Journal of medical ethics, I977, 3, 85-92

The literature of medical ethics: Bernard Haring

Brendan Soane Allen Hall, London

To the general reader and watcher of televisionprogrammes medical ethics may appear to besomething new. This is not so, for hundreds ofarticles and many books have appeared over the lastzo years or so to discuss and analyse the problemsarising from the practice of medicine. In this studyof two larger works - Medical Ethics andManipulation - both by Bernard Hdring, a RomanCatholic theologian - Father Brendan Soaneanalyses these in some detail and sets their ideas inthe context of what has already been written onthe major issues of medical ethics and what islikely to be foremost in discussion in the near future.Many readers of this Journal already have theparticular background of knowledge to see theproblems in medicine which are in fact ethicalbut the general reader may require help andenlightetmnent and this is now provided for aspecial field within the field.

Bernard Haring is probably the best known writeron moral theology (Christian ethics) in the RomanCatholic Church. He is a priest belonging to areligious congregation known popularly as theRedemptorists. He is a lecturer at the AccademiaAlfonsiana, a college for graduate studies in moraltheology in Rome, and a visiting professor of theJoseph and Rose Kennedy Institute for the Study ofHuman Reproduction and Bioethics. He has writtennumerous books, of which two are of particularinterest to students of medical ethics. These areMedical Ethics' and Manipulation2. The aim of thispaper is to explain the criteria of right and wrongwhich the author employs in these works. I willbegin by saying a word about the books.Medical Ethics is concerned with the ethics of

medical practice. It covers the whole field ofmedicine, and views its subject matter from thepoint of view of the Christian faith. Manipulation,which has the subtitle Ethical Boundaries of MedicalBehavioural and Genetic Manipulation, is morelimited in its scope. The word 'manipulation'denotes a wide variety of activities. It can be used ofmanufacture, whether literally by hand, or bymachine; or it can be used, by analogy, of the

'Medical Ethics. Bernard Hiring, St Paul Publications,Slough. I972.

'Manipulation. Bernard Haring, St Paul Publications,Slough. I975.

activities by which men act upon each other.Sometimes these activities are undoubtedly morallygood: for example, most forms of surgery, but atother times they are morally doubtful, or, as in thecase with torture and brainwashing, certainly wrong.Advances in biology, medicine and psychology haveincreased the range of manipulative activities whichare possible now or which might become possiblein the future. Haring's study concentrates onmanipulation in this field in an effort to determinethe criteria of right and wrong both in general andin particular cases.

Summary of Hiring's theoryI will begin by summarizing Hiring's theory. Theaim of medicine is to restore man's ability to func-tion as man where there is dysfunction. The aim ofbeneficial manipulation is to improve man's abilityto function, eg, by improving human intelligenceby genetic engineering, if that is possible. But manis a particular type of creature and what is a suitablegoal for medicine or for manipulation can only bedetermined when we know man thoroughly fromevery relevant point of view, ie, when we can give asfull as possible an answer to the question, 'What isman ?' Haring claims that the answer to thatquestion will be given by many sciences, includingthe science of theology.

What is man?Basic to Haring's moral theory is his understandingof what it is to be human. It is his belief that only amultidisciplinary study can answer the question'what is man ?'. He writes: 'It is on the greatquestion of "what is man?" that the moral theo-logian joins in dialogue with the behaviouralsciences and with medicine.' 3The biggest obstacle to a complete understanding

of man is, he believes, reductionism. Reductionismimplies any way of thinking which limits theunderstanding ofman to one part of his nature. Forexample, to discuss man while denying any realityto free will or spiritual values is to distort him. Thisis why in Manipulation he is severely critical of theAmerican behavioural psychologist B F Skinner.4

3Medical Ethics, p 6.4Burrhus Frederic Skinner is the author of several books

including: Walden Two (NewYork, Macmillan, 1953);Beyond Freedom and Dignity (New York, Knopf,I971); AboutBehaviourism (NewYork, Knopf, I974).

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86 Brendan Soane

Here is how he sums up Skinner's ideology:'Skinner is a radical environmentalist. He believes

that all human actions are nothing else than theresults of the individual's environment. Since theenvironment does condition man, he wants toproduce man as an inevitable product of an idealenvironment.' 5

'Skinner and his most ardent followers franklyconfess their belief that freedom is nothing elsethan an illusion, and that man has to be freed fromthis illusion.'6

In his attempt to sketch a description of what it isto be human Haring indicates that many disciplineshave a contribution to make. The contribution ofthe Christian Church is through the science oftheology. It would be impossible in a short article todescribe in any detail the contribution of theologyto an understanding of man so I will contentmyself with three examples. First, the doctrineabout heaven: this teaches that the ultimate goal ofhuman activity is not within the bounds of this lifeor of history. While avoiding any tendency to under-rate the importance of earthly tasks and realities,human activity must be viewed in a wider perspec-tive, sub specie aeternitatis. Secondly, the doctrinesof sin and the redemption: these alert us to the factthat many human troubles, whether individual orcommunal, have their origin in rebellion against theCreator. Likewise the merciful forgiveness of Godbrings man healing, and the fullest understandingof the meaning of healing in medicine sees it inrelation to the total healing of the person and ofsociety, a total healing which has a religious dimen-sion. Thirdly, any hesitation about man's right tointervene in the order of nature is dispelled by aright Christian understanding of the relativeautonomy of earthly realities in relation to thetranscendence of God, and of the role of man increation as lord of creation under the universallordship of God. Thus our understanding of manand his place in the scheme of things is influencedby Christian doctrine and our attitudes towards menwill be influenced in their turn. At present, fields inwhich the Christian doctrine is particularly signifi-cant include the debate over the morality of abortionand over the care of the dying and incurably sick.An understanding of man must also take account

of philosophy. Haring himself acknowledges hisdebt to a number of different schools of philosophy.Among the most important of these is theAristotelian-Thomist tradition, whose greatest ex-ponents were, as the name implies, Aristotle and StThomas Aquinas. This tradition emphasizes therationality of man, his consciousness, his ability toreflect on himself and his behaviour and his abilityto communicate in symbols. There is also thePlatonic tradition, named after Plato, with itsemphasis on love as characteristic of man. There is5Manipulaion, II2.WMaipulation, pp 13, 1 I4.

the personalist tradition whose greatest exponentsinclude Ferdinand Ebner and Martin Buber.7 Thistradition emphasizes that man is a person endowedwith autonomy, responsibility and the task ofshaping his own personality. It studies man as abeing who can best be understood as a person indialogue with other persons, divine and human.Finally there is that strand of modern philosophywhich stresses the distinction of the world of culturefrom the world of nature and sees the need for manto be a wise steward of nature, for it is the materialout of which culture is fashioned.When it comes to medicine, while of course he

acknowledges our need to learn from all studies inmedicine, he shows a preference for what he calls the'anthropological medicine' of such men as V vonGebsattel and Viktor Weizsaecker. This school,rather than confine its attention to the body of man,tries to see him in the round, as a person. In particu-lar, in psychology he owes a debt to Victor Frankl,Erich Fromm, Abraham Maslow, Gordon Allportand Erik Erikson.

In the past we had little knowledge of the bodilybasis of such 'spiritual' aspects of our nature asreason, will, religious sentiment, emotional life andso on. Hiring acknowledges that modern medicinehas greatly increased our understanding in this area.

The concept of healthOnce we understand what man is we can begin tounderstand the aims of medicine. I said at thebeginning of this article that the aim of medicine isto restore man's ability to function as man. When weknow what a man is we can know how he shouldlive, how he should function. Then we can see whatmedical treatment must aim at. Usually medicinewould claim that it aims at health. But what we aregoing to call 'health' depends on a correct account ofhuman functioning. To understand Hiring's ethicalcriteria it is necessary to know what he means byhealth. To explain this I would like to digress for awhile. I shall discuss the concept of normality. Theaim ofmental health practice is to achieve normality.But what is normality? In the light of the discussionof normality we can best understand Haring'sconcept of health.

According to Daniel Offer and Melvin Sabshin,9in mental health there are four functional perspec-tives on normality. There is no general agreement'as7Representative works would be: M Buber, Schrzften

uber das dialogische Prinzip, Heidelberg, I954;Schriften zur Philosophie. Miinchen, I962. F Ebner,Das Wort und die geistigin Realitaten. Regensburg,I92I.

8Representatives works are: V von Gebsattel,Christentum und Humanismus (Stuttgart, I960).Viktor Weizsaecker, Disseits undjenseits der Medizin(Stuttgart, I95I).

9Daniel Offer and Melvin Sabshin, Normality; Theoreti-cal and Clinical Concepts of Mental Health. BasicBooks Inc New York and London, I966.

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The literature of medical ethics: Bernard Hdring 87

to what normality is. The four are:I) Normality as health 'includes the traditional

medical-psychiatric approach which equates nor-mality with health and views health as an almostuniversal phenomenon'.'0 In other words you arenormal and healthy if you are not obviously ill, ifyou can function reasonably well in normal life.(The word 'health' is not used here in the senseunderstood by Hiring, as we shall see.)

2) Normality as utopia, 'which is best typified bypsychoanalysis, conceives normality as that har-monious and optimal blendingofthe diverse elementsof the mental apparatus that culminates in optimalfunctioning, or "self-actualization"."'ll Carl Rogersand Abraham Maslow work in this perspective.

3) Normality as average 'is commonly employedin normative studies of behaviour. This approach isbased on the mathematical principle of the bell-shaped curve and its applicability to physical,psychological and sociological data'2, that is,extremes of any characteristic are abnormal; onlythe middle range is normal.

i) Normality ashealthMost peopleare normal

2) Normality asutopiaNormality isan ideal to bestrivenforbutnever whollyattained

3) Normality asaverageAverage pos-session of acharacteristicis normal

III health Normality

Degree in which thecharacteristic inquestion is possessedby the individual

-+ Normality

Degree in which thecharacteristic in questionis possessed by theindividual

Abnorlity Normality Abnormality

Degree in which thecharacteristic inquestion is possessedby the individual

FIG I

"Oop cit p 98."op cit p 102.'Sop cit p 105.

4) Normality as process 'states that normality isthe end result of interacting systems that changeover time. In contrast to proponents of the otherthree perspectives, those who advocate this positioninsist that normality be viewed from a standpoint oftemporal progression','3 that is, what is normal inone time and place may be abnormal in another.We can attempt to illustrate these perspectives in

diagrammatic form (see fig. i).I am unable to illustrate the fourth perspective in

diagram form because of the temporal dimension.A person who is normal according to one of these

perspectives on mental health may be abnormalaccording to the others.

Haring's definition of health corresponds to thesecond functional perspective on normality, which,in the light of the influence on his thought ofpsychologists such as Maslow and Frankl, is notsurprising. This is his definition:

'A comprehensive understanding of humanhealth includes the greatest possible harmony of allman's forces and energies, the greatest possiblespiritualization of man's bodily aspect and the finestembodiment of the spiritual. True health is revealedin the self-actualization of the person who hasattained that freedom which marshals all availableenergies for the fulfilment of his total humanvocation'.14

This is autopian definition: note the use of super-latives and the incorporation of the concept of self-actualization into the definition. Note also thathealth is defined in terms of man's total vocation, avocation which can only be understood by a multi-disciplinary study which includes theology andphilosophy. The definition probably goes beyondthat which the average general practitioner employsconsciously in his day-to-day practice. Withoutdenying the obligation to get the best out of our-selves, I think that it is arguable that the doctor whoattempted fully to implement this definition in hispractice would have to conclude that everyone wasalways more or less unhealthy, and would have toinclude spiritual direction and counselling in hisrepertoire of skills. In fact the definition takes usbeyond the range ofwhat is usually understood to bemedical practice. But a doctor could work with amore limited definition while not denying thetruths implicit in Harnng's. What this definitionexcludes is a reductionism which ignores such vitalaspects of health as the relationship of physical well-being to the meaning and purpose of life.The definition is a holistic one, ie, it considers

man in the round, in the light of his vocation to livein community with God and others, and to play hispart in the life of mankind, both in the family andoutside it 'in openness to the other and to the

' 5community.13op cit p io8."Medical Ethics, p I54."Manipulation, p 56

,

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88 Brendan Soane

TherapyOne's understanding of health governs one'sunderstanding of the goals of therapy, so if oneaccepts a utopian definition of health one will alsoadopt a utopian goal for therapy. In Medical EthicsHiring is somewhat ambiguous about the definitionof illness: 'The definition of illness follows that ofhealth. Sickness as a diminution of efficiency and adysfunction of organs is a deviation from theanatomic-physiological norm'.'6He does not say what he means by norm here.

The context of the quotation suggests that he usesthe word 'illness' in accordance with commonusage. But when he discusses therapy his point ofview is utopian: 'My approach is... based on abroader concept of health as wholeness and woulddefine healing as aiming chiefly for wholeness'.'7We must interpret this in a holistic perspective.

That it can have important practical implicationscan be seen in the context of the debate aboutcontraception within the Catholic Church. Thepapal encyclical letter Humanae Vitae'8 (Of HumanLife) (Papal encycicals are known by their first twowords in the Latin) taught that it is immoral to useanovulant pills to prevent conception by inducing atemporary sterilization. Whatever the merits of thatjudgment, it did allow the use of therapeutic meansnecessary to treat diseases of the organism eventhough an impediment to procreation should resulttherefrom. The author of the encyclical probablymeant that they could only be used to suspendovulation when some physical dysfunctionmade thisnecessary. The sterilizing effect would be consideredto be an unsought secondary effect. Hiring inter-prets the teaching in the light of his own under-standing of therapy: 'As to the method itself, thephysician will judge according to the generalconcept of therapy, that is, in view of the bestpossible service to the person's health.'"9He goes on to explain that he refers to the total

concept of health, embracing the overall wellbeingof the human person, in his capacity to reciprocategenuine love and fulfil the vocation of spouse orparent. Hiring's concept of health leads to aninterpretatation which would allow the use ofcontraceptives if they seemed to be the best meansto enable a couple to fulfil their total vocation notjust if they were necessary to cure some physicaldysfunction. So, if an attempt to practice periodicabstinence as a means of regulating births were toturn a woman into a bundle of nerves, Haring wouldadvise the use of contraception. For a devoutCatholic determined to adhere to the papal teachingthis interpretation could make a lot of difference.

'Medical Ethics, p I57"Manipulation, P 57."In English translation The Regulation of Birth,

Catholic Truth Society, London I968, Do 4II."Medical Ethics, p 88.

The principle of totalityThe history of moral theology is a long one andtheologians have had to cope with many questionswhich are now buried in the past. In the processthey have developed a number of conceptual tools.One such is the principle of totality. This was framedto help people to decide when a surgical interventionis licit. A recent formulation of the principle is givenby George Lobo S J: 'Any treatment, includingmutilation, is licit if it is necessary for the saving orthe wellbeing of the whole individual organism'.20Interpreted restrictively this definition would notpermit surgery to alleviate anything other than aphysical complaint. For example, it would permit theremoval of a cancerous ovary, but would not permitthe sterilization of a woman who wished to limit herfamily. The principle was interpreted restrictivelyat first. But more recently it was reinterpreted toallow mutilation for the spiritual wellbeing of theindividual. An example of this would be kidneytransplants among the living. The more restrictiveinterpretation could not permit these becausesurgical intervention was not aimed at the cure ofany complaint of the donor's. The wider interpreta-tion would allow the donor to give his kidney for hisspiritual advancement. If all this seems a little odd itmight be worth pointing out that the principlewould exclude compulsory sterilization for the well-being of the nation. The totality in question is thetotality of the person, however this is conceived,not of society. There is a point in trying to discernthe limits of what is licit. In any case Haring extendsthe concept of totality from physical and spiritualwellbeing to the wellbeing of the whole person.Thus he writes with reference to genetic mani-pulation:

'The main criterion is the principle of totality -not a totality of mere organic functions but aperspective of wholeness that considers the totalvocation of the human person. It is not just aquestion of the meaning of the bodily organism; themost urgent issues relate to the meaning of anintegral human life in response to man's earthly andeternal values.'2'Thus any attempt to alter man's gene structure

should be done with an eye to the ultimate purposesof life. If it were possible, for example, to produce arace of strong labourers, who were unable to com-municate intelligently (see Brave New World byAldous Huxley) this would be immoral.

George Lobo criticizes Hiring's interpretation.He claims that it makes the principle of totality apurely formal principle, ie, it does not tell us what isor is not licit. What does, in fact, serve man's totalvocation? The principle does not tell us. Haringwould probably reply that a study of man from a

2"George V Lobo, S J, Current Problems in MedicalEthics St Paul Publications, Allahabad, 1974, p 33.

21Medical Ethics, p 62.

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The literature of medical ethics: Bernard Hdring 89

multidisciplinary point of view would answer thatquestion.

In accordance with this interpretation of theprinciple Haring will permit sterilization if it is theonly way of ensuring the wellbeing of the person, if,for example, there should not be another child andno method of birth regulation will work. Thus,contrary to the opinion of some in the CatholicChurch he would allow surgical intervention tomeet a problem which is of social or psychologicalrather than physical origin.

Biology and moral norms

It has always been difficult for men to know howthey are to know the will of God in cases wherenothing seems to be revealed in the scriptures. Onetradition, possibly under the influence originally of apantheistic stoic philosophy, sought to discover thewill of God in the ordinary workings of nature.Thus the laws of biology were thought to be in someway normative for morality. In this tradition wecan put the following quotation from Edwin Healy:'The faculties and powers of man must be usedaccording to the purpose for which they wereevidently intended by nature and in the mannerevidently intended by nature'.22The implications of this can be seen in the field of

sexual ethics. The sexual organs were supposed tobe evidently intended by nature for procreation.Therefore to use them in any way which excludedprocreation would be considered immoral. Thiswould rule out contraception; masturbation, evenfor fertility tests; artificial insemination, exceptassisted insemination; all oral, anal and homosexualacts, and bestiality. Without ignoring other reasonswhich are given within the Catholic tradition forcondemning all or some of those acts, it is importantto note the force of this principle and its implica-tions. When it comes to a consideration of geneticmanipulation and the suggestion that we mightalter the human genetic make up, the principlewould seem, at least prima facie, to rule it out. Manshould remain, it would seem, as God made him.As might be expected from his understanding of

the principle of totality, Haring rejects the sugges-tion that biological laws can be normative in moral-ity. He writes: 'The biological nature of man as apartial aspect of his being does not bear anydefinitive normative character. It can never set anintangible limit but it does, very often, have anindicative character.'23

This means that the norm governing behaviour iswhat is reasonable to enable persons to fulfil theirtotal vocation, not what is biologically normal. Inthe light of this Haring rejects the traditional

22Edwin Healy, S J, Medical Ethics, Loyola UniversityPress, Chicago, I956, p II.

'8Medical Ethics, p 56.

Catholic teaching that the only means which mayever be licit for the regulation of births is eithertotal abstinence or the observance of biologicalrhythms, whatever hardship these may cause inparticular cases. He further rejects the teaching thatartificial insemination by husband (artificial in-semination by donor he condemns for other reaons)is to be condemned because it is a departure fromnormal sexual intercourse. His opinion is that in thecases in question the limit to what is licit is set bythe requirement that, in marriage, the unity betweenlove and procreation be retained, in the sense thatmarriage be a generous procreative union. It is thisrequirement which excludes insemination by donor,artificially or naturally, and which would exclude adeliberately childless marriage for no very goodreason. That the biological nature of man has anindicative character implies that medicine wouldusually imitate biological laws and bring them to fullfunction wherever possible. But this is not alwayspossible where the requirements of total health arethe goal. Hence the justification of artificial in-semination or contraception in certain cases. But theuse of the infertile period would be preferred tocontraception and contraception to sterilization.

I said above that the quotation from Edwin Healywould seem to exclude beneficial genetic manipula-tion on the grounds that it would appear to gobeyond the Creator's design for human nature.Haring points out that a full understanding ofhuman nature, which goes beyond the merelyphysical, includes the rational aspect of humannature. This implies that it is natural to shareexperience and to undertake continual research andreflection together with others. Man experimentsand even experiments on himself. He is not boundto every detail of his present biological make up. Hecan use his reason to adjust it. He writes:

'Experimentation belongs more and more visiblyto the very nature of man, and this is particularlytrue with respect to medicine in either treatment orprophylaxis. Historicity, that is, being by becomingand becoming by being in the great stream ofhumanhistory, does indicate a direction of meaning and ofvalues. However, not all that man has today and noteven all that constitutes his direction is alreadywritten in his existence as we now find it. Noteverything has to be determined once and forever.'No concept of human nature is adequate

without special attention to planning and foresightin view of man's great goals, of time-bound oppor-tunities and attendant dangers.'24

So it is in the nature ofman to consider his wholevocation and to seek the best means of achieving it,even if this means altering the genetic code. Thebiology of man as we find it does not provide anabsolute norm for therapy. This leads then to thepossibility of discussing manipulation.

24Medical Ethics, pp 56/7.

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go Brendan Soane

ManipulationHaing distinguishes two forms of manipulation inthe field of medicine. He says manipulation 'mayrefer in one case to an aggressive and somewhatirresponsible shaping or reshaping of man, and inanother, to a beneficial shaping of the given"material" of man's biological self or his psychicdeterminism'.25The criterion of right and wrong in manipulation

is one of the main theories of the book Manipulation.In this work Haring's interests go beyond the goalsof therapy which, however utopian a definition ofhealth is adopted, does denote correction of dys-function. Manipulation (unless the word is used in apejorative sense) implies improvement.

In Medical Ethics Haring observes that changes inthe environment are changing the biosomatic andpsychosomatic nature of man whether we like it ornot. Recalling the doctrine that man, as image ofGod, is the representative of God over the materialcreation, he suggests that conscious planned changeis licit and preferable to unplanned change. Headvocates 'wise piloting'. However, there are boundsset, not only by limited knowledge and techniques,but also by man's dignity and freedom. He writes:'Man must use his creative capacities only independance on God, that is, in a spirit of responsi-bility for history and for his vocation as a person incommunty'.26He says that the main criterion is the principle of

totality as defined above. Totality embraces 'thedignity and wellbeing of man as a person in all hisessential relationships to God, to his fellow men andto the world around him'.27He emphasizes that the totality in question is the

person in his essential relationships; not the societyor the isolated individual. The former of theseinterpretations would be collectivistic, with all thedangers of that type of political ideal for humanfreedom, while the latter would be individualistic,with a consequent failure to do justice to the rightsand duties of persons in society.

Freedom and dignityWhereas in his Medical Ethics the emphasis in thediscussion of criteria for manipulation is on totality,in Manipulation Hiring places the emphasis onfreedom and dignity. This is a difference of empha-sis rather than a choice of a different criterion.Whether we are considering what goals we can aimat in manipulation, or what means we may use, wemust take account of human freedom and dignity.This is the main theme of Manipulation.

'The final concern and criterion in discussingmanipulation is freedom'.28"Medical Ethics, p 59.26Medical Ethics, p 6i.27Medical Ethics, p 62."Manipulation, P 50.

and ....'It is my thesis that he (man) has to interpret his

stewardship in the light of his noblest vocation. Inthat interpretation, he can interfere with andmanipulate the functions of his bios and psyche inso far as this does not degrade him or diminish hisown or his fellow man's dignity and freedom. Notonly nature around him, but his own natural being -his biological, psychological reality - calls for hisfree stewardship, his creative cooperation with thedivine artist.'29Haring does not define freedom, but he seems to

mean autonomy. Not the absolute autonomy whichwould deny any divine or human authority, but anautonomy which is lived in submission to the will ofGod. He writes: 'He (man) must not allow anyoneto manipulate him in his inner sanctuary, hisconscience, his self-interpretation, and his reachingout for meaning and for significant personalrelationships'. 0He adds: 'The fundamental condition for

being truly free... is our repose before God'.3'To attempt to explain the apparent paradox of a

freedom which can at the same time be a submissionwould take us far beyond our present purpose. In anycase we should note that, where men respect God,they should respect other men as children of God.

Haring places a high value on human conscious-ness and self determination. He thinks that certainforms of psychiatry, instead of aiming athuman free-dom, can make a person dependent on thepsychiatristor impose the psychiatrist's own materialistic orreductionist ideology on the patient. This is a harm-ful form of manipulation. Likewise some tech-niques of behaviour therapy, by attempting tobypass free choice, can diminish freedom, and aretherefore unworthy of human dignity. Withoutexcluding operant conditioning where it is necessaryhe favours self education wherever possible,because it enables the person to enlarge the area ofhis free control of his unconscious processes. Thereductionism of such as B F Skinner, because itdenies human freedom, is a threat to freedom.Evidently the criterion of freedom and dignity hasimportant implications where there is a question ofbehaviour modification, whether for individuals orpopulations, and where the question of the choice ofmeans arises. But it is necessary to understand whatis meant by human freedom and the conditionswhich favour it. Such knowledge can only beacquired by a multidisciplinary study.

A teleological approachThere are two principal types of ethics. Deontol-ogical ethics looks to values, duties and rights. Tele-ological ethics looks to the goal to be reached and"Maniuplation, P 70."°Manipulation, p 50.3"Manipulation, P 5o.

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The literature of medical ethics: Bernard Haring 9I

the means which naturally favour the attainment ofthe goal. Both types of ethics are useful in determin-ing criteria. A teleological perspective would beginfrom the belief that human beings seek happiness.It would try to identify what happiness is and whatare its conditions. Here also a multidisciplinaryapproach is needed. Hiring writes: 'Only byforming the best possible concept of man's voca-tion and acquiring an adequate knowledge of hisinner dynamics can we come to an understanding ofthe nature and quality of that happiness which cangive us orientation in our ethical decisions.'32

Haring mentions two sources which will be usefulin this context, psychology and the gospel. Thepsychology of the existential psychologists teachesus that man has, as part of his intrinsic structure,basic needs that orientate him towards self actualiza-tion, integration, psychological health, creativityand productivity. Reflection on these needs and theorder in which they must be satisfied, while bearingin mind the difficulty of distinguishing the genuineneed from the selfish and false, does reveal some-thing of the goals of manipulation and the means tobe employed.

However, it can happen that the satisfaction of aneed could clash with some duty owed to others. Inthis case, he teaches, preference must be given tothe most valuable and urgent, both for our ownself actualization and the self actualization of thecommunity in justice and peace. This is in the spiritof Aristotle, who taught that, although philosophymight be more excellent than eating, it would bebetter to feed a starving man than to teach himphilosophy. Even a desire to travel in order tobroaden one's horizons might have to yield to aduty to stay at home and support one's family: 'Noright and no duty is absolute when it militatesagainst higher or equally high rights and dutiesto oneself or to others and to society'.3A teleological account of the type described is not

enough by itself to enable us to determine ethicalcriteria. He writes: 'A more teleological considera-tion that does not take into account the complexityof human nature, human history, and the frequentsituations of conflict, is not complete. Yet we do notrenounce a teleological vision of man as an ethicalbeing, being in becoming more humane'.3He gives a list of the more important values which

have to be considered as principal ends in a tele-ological vision, and which are also criteria whichshould govern means of beneficial manipulation.Any means which makes the attainment of theseends more difficult should not be used. I will quotea few items from the list: 'Man's noble vocation andhis innermost nature include certain capacities thathave constantly to be developed: to reciprocate love,to relate to other persons and communties...;33Manipulation PP 73,7433Manipulation3 P 77."Manipulation, P 77.

to adore, to admire, to revere and to contemplate ...;to treasure up experience and shared reflection . . .;to develop the sense of freedom in solidarity ...; toshape the world to be most expressive of andconducive to freedom and fidelity', justice, love,dialogue and mutual respect'.36But the teleological approach alone is not enough.

The discussion of what makes man happy and ofhow best we should behave towards one another,including the attitudes the scientist should taketowards those he manipulates beneficially, has muchto learn also from the gospels. Haring writes:'Christ's life and death and his teaching find asynthesis in the sermon on the mount, specificallythe beatitudes. They manifest better than anythingelse the dynamics of growth in freedom and incommitment to the liberation of all people and, atthe same time, the dynamics of happiness'.36The beatitudes teach us what qualities we should

have if we are to become happy and, at the sametime, they teach us the attitude we should have toone another.

The discriminating person

It is not sufficient to draw up lists of ethical criteriawhich could be consulted like a book of rules.Choices of goals and means will be made best bypeople who have made the criteria their own, whohave internalized them.

'Those whose fundamental option is for freedomand respect for all people attain a connatural senseof the good that helps them to interiorize theobjective criteria. This connaturality with the scaleof values makes the right choices easy for them.'37

In other words, the good man, because goodness isnatural to him, makes good choices as a matter ofcourse.

Final comment

Hiring's moral theory appears to me to be in linewith the best traditions in moral theology. It is notin agreement with some moral theologians in itsassessment of the place of biological norms in ethicsand its interpretation of the principle of totality.This is why Hiring's views are often more lenientin particular instances than those of the teachingauthorities in Rome. However, many theologiansshare Hiring's approach to ethical dilemmas. Ofcourse the more rigorous approach can be lenientlyinterpreted in practice by appeal to such principlesas that of the lesser evil, which would prescribethat in a conflict of values, where each course whichis open is bad, the lesser evil is to be preferred.Likewise there is the general pastoral principle that

"Manipulation, pp 77, 78.""Manipulation, p 79.37Manipulation, p 82.

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92 Brendan Soane

people should regard moral law as a guide pointingto good living and hence to what is to be aimed at,rather than a code, to be adhered to rigorously,even when the attempt to do so is damaging.However, despite this, Haring's theory seems to bebetter founded than the other.There are one or two aspects of Haring's theory

which could profitably be discussed further. Thefirst concems the nature of medicine. Accepting thatit must be holistic, one wonders if a utopiandefinition of health does not extend the aims ofmedicine beyond what could reasonably be con-sidered to be the scope of medicine. Further,Haring draws some aspects of his understanding of

man from existential psychology. One mightquestion whether the picture of the mature, self-actualized man which is drawn by this school is theproduct of scientific judgment, or is it influenced byvalue judgments which would be made differentlyin other cultures ? For example, would a ZenBuddhist agree with the picture ?The value of a theory can only be tested in

practice. Haring's theory does not pretend to offer aneasy solution to concrete problems. It aims only tooffer an orientation, a number of considerationswhich the person who has to decide should bear inmind. I think that what it offers is sound andworkable.

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