Back

    17.    Science Museum, London "Ignaz Semmelweis. Back

    18.    Florence Nightingale, "Notes On Nursing, What It Is and What It Is Not, 1859; also see:
             Mary L Coakley, The Faith Behind the Famous: Florence Nightingale,
                Christianity Today Library; and see:
             MDNews.com staff, "Hand Washing and Health: A Lifesaving Connection, Feb. 23, 2011," Back

    19.    Julie Rehmeyer, "Florence Nightingale: The passionate statistician, ScienceNews.org, Nov 2008. Back

    20.    Science Museum, London, "Joseph Lister" Back

    21.    MDNews.com, staff, "Hand Washing and Health: A Lifesaving Connection," Feb 23, 2011. Back

    22.    Frederick Copleston, S.J., "III. Philosophical Activity of Socrates," A History of Philosophy,
                Vol I, chapter: "Socrates," Back

    23.    St. Thomas Aquinas, "Of Prudence, et. seq.," "Treatise on the Cardinal Virtues"
                Summa Theologica SS, Questions 47-56 Back