CHALLENGES

OF CATHOLIC DOCTORS
IN
THE CHANGING WORLD

PROCEEDING
OF

The 15th AFCMA CONGRESS

SANUR PARADISE HOTEL
BALI, OCTOBER 18 21, 2012

CONTENT

1. Congress Agenda
2. Keynote Lecture
The Mission of the Catholic Physician today
By H.E. Msgr Jean Marie Mupendawatu
(Secretary, Pontifical Council for Healthcare Workers)

3. Alimurung Lecture
State-of-the-art of the current medical knowledge. Value and its consequences
By DR Dr FM Judajana SpPK (K)

4. Paper of Main Session

Session 1 : Challenges of Catholic Doctors in Upholding Biom edical Ethics
Challenges of Catholic Doctors : From Ethics to Bioethics
By RD. Dr. Agustinus Ryadi

Session 2 :

Challenges of Catholic Doctors at the beginning of hum an life (P anel Discussion)

Session 3:

Challenges of Catholic Doctors at the end of hum an life (P anel Discussion)

Session 4 : Challenges of Catholic Doctors in P rom oting N atural Fertility Aw areness (P anel
Discussion)
Session 5 : Controversy in the use of condom in HIV prevention (P anel Discussion)

5. Free paper
6. Congress Committee

CONGRESS AGENDA

15th AFCMA CONGRESS 2012

Sanur, Bali, INDONESIA
October, 18 21, 2012

Theme:
Challenges of Catholic Doctors in the Changing World

PROGRAM
Date/Time

Topic

Speaker
Thursday, 18 October 2012

10.00 16.00

Registration

16.00 17.30

Opening Mass

17.30 18.30

Opening Ceremony

18.30 19.30

Keynote Lecture: The Mission of the Catholic

Physician today

19.30 22.00

H.E. Msgr Jean Marie Mupendawatu

(Secretary, Pontifical Council for Healthcare
Workers)

Welcome Reception
Friday, 19 October 2012

07.30 08.15

Morning Mass

08.15 09.00

Alimurung Lecture :

DR Dr FM Judajana SpPK (K)

State-of-the-art of the current medical

knowledge. Value and its consequences.
09.00 09.30

Coffee/Tea break

Session 1 : Challenges of Catholic Doctors in Upholding Biom edical Ethics

09.30 10.00

Challenges of Catholic Doctors : From Ethics to

Bioethics

RD. Dr. Agustinus Ryadi

Session 2 :
10.00 12.00

Challenges of Catholic Doctors at the beginning of hum an life

Panel Discussion.
Topic: Medical Intervention in the beginning of life
Presenter: Dr Rudy B.T. Sp OG
Panelist:
1.
2.
3.
4.

12.00 13.00

Session 3:
13.00 15.00

Fr Dr Benny Phang OCarm (Chair person)

Fr David Garcia OP: viewed from moral theological aspect
Dr V Edna Monzon: viewed from clinical aspect
Fr Joseph Tham, LC : viewed from bio-ethical aspect

Lunch/AFCMA council meeting

Challenges of Catholic Doctors at the end of hum an life

Panel Discussion.
Topic : Ordinary and Extraordinary Care in Chronic Illness
Presenter : Dr George Isajiw KM
Panelist:

15.00 15.30

1. Prof Dr Maramis (Chair person)

2. Fr Dr Stephen Fernandes: viewed from moral theological aspect
3. Prof. Dr Alex Delilkan: viewed from clinical aspect
4. Fr Dr CB Kusmaryanto SCJ :viewed from bio-ethical aspect
Coffee/Tea break

Session 4 : Challenges of Catholic Doctors in P rom oting N atural Fertility Aw areness

Moderator

Sister Mary Ann Lou M.D

15.30 16.00

Natural Family Planning

Dr Ian Snodgrass

16.00 - 16.30

Fertility Treatment through Medical and Surgical

NaPro technology

Sister Arlene I-Ren Te M.D

16.30 17.00

Q&A

17.00 --20.00

Banquet preparation

20.00 22.00

Congress Banquet

Victor Chen Kun Chang M.D

Saturday 20 October 2012

Session 5 : Controversy in the use of condom in HIV prevention

08.00 08.45

Morning Mass

09.00 09.20

Clarification of Pope Benedicts Statement on the

Use of Condom in HIV Prevention

09.20 09.40

The Effectiveness of the Use of Condom in HIV

Prevention: viewed from epidemiological
perspective

09.40 10.00

The Effectiveness of the Use of Condom in HIV

Prevention: view from medical perspective

10.00 10.30

Q&A

10.30 11.00

Coffee/Tea break

Session 6 : Free paper

11.00 12.45

Prof. Dr D.N. Wirawan MPH

Dr Peter Au-yeung

P aralel , @ 15 mnts + QA 5 mnts

Free paper (1a)

Free paper (1b)

1. Fransisco A Woo, MD: The role and

challenges of a Prolife physician
2. Joon-Ki Kang M.D.: How can we do care of
the handicapped child
3. Dr Shigeki Hitomi: The Health care System of
Old Clergies in Japan
4. Dr Hana Claus : Human Sexuality, the Teen
STAR Program and Approach
5. Prof W Maramis : The Right to Live and the
Right to Die ?

12.45 13.45

Fr David Garcia

Lunch

6. Dr Fumihiko Shinozaki : Medical Mission at

Philippines Rural Agriculture District- 25 years

Report
7. Peter J. Manoppo, MD, FINACS, FICS : Do
something or do nothing
8. Sr Mariola Zofia Stawasz, D.MIN: The
importance of spirituality, religion in clinical
practice
9. CP Chen, RN, MSc :Exploration of the spiritual
interaction among health care workers in
Catholic health system
10. Dr FX A Prasetyo : Catholic Medical Association
events as a collaboration between Catholic
medical doctors, paramedics and medical
students

13.45 15.30

Free paper (2a):

Free paper (2b):

1. Fr JH (Gino) Henriques CSsR : The Role of

Catholic Doctors in Humanitarian Aid
2. Dr. Nicholas Hung: Management of

6.

AIDS/HIV cases in Ho Chi Minh city Vietnam

3. Dr Kristina Ulob Ma : A prospective study on
the analgesic effect of breastfeeding among
neonates in a tertiary government hospital
4. Dr Ramon E Nadres : Awareness of Church
Teaching on IVF among catholic doctors and
young couples in Jakarta and Surabaya
5. Dr Shigeyuki Kano : Christian Solidarity as a
strong social capital to fight against Malaria
in the Philippines

15.30 16.00

Coffee/Tea break

16.00 19.00

AFCMA Country Report

19.00 22.00

Free time

7.

8.
9.

Sister Mary Ann Lou Challenges? How to face

with a faith-filled simplicity
Y. Takei M.D.First introduction into Japan of
Creighton Model System and Napro Technology
(CMSNapro) and its practice with Japanese
young couple
Dr Nobuaki Sakai, D.D.S., D.D.Sc.: Primary
Health Care in a District of East Timor by a
Nonprofit Organization
K, Pranarka MD : Bioethical issues in
placement of the elderly in Panti Wredha:
Indonesian (Catholic)'s perspective

Sunday 21, October 2012

09.00 10.00

Conclusion of the Congress

Closing Remarks

10.00 12.00

Closing Mass & Ceremony

12.00 13.00

Farewell lunch

Fr JH (Gino) Henriques CSsR

Opening speech by Indonesias Minister of Health

Address by
Her Excellency Dr. Nafsiah Mboi, M.Ped, MPH
Minister of Health, Republic of Indonesia
at
15th Congress of the Asian Federation of Catholic Medical Associations
18 October 2012, Bali, Indonesia

It is my pleasure to welcome you all to the 15th Congress of the Asian Federation
of Catholic Medical Associations
Let me also extend a particularlywarm welcome to Your Excellency Monsignor
Jean Marie Musivi Mupendawatu, Undersecretary of the Pontifical Council for
Health Care Workers, and representative of His Holiness Pope Benedict XVI.
You have travelled far to join us, Your Excellency, and you honor our country
and our region with your presence.
Before turning to the specific topic of this Congress, I take the opportunity to
express the appreciation of the Government of Indonesia for the widespread and
invaluable contribution of faith-based communities to many facets of national
development. Since before our Independence in 1945, the Catholic contribution
to Indonesian education has been noteworthy for the discipline and high
standards given to young people of all faiths and at all levels of education.
Catholic activity in the field of health, likewise, has covered a wide and valuable
spectrum of work reaching from simple clinics in isolated communities across
the country to urban university centers offering the highest quality of medical
education, service, and research.
Excellencies, Friends, and Colleagues
Let us turn now to your Congress. I salute the organizers of this gathering for the
theme they have chosen: Challenges of Catholic Doctors in the Changing
World. Too often we doctors feel so overburdened with our tasks that we rush
7

forward trying to do our best, but take little time for reflection and sometimes
hardly notice the changes around us which influence our patients, our
profession, and our communities. I urge you to take advantage of the feast your
committee has prepared to give you intellectual and spiritual refreshment during
the next three days.
To complement your discussion, I would like briefly to mention two (among
many) challenges faced by our health system as we endeavor to assure that our
people have equitable access to effective, ethical, appropriate health care. I ask
your consideration of these as I believe they are issues which will benefit from
your engagement in your respective countries if you are to be effective in
addressing the challenges you face as Catholic doctors in the changing world.
The two issues I am going to raise may be called social-operational aspects of
contemporary health care.
1.
How to reach marginalized brothers and sisters and serve their health
needs? In all of our countries we have people who are marginalized perhaps by
occupation and life style (for example sex workers and people who inject drugs);
perhaps by ethnicity, faith, gender, or sexual orientation; perhaps by age or
limited mobility. The largest numbers of marginalized people in most of our
countries are the poor, people without skill, resources, or connections, and in
most settings, people without voice. But these people are Gods children and the
dictates of faith and medicine require action.
This is an area where Catholic services in Indonesia have made important
contributions. I would urge you, in addition to your own direct service, to help
build systems, empowering the people most directly affected to work together
for their own benefit. These mutual support networks should ally themselves
with health care providers and health care systems and in this way acquire
useful links to information, resources, and, technical services, as needed.
Clinical work is important but it is not enough for these people. Their health
needs are broader, and across Asia we find wonderful examples of how much
they can do for themselves when we learn to work with them building capacity,
solidarity, and self respect. My friends - I ask that you be generous with your
knowledge and invest in our marginalized brothers and sisters. This is an issue
of public health. It is also an issue of fair play and community responsibility.

2. Addressing quality of life issues and changing lifestyles: Many years ago, as
a pediatrician and later as Chair of a province-wide village family welfare
movement in a very poor province in Eastern Indonesia, I was much involved in
activity for child survival. We worked with health care providers, with expectant
mothers, with community and religious leaders to reduce our very high infant
mortality rate. I am happy to say we made considerable progress. But as we
talked about child survival I always raised the next question: survival for what
kind of life? We had to work just as hard to improve the life chances and quality
of life of the newborn, the child, and ultimately adult he or she would become. In
general, however, at that time most of that was seen as work beyond the health
system.
With advances in public welfare and national incomes across our region
demographic profiles are changing. Child survival is progressing well. We have
a growing population of adolescents and young adults many of whomare
delaying marriage, and for the first time, we have a significant, growing
population of older people. Our medical practitioners and health systems are
increasingly being called upon to meet expanded challenges related to adolescent
sexual and reproductive health and the new issues of longevity.
This combination of factors calls for a reorientation of health systems to increase
attention to health promotion and preventive services to focus on health and its
maintenance, always cheaper than treatment, while continuing the equitable
provision of humane, professional clinical services, as needed.
Our health system in Indonesia is working in this direction both within our own
sphere of responsibility as well as in expanding partnerships with other
government agencies and civil society including faith-based communities. For
example, issues such as air quality, occupational health, tobacco control,
increasing health-threatening high risk behavior among adolescents and young
adults all have direct impact on both long and short term public health and the
quality of peoples lives.
As with the challenge of reaching our marginalized people, these issues of
quality of life and life-style call for partnership, advocacy, and collaboration.
These are perhaps new skills and concerns for doctors but I suggest they are
increasingly important skills if we are serious about addressing health challenges
in the changing world. My friends, I speak to you from experience and from the
9

heart. In the increasingly complex world in which we live many factors outside
our control have decisive influence on health outcomes. We need to learn how to
influence them not to change our goals but using new tools to build healthier
individuals, families, and communities.
Excellencies, Members of the Conference of Bishops, Esteemed Colleagues
and Guests,
Before concluding, allow me to touch on one additional issue, a subject which I
was asked to address later in your Congress. Due to other obligations,
unfortunately I will not be able to be with you. I refer to the AIDS epidemic and
the place of the condom as a crucial element in an effective, equitable,
comprehensive, response.
It is clear that regardless of whether sex takes place between husband and wife,
between two men, between female sex worker and her client, or the condom is a
tool which, as the Holy Father has pointed out, makes it possible for the person
who is HIV positive to take the moral and responsible step of protecting his or
her partner from exposure to HIV infection. His Holiness said further that the
use of the condom to reduce the risk of infection is the first step on the road to
more humane sexuality rather than risking the lives of others. The place of the
condom in the response was acknowledged and clarified. It is for prevention of
transmission of infection. There can hardly be a more important tool.
As Minister of Health in Indonesia and former secretary of the National AIDS
Commission I honor these thoughtful observations by His Holiness and was
grateful for the support this guidance gave and still gives for implementation of
the full and comprehensive approach to prevention of HIV infection. I ask you all
to reflect upon these words and their importance in our global, national, local,
and personal efforts in the field of health.
My Friends,
I am pleased to have had this opportunity to say these words of welcome and to
open your Congress. In the next few days you will have many presentations and
rich discussion I hope you will remember this opening as a call for

justice in provision of health information and care

responsibility as professionals in the field of health, as citizens, and as people

of faith
10

partnership not as a last resort when one gets stuck but as a vital tool to
help address the challenges of ethical, humane health development in a
changing world

I pray that you may be the salt of the earth 1 in performance of your work
among Gods children and that the deliberations in this Congress and the
fellowship among you will help you retain your taste long into the future.
In conclusion, asking Gods blessing I declare this 15th Congress of the Asian
Federation of Catholic Medical Associations open.

Thank you. God bless you.

Dr. Nafsiah Mboi

Minister of Health, Republic of Indonesia

Mathew 5:13. You are the salt of the earth. But if salt loses its taste, with what can it be seasoned? It is
*
no longer good for anything but to be thrown out and trampled underfoot.

11

KEYNOTE LECTURE

The Mission of the Catholic Physician Today

Msgr. Jean-Marie Mupendawatu
Secretary of the Pontifical Council for Health Care Workers

Introduction

It is a great joy and honour for me to represent the Pontifical Council for
Health Care Workers at this 15th Congress of the Asian Federation of Catholic
Medical Associations. I bring to you the greetings and blessings of the President,
Archbishop Zygmunt Zimowski, who asked me to convey his apologies for not
being able to be with us today, since he is currently attending the Synod of
Bishops on New Evangelisation in Rome. He however promised his prayers for
all of you and wishes you fruitful deliberations.
I thank the organizers of this Congress for the invitation extended to me to
participate in these days of reflection, sharing and learning, particularly
discussing the Challenges of Catholic Doctors in the changing world. My sincere
gratitude goes to our host country, Indonesia, and particularly the beautiful city
of Bali for the wonderful hospitality and organization.
The subject that has been assigned to me is not an easy one. One can speak
about the mission of the Catholic physician today in a general way or by
inventing at a desk prescriptions that will not satisfy anyone. To speak today
about this subject to people who have six centuries (four more than our western
Europe) of history of the art of medicine may appear presumptuous. I will thus
confine myself to presenting some outlines which will deserve greater
exploration during the dialogue over the next days.

12

1. The Mission of the Physician and Changes in the Art of Medicine

-The Sacredness of the Art of Medicine the Hippocratic Oath

Let us ask ourselves, first of all, if there still exists what is called the
mission of the physician. The history of medical ethics clearly shows us that the
art of medicine was considered a special form of service, both of a religious and a
secular type. The practice of medicine is rightly referred to as a profession and an
examination of the word profession can help us grasp the message it ought to
convey. The word profession has a religious origin and comes from the Latin
word profiteor, to profess. Traditionally, this was used to describe the public
profession of faith or religious consecration. Thus a professed person was one
who was consecrated to a ministry or confessed this fact in public. Therefore, a
medical doctor, like the priest was a person consecrated to a form of ministry
and this fact was publicly recognized. Hence, the practice of signing a pact or
taking an oath and thus promising to exercise his profession in a correct and
upright way. In this sense, one could certainly talk about a mission. 2 The
physician, like the priest, had God as a witness and guarantor of the rectitude of
his professional activity. One need only think of the art of medicine of China, of
ancient Mesopotamia, of Egypt, of Greece and of Rome. Everything was
surrounded by a sacred aurora, as a result of which the physician was seen as a
priest.
The Hippocratic Oath has been rightly seen as the paradigm of the art of
medicine as a mission. By taking this oath a young doctor would pledge to
respect a certain set of rules and regulations. These norms include an
undertaking to avoid causing harm, to act to the greatest benefit of the patient, to
practice the profession in a pure and holy fashion, to be faithful to the principle
of professional secrecy, to refrain from inducing abortions, and so forth. By
means of the public declaration of this oath the novice was able to enter the

Diego G. Guillen, The Hippocratic Oath in the Development of Medicine, in Dolentium Hominum 31
(1996) 22-23.

13

category of those who professed, or to put it another way, of professional

practitioners. 3
This tradition, handed down the centuries, has been received and
appreciated in the history of Christianity until our times. We cannot outline here
the whole of the history of health assistance. I will only cite the names of St.
Benedict, St. Camillus. St. Riccardo Pampuri, St. Giuseppe Moscati, the Blessed
Damian and the Blessed Teresa of Calcutta. Other interpreters of the history of
health assistance belong to other, more secular traditions, figures such as Galen,
Percival, Nightingale and Dunant, but whatever the case they have defended a
certain image of service.

- Medical Paternalism
The position of Hippocrates was for a long time labelled medical
paternalism. In truth, Hippocrates in his writings outlined a physiognomy of the
physician as an ally of the patient and respectful of his teacher and his
colleagues.
Paternalism goes back to the nineteenth century with Thomas Percival
(17401804) who, in his book Medical Ethics, portrayed the medical doctor as a
gentleman, a minister of the sick in the secular sense, upholding for him all
decisional power as regards treatment and care for the patient. Central to this
tradition was the ideal of the medical profession as a body of people primarily
dedicated to the service of others rather than to self-interest. This was a vision
3

Diego G. Guillen, The Hippocratic Oath in the Development of Medicine, p. 24. As regards the care
of the sick, I will prescribe the most appropriate regimen, according to my judgment and knowledge and
will defend the sick from all harm and disturbance. Neither will any request avail to induce me to
administer poison to anyone, nor will I ever so advise. Similarly, I will not operate on women for the
purpose of impeding conception and procuring abortion. And, in truth, I will keep my life upright and my
art immaculate. Nor will I perform operations to remove stones from those suffering therefrom, but will let
surgeons expert in this art do so. I will enter any house solely to bring aid to the sick and will refrain from
every unjust action and immorality, as well as from all impure contact. And, in practicing my profession, I
will keep silent, unless given permission, about all that I see and hear in the common life of men, even if
independent of the medical art. If I unalterably keep faith with this oath and am able to observe it loyally,
may I be granted every satisfaction in life and in the art, and may I always enjoy a well-deserved good
reputation among men.
But if I should not keep my oath or should swear falsely, may just the opposite befall me... The
Hipprocratic Oath, in Dolentium Hominum 31 (1996) 9.

14

that influenced all of medical ethics in the United States of America and the West
until the middle of the last century. It goes without saying that some physicians
would fail to live up to this ethic. However, when this happened they were
recognized as morally delinquent and their action were never legitimated or
defended as morally acceptable alternatives.

- The Secular Vision of Medicine and the Autonomy of the Patient

Today this vision is opposed by the autonomy or rather the selfdetermination of the patient, with an associated overturning of medical ethics.
The overturning of medical ethics goes back to the end of the 1960s. A reading of
this change has been engaged in by Edmund Pellegrino and David Thomasma in
their book Helping and Healing, which has also been translated into Spanish and
Italian. Over the last thirty years (today we can say fifty), write these authors,
more changes have taken place in medical ethics than was the case in the history
of the previous twenty-five centuries.
From the famous Hippocratic Oath, which upheld the sacredness of the
art of medicine, and, from a certain late reading, from so-called medical
paternalism, there was a move towards a secular vision of medicine and a strong
emphasis on the autonomy of the patient, with consequences that are in front of
everyones eyes.
Today almost every principle of the traditional ethical standard is being
questioned. Some interpret the relationship of a physician and a patient as a legal
contract instead of moral covenant, others prefer to think of it as a commodity
transaction or an exercise in applied biology. Abortions are legal in many
countries, confidentiality can be violated in certain circumstances, patient
autonomy overrides the physicians autonomy, physician self-interest is
exploited to limit costs in managed health systems, according to some
psychiatrists sexual relations with patients can be part of a therapeutic regimen,
while others defend assisted suicide, as well as direct and indirect euthanasia.
Most significant in all this is the challenge to the ideal of a profession as a
group in society dedicated to a special way of life a life of service in which selfinterest yields to altruism. To practice medicine was tantamount to a vocation in

15

the religious sense. 4 There is a growing tendency to look at the medical

profession any other occupation. Medicine as a career (means of livelihood,
prestige, power, and advancement) was secondary to medicine as a calling and a
vocation.
For many such ideals are untenable in contemporary socio-cultural milieu.
We are experiencing an erosion of moral standards in various spheres of public
life, in business, politics and government, such that for an increasing number of
people this seems an acceptable reality. Many have abandoned the idea of
medicine as profession and a vocation. There has been a progressive descent
from vocation to career in medicine. Pellegrino and Thomasma observe that the
common devotion to an ideal is being replaced by confusion, doubt, dissent and
depression. Moreover the future of medical ethics is in doubt as a consequence.
There is a growing conviction that old professions like medicine or ministry are
not essentially different from business or its occupations, and therefore why
should it be held to a standard of altruism. Yet medicine is typically a moral
enterprise; it requires a vulnerable person to trust in the competence and
goodwill of someone who professes to help. It involves a relationship grounded
in the needs of wounded humanity.

1.1. The causes of this transformation

The causes of this transformation can be led back to three factors: the
democratic management of power (benign authoritarianism no longer
acceptable); public education (demystifies the professions the triumphs and
failings of the professional life are revealed in novels, television programs,
printed media, soap operas); and moral pluralism (dilemmas of modern medical
care and growth of a moral diversity, the homogeneous value system (based on
Judeo-Christian ethic) is challenged- doctors and patients cannot assume
consensus of fundamental question about human life, its meaning, purpose, and
worth- hence moral individualism). 5 Doctors and patients increasingly resolve
moral disputes in court. Patient autonomy replaces beneficence as the dominant
principle in medical ethics. The profession is divided in several issues: specific
4

Edmund D. Pellegrino and David C. Thomasma, Helping and Healing: Religious Commitment in Health
Care, Georgetown University Press, Washington D.C. 1997, p.87.
5
Edmund D. Pellegrino and David C. Thomasma, Helping and Healing: Religious Commitment in Health
Care, pp. 88-90. For the Italian version see E.D. Pellegrino and D.C. Thomasma, Medicina per vocazione
(Dehoniane, Rome, 1994), pp. 111-114.

16

moral issues of abortion, voluntary euthanasia, reproductive technologies and

the nature of the physician-patient relationship. To this should be added at this
point a fourth factor, which is the transformation of hospitals and nursing homes
into companies that have to be managed.
Bearing these factors in mind, medical ethics cannot be understood in the
same way as it was understood until the 1960s. Beyond the fact that many
problems that were a matter of medical ethics are today claimed by bioethics, the
very relationship between the doctor and the patient, which is central in the
approach of medical ethics, is no longer to be understood in the traditional way.
There is need to rethink the concept of profession and the moral
obligations that flow from it. Four fundamental features of a profession:

1.2. Benefit in trust as a solution to the conflict between the autonomy of the
patient and the duty of the medical doctor
The conflict between the autonomy of the patient and the duty of the
physician can be solved only in a relationship of mutual trust. Benefit in trust is
the formula used by Pellegrino and Thomasma to express this relationship.
But because of the changes mentioned above, this relationship is no longer
confined to the medical doctor and the patient. The family, other professional
figures of health care, the managerial system of the local health-care company,
and health-care policies, are all factors that have entered the stage. As a result of
which, to simplify, one may say that medical ethics concerns at least three
components: the patient, the medical doctor and other professional figures, and
society, in an order of importance that is inverted compared to the past. We will
see below some connotations of this relationship.
Faced with these changes, the temptation would be to declare medical
ethics dead because of choices to do with careers and/or remuneration.
For those who do not have a religious vision of life, observe, instead,
Pellegrino and Thomasma, it is at least possible to bear in mind a morality that
arises from within the medical or health-care (as one prefers) profession itself.
In our epoch, which is marked by moral pluralism and thus by a rejection
of a single moral approach, which in the Western tradition of medical ethics is
the Judeo-Christian approach, unless one wants to reduce medicine to what for
17

more than a few it is already, namely a source of gain and a pretext for a career,
there is still the possibility of looking at what in the profession of health care
distinguishes it from other professions.

1.3. The four phenomenological characteristics on which is based the moral

character of medicine as a profession
The four phenomenological characteristics on which the moral character of
medicine as a profession is based, following the thought of E. Pellegrino and D.
Thomasma, are:
-

the nature of the human needs addressed (health, wisdom, salvation,

justice);
- the state of vulnerability of those it serves (the relationship between the
medical doctor and the patient is not one of parity: the power to help or
otherwise the patient is in the hands of the professional);
- the expectations of trust that it generates (these are based upon the
profession itself of the medical doctor, on his or her will to help the sick
person and make available his or her own professional knowledge);
and the social contract that is involved (or in line with the Anglo-Saxon
phrase, drawn from the Biblical image, the covenant or alliance/pact, that is
established between the medical doctor and the patient). 6 Here is indicated the
framework within which the art of medicine can find its lustre, defeating
nostalgic temptations, on the one hand, and attitudes involving abandonment,
on the other.
In dwelling for a moment on the characteristics mentioned above, one
should say that if the nature of man invokes health, wisdom, salvation and
justice, these needs become even more acute in a state of suffering or illness. A
medical doctor, or more in general a health-care worker, cannot abuse his or her
superiority but, instead, is called to make up for the vulnerability of the patient,
who places his or trust in the medical doctor, and this can be revoked only at the
moment of death or when this trust comes to be absent on either side. The
relationship between the health-care worker and the patient is not of a
commercial kind but, rather, acquires the characteristic that one of the highest

Edmund D. Pellegrino and David C. Thomasma, Helping and Healing, p. 91-94.

18

exponents of modern bioethics does not hesitate to compare to the covenant

between God and the chosen people. 7 This brings us to the second step.

2. The Mission of the Catholic Physician

Whereas for everyone a profession implies its own internal morality, for
the Catholic physician this is an authentic mission. The Charter for Health Care
Workers offers us a good pathway by which to outline the mission of the Catholic
physician.
For a summary I will use a presentation by L. Cantoni. 8 The introduction,
which has the significant title Ministers of Life (nn. 1-10, pp. 7-18), sees in
service to life the nature of the activity of health-care workers. It constitutes a
form of Christian witness: The principal and symbolic expression of taking
care is their vigilant and caring presence at the sickbed. It is here that medical and
nursing activity expresses its lofty, human and Christian value (n. 1). The
activity of a heath-care worker is based upon an interpersonal relationship: The
health-care worker is the good Samaritan of the parable, who stops beside the
wounded person, becoming his neighbour in charity (cf. Lk 10:29-37) (n. 3). It
is then emphasised that Service to life is such only if it is faithful to the moral law,
which expresses exigently its value and tasks (n. 6). The health-care worker
draws his behavioural directives from that field of normative ethics which
nowadays is called bioethics. Here, with vigilant and careful attention, the
magisterium of the Church has intervened, with reference to questions and
disputes arising from the biomedical advances and from the changing cultural
ethos. This bioethical magisterium is for the health care worker, Catholic or
otherwise, a source of principles and norms of conduct which enlighten his
conscience ad direct him especially in the complexity of modern biotechnical
possibilities in his choices, always respecting life and its dignity (n. 6).
The first chapter, Procreation (nn. 11-34, pp. 19-33), analyses by subsections Genetic Manipulation (nn. 12-14), Fertility Control (nn. 15-20) and
Artificial Procreation (nn. 21-34).
7

Ramsey, P., The Patient as a Person (Yale, 1971).

Cantoni, L., La "Carta degli Operatori sanitari". Una presentazione, Cristianit n. 239 (1995).

19

As regards the subject of genetic manipulation, a clear distinction is made

between interventions that are truly and directly curative, and morally licit, and
those that alter the genetic patrimony, which are contrary to the personal dignity
of the human being, to his integrity and to his identity (n. 13). After referring to
the criteria for a moral assessment of the regulation of fertility, and in particular
the, at the same time, inseparably unitive and procreative nature of the conjugal
act, the document states that while it is lawful, for grave reasons, to take
advantage of the womans fertility and forgo the use of marriage in the fertile
periods, recourse to contraceptive practice is illicit (n. 17). The problem is not
that of a distinction simply of techniques or methods, where the decisive
element would be the artificial or natural character of the procedure; the
ultimate reason for every natural method is not just its effectiveness or biological
reliability, but its consistency with the Christian vision of sexuality as expressive
of married love (n. 18).
As regards artificial procreation, the Charter emphasises that The desire
for a child, sincere and intense though it ought to be, by the spouses, does not
legitimise recourse to techniques which are contrary to the truth of human
procreation and to the dignity of the new human being (n. 25). In particular, the
only artificial means that are exclusively morally licit are those whose function
is merely to facilitate the natural act, or to ensure that a normally performed act
reaches its proper end (n. 23): such is the case with homologous artificial
insemination.
Life is the subject of the second chapter (nn. 35-113) which is organised
into twenty sub-sections addressing the many questions connected with
prevention, treatment and rehabilitation. This is an area that does not allow a
summarising approach but which finds its unifying moments in the declaration
that From the time that the ovum is fertilised, a life is begun which is neither
that of the father nor of the mother; it is rather the life of a new human being
with its own growth. It would never be made human if it were not human
already (n. 35), and in the observation that every intervention on the human
body touches not only the tissues, the organs and their functions, but involves
also at various levels the person himself. Health care must never lose sight of
the profound unity of the human being, in the obvious interaction of all his
corporal functions, but also in the unity of his corporal, affective, intellectual and
spiritual dimensions. One cannot isolate the technical problems posed by the
treatment of a particular illness from the care that should be given to the person
of the patient in all his dimensions. It is well to bear this in mind, particularly at a
20

time when medical science is tending towards specialisation in every discipline

(n. 40).
The third and last chapter, Death (nn. 114-150), argues forcefully that
For the health care worker, serving life means assisting it right up to its natural
completion. Life is in Gods hands: He is the Lord, He alone decides the final
moment. Every faithful servant guards this fulfilment of Gods will in the life of
every person entrusted to his care. He does not consider himself the arbiter of
death, just as and because he does not consider himself the arbiter of anyones
life (n. 114).
This is a subject that of assistance for the dying that requires renewed
and constant attention: the cultural context described above, indeed, tends to
reject death and the dying because they pose to medicine and health-care
workers questions which they if they are only technicians of health do not
know how to answer. A dying person is thus misled about his or her condition,
or marginalised, or an attempt is made to make death belong to events that are
determined technically, producing them: such is the case with euthanasia or
postponing death: such is the case with exaggerated treatment; For the doctors
and their assistants it is not a question of deciding the life or death of an
individual. It is simply a question of being a doctor, that is, of posing the
question and then deciding according to ones expertise and ones conscience
regarding a respectful care of the living and the dying of the patient entrusted to
him (n. 121).
In particular, Deathmust be evangelized: the Gospel must be announced
to the dying person. The announcement of the Gospel to the dying finds
especially expressive and effective forms in charity, prayer and the sacraments
(n. 131).
If, as has been my aim, the mission of the Catholic physician has been
outlined at the level of its principal and basic aspects, one should, lastly, ask
oneself how it provides an answer to contemporary challenges.
In this presentation of the Charter for Health Care Workers I have already
referred to certain requirements. I wish to explore here other aspects which seem
to me to be very important.
It is to be remembered that the Charter for Health Care Workers was
published in 1995, since then there have been several pronouncement of the
teaching office of the Church concerning the developments in the scientific field,
21

their application in medical science and the regulations that ought to guide the
research and application.
As the Pontifical Council explains: In the Charter of 1994, the Magisterium
of John Paul II as regards Evangelium Vitae was not envisaged, with the whole
question of the role of Catholics in politics. We know, in fact, that today amongst
the most urgent questions there is also justice in the allocation of financial
resources for the common good and social justice, according to the two principles
of solidarity and subsidiarity. We may think of the questions of the end of life
and the answers that in 2007 the Congregation for the Doctrine of the Faith gave
as regards alimentation and hydration. We may think, lastly, of the Instruction
Dignitas Personae which addresses some of fundamental questions above all in
the application of biotechnologies at the beginning of life: stem cells, the
reduction of embryosindeed, these major questions were not in the Charter of
1994 and thus it is advisable, indeed necessary, to update this new Charter.
Beyond health-care workers, the new reference points are in my view
politicians. Precisely because, as we also recently heard during the visit of
Benedict XVI to Africa, social justice, the allocation in line with justice of
financial resources, is an emerging question, above all in the old continent where
financial problems are also beginning to have an influence on the management of
the common good in essential services in countries which are called the richest
countries. 9
These observations appear to me to be valuable for the geographical
context in which we find ourselves as well.

3. The Anthropological Vision

But although, on the one hand, we may refer to the urgent need for
judgement and a moral practice in harmony with the Magisterium of the
Catholic Church, on the other, it should be said clearly that the mission of a
Catholic physician today is not confined to the ethical aspect. The
anthropological vision should always be borne in mind.
The challenge of today is the overcoming of a positivistic vision which
today still defines medicine.
9

R. Gisotti, Interview with Fr. Chendi, Vatican Radio, 29.11.2011.

22

A suffering man cannot be seen as an agglomerate of organs and tissues.

He should be seen, rather, in his wholeness as a living being, on the one hand,
and in his mysteriousness, on the other.
Salvifici doloris (SD) by John Paul II appears to me to be the Magna Carta of
this vision (cf. Introduction, chaps, I, II, II). 10
In it we see outlined the whole of the history of salvation and in particular
the relationship between the Love of God and human suffering, within the
framework of a design which does not, however, eliminate, mystery. I will quote
in particular n. 4 of SD: Human suffering evokes compassion; it also evokes
respect, and in its own way it intimidates. For in suffering is contained the
greatness of a specific mystery. This special respect for every form of human
suffering must be set at the beginning of what will be expressed here later by the
deepest need of the heart, and also by the deep imperative of faith. About the theme
of suffering these two reasons seem to draw particularly close to each other and
to become one: the need of the heart commands us to overcome fear, and the
imperative of faithformulated, for example, in the words of Saint Paul quoted
at the beginningprovides the content, in the name of which and by virtue of
which we dare to touch what appears in every man so intangible: for man, in his
suffering, remains an intangible mystery.11
Spe Salvi by Benedict XVI describes in a masterful way other aspects of this
vision, in particular ministerial cooperation with the love of God and
compassion: The true measure of humanity is essentially determined in
relationship to suffering and to the sufferer. This holds true both for the
individual and for society. A society unable to accept its suffering members and
incapable of helping to share their suffering and to bear it inwardly through
com-passion is a cruel and inhuman society. Yet society cannot accept its
suffering members and support them in their trials unless individuals are
capable of doing so themselves; moreover, the individual cannot accept another's
suffering unless he personally is able to find meaning in suffering, a path of
purification and growth in maturity, a journey of hope. Indeed, to accept the
other who suffers, means that I take up his suffering in such a way that it
becomes mine also. Because it has now become a shared suffering, though, in
which another person is present, this suffering is penetrated by the light of love.
The Latin word con-solatio, consolation, expresses this beautifully. It suggests
10
11

John Paul II, apostolic letter Salvifici doloris (LEV, Vatican City, 1985).
Ibid., n. 4.

23

being with the other in his solitude, so that it ceases to be solitude. Furthermore,
the capacity to accept suffering for the sake of goodness, truth and justice is an
essential criterion of humanity, because if my own well-being and safety are
ultimately more important than truth and justice, then the power of the stronger
prevails, then violence and untruth reign supreme. Truth and justice must stand
above my comfort and physical well-being, or else my life itself becomes a lie. In
the end, even the yes to love is a source of suffering, because love always
requires expropriations of my I, in which I allow myself to be pruned and
wounded. Love simply cannot exist without this painful renunciation of myself,
for otherwise it becomes pure selfishness and thereby ceases to be love. 12
Thus the Magisterium of Benedict XVI constantly helps us to reflect that
our experience is not a memory of the past but, rather, requires the
contemporary imperative of the Christian Event. 13
It also leads us to overcome spiritualism, on the one hand, and moralism,
on the other, perceiving clearly that that the action of a Christian cannot be
reduced to the mere action of some social agency 14 but is a sign of the charity of
Christ in the world.
Thus the figure of the Good Samaritan remains the emblem of the Catholic
physician today. It is his image, we could say his identity, that remains, despite
the changes of history. This, far from stopping our action, leads us to look for
ever new forms 15 of being protagonists. This requires a kind of integrating
encounter between profession, vocation and mission. Beyond technicalprofessional expertise, ethical responsibility is required; it is self-evident that
technical-professional expertise is not sufficient, ethical responsibility is needed.
In particular, ethical-religious professional formation for all health-care
professionals is needed, in particular for Catholic health-care workers. The
presence of ethical committees appears to be no less important for the taking of
the right decisions which are not only of a procedural character but should be
based upon a solid moral foundation. Lastly, we should take into account the
changes that have taken place in the health-care field, without forgetting about
the propium of the Christian dimension.

12

Benedict XVI, encyclical letter Spe salvi (LEV, Vatican City, 2006), n. 38.
Benedict XVI, encyclical letter Deus caritas est (LEV, Vatican City, 2005), n. 1.
14
Ibid., nn. 28-29.
15
John Paul II, post-synodal apostolic exhortation, Christifideles laici (Vatican City), n. 53.
13

24

I believe that as regards the changes that have taken place in the field of
health care, we can in summarising fashion say the same as the Supreme Pontiff
did in his first encyclical: Lovecaritaswill always prove necessary, even in
the most just society. There is no ordering of the State so just that it can eliminate
the need for a service of love. Whoever wants to eliminate love is preparing to
eliminate man as such. There will always be suffering which cries out for
consolation and help. There will always be loneliness. There will always be
situations of material need where help in the form of concrete love of neighbour
is indispensable. The State which would provide everything, absorbing
everything into itself, would ultimately become a mere bureaucracy incapable of
guaranteeing the very thing which the suffering personevery personneeds:
namely, loving personal concern. We do not need a State which regulates and
controls everything, but a State which, in accordance with the principle of
subsidiarity, generously acknowledges and supports initiatives arising from the
different social forces and combines spontaneity with closeness to those in need.
The Church is one of those living forces: she is alive with the love enkindled by
the Spirit of Christ. This love does not simply offer people material help, but
refreshment and care for their souls, something which often is even more
necessary than material support. In the end, the claim that just social structures
would make works of charity superfluous masks a materialist conception of
man: the mistaken notion that man can live by bread alone (Mt 4:4; cf. Dt
8:3)a conviction that demeans man and ultimately disregards all that is
specifically human. 16

4. By Way of a Conclusion
All of this leads us to say that our presence is as valuable as ever, both in
public institutions and in charitable ones, and shows that there is ample space for
action that offers suffering man welcome, concern and care in his largest and
deepest dimension.

16

Benedict XVI, Deus caritas est, n. 28.

25

One the other hand, by now for some time, on the part of the leaders of
public health care there has been the perception that there is a need to humanise
hospitals. 17
The great increase in the number of conferences and seminars on various
aspects of care and in particular of caring: do they not document, perhaps, a
nostalgia for that charity of our Saviour and of those who have followed him? To
perceive this cry of society, even though it is a submerged cry, I believe, is our
task.
It is no accident that after the religious Orders and Brotherhoods, new
Institutes were born, such as the Sisters of Charity of Mother Teresa of Calcutta.
It is sufficient to be attentive to the signs and the circumstances, as Francis of
Assisi was with the leper encountered in the countryside of Assisi or as Mother
Teresa was with the poor man abandoned at Calcutta station.
In this we are helped by John Paul II who, when writing his post-synodal
apostolic exhortation on the laity, which has already been mentioned, spoke,
when referring to the possibility of the mission of sick people and the suffering,
about a new and even more valuable manner 18 and, in his apostolic exhortation for
the new millennium, he exhorted Christians to stake everything on charity and
stated that Now is the time for a new creativity of charity. 19 There is ample
space in hospital institutions, in nursing homes, in nursing and medical schools,
in private homes, in special refuges for the sick, everywhere, for our
contribution, remembering that the forces that move history are the same as
those that make the heart of man happy. 20

One work that everyone should read: Brusco A., Umanit per gli Ospedali (Salcom, Brezzo di Bedero,
1983).
17

18

John Paul II, Post-synodal apostolic exhortation Christifideles laici, n. 53.

19

John Paul II, apostolic exortation Novo millennio ineunte, nn. 49, 50.

20

Giussani. L., Qui e ora (1984-1985) (Biblioteca Universale Rizzoli, Milan, 2009), p. 45.

26

ALIMURUNG LECTURE

STATE-OF-THE-ART OF THE CURRENT MEDICAL

KNOWLEDGE
Its values and consequences

Dr. F. M. JUDAJANA dr SpPK (K)

Surabaya - Indonesia

Abstract
The recent insight, that the multi factor interaction has a great role in the
problem of human life related with health and the challenge is managing the
expectations of the medical community and the public at large which has already
been set by speculation, promises, and repeated exposure to head lines about
many spectacular medical breakthroughs or discoveries.
Caused by the many emerging diseases in the society , the social culture
pattern is changing, global climate exchange and more complexes, based on
those conditions, the question is how the medical expert can contribute a rational
medicine framework in the future, as a new orientation of medical progress, in
order to solve the human medical problem.
Parallel to all of those conditions, the level of development in medical
sciences is predicted to grow at extraordinary rates over the next 10 years, fuelled
by molecular biology, genetics, immunology,
regenerative medicine,
neuroscience, human reproduction, nanomedicine and the elusive dream of
personalized medicine, etc
The threshold of new revolution in medical science , like stem cells as a
regenerative medicine which is supported by the biotechnological advances ,
have brought us great promises but genuine concerns as well.

27

The genomic and the gene expression related with the human
development and reproduction, have a great role as Genomic-scale gene
expression profiling can reveal cellular physiology with unprecedented richness.

This technology is being used to define the gene expression targets of

individual regulatory proteins and signaling pathways . One of the most exciting
developments has been the implementation that the genetic material has a great
role in the pathogenesis of diseases and give new insight into the bodys control
system
The value of medical research related the implementation, is actually
based on the question focused : what is the main role of medical experts in order
to solve the medical problem, like the problem of diagnostic, therapeutic,
prevention, and medical rehabilitation, in order to achieve the human welfare
associated with the holistic approach, the medical ethics and the human dignity .
The most important thing of the medical advances is based on the
research activities which should be known in depth about the main value of
medical progress associated with the human dignity as essential ingredient. As
we know the concept of human dignity is meaningful, it is nothing more than
capacity for rational thought and action, features conveyed in the principle of
respect for autonomy , also originates in religious and human rights .
The consequences , medical experts must have understanding in depth
and more detail about the positive and negative impact of medical progress, to
analyze a medical situation very carefully before making a medical decision, and
to monitor or to evaluate all medical risks and then have a good step to
compose the reposition and redesign of all medical activities.
Based on those reasons, this presentation is focused on (1) the highest
development of recent medical research and the perspective , in other word
known as state-of-the-art-of the current medical knowledge (2) looking at some
converging changes taking place in the health-care landscape that create a
scientific and the medical infrastructure, (3) considering challenges that need to
be addressed with regard to clinical evidence standards for validating data
associations, (4) considering how the medical expert can help construct a
rational medical framework based on physically, psychology and spirituality in
order to achieve the excellent medical competency (knowledge, skill and mental
attitude).
28

The excellent medical progress give a new insight that the role of medical experts
should know medicine as a expansive discipline to serve a major bridge between basic
science, clinical medicine and socio-cultural based on the excellent morality.
Key words : state-of-the-art, medical knowledge, human reproductive,
regenerative medicine, personalized medicine

Introduction
According the recommendation of the World Medical Association (1964)
The Declaration of Helsinki was issued. Article 11:

It is a duty of physicians who participate in medical research to

protect the life, health, dignity, integrity, right to self determination, privacy,
and confidentiality of personal information of research subjects
As we know, that the basic characteristic of science and knowledge is the
basis for all human action, intrinsically linked to people, created dynamically
and actually is the result of a cognitive process based on research activity.
The medical research activity refers to a class of activity designed to
develop or contribute to the medical science and knowledge. Actually the
medical science and knowledge consists of theories / conceptual framework,
hypothesis, principles of relationship, or the accumulation of information, in
order to contribute for the solution of the real health problem.
Research involving human subjects may employ either observation or
physical, chemical, or psychological intervention; it may also involve the patient
subject and the researcher relationship as the most important factor , in order to
do something based on a protocol that clearly state : the aim of research.
In detail, medical research activity in human subjects includes : studies of
physiological, biochemical or pathological process or the response to specific
intervention whether physical, chemical or psychological in healthy subjects or
patients and control trial of diagnostic, preventive or therapeutic management.
The possibility of successful research in human subjects based on the
development and breakthrough of medical science and knowledge
The researcher and the professional whose role is to combine investigation
and treatment has a special obligation to protect the rights and welfare of the
patient-subject or the patients safety orientation. In other words, the medical

29

researcher have a duty to discover or to invent a medical solution, in order to

improve the human health associated the human dignity as the highest value.
Thus, the medical research protocol should be scientifically and ethically
appraised by one or more suitably constituted review bodies, independent of the
investigator and to prevent the moral hazards.
Molecular Biology :
In the wake of scientific breakthroughs, especially in genomic research
and the better understanding of various genetic disorders and physical and
psychological traits that it promised, expectations for the development of new
treatments and cures for various medical conditions has grown tremendously.
The Human Genome Project was therefore accompanied by multiple
superlatives : the genome it self was described as the book of life and it contain
the medical information and biological material of individual, linking this data
with sensitive genetic information. ( Y Bregmann, 2004)
There are grand challenges in the genomic research and formulated into
three major themes : genomics to biology, genomic to health and genomics to a
society. (Francis S Collin, Eric D Green, Allan Guttmacher, 2003)
Genomics to biology means elucidating the structure and function of
genomes. It has 5 (five) grand challenges : 1) Comprehensively identity the
structural and functional component encoded in the human genome, 2) Elucidate
the organization of genetic networks and protein pathways and establish how
they contribute to cellular and organism phenotypes, 3) Develop a detailed
understanding of the heritable variation in the human genome, 4) Understand
evolutionary variation across species and the mechanisms underlying it, 5)
Develop options that facilitate the widespread use of genome information both
research and clinical setting. ( Francis Collins et al, 2003)
Genomics to health means translating genome-based knowledge into
health benefit. It has 6 (six) grand challenges : 1) Develop robust strategies for
identifying in the genetic contributions to disease and drug response, 2) Develop
strategies to identify gene variants that contribute to good health an resistance to
disease, 3) Develop genome- based approaches to prediction of disease
susceptibility and drug response, early detection of illness and molecular
taxonomy of disease state, 4) Use new understanding of genes and pathways to
develop powerful new therapeutic approach to disease, 5) Investigate how
30

genetic risk information influences health strategies and behaviors, and how
these affect health outcomes and cost, 6) Develop genome-based tools that
improve the health . ( Francis Collins et al, 2003)
Genomics to society means promoting the use of genomics to maximize
benefits and minimize harms. It has 4 (four) grand challenges : 1) Develop policy
options for the uses of genomics in medical and non-medical settings, 2)
Understand the relationships between genomics, race and ethnicity, and the
consequences of uncovering these relationships, 3) Understand the consequences
of uncovering the genomic contribution to human traits and behaviors, 4) Asses
how to define the ethical boundaries for uses of genomics. ( Francis Collins et al,
2003)
According the research on Immune genetic as one of the genetic of the
host associated with infectious disease base on the host response to an infectious
organism is critical in preventing disease, it must be tightly regulated to prevent
the immune mechanisms from directly contributing to pathologic response. For
instance, association HLA as immune genetic marker with the HIV infection, has
found, that the HLA-B35, HLA - A1, HLA-Cw7, HLA-DR3 as a susceptibility
gene and the HLA-A3, HLA-B14, HLA B17, HLA -DR7 as a protective gene.
The positive consequences as a tools for remind some bodies has
susceptibility gene to be careful in their life, in order to prevent the HIV AIDS
infection. When some bodies has the protective gene, there are negative
consequences related to behavior deviation which can disturbances of society.
Personalized Medicine :
Personalized medicine is a new medical orientation emphasizing the
systematic use of information about an individual patient to select or optimize
that patients preventive and therapeutic care. It could broadly be defined as
products and services that leverage the science of genomic and proteomics and
seeks to provide an objective basis for consideration of such individual
differences.
Human Health Span and Life Span ( Human Life Expectancy)
Human life expectancy , in the space of mere century, has become much
better longer than ever before. This primarily reflects the improved social and
physical condition of living, along with the strengthening of civil institutions;

31

circumstances which in particular have greatly diminished childhood deaths

from infections and malnutrition.
The profile of human health is mixed, it faces various unfamiliar large
scale risk to health and needs the supporting medical research, medical care and
disease prevention. Progress in those areas and disease prevention program
depends upon on a deep understanding of physiological and pathological
processes requiring the theoretical concepts and research involving human
subjects.
The research focus in order to know the human life expectancy to
search the role of telomere and associated with the genetic profile, but up to now
is not established. There are great opportunities for research on the genetics on
the genetics of human aging , particularly given the huge fund of information on
human biology and patho - biology and the rapidly developing knowledge of the
human genome ( G.M. Martin, A. Bregman, N Barzilai, 2007)

Human Reproduction
Advanced in Human reproduction based on dream or science fiction from
Aldous Huxley at 1932 realistically described the technique of IVF ( in Vitro
Fertilization) we know it. The reproductive technology have made it technically
possible for the early human embryo to be realize, i.e intra cytoplasm sprm
injection (ICSI )revolutionized the concept of the natural fertilization process.
As we know the human fertilization is a complex process requiring about
24 hours for completion, it begin with spermatozoon, the male gamete,
penetrating the ovum or female gamete and culminates un the mingling of the
genetic material from each to form a single-cell zygote. (K Dawson, 1987)
All of the process of fertilization to be possible in the uterine or fallopian
tubes of the female, but recent medical advances resulting has demonstrated in
vitro fertilization technique.
Argument in support of fertilization as the time at which full moral status
is required with emphasis on the potential of the newly-formed entity ( K
Dawson, 1987).
The Arguments Examined :
1. The genetic argument : that entities are genetically human being
created
32

2. The discontinuity- continuity argument : numerical continuity ( two

gametes one zygote) and no numerical discontinuity like parthenogenesis
(development of the egg without fertilization by a sperm )
3. The individuality argument : a new human individual organism with
internal potential to develop into an adult, . Comes into existence as a result of the
fertilization process ! ICSI revolutionized the concept of the natural fertilization process
Assessment of the arguments claiming that fertilization is the time at
which full moral status is acquired is now extremely relevant as policy-formation
and legislation for the regulation of reproductive technology and pre-embryo
research.( K Dawson, 1987)

Regenerative Medicine
In these third millennium there are a lot of exciting research work can
stimulate the level development of basic medical science like stem cells, and
build a new insight as a recent biotechnological advances , and has brought us
great promises but genuine concerns as well. The medical science and technology
breakthrough showed the ability to manipulate human gametes to create new
entities of life, can potentially provide new knowledge of diseases, find new
cures, new strategies to prevent the disease. The new important point of these
advanced medical science is regenerate tissues and organs to replace damaged
ones and is called as regenerative medicine or stem cell .
Sir John B Gurdon and Shinya Yamanaka are Nobel Prize Winner in
medicine 2012, as a scientists who have done excellent scientific work and their
discovery that mature, specialized cells can be reprogrammed to become
immature stem cells capable of developing into all tissues of the body.
The list of disease treated by stem cell are Genetic Disease like Down
Syndrome, Neural Disease : Parkinson, Metabolic disease like Diabetes Mellitus,
and also Chronic Hepatitis , Liver Cancer, Renal Failure, Infertility ( Male and
female), Rejuvenation, Coronary Heart Disease, and Blood Malignancies .
There are a many argument discussing the technique of this matter , in
other words multi issue of the stem cell like ethical/ moral issue, business,
political, social / legal, biomedical , and pharmaceutical issue . One of the key
words for understanding the latest issue in bioethics is pluripotent stem cell
research, which is being discussed intensely in medical congress around the

33

world. This is because such research is expected to lead to development of

medical treatment of incurable diseases.

Emerging and re- / emerging of infectious diseases

The incidence of reemerging diseases is obvious rapidly increasing and it
may have existed previously, such as malaria, tuberculosis (TB), measles etc.
Specific factors precipitating the emergence of diseases can be identified in
virtually all cases. These include environmental changes, demographic factors,
host immunity, microorganism variants and drug resistance suggesting that
infection will continue to emerge, probably increase and emphasizing the urgent
need for effective surveillance and control.
As reported emerging and reemerging diseases are a heterogeneous group
of infectious diseases each have its own biology, diagnosis, treatment and
prognosis. The basic science front has advanced rapidly and provided to explore
many different approaches , such as immunology and molecular biology.
The Immunology approach of reemerging diseases has been advanced
on two major front. First, the elucidation of the basic mechanisms associated
antigen recognition, elimination, rejection and immunological protection from
recurrence. Second, the application of the knowledge of
immunological
memory to reemerging diseases as a tool in order to solve the clinical problem (
diagnostic, therapeutic and prevention).
Over expressed emerging or reemerging pathogens such as molecularly
defined mutated antigen; this antigen as a target of specific immune reaction and
has been encountered as a danger signal. The current studies have shown that
few immune competent cells ( activated T cells and B cells) are exposed to
antigen,
The immune consequence of infectious tissue induced MHC molecules
ex-pression on antigen
presenting cell and have also shown, that an
immunological reaction occurs in all organs in response to a number of diseases.
However, most infectious diseases express MHC class II molecules, in
order to recognize the new mutated antigen and also express the MHC class I
molecules in order to eliminate those antigen.
This finding opens the path to develop effective means of immunotherapy
and improved the diagnosis for lesions, in order to apply the current strategies
34

for the developing of immunodiagnostic, immunotherapy-based treatment

through a infected target cell .
There is now strong evidence that genetic factors are involved in most
infectious diseases and the essential effort for identifying the genes and alleles
influencing the development of human infectious diseases has been carried out.
Progress in the genetic dissection of infectious diseases will also come
from the complementary analysis of the various biological and clinical
phenotypes associated with a given infectious agent, strongly suggesting that
host factors play an important role in susceptibility or resistance to infection.
In order to know the regulation process between different types of
pathogen and the host immune system, as well as the regulation factor of the
cross talk between the different components of the immune response in human
as the host, it is important to get an understanding of the immune genetic
system.
The evidence of the influence of immune genetics to the reemerging
diseases is provided by the following observations :(1) the level of infection often
differs greatly among infected subjects, (2) some infected subjects do not develop
clinical disease, (3) the clinical manifestations of disease (severity, time to onset,
duration of disease etc) may differ greatly among symptomatic patients.
In particular, advances in genomic, proteomics and immunology have
helped a better understanding mechanisms of pathogenesis, host immunity, and
drug resistance in order to identify new drugs target and developed new
vaccines and diagnostics.

Neurosciences
One of the new revolution in medical science is neuroscience which is
supported by the biotechnological advances , have brought us great promises
but genuine concerns as well. It has many discipline developed like behavior
science/ psychology, human development , oncology, communication system etc
and have a grand callenges in the future
The level development of neuroscience has advanced rapidly and
provided tools with which to explore two different approaches to CNS tumors is
immunology and molecular biology. The present focus is at the molecular level
and to exploit genetic abnormality of the malignant cell, by means of highly
35

specific diagnostic, treatment and prevention. Over expressed or mutated

proteins or mutated oncogen growth factors receptors in CNS tumors,
molecularly defined as foreign antigen; TAA (tumor associated antigen) yield
rational as a target of specific immunologic reaction and also has been
encountered as correct presentation and co stimulatory / danger signal.

Nano Medicine
Nanomedicine is the use of nanotechnology to achieve innovative medical
breakthroughs and has a great clinical application. ( L Zuo et al, 2007)
The monitoring, repair, construction and control of human biological
systems at the molecular level using engineered nano devices and
nanostructures. Application of nanoscale technologies to the practice in
medicine especially the diagnostics, prevention, treatment and to gain
understanding of complex underlying diseases mechanism
Actually the Nanomedicine based on the advanced of Nanotechnology
research and development at the atomic, molecular, or macromolecular levels in
the sub -100-nm range (0.1-100 nm) to create structure devices and systems that
have novel functional properties The design, characterization, production and
application of structures, devices and systems by controlled manipulation of size
and shape at the nanometer scale .
The areas of potential development of nano medicine are: devices and
nano sensors for early point-of-care detection of disease and pathogens,. Also the
identification of novel biologic target/receptor / ligands for imaging diagnostic
and therapy, construction of multifunctional biologic nanostructure, devices and
system for diagnosis, and combined drug delivery (theranostics). The
Nanotechnology for tissue engineering and regenerative medicine, biomemitic
nanostructure from understandingof biologic systems

Recommendation
In order to enhance the health services, a Catholic Physician or medical
professional needs the value proposition, especially the human dignity. For this,
faith implementation and updating the medical knowledge with a strategic plan
to determine the value of the contributions and how it improves overtime.

36

References :
1.
Andorno R (2009). Human Dignity and human rights as common
ground for a global bioethics. J of Med and Phil. p 1- 13
2.
Bregman EY (2004) . Genetic databases and Biobanks ; Who
controls our genetic privacy ? Articles
3.
Collins FS, Green ED, Guttmacher AE, Mark SG (2003) . A vision
for the future of genomics research. A blueprint for the genomic era. Nature, vol
422, p 835 -847
4.
Dawson K (1987). Fertilization and moral status : a scientific
perspective. J of med ethics, 13, p 173 -178
5.
Martin G, Bergman A, Barzilal N ( 2007). Genetic determinants of
Human health Span and Life Span : Progress and New Opportunity. Plos
Genetic, www.plosgenetic .org, July, 3, issue 7, e125
6.
Morinaga S (2008). The current debate on Human Embryo
Research and Human Dignity. J of Phil and Ethics in Health and Med. 3, p 3-23
7.
Pullman D ( 2010). Human Non- Person, Feticide, and the Erosion
of Dignity. Bioethical Inquiry, 7, p 353 364.
8.
Tower J, Arbeitman M ( 2009). The Genetics of gender and life
span. J of Biol. 8 , article 38 ( doi:10, 1186/jboil 141)
9.
Staudt LM (2001).
Gene expression physiology and
pathophysiologi of the immune system. Trends in immunol. ,22, p 35 -40
10.
Zuo L, Wei W , Morris M, Wei J, Gourbounov M ( 2007). New
Technology and Clinical Application of Nanomedicine. Med Clin N Am , 91, p
845 - 862

37

PAPER OF MAIN SESSION

Session 1 : Challenges of Catholic Doctors in Upholding Biomedical Ethics

Challenges of Catholic Doctors:

From Ethics to Bioethics

Agustinus Ryadi
Widya Mandala Catholic University Surabaya - Faculty of Philosophy
gusrynew@gmail.com

The important thing is when the storm comes, never scroll on the sail.
Take it as a challenge! Who knows it will be a blessing for you. (Kartajaya,
Hermawan, Grow with Character: The Story, PT Gramedia, Jakarta, 2010, p.243)

I write this paper for 15th AFCMA (Asian Federation of Catholic Medical
Association) Congress 2012 on October 18 21, 2012 in Denpasar, Bali, Indonesia.
I was asked to present a speaker, on Friday, October 19, 2012. The theme of the
15th AFCMA Congress 2012 is Challenges of Catholic Doctors in the Changing
World.
My question is What is the meaning of challenge? Challenge is
something that needs great mental of physical effort in order to be successful and
which therefore tests a persons ability. I think, the challenge of Catholic doctors
is the lack of leisure. If Catholic doctors have some leisure, they will be able to
understand better about ethics and bioethics. For this reason, I will discuss the
lack of free time and how to solve it. Further, I will clarify the specific challenge
of Catholic doctors in ethics and bioethics.
01.
The Lack of Leisure
Catholic doctors nowadays are people with no more leisure 21. All of their
time is stuffed with works, pursuing needs, ambitions, and dreams. Their hectic
21

Leisure derived from Greek word schole

38

life makes them robot like operated by work machine. Catholic doctors are
dragged and dictated by wild time (Vulgaeres Zeitverstandnis - Martin
Heideggers term) that they are not able to live a deeper life.
However, some Catholic doctors respond it with this answer, We enjoy
our leisure time freely and openly at malls, plazas, night clubs, etc. according to
Zygmunt Bauman (Celia Lury; 1998), malls and the kinds offer commodities
tagged with certain price, that make consumers not free anymore. Price tags lock
the consumers freedom, especially to decide. Price tags (daily hectic, Martin
Heidegger uses the term Besorgen) push down and define time.
Leisure (Fransiscus Simon, 2007) filled with discussing about truth and
effort to carry it on; reflecting about many life events which have, being, and will
occur activities which is now being vanished. Leisure time is now being crashed
repeatedly and massively by consumerism logic. Catholic doctors are now being
sick because they dont have time to discuss about ethics truth and bioethics as
well as to try to foster them. And thus, they are not able capable of developing
the rational morality.
The awareness of leisure has been known by classic Greek philosophers,
especially Aristotle (384BC-322BC). He has dreamt that his people have
abundant leisure. The reason is work consumes all the time and with working
man does not have leisure for the republic and friends (adopts Xenophons
words). However, can we expect this nowadays? We are expecting to enjoy or
even celebrate moments of meditative, contemplative, and romantic as the rites
of liberating man from the prison of work.
02.
The Specific Challenges of Catholic Doctors in Ethics
I limit the topic with three challenges of Catholic doctors in ethics, the
ambiguous attitude of the Faculty on the medical ethics; Catholic doctors are the
subject of morality, and ethics that is diminished into obligatory ethics (legality,
law).
First, medical ethics as a subject has only recently been put into the
medical faculty curriculum although medical doctor is the oldest profession in
the history that pays special attention to ethics. It was only in 1960s when
biomedical ethics was adopted as a topic at the study and research at the medical
faculty. It was started from United State 22 and then spread out all over the world.
This is because humaniora 23 position is weak in the academic world. The speedy
22

Bertens, K., Etika Biomedis, Kanisius, Yogyakarta, 2011, p.28

Humaniora is a science that intended to humanize human, confirmed Tjaja, Thomas Hidya, Humanisme
dan Skolastisisme: Sebuah Debat, Kanisius, Yogyakarta, 2004.

23

39

and fascinating development of empiric science and technology is definitely the

main cause of it. Consequently, the medical faculty curriculums are stuffed with
these developments and yet still more space to be provided for medical-technical
developments in the curriculum.
Second, Catholic doctors do not grow as the subject of morality as they
always ask have I accomplished all the medical duty, law, and ethical code?
They are striving with moral questions, regulations, or norms or principles to
obligate. Consequently, they fail to verify on what reasons they should obey
certain rules. Utilitarianism, for example, does not answer why someone has to
do moral act, but rather answers what should be done if he wants to do moral
act. Therefore, Catholic doctors do not have the awareness as the subjective
moral.
Subjective moral is a specific self-awareness; its perspective about the
world is specific. Therefore we need to change that perspective to be beyond the
subjective moral. Moral interpretation does not only try to decide on how a man
should live, but also put life as the subject in a boarder and meaningful picture 24 .
We have to get beyond subjective moral. Because I is the interpretation
and it is defining the starting point of an interpretation. The I who is aware is
not all being for the self. I agree with F. Nietzsche (1844-1900) to get beyond the
government and communicating directly to the lower parts - especially the
body if we want to have a better knowledge about the self-territory. To get
beyond subjective moral is being oneself, with acknowledgement that one self is
the achievement of himself.
Third, the problem faced by ethics is the biased development. Modern
ethics becomes ethics based on principles and obligations only, because it is
stressing on obligations only and in this case always searching for relevant
principles, for example, I. Kants deontology ethics. According to Kant (17241804), an act is moral if it is done because of respecting moral law only. A man
acts morality when he realizes he is under moral law and does the moral law for
the respect of the moral law itself. The attitude deserves to be regarded as the
real morality because obligation is done for obligation.
This attitude is autonomous because a person obeys moral law not
because of there is an authority that demands it, but rather because he himself is
aware it as an obligation. He, as individual, is responsible toward his own
reason, is and is not aware of his obligation, and what he is aware as an
obligation does not obligate. A person does his obligation not for the sake of a
24

Poole, Ross, Moralitas & Modernitas di bawah Bayang-bayang Nihilisme, Kanisius, Yogyakarta, 1993,
p.164.

40

motive 25 that is obligated from him, but rather for the sake of the obligation
itself. Accordingly Kants ethics is purely deontological 26.
Kants deontological ethics is challenged by utilitarianism. Utilitarianism
is not able to understand Kants discourse about obligation. Obligation for
utilitarianism is whatever giving the best result for humanity. Good results are
counted in the empiric unit of enjoyment. Utilitarianism seems to be more
rational compared with Kants deontology because utilitarianism is able to show
the benefits of moral act. In other word, utilitarianism does not answer why he
has to do moral act, but rather answers to what should be done when a man
wants to do moral act.
Modern ethics always elaborates the question what should I do and
pays less attention to what kind of person should I be? Focuses so much on
how we act every single act is it in accordance with the obligations and
ignores the attitude behind the source of the acts. Therefore, the very exclusive
ethics approach that becomes ethics based on principles and obligations needs
to be transformed into ethics based on virtues and moral character. In other
word, we have to develop and bring back Aristotles virtue ethics 27.
I propose to the Catholic doctors to take time to reflect the ethics. Ethics
does not give definite knowledge so that ethics fails to determine exactly how a
man in a specific situation should act. Ethics can only support in developing
practical wisdom (phronesis) so that the person in a concrete situations capable of
deciding. This ethics supports mans autonomy. Therefore, the knowledge given
by ethics is knowledge in a broad outline (typo).
Besides, Catholic doctors need to totally understand that the purpose of
ethics is not to know what a good life is, but rather how to make people live a
good life. I take the example of Aristotle by comparing ethics with medical
science. Medical science is a science of how to make people healthy it is not a
science of health.
03.
The Specific Challenges of Catholic Doctors in Bioethics
I will discuss three challenges of Catholic doctors in bioethics: the name of
bioethics, the influence of empiricism, and the culture of death.

25

Ethics is no longer able to do its function as the way of man to achieve the substance of truth if it
abandons the theological view about mans intrinsic destiny. Hence, ethics loses its reference to give the
basis on its principles because the guidance loses its function if the road does not have a direction
26
Magnis-Suseno, Frans, Pijar-pijar Filsafat: Dari Gatholoco ke Filsafat Perempuan, dari Adam Muller
ke Post Modernisme, Kanisius, Yogyakarta, 2005, p.267.
27
Virtues focuses on a moral question: What kind of man I should be?

41

Firstly, Bioethics seems to be problematic to consider ethics as an applied

science (applied concept). Ethics may guide and use sciences, but in itself it is a
practical view of life, not as an area of theoretical knowledge. There are two steps
for the enlargement of ethics to bioethics. The first step is to enlarge the ethical
field into a new domain of possible manipulation. The second step is that in
enlarging the ethical field we cannot avoid that biotechnology tends to convert
all living beings human or non-human, into objects of manipulation.
We may use the name of bioethics with biomedical ethics, health-care
ethics, etc. But the most important thing is the goal of the name. Bioethics tries to
think moral problem related to health-care, especially on developing biomedical
science and technology 28. These moral problems may arise in every phase of
human life, but the most problematic ones are the beginning and end of life. If
these kind of ethical problems arise, as responsible human, we should try to find
a reasonable solution. So, the challenge of doctors in bioethics is just the same
with that of ethics, but to be added with the effect of science and technology for
Catholic doctors.
There are two reasons why we should be careful to the development of
modern science and technology. The first reason, every development in modern
science and technology always brings specific positive and negative sides, which
relate to the moral responsibility. Who will be responsible if one day it is proven
that the negative side of the technology be larger than the positive side?
Furthermore, how if that negative side cannot be controlled or withdrawn
anymore? How if this development brings health problems known after so
many years later? Who will be morally responsible with these all?
The second reason, there is something principally can be done, but does
not mean morally be allowed to. What is developed and produced by modern
science and technology, does not mean can be morally developed and applied.
What scientifically can be achieved by modern science and technology, does not
mean morally can be approved and justified to be developed an applied
commercially. For example, ethical problem faced by fertilization in vitro 29: sex
selection, surrogate mother, the protection against uterus rental transaction
(uterus commercialization), where will the excess of embryo which is not planted
in uterus be placed?

28

Bertens, K., 2009, hlm.197.

Robert Geoffrey Edwards is the father of fertilization in vitro, he gives solution for spouses who find
no way to have descendants. See KOMPAS, Thursday, October 14, 2010
29

42

Surrogacy 30 brings a new ethical question, how to prevent the uterus

rental transaction which leads to uterus commercialization. The other ethical
problem, where will we keep the excess of embryo which is not planted into
uterus? As we acknowledge, they take more than one ovum to be fertilized in
vitro to anticipate if there is failure. There can be two, three, or even seven ovum,
all of them united with the fathers sperm in petri plate. However, when
fertilization is successful, there are only two embryos in maximum that can be
planted in the mothers womb. Where are the rest?
Secondly, the doctors are very affected by empiricism. They believe that
the valid science should begin with experience (empeiria). Empiricism becomes
the fundamental sentiment of all forms of scientific research and Catholic doctors
are influenced by it. Empiricism shapes man (read: Catholic doctors) who always
stresses on physical or psychological experience as the factor of their basic
knowledge. All knowledge can be traced through physical experiences. This
means knowledge can be got through experiences, especially through
observation and research.
Man who is used with empiricism has the territory of natural science. This
territory is produced by scientific thought through research process, abstraction,
and objectification. Catholic doctors exclusively put this territory as the territory
of scientific objects which conforms to mechanism law of cause and effect.
Consequently, the objects in this territory can be measured in quantity and
totally manipulated as technical and instrumental matter. Rain, ocean wave,
climate, disease, and man as biological organism are in this territory. George
Lukacs (1885-1971) uses the term reification (materialized) for man in this
territory, because doctors are used to using abstraction and objectification. In
other word, this territory is detached from soul appreciation. The life world
(Lebenswelt) which was being internalized is now gone with this objectification 31.
Eventually, science is no longer to improve knowledge, to broaden the
horizon of mans existence and life, but rather as the medium to increase the
productivity of the commodity production machine. For example, metabolism
research will help us to figure out how big a culture and environment influence
genetic changes. The research can also be used to prevent obesity, metabolic

30

The ethical debate on that two possibilities is very controversial. Many gulf countries allow this kind of
surrogacy to the second wife, but after the Bioethics on Human Reproduction in Islam World Conference,
held in Cairo in 1991, this fatwa is withdrawn, surrogacy of second wife is prohibited. See Mohamad,
Kartono, RG Edwards Membuka Pandora, in KOMPAS, October 12, 2010
31
Hardiman, F. Budi, Melampaui Positivisme dan modernitas: Diskursus Filosofis tentang Metode Ilmiah
dan Problem Modernitas, Kanisius, Yogyakarta, 2003, 0.24-27.

43

syndrome, and especially to improve the health of the next generation. 32 Science,
especially biology does not ask what life is, when life begins.
Yet, we still find people who study bioethics. Eilidh Campbell St. John,
Stuart Blacker, and Dr. Adam Schulman are striving for secular bioethics that is
able to solve all moral dilemma which are brought by medical and biology
technology development. They develop a bioethics which builds moral
principles mainly based on humanity concerns. Meaning, ethical justification on
medical act or research that uses man as the research object is no longer based on
man dignity concept, but rather on a very casuistic examination on humanity.
Dangerously, such a humanity motive often falls into utilitarian
examination that mainly focuses on the as much benefit accumulation that can be
achieved in a medical act. Where as many utilitarian approaches in the moral
problem solving often hurts justice, including man justice categorized as not yet
possesses persona dimension, incapable of thinking rationally, or not yet
autonomous - like embryo 33.
I agree with Robert S. Morison, the challenges of doctors, especially
Catholic doctors in the development of biological technology is in a threat to
make man as a research and experiment object. While bioethics in medical world
itself has switched from probable damage of the unidentifiable persons into more
subtle and complicated problems. Euthanasia, for example, can a doctor be
justified of stopping medical treatment and food supply to a terminal patient?
Can it be justified to stop medical supporting life equipment, or other medical
equipment for a specific patient (not at terminal condition yet)?
The challenge seen by Morison is the secularization of universities. When
the bioethics experts take part in education by teaching and supervising doctors
or biologists candidates, they confront with the positivists 34 who categorize
values questions as meaningless. It will be more dangerous when positivists
dominate the majority strategic decisions in the academic world. Eventually the

32

Aristiarini, Agnes, Uji Genetic Mencari Metabolisme Sehat, dalam KOMPAS, 29-11-2012.
Utilitarianism is very distinctive in Peter Singers opinion. All man belongs to homo sapiens species but
not all of man is persona. Man can be said persona or human person if he has self-awareness, selfcontrol, sensitivity for the future, the reflective awareness of the past, inter-personal ability, communication
ability, and curiosity. Singer, Peter, Practical Ethics, Cambridge Univ. Press, NY, 1979, p.75.
34
The main problem is that social science value free as natural science? The value freedom supporters give
an affirmative answer that if social science wants to be regarded as a science; it has to give normative laws
and scientific predictions as natural science. To achieve this goal, a social researcher has to produce
scientific descriptions and explanations which are fair and not giving any justifications. Hence, a scientist
and researcher should be able to free his feeling, assumption, and moral judgment, so that he gets objective
knowledge about social facts. Hardiman, F. Budi, Menuju masyarakat Komunikatif: Ilmu, Masyarakat,
Politik dan Postmodernisme Menurut Jurgen Habermas, Kanisius, Yogyakarta, 2009, p.28.
33

44

fast and amazing development of empirical science and technology weakens the
ethics.
Thirdly, Catholic Doctors face the death culture. The opposite of it is life
culture. These two terms are from Pontifical Pope John Paul II who takes great
concern to the dignity of mans life (EV, no 50). The death culture is the fact that
there are many death caused by murderer. Moreover, the modern
biotechnologies have created new possibilities of manipulating human life in its
different stages of development, from the moment of conception of a fertilized
human egg to the adult human being. Therefore, the first step is to enlarge the
ethical field to this new domain of possible manipulation.
The threat against life is the Malthusian fright toward the explosion of
population. Professor Thomas Robert Malthus (1766-1834) suggests the family
planning. He describes the danger of the surplus of population compared with
the natural resources which are not able to support the growing of the
population. In Indonesia, the fright of the population explosion haunts the
government that it uses abortion as the medium to control birth (Family
Planning Program 1980-1998).
I suggest the Catholic doctors to take some time to reflect about bioethics,
so that they are able to understand the danger behind the power of available
media and the dangers in biology. Also, that they are aware of how far they can
take the ethical questions arisen from the development of technology and the
orientation toward special problems
Finally, Catholic doctors need to rearrange the strategy that has been, will
be, and now need to be taken. Professor Bone 35 states about the need of the
magisterium of ethical, dialogical, and conscience role commission. The
development of science and technology brings new ethical problems. These
problems demand deeper ethical reflections and a regulation system, too.
Therefore, ethical commissions are needed by the decision makers, governments,
or countries to consults and make decisions.
However, ethical commissions have some certain limitations in consensus
that are not adequate to gain a right and deep agreement. Therefore we need a
pluralistic dialog to give deep ethical judgment on the basic problems. Besides, it
is necessary to promote, educate, and much more urgent, to develop the
conscience, because ethical responsibility on individual conscience is human
character.

35

Bone, Edouard, Bioteknologi dan Bioetika, Kanisius, Yogyakarta, 1998 (Trans. English, 1985), p.72-79.

45

04.

Conclusion

Catholic doctors should take leisure time for soul feed, including
reflecting from ethics and bioethics point of view. When they are trapped in
routine works, they do not have many choices to manifest their selves as they
want to. The expensive leisure time is as expensive as our dignity before the
consumptive objects. In other words, leisure time is only the other part of
excessive mass consumerism. Leisure time has now successfully grabbed the
Catholic doctors.
The way out from the trapping work situation is idleness. Paul Lafargue
(2008): We are lazy in everything, except for love and drink, except (of course)
for idle. We even forget about love and drink which are the content of what
we call as leisure. This could be a warning. Not only for those who chase all their
need and ambitions, but also for who exploit time for never ending works. I
replace Lafargues suggestion with the similar one: We are lazy for everything,
except for ethics and bioethics, and except (of course) for idleness.
It is necessary for Catholic doctors to be habitual (habitus) with ethics and
bioethics. Habitus is a combination of disposition and generative clarification
schemes. Disposition is in human thought, only appears through and because of
the individual practice as the actors and their interaction to each other, with
other elements of the environment. Disposition marks the individual system,
habits, and manner in self-action such as standing, walking, and gestures.
Whereas, generative classification schemes are schemes of order from daily
practices which are deeply internalized especially in the body.

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48

Session 2 : Challenges of Catholic Doctors at the beginning of human life (Panel Discussion)

MEDICAL INTERVENTION IN THE BEGINNING

OF LIFE
Dr. B Triagung Ruddy Prabantoro, dr, SpOG.

INTRODUCTION
Definition of Pregnancy: a state in which the fetus is carried within the body of a
female which is initiated with the process of conception and ended with labor.
Pregnancy starts with the release of the ovum (ovulation) and its contact with the
sperm which is also a live cell. Ovulation normally occurs approximately 14 days prior
to menstruation and is commonly known as fertile period. The ovum is then caught
by the Fallopian tubes and moves towards the ampulla where conception normally
occurs. Semen is released during intercourse and adds up to about 2.5-3 milliliters and
consists of 20 to 45 million sperm cells. Sperm cells last about 48 to 72 hours in the
female genitalia. During ovulation, the mucous surface of the cervix becomes more
watery which allows sperm cells to easily enter the uterus. It takes around 5 minutes for
a sperm cell to reach the ampulla of the Fallopian tubes. The cells which form the lining
of the Fallopian tubes also play a part in enabling sperm cells to easily come in contact
with the ovum and allow conception and the formation of the zygote to occur.
The ovum usually comes in contact with the sperm in the ampulla of the
Fallopian tubes. This process is known as conception and causes the chromosomes of
each of the cells realign itself by finding its corresponding partner which then allows the
growth and development of the tissues and organs involved. Conception produces what
we call a zygote which will grow into a fetus and eventually a baby for the next 280-288
days.
The zygote then evolves into a morula, blastula and then a blastocyst which has a
cavity filled with liquid inside. Blastocysts then grow into 2 types of tissue, the
embryoblast (or inner cell mass which will become an embryo) and the trophoblast
(nutrition provider which will become the placenta) and during this process will slowly
progress to the uterus. It takes approximately 5 to 6 days for the blastocyst to travel from
the ampulla of the Fallopian tubes towards the uterus. Meanwhile, a change occurs
within the lining of the uterus which becomes more fertile and ready to be implanted by
the blastocyst. The insertion of the blastocyst into the lining of the uterus is called

49

implantation /nidation. Implantation occurs on days 5 to 8 after conception and is

usually finished by day 9 or 10.
After nidation, the will-be fetus receives nutrition from the uterus via the
placenta. The placenta produces hormones to help ensure the pregnancy and allows
exchange of oxygen, nutrients and waste between the fetus and the mother. The
complete formation of the fetus occurs between weeks 18 and 20.
The blastocyst gradually develops until the pregnancy is at term. Conception,
nidation and growth and development within the uterus form a continuous chain.

Life starts at the moment of conception is what is perceived by in the Indonesian

version of the Hippocratic oath which states that a physician will respect human life
from the moment of conception.

MEDICAL INTERVENTION
Medical intervention practiced in the beginning of life includes abortion, assisted
reproduction, stem cell therapy, contraception and cloning.

1.

ABORTION

After conception, the zygote may experience nidation in the Fallopian

tubes which may result in ectopic pregnancy and may endanger the mothers life
or otherwise successfully lodges and implants itself in the uterus but is
constantly threatened by spontaneous abortion. Therefore, it is essential for us to
protect the life of an embryo which itself faces lots of challenges to successfully
reach at term age for labor.
In considering practicing intentional abortion there are a few things we
must understand which are as follows:
a.
For those who believe that results of conception and nidation are
parts of life that must be respected and honored will not be willing to follow
through with abortion for whatever reason.
b.
For those who believe that the result of conception and nidation are
not yet living but has potential to live may be willing to follow through with
abortion provided specific reasons.

50

c.
For those who believe that the result of conception is merely a
small part of life may most likely be willing to follow through with abortion
regardless of its reason.
From a universal religious stand point, most faiths do not condone abortion
because it is considered as a vicious form of murder due to the fact that a fetus cannot
defend itself and is at its most vulnerable. In dealing with the increasing number of
requests from individuals to undergo abortion, some countries have legalized abortion
which then becomes the responsibility of the medical practitioners involved and the
patients requesting abortion, minding several specific prerequisites.
Several common reasons to undergo abortion are as follows:

1.
2.

Unwanted pregnancy (unmarried mother, left by partner)

Unknown parentage of the baby (pregnancy which resulted from

rape)
3.
Age of previous child is considered still too young, space between
previous pregnancy and the current is considered too close
4.
Pregnancy occurring while using contraception
5.
Pregnancy not supported by family
6.
Etc.
The act of performing or going through with abortion usually concerns legal
issues, religious views and moral and ethical humane considerations. In Indonesia,
which is ideologically based on Pancasila, the government does not condone abortion
with exception of abortion performed under vital medical indication where the
pregnancy in itself may endanger the life of the mother, among them: pregnancy with
heart, lung, kidney, liver diseases and hyperemesis which may disturb the patient
psychologically or pregnancy as a result of rape. In the event of abortion with vital
medical indication, doctors are asked to perform abortion because to follow through
with the pregnancy will be dangerous and may result in death. Abortion performed by
professional medical practitioners will most likely result with no significant
complication other than psychological outcomes such as regret and grievance.
Most people, to rid themselves of the shame of pregnancy may go through illegal
means by going to medicine men/shamans which have no reliable knowledge of the
anatomy of female reproduction system. Experience shows that actions performed by
these said individuals usually resulted in acute complications such as hemorrhage,
infection and sepsis, laceration of the female reproduction system which may cause
secondary risks, and in total contribute up to 40-45% maternal death.
Most of these acute complications need specific medical intervention, which if
done professionally may save the life of the patient. As a long term result that may cause
51

secondary complications are chronic infection which may cause organ adhesion and
may contribute to the disruption of reproductive functions which may result as inability
to become pregnant in the future.
With this elaboration, abortion still poses a controversy between the need to
suppress rapid population growth and the issue of human moral decadence.

2.

ASSISTED REPRODUCTION

When conventional means of sexual intercourse fail to produce offspring,

assisted reproduction may be an alternative to obtain children. Assisted
reproduction enables conception to be done artificially and outside of the human
body. The pros and cons of this method, when perceived through a religious
point of view may be the ultimate deciding factor for many couples in our
society.
Assisted reproduction consists of 3 stages:
1.
First stage
This stage consists of preparation for ovum pick-up which consists of
down regulation followed by stimulation therapy. Down regulation phase is a
process to create a menopausal-like condition in order for the ovaries to be ready
to receive stimulation therapy. This phase occurs for 2 weeks to 1 month. After
down regulation is completed, it is then followed by stimulation therapy. The
goal of this therapy is to induce follicle growth within the ovaries. With
increasing number of follicles, it becomes easier to obtain a mature ovum during
ovum pick-up. The maturation of the ovum is monitored daily through blood
examination of the female patient and also with ultrasonography.
2.

Second stage

Ovum pick-up (OPU). This phase is done when there are 3 or more follicles with
a diameter of more than 18 milimeters in the morning and the growth of the follicles are
at similar stages. E2 levels should also be at 200pg/ml which indicates a mature follicle.
The ovum pick-up is done by inserting a syringe through the vagina using
ultrasonography as guidance. After the ova are extracted, those ova are then fertilized
with the male sperms extracted from the female patients partner, spouse or sperm
donor, all of which has previously been processed and selected. The ovum and the
sperm which has been put together in a petri dish is then allowed to reproduce within
an incubator where it is monitored for the next 18 to 20 hours and after 24 hours it is
expected to result as a fertilized egg.
52

3.
Third stage
Post OPU stage. This stage consists of 2 phases which are embryo transfer
and pregnancy supporting drugs. The embryo transfer phase is a process which
inserts 2 or at a maximum 3 to 4 embryos which have been selected into the
uterus. After the process is completed, it is then followed by pregnancy
supporting medication which prepares the womb to be able to accept the embryo
implantation in order for the embryo to be able to commence a normal growth
and development. If in the next 14 days menstruation does not occur, an
examination of -HCG and urine and in the following week an ultrasonography
is done.

3 types of assisted reproduction techniques which are commonly used are as

follows:

1.
In vitro fertilization (IVF)
When using this technique, 50.000-100.000 sperm cells are joined with one
ovum in a petri dish filled with culture medium which then results in
conception. The advantage of this technique is that it is easily done, relatively
cheap and there is no manipulation of the ovum (natural). However, if the sperm
cells involved have defects, it is difficult for the sperm cells to go through the
barriers of the ovum which may hinder the occurrence of fertilization.
A development of this technique which uses PZD (Partial Zone
Dissection), the sperm cells are sprayed into the ovum after a crease is made in
the ovums wall to enable easier contact between the ovum and the sperm.
Another technique is SUZI (Subzonal Sperm Intersection) where the sperm cells
are injected directly into the wall of the ovum. However, even this technique has
yielded less than satisfying results.
2.
Intra Cytoplasmic Injection (ICSI)
This technique is done by injecting one sperm into one ovum which then
results in conception. The advantage of this technique is that it enables a male
donor with azoospermia (no presence of sperm cells within extracted semen) or a
very low number of sperm cells with poor quality to achieve better results. ICSI
must be accompanied by a direct extraction of sperm cells from either the
testicles or reproductive ducts.

53

There are 2 techniques commonly used to extract sperm cells: MES

(Microsurgical Sperm Aspiration) where sperm cells are directly extracted from
the epididymis and TESE (Testicular Sperm Extraction) where sperm cells are
extracted from the testicles.
ICSI is difficult to be done because it requires a specific device called the
micromanipulator which eventually results in higher cost.
3.
In Vitro Maturation (IVM)
This technique is relatively new and is done by allowing the ovum to
mature in the laboratory before it is fertilized. The success rate of this technique
is considered very rewarding. The procedure is simple, where it only takes one
menstrual cycle which in turn can reduce the use of hormonal drugs. The cost is
also relatively cheaper compared to IVF.
The overall success rate of assisted reproduction with the development of
medical technology is approximately 25-50%.

3.
STEM CELL THERAPY
Definition: Stem cells are undifferentiated cells which own the potential to
grow and develop into various types of cells of the body.
General characteristics of stem cells:
1.
Possesses the ability to differentiate into other types of cells, stem
cells may transform into various mature cells such as nerve cells, myocard cells,
pancreas cells, etc.
2.
Possesses the ability to regenerate itself which enables the stem cell
to make an exact copy of itself by cell division
Types of stem cells

A.
Classification based on ability to differentiate
1.
Totipotent: cells which may differentiate into all types of cells (e.g.
zygote/fertilized ovum)
2.
Pluripotent: cells which may differentiate into 3 germinal layers
(ectoderm, mesoderm and endoderm) but cannot become extra-embryonic tissue
such as the placenta and umbilical cord (e.g. embryonic stem cell)
54

3.
Multipotent: cells which may differentiate into many types of cells
(e.g. hematopoetic stem cells)
4.
Unipotent: cells which may only differentiate into 1 type of cell, but
unlike non-stem cells, the unipotent stem cell has the ability to regenerate itself
(self-regenerating and self-renewing)

B.
Classification based on cells origin
1.
Zygote which is the stage immediately after conception
2.
Embryonic stem cells which are cells extracted from the inner cell
mass of a blastocyst. This is usually obtained from unused embryos from IVF
procedures. However, a technique has been developed in order to extract the
embryonic stem cells without endangering the embryo. In the future this may be
something to consider in the ethical debate of embryonic stem cells
3.
Fetus which is a development of the embryonic phase until
immediately before labor. Fetuses are usually provided by abortion clinics
4.
Umbilical blood stem cells which are stem cells obtained from
placental and umbilical blood immediately after the fetus is born. Umbilical
blood stem cells are hematopoietic stem cells and some classify these cells as
adult stem cells.
5.
Adult stem cells which are cells extracted from a mature tissue,
among them the bone marrow. Stem cells from bone marrow consists of 2 types
of cells: hematopoietic stem cells and stromal stem cells (mesenchymal stem
cells). Other tissues such as the central nervous system, fat tissue, skeletal
muscles and the pancreas are also considered to contain adult stem cells. Adult
stem cells have a plastic characteristic, which means that other than
differentiating into cells of its origin it may also differentiate into other types of
cells.

The Role of Stem cells in Research:

1.
Gene therapy
Stem cells (in this matter, hematopoietic stem cells) are used as a
transgene carrier into the patients body and afterwards are monitored to see if
these stem cells prevail to express certain genes within the human body. Due to
stem cells owning a self-renewing quality, gene therapy does not have to be

55

administered repeatedly. Hematopoietic stem cells can differentiate into various

types of cells; therefore the transgene is able to inhabit many types of cells.
2.
Understanding biologic processes namely the development of an
organism and cancer growth. Using stem cells, we can learn the fate of cells, both
normal and cancerous cells.
3.
Discovery and development of new drugs where stem cells may be
used to learn the effects of drugs towards various tissues.
4.
Cell therapy in the form of replacement therapy. Because stem cells
are able to live outside of the human organ in a petri dish, manipulation of the
stem cells may be done without disrupting the human organs. Manipulated stem
cells may then be transplanted into the human body to deal with certain diseases.

There are 3 types of diseases that can be managed using stem cells:

1.
2.
3.

Autoimmune diseases
Degenerative diseases
Malignancy (leukemia and other blood illnesses)

Reasons behind stem cell usage in cell-based therapy

1.
Stem cells can be obtained from the patient himself/herself which
leads to an autologous transplantation where potential rejection can be avoided.
Stem cell transplantation can be done without a suitable organ from a donor.
2.
Stem cells have a vast quality for proliferation where from
minimum sources, a large number of cells can be yielded (e.g. in vast burn
injury)
3.
Stem cells are easy to manipulate to replace genes which are no
longer functioning by means of gene transfer
4.
Stem cells have the ability to migrate to the target tissue, integrate
into the tissue and interact with surrounding tissue.

Advantages and disadvantages of using certain types of stem cells in cell

based therapy
Advantages of embryonic stem cells:

1.

Easily obtained from fertility clinics

56

2.
Pluripotential which enables it to differentiate into all types of cells
of the body
3.
Immortal with a long life span and in culture can proliferate
hundreds of times
4.
Low possibility of rejection
Disadvantages of embryonic stem cells

1.
May incite tumor. Every contamination of embryonic stem cells
with an undifferentiated cell may cause cancer
2.
Always allogenic which can potentially cause rejection
3.
Ethically controversial
Advantages of umbilical cord blood stem cells:

1.
Easily obtained (supported by a large number of umbilical cord
blood banks)
2.
Ready to use because the stem cells have already went through
prescreening, testing and freezing
3.
Minimal virus contamination compared to stem cells taken from
the bone marrow
4.
Easily extracted, poses no risks or pain to the donor
5.
Risk of GHVD (graft versus host disease) is comparatively lower
than stem cells taken from bone marrow and transplantation can still be done
even though the HLA does not match perfectly
Disadvantages of umbilical cord blood stem cell:

1.
2.

Possibility of contracting genetic diseases

Limited number of stem cells yielded

Advantages of adult stem cells:

1.
2.
3.

May be extracted from the patient to avoid immunological rejection

Already specialized which simplifies induction
Poses no ethical debate

Disadvantages of adult stem cells:

1.
Limited number of stem cells yielded
2.
Shorter life span compare to embryonic stem cells
3.
Multipotential which means that capability to differentiate is not as
versatile as the pluripotential cell
57

4.
CONTRACEPTION
Contraception is defined as means to avoid conception with the help of
devices or drugs. It is also commonly called anticonception.
Requirements of an ideal contraception:
1.
Safe and reliable
2.
No side effects
3.
Duration of action can be set at will
4.
Does not interfere with sexual intercourse
5.
Needs no medical assistance or tight control during use
6.
Simple usage
7.
Cheap so that it may be available for all members of society
8.
Accepted by the couple as recipients

The success of a contraception method depends on whether or not semen and/or

sperm cells may be intercepted disabled or killed in order to not enter the fertilization
arena or whether or not the ovulation occurs in order for the ovum to be able to meet the
sperm cells.

Several methods of preventing pregnancy:

a.
Avoiding to spill semen inside the vagina-abstinence and coitus
interruptus
b.
Avoiding the female fertile/ovulation period- calender system/
Billings ovulation method
c.
Covering the cervix to avoid the sperm from entering the uterus
and fallopian tubes-diaphragm, cervical cap
d.
Killing the sperm cells inside the vagina-spermicide
e.
Preventing conception and/or nidation-Intra Uterine Device (IUD)
f.
Suppressing or diasbling the sperm cells-male birth control pills
g.
Suppressing ovulation so no ovum is released-hormonal
contraception
h.
Cutting, tying, or clipping the fallopian tubes or vas deferenspermanent contraception.

58

Types of contraception:

1.
Coitus Interruptus
Method: Withdrawal of the penis from the vagina before ejaculation
occurs. The semen is intentionally spilled outside of the vagina in order to
prevent sperm cells to enter the fertilization arena. This can be done because
ejaculation is usually a conscious reflex for most men.
Effectiveness: failure rate: 18-38%
2.
Postcoital Douche
Method: Spraying or irrigating the vagina using water or a solution
containing disinfectant and spermicide immediately after coitus with the goal to
remove all semen out of the vagina
Effectiveness: failure rate: 31-61%
3.
Prolonged Lactation
Method: breastfeeding an infant as long as possible . during breastfeeding
the possibility of pregnancy to occur will be lower. The reason behind this is not
entirely clear.
Effectiveness: ?
4.
Avoiding Ovulation (Billings Ovulation Method)
Method: this works by monitoring the classic signs and symptoms that
occur during fertile period and otherwise in one menstrual cycle. To avoid
pregnancy, abstinence is practiced during the fertile period of every menstrual
cycle.
Effectiveness: failure rate:0-7%
5.
Condom
Method: the condom acts as a sheath that covers the penis during coitus
which in turn will prevent semen from entering the vagina because the semen is
contained within the condom.
Effectiveness: failure rate: 15-36%
6.
Diaphragm
Method: both the diaphragm and the cervical cap act as a barrier against
semen to prevent it from entering the cervical canal. To enhance their effectivity,
spermicide may be applied on the cap.
Effectiveness: failure rate: 9-34%
59

7.
Spermicide
Method: spermicides can disable and kill sperm cells, cover the cervix and
also change the consistency of the vaginal mucus so that it does nor pose ideal
conditions for sperm cell activity and mobility. Spermicides are applied as deep
as possible into the vagina and concentraated in the posterior fornix
approximately 5 minutes prior to coitus.
Effectiveness: failure rate: 3-30%
8.
Contraceptive Pills
Method: suppresses ovulation, increases the viscosity of the cervical
mucus and prevents fertilized ovum from implanting itself in the uterine wall.
Effectiveness: failure rate: 0.1-0.7%
9.
Contraceptive Injections
Method: Suppressesovulation,increases the viscosity of cervical mucus,
thins the endometrium which results in its inabilty to be implanted and also
blocks tansportation of a fertilized ovum.
Effectiveness: failure rate: 0-0.8%
10.
Implants
Method: Suppresses ovulation, increases the viscosity of cervical mucus
and disturbs the formation of endometrium which eventually prevents
implantation.
Effectiveness: failure rate: 0-0.04%
11.
Intra Uterine Device
Method: Acts as an obstacle for sperm cells to enter the Fallopian tubes
and prevent implantation into the uterine wall.
Effectiveness: failure rate: 1.5-3%
12.
Tubectomy
Method: a procedure is done on both Fallopian tubes to prevent a meeting
between the ovum and sperm cells
Effectiveness: failure rate: 0-0.4%

60

13.
Vasectomy
Method: both the left and right vas deferens are either tied or cut so that
the semen ejaculated no longer contains sperm cells.
Effectiveness: almost 100%

5.
CLONING
Cloning is a technique of creating offspring with the same genetic code as
its parent. This can be done to plants, animals and humans. In other words,
cloning duplicates the same genetics of an organism and replace the nucleus of
the ovum with the nucleus of another cell.
The goal of cloning in plants and animals is basically to enhance the
quality of those said plants and animals, increase its productivity and to search
for natural medication for many human diseases especially chronic illnesses in
order to be able to replace chemical drugs that may have side effects harmful to
the human body.
Human cloning is a technique to produce offspring with the same genetic
code with the human parent. This can be done by taking a somatic cell from the
human body and extracting its nucleus and implanting it inside an ovum which
has been rid of its own nucleus with a method similar to fertilization and
artificial insemination.
With this method, human cloning can be performed by taking the nucleus
of an individuals somatic cell and insert it into an ovum taken from a female
donor. With specific chemicals and electric shocks, the nucleus is fused with the
ovum. Afterwards, the combined nucleus and ovum is transferred into the
womb of a woman so that it may replicate, grow and differentiate until it
becomes a complete human fetus. This fetus may be delivered naturally and will
have the exact genetic code as the parent in this case the donor of the somatic cell
nucleus.
The first cloned human was given the name EVE, a girl who is now 5
years old. So far she hass been healthy is now in kindergarten in the suburbs of
Bahamas. However, the truth behind this claim has yet to be verified.

61

The debate between scientists regarding cloning is continuously ongoing

even when concerning animal cloning let alone human cloning. The group
against cloning tends to think that cloning will have negative impacts on life.
Some of their arguments are as follows:
Destroys human civilization
Treats humans as objects
If cloning is done on humans, it is not impossible to find that in the
future humans will be nothing more than mechanical beings created at will by
those who have capital. This is seen as a threat to humanity
Cloning will incite a sense of domination among one group over
another. Cloning is usually done on humans with special abilities or physical
traits and it is a concern that these humans created from cloning might feel
more superior and it is not an impossibility that these clones may even be
superior in all walks of life.

On the other hand, the people that agree with cloning argues as follows:

Cloning is now needed especially concerning organ transplant

Cloning is expected to be the solution to save endangered species
Cloning can be a solution for infertile women that wish to have a
biological child

Cloning therapy
Cloning therapy is also known as Somatic Cell Nuclear Transfer (SCNT) and has
the goal to avoid risk of rejection.
In cloning therapy, the nucleus of an ovum is replaced with the nucleus of the
recipients cell (for instance taken from the buccal mucosa). Afterwards the ovum is then
charged with electricity until the ovum experiences DNA reprogramming and
consequentially becomes a blastocyst. The inner cell mass is then taken as an embryonic
stem cell and inserted into the recipients body until it differentiates into the cells of the
wanted organ (myocard cells, pancreas cells). This procedure will likely result in no
rejection from the recipient because the cells planted possess the genetic material of the
recipient himself or herself.

-o0o62

ABSTRACT
Pregnancy is a state in which the fetus is carried inside the female body which is
preceded by the process of fertilization and ended by labor. The role of the medical
profession in pregnancy in this modern age is significant whether in assisting pregnancy
and labor or in other medical interventions concerning pregnancy and early human life.
Some of the known medical interventions in early life are abortion, contraception, in
vitro fertilization, stem cell therapy and cloning. These medical interventions have long
been subject of ongoing public debate. Religious views often weigh heavily in
consideration of going through with these interventions both for the patients and also
for medical professionals. It is a challenge faced by Catholic doctors everywhere, to be
both professional and scientific but also to practice the teachings of the Church. In order
to do so, it is essential to fully comprehend when exactly does human life begin, what
medical interventions in early life are and how they affect human life at its earliest stage.
Life is generally perceived to begin at the time of fertilization and interventions such as
abortion, contraception, in vitro fertilization, stem cell therapy and cloning in one way
or another intervene with this process. It is therefore of great importance to be able to
have moral values and standards as a focal point of consideration in determining
whether or not these interventions may or may not be done.

63

Medical Intervention in the Beginning of Life

( Clinical Aspect )
Victoria Edna G. Monzon, M.D.,FPCP, FPCC, FSGC, ACP
Professor, Dept. of Bioethics & Dept. of Medicine
Faculty of Medicine & Surgery, University of Sto. Tomas, Manila ,Philippines

In our usual daily practice we are often confronted with problems

affecting two lives whom we take care of as in those cases of high risks
pregnancy. Some of the high risk pregnancies are: Pulmonary hypertension
either primary or secondary to a Congenital heart disease with Eisenmengers
syndrome, Marfans syndrome with aortic vessel anomalies,
peri-partal
cardiomyopathy , valvular heart disease with or without congestive heart
failure, hypertension of pregnancy as in preclampsia or eclampsia and other
causes of hypertension and also cervical, ovarian and uterine cancer in a
pregnant woman. For the interest of time I will just limit my discussions to the
commonly encountered problems in high risks pregnancy confronting us
Catholic physicians attending to such kind of problems specially now a days
when most textbooks in obstetrics advocate termination of early pregnancy in
these high risks cases. We know that direct abortion or termination of non-viable
pregnancy to be able to avoid further danger to the mother cannot be morally
justified. The deliberate and intentional destruction of the unborn child is
professional misconduct.
Let us discuss the case of a pregnant cardiac with chronic valvular
disease in pregnancy . Ideally we should evaluate the patient clinically as to how
severe the lesion is and what can possibly happen when the woman gets
pregnant. For those who are contemplating on getting pregnant they should
undergo cardiovascular assessment including their functional capacity. In
symptomatic patients further cardiac workups should be done to assess the
anticipated risk of pregnancy and must be discussed with the patient and her
husband . Those who are asymptomatic but with severe valvular obstruction
may be adviced to undergo the intervention like percutaneous mitral balloon
valvotomy or if it is not feasible mitral valve surgery. For those with moderate

64

lesion but still asymptomatic the mitral valvular area and exercise tolerance may
be taken into consideration and regular follow up has to be advised.
In those patients who are already pregnant , adequate evaluation of her
cardiovascular status must be done . For those who are asymptomatic proper
control of their heart rate, reduction of left atrial pressure , blood volume
reduction by salt restriction and judicious use of oral diuretics Aggressive use of
diuretics must be avoided to prevent hypovolemia and reduction of uteroplacental perfusion. Mitral valve balloon valvotomy or mitral valve surgery
may be offered if symptoms persist inspite adequate medical treatment. These
issues have to be discussed by the attending obstetrician, cardiologist and
anesthesiologist and once they have come up with a consensus this have to be
discussed with the patient and her husband/ family.
Another issue to be handled is the timing and mode of delivery. The
obstetrician , cardiologist and anesthesiologist have to discuss it with the patient
for a free and informed consent. Vaginal delivery with epidural anesthesia and
shortening of second stage of labor is safe and can be done in majority of
valvular heart disease patients. Cesarean section is usually done for obstetrical
indications and in cardiac patients with cardiac instability.
Sometimes an emergency cardiovascular surgery may be indicated and
this can be justified in the light of the principle of double effect. The good effect
is the correction of the pathology endangering the life of the mother ( severe
mitral stenosis in congestive heart failure not responsive to the medical treatment
) thus saving her from a more or less dangerous situation. The evil effect may
range from fetal death or premature labor.
If a future pregnancy would be too risky will contraception and
sterilization be the solution to the problem? The answer is no.
The use of contraceptive pills may cause some medical problems some of
which are thromboembolism because of increasing blood coagulability or
hypertension and breast cancer.
Sterilization as a means of preventing future pregnancy that one fears
might aggravate a serious cardiac or renal disease is considered directly
contraceptive and is immoral. It should be understood that when a contraceptive
result is intended as a means to a therapeutic end (sterilization to prevent
pregnancy in the presence of cardiac disease ) the sterilization is directly
contraceptive and is contrary to the moral law. Instead of doing contraceptive
65

sterilization, treatment of the underlying cardiac condition should be done. The

principle of totality cannot rightfully defend a directly contraceptive sterilization
as this is an act of mutilation.
There is no excuse for a catholic doctors to have anything to do with
procedures which are directly contraceptive . Grave scandal is caused by a
catholic doctor who temporizes in this matter. Likewise, a catholic physician
may not instruct or recommend to a patient the use of contraceptives nor refer a
patient to any physician who is willing to do it without compromising his moral
integrity.
Patient should be counselled about possible risk of future pregnancy and
the couple can be taught natural regulation of birth which entails no side
effects, no expense , 99% effective and brings the couple closer to each other
because now the burden does not lie on one of the couples only but more of a
shared responsibility.
The other case I would like to discuss is a case of pregnant patient with
cervical cancer.
Generally the pregnancy does not aggravate the cancer condition of the
mother. However if there is a need to institute definite intervention to save both
the mother and the baby then this is where the attending obstetrician should
recommend what is for the best interest of the mother and the baby. If the baby
will be endangered by the treatment being contemplated and he is already viable
then delivering the baby to avoid more harm can be justified by the principle of
double effect. If the baby is not yet viable and there will be no danger for both
mother and the baby, then temporizing the intervention until the baby is viable
will be another alternative. If however further delay in giving the mother the
chemotherapy will cause more danger to both, then the chemotherapy may be
instituted and can be justified by the principle of double effect. Fear of the toxic
effects of the chemotherapy should not be a reason to terminate a non-viable
pregnancy. The treatment must be of its very nature directed to saving both lives
but if the mother or the baby dies the treatment is not directly destructive of the
life of either.

In some cases induced labor may be indicated and the moral problem
here arises out of the fact that premature delivery constitute some danger to the
baby , depending upon the age of gestation after viability. This can be justified
66

by the principle of double effect. When the fetus has reached the age of viability
two questions have to be asked:
1. Is there any less dangerous method by which the good effect can be
sought with reasonable hope of success?
2. Is there a proportion between the danger to the mother warded off by
the induction of labor and the fetal danger incurred by the procedure?
The third case that I will be dealing with briefly is the case of a
direct assault on a severely defective infant like the case of an
anencephaly. Now a days there are proponents of early or direct
termination of such infants and they use some of them for organ
donation or for research. They claim that it will be causing more harm
to the mother to wait for nine months when after all their lives may not
last long or may not even survive even after delivery. However early
termination of such pregnancy is a form of direct abortion and is not
morally justifiable. It is not within the power of a Catholic physician to
directly end somebodys life. No matter how defective the infant is, he is
still a human person and deserves to be respected.

67

Medical Intervention at the Beginning of Life

Fr. David Garca, o.p.

One of the most vulnerable humans today is the human embryo. But not
all would agree with that statement, or at least wont feel any sympathy about it.
The reason? Some academics today believe that not all humans are persons.
Perhaps the most popular proponent of such truism is Peter Singer. Here is a
piece of his mind: The fact that a being is a human being, in the sense of a
member of the species Homo sapiens, is not relevant to the wrongness of killing
it; it is, rather, characteristics like rationality, autonomy, and self-consciousness
that make a difference. Infants lack these characteristics. Killing them, therefore,
cannot be equated with killing normal human beings, or any other self-conscious
beings. () No infant - disabled or not - has as strong a claim to life as beings
capable of seeing themselves as distinct entities, existing over time. 36
This view is by no means an exotic account of an isolated thinker. In fact,
it has become the normal way of thinking even for some Christian philosophers.
Notoriously, Tristram Englehard, a former Catholic and now an Orthodox
Christian has very similar views: Not all humans are persons. Fetuses, infants,
the profoundly mentally retarded and the hopelessly comatose provide examples
of human non-persons. Such entities are members of the human speciesbut
they do not have standing in the moral communityOne speaks of persons in
order to identify entities one can warrant blame or praise. For this reason, it is
nonsensical to speak of respecting the autonomy of fetuses, infants, or
profoundly retarded adults who have never been rational. 37
These views as extreme as they might seem to traditional folks are started
to be accepted naturally by many at academic levels. In the past, the idea that the
human embryo was not alive seemed to have been the idea that fed the right to
terminate human embryos. Today, with the advance of technology and a more
36

nd

Peter Singer, Practical Ethics, 2 ed. (Cambridge: University Press, 1993) pp. 182
37
nd
H. TristramEnglehardt, Jr. The Foundation of Bioethics, 2 ed. (New York: Oxford University Press, 1996),
p. 139

68

biological understanding of embryonic development, that idea seems to start to

fade in the past. More and more scholars seem today inclined to believe that
yes the human embryo is a human being, but that does not give it ipso facto
any rights, since only persons are subjects of rights and duties, and therefore if
human embryos are not persons, they should enjoy no rights, and having no
right to life could be terminated for proportionate reasons.
Can we give a reasonable answer to such a challenge?Practically all
arguments that distinguish between human beings and persons coincide in
assigning personhood to individuals who exercise capacities characteristic of
personhood, whether we talk about being sentient, conscious, autonomous, or
self-aware, etc. So the argument goes that human individuals achieve
personhood only when they exercise characteristics typical of human persons. In
this vein, some humans have not achieved that status while other humans may
have lost it, as in the case of comatose or PVS patients. By the same token, if the
criterion picked for personhood is being sentient, some other beings that are not
humans may exhibit the same traits and thus must be considered persons and
subjects of rights.
The question is then, do humans become persons when they exercise
personal capacities or do they exercise personal capacities precisely because they
are humans?
The answer to this question depends in turn on what we understand by
personhood. If personhood is some kind of arbitrary dignity we assign to some
beings, we may decide to do it because of the exercise of their capacities. For
example, we might think that jumping is a quasi-divine capacity and then we
decide to give kangaroos a special rank among animals precisely because they
are such good jumpers. In such a case, non-jumping kangaroos, like those who
are too young, too old or too arthritic to jump, will be lacking such quasi-divine
dignity. Likewise, we may say that frogs are quite good jumpers too and so
should be next to kangaroos as to dignified beings is concerned.
Is personhood such a quasi-divine dignity? If that were the case, personal
dignity would depend on the exercise of personal capacities, whichever those
capacities are and whoever decides they are. But what makes us persons?
The traditional concept of person since Boethius penned it downin the 6th
century has been an individual substance of rational nature (rationalis naturae
individual substantia). This rational nature makes us persons; not the exercise of
69

the personal capacities. It is the nature of the kangaroo that makes it jump, and
not his jumping that makes him a kangaroo.
Rationality brings along the knowledge of the effects of our actions and
the dominion we can exercise with it. What makes humans persons is their
capacity to have dominion over their actions, and precisely by that dominion
achieve a certain dominion over their lives. No other animal, no matter how
sentient and intelligent, has the capacity to ponder about what to do with its life.
This is the very reason why we dont hold animals responsible even if they
commit terrible crimes and since they are not responsible, they can have no
duties and being incapable of duties are likewise unfit for rights. Responsible
entities are subjects of rights and duties and that makes them persons. We should
respect animals, not because they have rights, but because humans are the only
creatures with the duty to be stewards of the environment and have learned to
become responsible for it.
If humans become persons at some point in life, then human embryos,
comatose patients and even infants will not be subjects of rights and could
therefore be terminated if the situation asks for it. However, if personhood is
something inherent to human beings, then all individuals of the human species
have it and thus they are all subjects of rights.
Applying this to the human person, we could safely say that humans
exercise personal capacities precisely because they are the kind of beings that
have the active potentiality to do that. And even when this active potentiality
cannot be exercised for whatever reason, they are still human, that is they are still
the kind of beings able to exercise personal capacities. If this is the case, we dont
become persons when we start to show personal capacities; we are persons
because we are the only kind of animal that has the intrinsic potentiality to
exercise personal capacities. We are the only personal animal.
At the bottom of associating personal dignity with the exercise of
capacities rather than with the being who exercises those capacities lies the
Nominalistic blindness to the existence of human nature coupled with a
Cartesian dualism of the person.
If, as Nominalism affirmed, there are no universals; that is, if there is not a
certain reality that all humans have in common, which we call human nature,
and human nature is simply a figment of our reason, merely a name we have
decided to create, then obviously, only particular individuals exist in total
70

disconnection of other individual of the same species. And if there is no human

nature, no reality what all humans share, human dignity can only be assigned to
particular individuals case by case. And if the dignity of being human is assigned
to the capacity to think, or being autonomous, then only individuals who
exercise that thinking or that autonomy enjoy the dignity of being persons, while
those who fail momentarily or permanently to exercise that autonomy are not
persons momentarily or permanently.
The implications of these philosophical distinctions are crucial to the
future of human kind. Our civilization prides itself of having conquered new
heights of the appreciation of human dignity. We dont consider people of other
races inferior because they are different. Women are only relatively recently
allowedto vote because we have come to understand that we are all equal
indignity. Such a statement that we often take for granted is precisely now more
challenged than ever. If humans who cannot exercise personal capacities are not
persons, we are not all equal in dignity. As long as we associate rights with the
exercise of certain capacities, there will always be unjust discrimination against
those who fail to exercise such capacities.
In this regard, we should ask ourselves where this idea that we are all
equal in dignity come from. We can trace it back officially, at least as back as the
4th century. Lactantius, a Christian author, and advisor to Roman emperor
Constantine I, was already aware of the connection between the Christian beliefs
and human equality: Equity is not to judge aright, but the virtue of being equal
to all () God, who has created and given life to all men, has will that all were
equal () This is why there could not be justice for Greek and Romans. They
allowed to a diversity of degrees: poor and rich, humble and powerful, citizens
and princes. They were not all equal and there was no equity. 38
Perhaps it is not surprising that precisely when Christian ideas are being
neglected a parallel neglect of human dignity and equality is supplanting it. It is
not only the status of the embryo what is at stake but the very personal dignity of
human beings.
Being stewards of fellow human beings at the beginning of life means to
care for them as what they are: the kind of beings that enjoy personal dignity,
which is equal in all human beings and makes them inalienable subjects of rights,
38

Lactantius, DivinarumInstitutionum, liber V, c. 15

71

including the right to life. A right that can never be violated by other human
precisely because all humans have the same basic human dignity of being
persons, whether or not they can exercise the capacities of that dignity.
But even the firmest and soundest ethical principles will not solve all
particular problems. Very often, genuine and well-meant therapeutic
interventions have undesired side effects that complicates the process of decision
making. The physician will equally need to know to what extent is his
therapeutic intervention truly right and when he should refrain intervening lest
something morally worst may happen.
That problem in itself is arguably the most difficult issue in Catholic and
secular ethics. So, let us be realistic and confine ourselves to the bare and
minimum essentials regarding this topic.
Doing good while tolerating unintended wrong side effects have been
traditionally understood under the application of the so called principle of
double-effect and the principle of cooperation with evil. Both principles are, I
believe, closely related. The application of these principles, however traditional
in the Catholic Church, is by no means clear-cut and lots of uses and abuses have
been derived from it. One of the most enlightened and insightful analysis of such
principle is the Medalist Address of E. Anscombe in 1982 39.
The typical example at stake would be the removal of a Fallopian tube in
cases of ectopic pregnancies, knowing that the embryo in such tube will entail
the death of the embryo. Other typical scenarios involve hysterectomy in
pregnant women, the so called indirect or therapeutic sterilization, etc.
In all this cases there are a good goal in mind (the therapeutic procedure),
a due proportion between benefits and harms and a wrong side-effect that is
tolerated but must not be intended. What is crucial in this application is to avoid
falling into the proportionalistic temptation of justifying doing some evil in order
to achieve good effects. So, pivotal in the application of this principle is that the
wrong done must be a side-effect, or at least, not be the means by which the good
goal is achieved.
But, why is of such importance not to do a bit of wrong to achieve better
results?Because, while results may change the world, voluntary and intentional
actions change the agent who performs them into a better or worse person, a
39

E. Anscombe, TheMedalistAdress: Action, Intention and Double Effect. 1982

72

more moral or immoral person. So, what is intended and unintended in our
actions becomes crucial in the moral calculation of human acts.
And therein lies the problem. Can I just say that I kill an embryo to save
the mother, but the killing was unintended since I felt terribly sorry about it?
Obviously not. What we intend does not depend on our wishful thinking or
emotional reactions. We intend not only the goals of our actions but all the
means by which we achieve such goals. In the famous example of Aristotle, the
captain of the boat may decide to throw his cargo overboard to save his boat and
his crew during a storm, and no matter how reluctant he is, his act of throwing
the cargo overboard is voluntary, and we will have to say, voluntary and
intended. Or could we say he threw the cargo unintentionally?
In the same vein, in a realistic world where multiple effects are
interconnected, we can hardly choose to do something that is altogether and
under all circumstances good. Every time we do something good, some bad
consequences may follow and some of these will be foreseeable. These
foreseeable, undesired side-effects must be necessarily tolerated in many cases. If
we intend to do something that is simply impossible. Travelling involves
polluting the air, and often contributing to the depletion of non-renewable
resources, and still we choose to do it because we think there is a proportion
between the good we will do and the evil side-effects we must tolerate.
To sum up, while we must not intend to do any wrong, we often need to
tolerate some wrong side-effects. The bottom line is that the wrong done is worth
doing because of the greater benefits, and most importantly, is not the means to
achieve the good goal we intend to achieve in the first place.
In practical terms, and for the practice of health care in the beginning of
life, this means, that we must never kill a human embryo even for the gravest
cause because it is equal to all human beings in dignity and because we must
never do wrong, even with good intentions. The logical implications of this
conclusion mean that any act done to the embryo that is not directly
therapeutical to the embryo will be an offense to its dignity. Therefore all kinds
of experimentations on human embryos, embryonic stem cell research and
therapeutic cloning would be clearly unethical.

73

Challenges at the beginning of human life

viewed from bioethical aspect
Fr. Joseph Tham, LC, MD, PhD
Professor, School of Bioethics, Regina Apostolorum Pontifical university, Rome
Fellow, UNESCO Chair in Bioethics and Human Rights
Visiting Professor, Holy Spirit Seminary College, Hong Kong

In this paper, I will discuss four challenges that can be observed. 1) The
secular and Catholic divide that gives rise to two contrasting visions of bioethics:
the secular vision based on utilitarianism and materialism, whereas the Catholic
vision is based on natural law and human dignity; 2) This divide is most evident
in beginning of life issues, on the moral status of the human embryo defined
functionally or metaphysically; 3) another related challenge is the ambivalent
role of science and technology as it confronts ethics, which often becomes a will
to power nihilistic approach; 4) Finally, there is the recent question of
intercultural dimension of bioethics, of whether there can be global or universal
ethics in the presence of cultural diversity and plurality.
First, there is the secular and Catholic divide that gives rise to two
contrasting visions of bioethics. Many societies have undergone a process of
secularization where religion increasingly plays a less important role in society.
In many places, the voice of religious groups is not taken seriously. In the areas
of bioethics, the dominant views tend to be liberal and secular. This vision is
often utilitarian and materialistic. That is, the human person is not considered to
not have intrinsic value, but his value is dependent on his contribution to society.
In that light, using embryos that are destined to die would provide use to
science, and babies born with anencephaly would be useless and should be
aborted in the first place. On the other hand, the Catholic vision is based on
natural law and human dignity. Everyone is valuable in the eyes of God, because
he is created in Gods image and likeness. Hence, Catholics believe in equality of
all persons, irrespective of their appearance, usefulness, age, or gender. This
divide is seen for example, in the debate on human rights. While the secularists
wish to include abortion and gay rights, Catholics insists on the inclusion of the
right to life of the unborn.
74

Second, the secular-religious divide is most evident on the moral status of

the human embryo.
The Catholic tradition based on natural law and
metaphysics understand human life at the moment of conception. Thus, the
embryo deserves respect and protection because it has intrinsic dignity. The
secular vision however understand personhood functionally, thus for some
writers such as Peter Singer, the unborn, the anacephalic child, the newborn, the
mentally handicapped, and the comatose are not persons, whereas higher
primates such as a chimpanzee are persons. He bases this definition on the
presence of certain functions such as intelligence, self-awareness, or capacity for
decision making, etc. This latter position is increasingly taking hold in society
because the traditional concept of nature has been challenged since the advent of
evolutionary theories. Nature is no longer viewed as something static and
unchanging, but if we were evolved, then human nature can changewe are just
highly evolved animals. Thus, we can also engineer our evolution further by
using technology to re-create humanity, towards a perfect race. This is already
happening with the technologies of IVF, preimplantational genetic diagnosis
(PGD), embryonic stem cells, cloning and synthetic life. With the addition of
nanotechnology, cybernetics, and neuroscience in the mix, the possibility of
creating a new human racetranshumanismis becoming more and more
likely.

Another related challenge is the ambivalent role of science and technology

as it confronts ethics. There is the tendency of scientific positivism or scientism,
which claims that only in science can truth be found. Science is also progressive
and beneficial to society, and therefore no limits should be placed upon it,
including ethical ones. Science has become the new goddess in society, replacing
religion, as evidenced by the amount of money societies spend on healthcare.
Thus, technological means are thought to enable us to eliminate all sufferings
and delay death. There is however an ambivalence towards modern technology
which can save us or destroy us. Technological progress is accompanied by an
exalted understanding of freedom and choice. Hence, we often see a will to
power scenario in bioethics, where ones desire or will, coupled with
technological power, translate to means she can perform rightfully what is
possible. An infertile couple who wills to have children employs reproductive
technology (power) to produce offspring, a couple who does not want more
children uses contraception or sterilization (power) to control their future, a
woman undergoes abortion (power) to eliminate the unwanted pregnancy,
75

and a scientist wills to synthetic life or cloned humans by means of technological

powers at his disposal. Will to power means that truth is what I make it to be,
since there is no longer objective truth outside of me. Hence, moral relativism
(there is no truth) will eventually lead to nihilism where nothing under the sun is
objectionable.
Finally, in the presence of cultural diversity and plurality, there is the
question as to which religion or worldview on bioethical issues is correct. For
instance, not all religions consider the embryo in the same way Catholics do. In
this situation, we are faced with the question of whether there can be global or
universal ethics that transcends all cultural differences. In todays globalized
reality, this question is becoming more pressing. Pope Benedict XVI has spoken
repeatedly on the importance of the intercultural dimension of bioethics.
Western societies face this challenge more acutely than Asian societies because
Christianity was the dominant worldview in the former but a minority in the
latter. Asian Catholics can therefore assist the universal church in this area on
how to avoid the pitfall of religious syncretism and yet reject moral pluralism.
These are some of the challenges facing the Church at the beginning of
life. As a response to these challenges, there is a need to engage culture and to
influence it in the direction of culture of life. Two initiatives in this direction
have recently been launched by the UNESCO Chair in Bioethics and Human
Rights. The first is a Bioethics, Multiculturalism and Religion Workshop
organized, to be held in Hong Kong in December, 2013 with participation of
bioethics scholars from seven religions to discuss these important issues.
www.unescobiochair.org The second is the Bioethics Global Art Competition
inviting artists to portray through artistic medium these bioethical values, as the
modern world is quite sensitive to artistic representations. www.bioethicsart.org

76

Session 3: Challenges of Catholic Doctors at the end of human life (Panel Discussion)

END OF LIFE ISSUES IN THE TERMINALLY ILL

A CLINICIANS DILEMMA
ALEX DELILKAN, MBBSS(Spore), FRCA, FFARCS, FANZCA, FFARACS, FAMM
Rtd. Chair Professor, Anaesthesiology & Intensive Care, Universtiy of Malaya, Kuala Lumpur
Founder-President, Malaysian Chapter (in formation), International Association for the Study of Pain
(IASP)
President, MedicoLegal Society of Malaysia (2001 2004)
Emeritus Prof Anaesthesiology/Critical Care (conferred 2004), University of Malaya/UMMC Kuala
Lumpur, Malaysia

Introduction
One must understand that as clinicians, we are advancing in Critical Care
(Pre-operative Care, Resuscitation, Intensive Care and Pain Relief) or Caring for
the Critically Ill and that paradoxically new problems or ethical clinical
dilemmas are emerging what is life, what is death, the difference between
dying and death, who decides who lives and who dies?
The terminally-ill patient (e.g. the cancer patient) with an irreversible
unrelenting underlying disease process who is in pain poses peculiar and special
challenges as well as clinical dilemmas for the medical care-giver. Curative
therapy must take a back seat as palliative therapy (e.g. pain relief) becomes
paramount.
The end-of-life issues in the cancer patient dying in pain can be viewed
from the following aspects medical, ethical, legal and economic. The doctorpatient-relatives relationship can influence the medical/clinical dilemmas which
can even lead to a clash between medical ethical principles and the law. In our
countries where the law is often silent on such issues, one has to fall back on
common law.
The underlying cancerous disease process usually with metastases is
beyond containment, reversibility and cure. The management of pain in a dying
patient is, in such a situation, the crux of the ethical issues. Today, pain relief in
77

terminal cancer patients (depending on where the origin is and which organ is
involved) is more possible. Newer and better modalities/drugs/techniques are
available. Chronic pain relief teams are organised (surgical / medical
oncologists, anaesthesiologists / psychiatrists / psychologists / mood
counsellors / alternative medicine) and should be brought in. It is not acceptable
today in Malaysia to state as a solo doctor, I cannot relieve the pain so no
therapy should be provided, either leaving the terminal cancer patient to die in
pain or to terminate the life, to relieve pain and suffering that will justify
euthanasia.
The attitude of the doctor, the patient and the relatives can influence
medicolegal and medical ethical issues such as Futile Therapy (e.g. withholding,
withdrawing) which can lead one towards the slippery slope of euthanasia.

The Doctor
Pain relief is available and effective today and if one cannot provide
adequate palliative care in the dying cancer patient one should refer the patient
to an oncologist or an anaesthesiologist pain specialist, or to a palliative pain
centre/chronic pain clinics which are beginning to emerge in this country.
Everyone thinks he/she knows everything about pain (Hippocrates: to
know is one thing, merely to believe to know is another; to know is science,
merely to believe one knows is ignorance). As such, there is reluctance to accept
that there are others who might know more about pain and pain management in
the cancer patient. In a general hospital, the terminal cancer patient in pain might
also be viewed as a millstone around the neck of the primary specialist in charge
of him or her. Ethically and morally, one should refer the patient to those who
can relieve the pain.
The terminal cancer patient poses the ethical dilemma to doctors as to
whether futile therapy should be withheld, or instituted or withdrawn. It is
usually easier not to start than to withdraw after having started. Futile therapy in
the terminal cancer patient in pain can be considered from two angles curative
or medical treatment (obviously futile in advanced malignancies) and palliative
care or pain relief therapy; the latter is obviously not futile if pain relief is
achieved and the issue of withholding or withdrawing should not arise. The
dilemma doctors face arises when pain relief is not achieved and the terminal
cancer patient is dying in pain. The issue of alleviating suffering by allowing
78

death (treatment, disease, death) to take over or by hastening the event of death
(assisted suicide) brings one to the slippery slope of euthanasia.
The conflicting issues will boil down to a separation of assisted suicide
and euthanasia from palliative care focussing on the intention to cause death and
the intention to relieve pain. Legal issues will focus on the scope of the medical
duty to treat relating to withdrawal and withholding of life-saving and lifesustaining treatment. Regarding palliative care (pain relief) the focus will be on
what would constitute the appropriate standard of care, the causation and the
intention versus the legality of assisted suicide and euthanasia.
The major ethical issues relating to the end of life treatment centre on the
anxieties evoked within the medical personnel (if they are not trained in
palliative care) regarding the responsibility for causing death. An added
dilemma arises when there is a clash between the pharmacological
understanding of the nature and use of opioids versus the lingering myths and
fears of these analgenics/sedative medication producing addiction, tolerance,
dependence or even death (irreversible cardio-respiratory arrest of brain death).
To deal with the terminal cancer patient dying in pain and the multiplicity
of ethical issues, one must bear in mind the feeling of the patient and the
relatives. The patient often harbours feelings of abandonment, anger (why me?),
guilt (sins of the past?), fear (impending death) plus pain (inability to sleep). The
feelings of the relatives will revolve along love, responsibilities, frustration,
bearing the burden.
One of the greatest satisfactions in life is when one succeeds in relieving
the pain of a terminal cancer patient (in misery because of pain-interrupted
sleep). My hair still stands on end recalling one such patient grabbing and
attempting to kiss my feet in gratitude, saying Thank you doctor. Now, I can
finally SLEEP!

References:
Medical Dilemmas in the Evolution of Critical Care
- Medical Ethical, Moral, Cultural Beliefs and Potential MedicoLegal Issues
- Some Malaysian Experiences
by Alex Delilkan, Unipress Publishing, 2009, 124 pp

79

Ordinary and Extraordinary Care in Chronic Illness

: Perspective of Moral Theology
Rev. Dr. Stephen Fernandes

1.0. Introduction
With the rapid advances of scientific and medical knowhow it is possible
to manage and treat patients with technological procedures and devices such as
dialysis, tubal feeding, cardiopulmonary resuscitation (CPR) and mechanical
ventilation. However, these therapeutic interventions may impose a physical and
psychological burden on the patient and also a financial burden on the patient
and his/her family. Many patients and their families face dilemmas in making
the right ethical decision in choosing the appropriate and affordable medical
intervention that respects the dignity of the person. Applying the ethical
principles of non-maleficence (avoiding harm), beneficence (doing good), moral
discernment and informed consent is necessary to implement the proper
functioning of medicine in a humane society. The medical profession is urged to
follow norms that give primacy to the welfare of the patient in medical decision
making.

This paper is an attempt to explain the difference between ordinary care

and extraordinary care in the case of chronic illness. It will first clarify what is
chronic illness. Then it will shed light on the various ethical concerns involved in
life prolonging treatment and the ethical options available to the patient and his
/her family.

2.0. Chronic Illness Today:

Chronic illness is on the rise today. It is a human health condition that is
persistent or lasts for a very long time. Usually such illness cannot be cured
completely and is a leading cause of death. Most chronic illnesses are not caused
by infection. Examples of chronic illnesses include heart disease, diabetes, cancer
80

arthritis, Alzheimers disease, Parkinsons disease, sickle-cell anemia, chronic

respiratory disease, chronic kidney disease, chronic fatigue syndrome,
osteoporosis, HIV/AIDS and multiple sclerosis. In addition to medication, many
of these conditions can be improved through diet, exercise, and healthy living. A
chronic disease often requires extensive care by a healthcare provider. Accepting
that one must live with the limitations of a chronic illness can be emotionally
challenging. Depression is one of the most common complications of chronic
illness. On the other hand, terminal illness is a medical term to describe a disease
that cannot be completely cured or adequately treated and is expected to result
in the death of the patient within a short period of time. Diagnosis with a
terminal illness can be very traumatic for a patient and his or her family. It
disrupts the familys equilibrium and creates a crisis for the family. Knowing
how to offer comfort and provide emotional and spiritual support to a loved one
who has a terminal illness can be challenging. Terminally ill patients are offered
palliative care which provides pain relief and other measures designed to make
the end stages of terminal illness as comfortable as possible.

3.0. Ordinary and Extraordinary Care in order to prolong life

What duties do patients have to preserve their lives? What duties do
doctors and healthcare professionals have to preserve the lives of patients under
their care? The term 'ordinary' care is used to describe those means of prolonging
life which are morally required in view of the duty of the doctor and/or patient
to respect human dignity and preserve human life and health. The term
'extraordinary' is used to describe those means or measures which are not in this
way morally required. 40 Documents of the Churchs Magisterium clearly
distinguish between ordinary and extraordinary treatments. In 1957 in a
Congress of anesthesiologists Pope Pius XII gave a general criteria for
distinguishing treatments which are ordinary and extraordinary: normally
one is held to use only ordinary means (to prolong life) according to the
circumstances of persons, places, times and culture that is to say, means that do
not involve any grave burden for oneself or another. A stricter obligation would
be too burdensome for most men and would render the attainment of the higher,
more important good too difficult. Life, health, all temporal activities are in fact
subordinated to spiritual ends. On the other hand, one is not forbidden to take
more than the strictly necessary steps to preserve life and health, so long as he
40

Helen Watt, Life and Death in Healthcare Ethics: A Short Introduction, Routledge, New York, NY: 2000.

81

does not fail in some more important duty. 41 According to Pope Pius XII
ordinary medical treatment is treatment which offers reasonable hope of benefit
to the patient without imposing unacceptable burdens on the patient or others,
whereas extraordinary medical treatment is treatment which imposes intolerable
burdens on the patient and others. Extraordinary pain or discomfort or fear
which can accompany medical treatment or the financial cost of treatments to the
patient and his/her family can involve excessive burden. In such cases, there is
no obligation for a patient to take measures to promote life and health. The
burdens to the patient may vary greatly from one individual to another. There
are some patients who have great fear or repugnance at the prospect of losing a
limb through amputation and for them such a procedure could be considered as
extraordinary. The degree of repugnance which is sufficient to justify refusal of
amputation by an elderly patient with a limited life-expectancy may not be
sufficient to justify refusal by a younger and/or healthier patient. 42 A treatment
or life-sustaining measure can also be extraordinary if it is very hazardous or
disruptive for the patient. Thus, if a medical treatment has a high risk of making
a person permanently unconscious, the person could rightly refuse such
burdensome treatment and opt to live his or her life consciously. 43 A treatment
can also be extraordinary when it is futile to continue such treatment or the
burdens are disproportionate to the benefits. For example, when one is dying of
an illness, does he or she have the obligation to accept treatment for a second lifethreatening condition which is at a less advanced stage? Or resuscitation of a
terminal patient may impose burdens which, though not great, are excessive in
relation to the slight prolongation of life it may achieve. The aim in deciding not
to resuscitate may not be to shorten the life of such a patient, but merely to
withhold a treatment which is thought to promise insufficient benefit.

Further, Pope Pius XII maintained that life, that is, physical, bodily life is
subordinated to spiritual ends. What the Pope meat was that treatments that
prevent a person from pursuing the spiritual goal of life and at the same time
disabling the person would be extraordinary because of the terrible burden it
would impose on that patient. But preventing a noncompetent patient from

41

Pope Pius XII, The Prolongation of Life: An Address to an International Congress of Anesthesiologists,
1957.
42
Helen Watt, ibid.
43
William May, Catholic Bioethics and the Gift of Human Life, Our Sunday Visitor, Indiana, 2000, p. 255

82

bleeding to death or giving a patient antibiotics to combat flu would surely be

ordinary treatment. 44

The Declaration on Euthanasia by the Sacred Congregation for the

Doctrine of the Faith reaffirmed the traditional Catholic teaching that intentional
killing of innocent persons, for whatever reason, is always gravely immoral.
However, it stated that one is not obliged to use all possible means to preserve
and prolong human life. The Declaration explains the criteria for rightful refusal
of medical treatments. It affirmed that it would be possible to make a correct
judgment in order to determine whether the means used are proportionate or
disproportionate, but for that one has to study the type of treatment to be used,
its degree of risk, the cost of the treatment and its expected result and the state of
the sick person and his or her moral resources. 45 In judging what is ordinary
(proportionate) treatment and extraordinary (disproportionate) treatment in a
given circumstance, it is essential to consider the perspective of the patient and
the benefits and burdens of the medical treatment he/she receives. In other
words, judging rightly requires assessing whether the burdens of a treatment are
reasonable to accept in light of the hoped for benefits. Hence, in order to make a
right moral decision for the refusal of medical care it needs a detailed study of
concrete facts related to the specific treatment of the patient.

4.0. Is Artificial Nutrition and Hydration (ANH) part of Ordinary Care

or Extraordinary Care?
The Pontifical Academy of Sciences has also affirmed that necessary care,
including nutrition and hydration, is obligatory in the event of a permanent and
irreversible unconscious state, even when administered artificially. 46 According
to the Catechism of the Catholic Church even if death is thought imminent, the
ordinary care owed to a sick person cannot be legitimately interrupted. 47 The
Charter for Health Care Workers, published by the Pontifical Council for
Pastoral Assistance to Health Care Workers in 1995 states that nutrition and
hydration, even if administered artificially, are part of the normal care always
44

Ibid.
Sacred Congregation for the Doctrine of the Faith, Declaration on Euthanasia, 1980.
46
See Working Group, The Artificial Prolongation of Life and the Determination of the Exact Moment of
Death (October 1921, 1985), in Scripta Varia 60, ed. Pontifical Academy of Sciences, xxvii 114.
47
Catechism of the Catholic Church, no. 2279.
45

83

due to a sick person when they are not burdensome to him or her: their undue
suspension could constitute a true and proper act of euthanasia. 48

The Pontifical Academy for Life in the document Respect for the Dignity
of the Dying, published in December 2000, states the following:
The approach to the gravely ill and the dying must therefore be inspired
by the respect for the life and the dignity of the person. It should pursue the aim
of making proportionate treatment available but without engaging in any form
of overzealous treatment (cf. CCC, n. 2278). One should accept the patients
wishes when it is a matter of extraordinary or risky therapy which he is not
morally obliged to accept. One must always provide ordinary care (including
artificial nutrition and hydration). 49

In March 2004, Pope John Paul II during an International Congress on the

vegetative state stated:

I should like particularly to underline how the administration of water

and food, even when provided by artificial means, always represents a natural
means of preserving life, not a medical act. Its use, furthermore, should be
considered, in principle, ordinary and proportionate, and as such morally
obligatory, insofar as and until it is seen to have attained its proper finality,
which in the present case consists in providing nourishment to the patient and
alleviation of his suffering.

The obligation to provide the normal care due to the sick in such cases
includes, in fact, the use of nutrition and hydration. 50

48

Pontifical Council for Pastoral Assistance to Health Care Workers, Carta degli operatori sanitari (Charter
for Health Care Workers) (Rome: 1995), n. 120.
49
Pontifical Academy for Life, Respect for the Dignity of the Dying (2000), n. 6
50
John Paul II, Address to the Participants in the International Congress on Life-Sustaining Treatments
and the Vegetative State (March 20, 2004), n. 4

84

For Pope John Paul II, the provision of food and water is not a medical act
but part of ordinary care.

On 1 August 2007, the Congregation for the Doctrine of the Faith in a

response to the U.S. bishops affirmed that the administration of food and water
is obligatory to the extent to which, and for as long as, it is shown to accomplish
its proper finality, which is the hydration and nourishment of the patient. The
document stated:

When stating that the administration of food and water is morally

obligatory in principle, the Congregation for the Doctrine of the Faith does not
exclude the possibility that, in very remote places or in situations of extreme
poverty, the artificial provision of food and water may be physically impossible,
and then ad impossibilia nemo tenetur. However, the obligation to offer the
minimal treatments that are available remains in place, as well as that of
obtaining, if possible, the means necessary for an adequate support of life. Nor is
the possibility excluded that, due to emerging complications, a patient may be
unable to assimilate food and liquids, so that their provision becomes altogether
useless. Finally, the possibility is not absolutely excluded that, in some rare cases,
artificial nourishment and hydration may be excessively burdensome for the
patient or may cause significant physical discomfort, for example resulting from
complications in the use of the means employed. 51

It is clear that there is a grave obligation to administer artificial nutrition

and hydration insofar as it attains its proper finality, which is to nourish and
hydrate. Thus, it is morally obligatory to provide by tubal means food and
hydration to persons said to be in the "vegetative state" (now called post-coma
unresponsive state) in order to sustain their lives. Such provision of food and
hydration is not a treatment but is part of the ordinary care that ought to be
given to sick and debilitated non-dying persons. By withdrawing artificial
nutrition and hydration, the person will certainly die, not because of his or her
pathology, but because of dehydration and undernourishment. In principle,
51

Congregation for the Doctrine of the Faith, Commentary on Responses to Certain Questions
Concerning Artificial Nutrition and Hydration (2007).

85

artificial or assisted nutrition and hydration is a proportionate or ordinary means

of preserving life. The Vaticans Charter for Healthcare Workers clearly states the
the administration of food and liquids, even artificially, is part of normal
treatment due to the patient when this is not burdensome to them: their undue
suspension could amount to euthanasia in a proper sense. 52

But the Magisterium does not exclude the possibility that, in very remote
places or in situations of extreme poverty, the artificial provision of food and
water may be physically impossible, or due to emerging complications, a patient
may be unable to assimilate food and liquids, so that their provision becomes
altogether useless. 53 For example, when nutritional and fluid balance can be
restored only with severe burdens for the patient. This would include those who
need artificial nutrition and hydration near the time of death and is accompanied
by terminal pulmonary edema, nausea and mental confusion. In such instances,
James Childress and Joanne Lynn and physicians David Watt and Christine
Cassell affirm that providing fluids and nutrition is extraordinary life support. 54

5.0. Can Terminal Sedation be Justified for those Suffering Intolerable

Pain?
Terminal sedation is the administration of sedatives to terminally-ill,
conscious patients, whose pain cannot be otherwise relieved, to alleviate
suffering, but with the effect of inducing unconsciousness. Such a patient with
severe pain and suffering is sedated to a level of complete unconsciousness. The
intent of administering the drug is to relieve pain, not to produce
unconsciousness or accelerate death. 55 The Church teaches that no one is under a
moral obligation to refuse pain medication and accept physical pain as a means
of purification and mortification. Pope Pius XII, in his 1957 allocution on
analgesia stated:

52

Pontifical Council for Pastoral Assistance to Healthcare Workers, The Charter for Health Care Workers
(Rome: Vatican Press, 1995), no. 120.
53
Congregation for the Doctrine of the Faith, Commentary on Responses to Certain Questions
Concerning Artificial Nutrition and Hydration.
54
James Childress and Joanne Lynn, Must Patients Always be given Food and Water? The Hastings
Report 13 (October 1983), p. 17 -21. See also Peter Hung Manh Tran, Advancing the Culture of Death,
Pauline Publications, Mumbai, 2006, p/ 317.
55
See Americans United for Life Pain Medicine Education Act (2011).

86

Pain prevents the obtaining of goods and higher interests. It can be that it
is preferable for such a person and in such concrete situation; but in general, the
damages that it causes force men to defend themselves against it; undoubtedly it
will never disappear completely from humanity, but one can put its harmful
effects in narrower limits. 56

Death is often preceded or accompanied by severe and prolonged

suffering. Physical suffering can become so severe so as to cause the desire to
remove suffering at any cost. However, according to Christian teaching,
suffering especially during the last moments of life has a special place in Gods
saving plan. Some Christians prefer to limit their dosage of painkillers in order to
freely accept part of their sufferings and thus associate themselves with the
sufferings of Christ. However, such heroism cannot be imposed on people.

The intensive use of painkillers has the following 2 possibilities: i)

Administering pain-relieving drugs in deliberately high doses so that death will
occur is euthanasia. ii) However, the use of medication, consistent with the rule of
double effect 57, when the dying patient requires doses of medication that might
unintentionally hasten death, is affirmed, provided that the intention is only to
relieve specific symptoms such as pain or shortness of breath, and the suffering
caused by these symptoms is proportionately grave. By definition this is not
euthanasia.

John Paul II's teaching on the use of pain-killing drugs is instructive:

56

Pius XII, Allocution to Doctors on the Moral Problems of Analgesia (February 24, 1957), available from
the Catholic Association of Doctors, Nurses, and Health Professionals, Asia branch, http:// www.acimasia.com/Allocution_To_Doctors.htm.
57

The following is the double effect criteria: i) The drug is administered to relieve pain (the intention is
good); ii) The direct effect of the drug is to relieve pain (the object is good); iii) There is no other
reasonable available way of relieving pain that does not risk such drastic side effects and the dosage is
proportionate to severity of pain and increasing tolerance to the treatment (i.e. not an overdose) (the
means are proportionate); iv) Death is not directly intended but a merely foreseeable side effect.

87

... it is licit to relieve pain by narcotics, even when the result is decreased
consciousness and a shortening of life, "if no other means exist, and if, in the
given circumstances, this does not prevent the carrying out of other religious and
moral duties". In such a case, death is not willed or sought, even though for
reasonable motives one runs the risk of it: there is simply a desire to ease pain
effectively by using the analgesics which medicine provides. 58

Sr. Cecelia Marie Scaduto has given guidelines for the licit use of terminal
sedation as an end-of-life option for persons who are terminally ill and are
imminently dying, as the last option and in the most extreme circumstances for
the purpose of relieving excruciating pain and suffering and only under the
following conditions: 59

A terminally ill individual must be imminently dying and

experiencing intractable physical pain. It would not be licit to administer
terminal sedation to a person who is experiencing psycho-spiritual suffering.

All other licit means for pain control have been tried and have
proved to be ineffective for adequate pain relief.

Psychological and spiritual counseling and social support services

have also been provided and have proved to be ineffective in helping to control
pain.

Before receiving terminal sedation, the person must have fulfilled

moral, family, and religious obligations.

Full disclosure of the benefits and risks of terminal sedation have

been discussed with the individual, and informed consent has been obtained.

A DNR order has been obtained if it was not already in place.

However, ordinary life-sustaining treatments must be provided unless

they are determined to be too burdensome to the patient.

58

John Paul II, Evangelium Vitae, No. 65.

Sr. Cecelia Marie Scaduto, Terminal Sedation can be Licit in Ethics and Medics,
Vol. 35, No. 6, p. 3-4.

59

88

6.0. A DNR Order and the Prolongation of Life: Should a patient in an

emergency situation always be resuscitated?
A do-not-resuscitate (DNR) order is usually executed when death is
imminent. Life sustaining treatment is withdrawn from a patient either in a
terminal condition or in a permanently unconscious state when a medical
practitioner signs a do-not-resuscitate order on the request of the patient or his
representative, if the patient lacks capacity. The life-sustaining treatment
typically withheld is cardiopulmonary resuscitation (CPR). 60

CPR is administered both in the hospital for patients suffering cardiac

arrest or outside a hospital by healthcare rescue workers to a person who stops
breathing or whose heart stops because of cardiac arrest. Then drugs, machines
and other means will be used to try to restart them and this is called CPR. CPR
very often saves lives of patients suffering from cardiac arrest. The question is
whether CPR, despite its good effect of saving a cardiac victim's life, is always
the morally right thing to do and in the true best interests of the patient. The
Vatican Declaration on Euthanasia explicitly emphasizes that a person (or
his/her proxy healthcare decision-maker if the person is incompetent) can
rightly refuse treatments that do not offer a reasonable hope of benefit or involve
an excessive burden, or impose excessive expense on the family or the
community. An excessive burdensome treatment is a major criteria for
determining whether a proposed treatment is ordinary or extraordinary and
includes the treatment's riskiness, its bad side-effects and bad consequences on
the life of the person and excessive expense that would imperil the economic
security of the patient, the patient's family, and/or the community. 61
Withholding or withdrawing such treatments is not euthanasia. Further, in the
Catholic tradition a means has been judged useless if the benefits it promises are

60

Lisa Gasbarre Black, The Danger of POLST Orders in Ethics and Medics,

61

William May, Catholics and Do-not-Resuscitate Orders, The Moral Principles behind its Ethical Use in
Zenit News, 03 November 2010.

89

nil or if the benefits received are insignificant in comparison to the burdens it

imposes. 62

Thus, a do-not-resuscitate order is morally permissible only if one can

judge that CPR is excessively burdensome for a patient, taking into account his
or her situation and his or her physical and moral resources, or that CPR imposes
excessive financial burden on the family or community. 63

7.0. The Physician Orders for Life-Sustaining Treatment (POLST):

The Physician Orders for Life-Sustaining Treatment (POLST)also known
as Medical Orders on Life-Sustaining Treatment (MOLST) is generating cause for
alarm in Catholic healthcare circles. POLST orders include a DNR order (do not
resuscitate) an AND order (Allow Natural Death) which is to withhold
assisted nutrition and hydration and another order to refuse all antibiotics. The
POLST ensures that the patients wishes are followed. A patient could choose
any of the following three measures: The First Choice, Comfort Measures Only
which means providing only care that would relieve pain and suffering. The
Second Choice, Limited Additional Interventions which includes comfort care
but may also include intravenous IV fluids and antibiotics. The Third Choice,
Full Treatment. includes comfort care, IV fluids, antibiotics, CPR, the type of
breathing support, artificially administered nutrition and all other intensive
medical care measures including transfer to a hospital. It is important to note
that in POLST it is the patients desire to have or refuse CPR, to be taken to a
hospital, and whether or not to receive artificial nutrition. Alternatively, a person
can choose to Allow Natural Death, also known as Do Not Attempt
Resuscitation. On the surface, POLST appears to be a sincere effort to encourage
individuals to plan and address their end-of-life health care needs. However,
POLST has a detrimental effect on Catholic moral teaching in the health care
setting. It makes patient autonomy an enforceable right and gives all patients,
whether terminally ill or not, total control over their end-of-life care. It attacks
the sacred value of human life by allowing individuals to hasten their own

62
63

Ibid.
Ibid.

90

deaths on the basis of their subjective, personal intentions exerted independently

of ethical values of Catholic healthcare. 64

E. Christian Brugger and others have identified seven ethical problems

with POLST orders 65:
i) they may be implemented when the patient is not terminally ill, ii) no
patient signature is obligatory for the actual implementation. This lack of
informed consent is ethically irresponsible iii) no signature is required of a
physician when the order is implemented. Any doctor, nurse practitioner or
physical assistant can sign the document iv) the POLST orders travel with the
patient from one healthcare facility to another. If the documents are not revised
and updated according to the new clinical situations and patients changing
wishes, they risk ordering inappropriate measures v) the orders are effective
immediately vi) the POLST orders are initiated by non-physicians such as
healthcare personnel who have no experience in evaluating patients with
complicated medical problems. Further, they have no knowledge to determine
when the interventions are ordinary care and when they are extraordinary and
vii) they utilize a simple check box format for deciding complex life decisions.

I have chosen the first ethical problem considering the implementation of

POLST without terminal illness for further discussion. This is one of the main
difficulties with POLST is that any patient can refuse any treatment at any time
and that too for any reason whatsoever. First the POLST model excludes the
necessary process of inquiry that the Declaration of Euthanasia demands for
making a good moral decision. 66 Second, POLST allows withholding assisted
nutrition and hydration and also other measures of proportionate care that are
contrary to Catholic teaching. In 2004, Pope John Paul II asserted that
administration of Artificial Nutrition and Hydration (ANH) even by artificial
means should be considered, in principle, ordinary and proportionate, and as
such morally obligatory, insofar as and until it is seen to have attained its proper
finality. 67Third, POLST permits any patient, whether terminally ill or not, to
64

John Paul II, Evangelium vitae (March 23, 1995), n. 2.

E. Christian Brugger and others, Ethics and Medics, Vol. 37, no. 1, January 2012, p. 1
66
Ibid.
67
Pope John Paul II, Address to Participants in the International Congress on Life-Sustaining Treatments
and Vegetative State: Scientific Advances and Ethical Dilemmas, 20 March 2004.
65

91

refuse all life-sustaining care, including antibiotics and even food and water for
any reason including the intention of causing ones own death. Hence, POLST
leads to unacceptable risks to the patient and obliterates the ethical values of
Catholic Healthcare. Thus, the POLST paradigm can be contrary to Church
Teaching.

However, there are others who argue that POLST orders when executed in
a manner that is consistent with good medical practice and Church teaching, can
actually protect the sacred value of life and help patients make sound moral
decisions. 68 They state that the POLST form is a set of physicians orders about
life sustaining interventions and not to forgo these interventions. Also, that
autonomy is important because consent is involved, but autonomy is not
paramount in deciding about patient care.

8.0. Conclusion:
It is so important to provide the sick and the dying comfort, kindness,
compassion and love. Human life is a precious gift of God and we as responsible
stewards of Gods creation should do our utmost best to respect the dignity of
every single person. Modern therapeutic means often poses ethical dilemmas to
the medical practitioner as well as the patient and his or her family. But one
should uphold the value of life. Active euthanasia is morally wrong and should
not be considered a part of the medical practice. The Declaration on Euthanasia
asserts that any action or an omission which of itself or by intention causes
death, in order that all suffering may be eliminated is euthanasia. However,
when death is imminent in spite of the means used, it is permitted in conscience
to take decisions to refuse forms of treatment that would only secure a
precarious and burdensome prolongation of life, so long as normal care due to
the sick person in similar cases in not interrupted. 69 It is crucial to understand
that one can base decisions to forgo or withdraw medical treatment on a variety
of ethical principles. When forgoing medical treatment is ethically acceptable, the

68

Rev. John Tuohey, POLST Orders are not Dangerous, in Ethics and Medics, Vol. 33, no. 10, October 2010,
p. 3-4.
69
Sacred Congregation for the Doctrine of the Faith, Declaration on Euthanasia, 1980.

92

intention is never the death of the patient but rather the cessation of harmful
and/or non-beneficial treatments that is prolonging the natural dying process. 70

70

th

Thomas Shannon and Nicholas Kockler, An Introduction to Bioethics, 4 edition, revised and updated,
Paulist Press, New York, 2009, p. 147.

93

Ordinary and Extraordinary Means

Bioethical Perspectives
Dr. CB. Kusmaryanto, SCJ
Pontifical Faculty of Theology Weda Bhakti
National Bioethics Commission
National Commission of Health Research Ethics
Indonesia

1. Old question with a new face

The question of how far we have to defend life is not a new question but
in the last centuries it has becoming more difficult and complicated. The question
of defending life started to change in the last century because of new medical
technology.
There are some antique topics of defending life such as abortion, war,
murder and suicide which last until now but also emerge some new topics
because of the advances of new medical technologies. In the last century, people
who stop breathing will die but with new medical technologies they can be
resuscitated and kept to live for years.
The social-economical condition of the patient makes even more
complicated because it is possible that poor patient who need more treatment but
cannot afford any longer, what should the do? Does it mean that pro lifers have
to defend life of human being at all cost?
The question is more important since all living beings have rights and
obligation to defend their life against illness and death. There are twofold
reasons for this: Natural reason and Moral (Christian) reason

a.

Naturally:

Let us observe these phenomena:

Plants always lean to sun rise so that it will not die.

94

Animals run away to escape from danger

Human beings always look for medicine to cure their illness and
escape from danger.
All living being, naturally will preserve life and cure their sickness. This
capability is inscribe deep in the center of the existence as the give of the Creator.
Animals need not to learn how to escape from danger. Even they dont have to
exercise to have this capability.
b.

Christian Morality:

Life is a gift from God that is entrusted to human being to be guarded and
developed so that it will fruitful for human race. Since life is a gift, human beings
are not the master and owner of life but only a guardian and servant of human
life. Since human beings do not the master of their life, so they cannot give it to
other people either by murder or suicide. We can conclude that suicide and
murder are contrary to the natural law which is inscribe within human heart
because it contrary to the natural inclination of living beings. But the real
question has not yet been resolved: What does it means to defend life? Do we
have to sacrifice all things to defend life of human beings?
This question is a junction between obligation and limited resources and
the powerlessness of human beings in facing human illness and death.
Obligation can only be imposed if majority of people can do it or can afford it;
otherwise this obligation becomes unjust obligation. One can never be imposed
the obligation beyond their capacity because he/she can never fulfill it. What is
the meaning of obligation if he/she can never fulfill it? We cannot oblige
human beings to fly because human beings cannot fly. They will never fulfill this
obligation anyway! In other words, human beings have obligation as long as
he/she can do it. Something which is extraordinary, unusual, beyond capacity,
cannot be imposed as an obligation.
The fact that there are limited person who can do, it does not mean that
everybody have to do it. Since the ability of people in doing something is
deferent so the limit of defending human live in relation to medication also
different, for example: For poor family, it may happen that spending US $ 1000
for healthcare is extraordinary but for rich people is ordinary. It means that what
is obligation for a person or a group may not be obligation for the other.
We can conclude that the obligation to defend life of human being,
95

practically different from one person to another or from one group to another.
This means that we can do or not do without any (grave) consequences.
The above principle of rights and obligation are also valid in defending
life of human beings. There is a limit to defend life of human being: something
which is extraordinary means because most people cannot do it. In other words:
If most people can do it, it is not extraordinary anymore. It may happen that in a
certain step, we must say, enough so that we dont proceed aggressive and
futile treatment.
Pius XII Address to an International Congress of Anesthesiologists 1957,
said Natural reason and Christian morals say that man (and whoever is entrusted with
the task of taking care of his fellowman) has the right and the duty in case of serious
illness to take the necessary treatment for the preservation of life and health. This duty
that one has toward himself, toward God, toward the human community, and in most
cases toward certain determined persons, derives from well ordered charity, from
submission to the Creator, from social justice and even from strict justice, as well as from
devotion toward one's family. But normally one is held to use only ordinary means -according to circumstances of persons, places, times, and culture -- that is to say, means
that do not involve any grave burden for oneself or another. A more strict obligation
would be too burdensome for most men and would render the attainment of the higher,
more important good too difficult. Life, health, all temporal activities, are in fact
subordinated to spiritual ends. On the other hand, one is not forbidden to take more than
the strictly necessary steps to preserve life and health, as long as he does not fail in some
more serious duty. 71

We can summarize what is ordinary and what is extraordinary:

Medically, a means is ordinary if 72:
1.

Scientifically established

2.

Statistically successful

3.

Reasonably available

71

Pius XII, Riposte ad Alcuni Importanti Quesiti sulla Rianimazione, 24 Novembre 1957, dalam Pio XII,
Discorsi ai Medici, Edizioni Orizzonte Medico, Roma, 1959, pp. 612
72
Russell E. Smith, Ethically Ordinary and Extraordinary Means, dalam dalam Peter J. Cataldo dan Albert
S. Moraczewski (Eds.), Catholic Health Care Ethics: A Manual for Ethics Comittees, The National Catholic
Bioethics Center, Boston, 2001, hlm. 3B/1

96

Ethically, a means is ordinary if:

1.

Beneficial

2.

Useful

3.
Not unreasonably burdensome: physically, psychologically and
cost (economically)

The above criteria have to be fulfilled all in order to be ordinary and

obligation. In other word: lacking only one criterion makes it extraordinary and
not an obligation. The reality of ordinary and extraordinary has to be reviewed
hic et nunc (here and now). It means that what is ordinary yesterday it may
extraordinary now because of the changes in the seriousness of the illness; and
vice versa. Certainly, people may use an extraordinary means as long as there is
informed consent and do not make any unbearable burden for him and others.

2.

Application in clinical setting

The applications in clinical setting of ordinary and extraordinary means

are very important, for example:

Patients and their family do not have obligation to recourse further

medication or hospitalization if they do not have money anymore.

Patient and their family do not have obligation to look for further
medication if there is no more available medication.

Patients and their family do not have obligation to use the newest
and unverified medication

3.

Bioethical Contributions

a.
Interdisciplinary. By default, bioethics is an interdisciplinary
science whose aims are to secure human future (Van Renselaer Potter). As an
interdisciplinary science, bioethics calls for attention on whole human being and
not only medical aspect. It means that medical doctors consideration in making
medical intervention shout not based on medical indication only but also all
97

aspects of human beings: humanistic, socio-medical, legal, religious,

psychological approach and so on Furthermore, the issues of the end of life
involve many aspects of life and cannot be reduced into medical aspect.
It would be inappropriate the medical approach only in the end of life:

The consideration of ordinary and extraordinary means should be

considered not only in medical aspect but also in whole human values

The decision of using extraordinary means, although it may be

used, has to include all of human values

The decision of refusing treatment also has to based on all aspect of

human values.

For this reason, medical students have to learn broader value and
not only medical indications.

b.

Respect for autonomy

Most people agree on the 4 principles from Beauchamps and Childress:

Respect for autonomy, Nonmaleficence, Beneficence and Justice.
Respect for autonomy or respects for person (Belmont Report) have many
things in common but also some slight different. Respect for autonomy means
that whatever decision of the patient should be honored by medical doctors.
Respect for person implies some paternalistic factors so that it is obligation for
medical doctor to persuades patient to choose the most suitable (right and the
best) medication for her/him)
In the case of terminal ill in which some patients are unconscious, the
decision to pursues extraordinary medication should based on the most benefit
for the patient and all members of his family. In other ways, patient and family
has the rights to refuse the medication which burdensome for them. The
application of pure autonomy makes many difficulties in many countries
because of culture, way of life, religious view and habits.
To respect autonomy is to give weight to autonomous persons considered
opinion and choices while refraining from obstructing their action unless they
are clearly detrimental to other. However, not every human being is capable of
self determination because of illness, mental disability, or others circumstances. 98

 vulnerable subject. Such person need extensive protection, even to the point of
excluding them from activities which may harm them. Other person may need
less protection. The extend of protection depend the risk of harm and the
likelihood of benefit.

c.

Nonmaleficence, Beneficence

This is the most ancient of medical ethic with the ancient terminology,
Primum non nocere or above all, do no harm The principle of nonmaleficence
refers to the duty to refrain from causing harm: primum non nocere (above all,
do no harm). It is not enough refraining from dong bad thing (nonmaleficence)
but we have to promote the goodness or legitimate interest of other
(beneficence).
The medical doctors have the obligation to do the best possible medical
intervention for the benefit of the patient and not for the benefit of the doctors. It
means that if medication or drug has no benefit for the patient, it has to be
stopped and not recourse for aggressive treatment. Some medical doctors
because of unhealthy guilty feeling continue to give a precarious and futile
medications. In fact it is contrary to the bioethical principle of beneficence.
The burden of medication is measured not only economically but also
psychologically and culturally. It may happens that a mediation may benefit for
curing the patient but if the procurement of the medication causes unbearable
psychological burden, it become extraordinary. Euthanasia or killing person
contrary to this principle because physician is not doing good but do harm for
the patient. Some time we cannot escape from hurting or doing harm to our
patients in order to cure them.
In this case, it will be judged according to the principle of double effects:

The intention is the good effect and nor the bad.

The action itself is a good action or indifferent

The bad effect is proportionally smaller than the good effect.

The application of pint killer for the dying patient is permitted although it
can shorten life as long as the intention is not shortened life but alleviating paint.

99

d.

Justice

Justice underlines concern about how social benefits and burdens should
be distributed fairly. It does not allow that the sacrifices imposed on a few are
outweighed by the larger sum of advantages enjoyed by many. Therefore in a
just society the liberties of equal citizenship are taken as settled.
Being first virtues of human activities, truth and justice are
uncompromising. These propositions seem to express our intuitive conviction of
the primacy of justice. It includes fairness in distribution and what is deserved.
Justice is fairness conveys the idea that the principles of justice are agreed to in
an initial situation that is fair.
Based on the principles of justice, the consideration of ordinary and
extraordinary means has to consider about the burden and benefit:

It becomes injustice if a father has to sold all of his belonging in

other to finance his dying child while he has 5 other children. The other children
have the rights to have enough food, education and housing.

It becomes injustice for a father to spend a lot of money for

uncertain benefit of a therapy because burden and benefit should be bear
equally.

4.

Concluding notes

Knowing the limit of rights and obligation to defend life is very important
in order not to have unhealthy guilty feeling both physician and families. For the
medical staffs it is important so that they do not perform aggressive and futile
medicine. When the time comes to give up, medical personals do not have to
have guilty feeling. There is a limit in which we can say, Enough! We are not
morally obligate to use all available medical procedures and medications in
every set of circumstances.

Note:
Paper of Dr George Isajiw was not available.
100

Session 4 : Challenges of Catholic Doctors in Promoting Natural Fertility Awareness (Panel Discussion)

Natural Family Planning

A review
Dr Ian Snodgrass
Catholic Medical Guild, Singapore

Thank you for this opportunity to expound on Natural Family Planning

(NFP). We can compare the method effectiveness and risk benefits or the sociopolitical consequences of contraception.
But these are consequentialist
arguments. The Church prefers the Natural Law approach, seeing the person as a
creature of God. NFP is about integrating the person, love, sex and procreation
in marriage. A key phrase in Humanae Vitae describing sex is, ..if each of these
essential qualities, the unitive and the procreative, is preserved, the use of
marriage fully retains its sense of true mutual love...(1) NFP is as natural as sex
and has these same two meanings. But while the procreative meaning is clear
enough, the unitive meaning needs some elucidation. But in view of the
occasion and the audience, I want to use 2/3 of the time on the procreative
meaning ie fertility awareness and 1/3 on the unitive meaning or spirituality
awareness.

The Procreative Meaning.

NFP comprises a number of scientific natural methods of family planning,
all depending on regulating sexual activity according to the wifes immediate
fertile state, to postpone or achieve pregnancy.
Currently in use are
John&Evelyn Billings Billings Ovulation Method (BOM), the Creighton Model
System (CrMS) and NaproTechnology, the Sympto-Thermal Method (STM), the
Standard Days Method, the Two-Day Method and the Lactational Amenorrhea
Method (LAM) for postpartum states.(2) The Cyclotest 2 plus, the Persona (R)

101

fertility monitor and the unreliable Salivary Ferning Test are additional
technological methods.
We teach the Billings Ovulation Method (BOM) which was introduced
nearly 60 years ago after a 1968 paper (Burger et al (3)) and another in 1972
(Billings et al (4)) showed that the rising follicular oestrogen causes a vaginal
mucus discharge to change from cloudy and sticky to stringy and slippery over
an average of 5.6 days, peaking about 37 hrs before ovulation due to negative
feedback on FSH. LH is released and peaks in 16 hrs (range 0-2 days, Catt),
triggering ovulation another 16 hr later or about 0.9 days after the last day of
slipperiness (range -2 days to +3 days Billings 1972).
This slipperiness, the last day being called the Peak day, is called the
Peak Symptom i.e. the symptom related to the LH Peak, because LH was used as
the marker for ovulation. Unlike many other natural methods, the BOM
specifies only slipperiness, diagnosed by asking oneself how the vulva feels,
without wiping with tissue, touching with the fingers or internal examination
and without considering the appearance of the mucus in the identification of the
Peak Day.
The Peak is followed by a sudden change in the symptom, due to the fall
in oestrogen, rise in progesterone producing a G+ mucus cervical plug and the
reabsorbent action of the pockets of Shaw (Erik Odeblad 1964) (5)-(13), although
P mucus and sometimes S mucus may still be present for 1 day. This definition of
the Peak its the day of Ovulation in 80% needs to be borne in mind because
Brown has shown that women commonly have multiple hormone and mucus
patterns, not all of which are ovulatory. The Peak rule for postponing pregnancy
is to avoid intercourse for 3 days following the Peak.
Erik Odeblad, Biophysicist of U of Umea, Sweden, investigated the
biophysical characteristics of the mucus and the cervix around ovulation day
from 1954, using Nuclear Magnetic Resonance (NMR) from 1957. These are
some of his findings:
From 1966, he found 2 single-crypt mucus types the G mucus
(gestagenic) in the lower cervix, of which there are 2 types, the G- before
ovulation and the more cellular G+ due to higher progesterone after ovulation.
The second was the E mucus (oestrogenic) comprising L and S types. The L type
has ferning crystals and is secreted in pearls or loaves which lock in
malformed sperm, while the S type has needle crystals and channels sperm to
102

their crypts in 3-10 minutes. In 1977, he met Dr Kevin Hume while presenting
his GLS system in Sydney and thus began his participation in BOM.
In 1990, he described P mucus and its main subtypes P2 and P6, P2 with
good Friday palm crystals and P6 with hexagonal crystals. P2 mucus,
activated by low oestrogen and Z granules, lyses the cervical G mucus at the start
of the mucus symptom, sometimes removing it as a plug. P6 mucus is activated
by high and decreasing oestrogen at the end of the mucus symptom and releases
sperm from the isthmus crypts after their 15 hours sojourn to continue on their
journey to the tubes.
This mucolysis is possibly effected by its interaction with Z granules from
the cervical isthmus causing cleavage of large P6 pieces into smaller ones, a
process also responsible for the slippery sensation. Continued cleavage may
cause a loss of water retention and slipperiness to a watery symptom. This may
also contribute to the sudden symptom change after the peak.
P6 mucus comprises no more than 5-10% total mucus and production
varies, contributing to variable slipperiness in cycles or in women. The response
to the mucus symptom also depends on body movements, micturition and
coughing or sneezing. Stage fright can also discharge some watery S and P
mucus.
Mucus perception occurs at the surface of the minor labia of the vulva.
The minor labia are innervated by S3/S4 with oestrogen receptors on the dorsal
roots and can be markedly swollen around ovulation time. The total area of the
sensitive part of the minor labia decreases with the Pill and with age and
increases with parity. A personal observation is the effect that tight fitting
clothes and underclothes, such as pantiliners, thongs and G strings, may have on
masking the slippery symptom. We routinely advise our clients accordingly.
The mean number of mucus days also declines with age from 6 at 15 years
to 4-5 at 20 and to 2 at 35 years. The Pill worsens this decline by an extra year for
each year on the Pill, but each pregnancy rejuvenates the Cervix by 2-3 years.
Additionally with age, the amount and stringiness may be maximal on the Peak
day, unlike in the younger woman where it is just before the Peak.
Another event discovered by Odeblad is the appearance of an inguinal
lymph node 1 or 2 days around ovulation day on the same side as the ovulation
in 70%. This may help in overcoming infertility and avoiding ovulation on the
side of a damaged tube.
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Cervical F (foetal) mucus comprises 1-4% and has no special function

but may cause a continuous unchanging discharge in young women. The vagina
has a stratified epithelium which reacts strongly to estrogen stimulation and may
desquamate as a continuous unchanging discharge in long cycles, where is a
cause of the Basic Infertile Pattern (BIP)
The characterisation of the BIP in the early pre-ovulatory days before the
mucus pattern, has added value to the BOM because unlike the older BBT
method it enables intercourse in the preovulatory days if a couple is postponing
pregnancy. Also, it makes the BOM suitable for use in cycles with long
preovulatory phases in relatively infertile states such as lactation amenorrhoea
and premenopause.
The BIP can be dryness, unchanging mucus or both. Unchanging is so
designated after 14 days of the same mucus discharge in long cycles or in 3
successive normal length cycles.
Rules (first 8, now 3) for the BIP days to postpone pregnancy were applied
to proven fertile women in the WHO multicentre trial in the early 1980s showing
99% method effectiveness for delaying pregnancy.(14) These rules are: 1) avoid
intercourse during bleeding, 2) use the BIP evenings but abstain the day after
and 3) abstain during each change of BIP that does not lead to a Peak and for 3
days of the BIP following this change. If the change of BIP proceeds to a Peak,
abstain for all the days of the change to the last slippery day and apply the Peak
rule.(15)
The BOM is also used to achieve pregnancy, and I will leave the details to
the next speaker. It is worth repeating, however, that the BOM official website
reports success in 111/172 (65%) subfertile couples including 7/20 (35%) who
had previously undergone AI or IVF. All couples attending 17 BOM centres
from 1999-2003 were included in the study on an intention to treat basis.(16)
James Browns contribution was another essential component in the
development of Fertility Awareness beyond the normal regular cycle. His paper
published online on Oct 5 2010 was a review of his previous results that
demonstrated clearly that women in fact have erratic fertility and that ovulation
is not always associated with fertility.(17) The following description is from his
paper.
104

His study of 750,000 hormone profiles from 24 hour urine collections over
the years used 3 different methods of measuring the 3 oestrogens and 2 methods
for progesterone. He also carried out 5 year longitudinal studies in the same
woman. In most cases, he expressed values as g/24h for total oestrogens (TE)
and mg/24h for pregnandiol glucuronide, while accounting for the adrenal
output of <10g/24h TE and <0.5mg/24h pregnandiol from the adrenals after
puberty.
Urine studies continue to be used for mass studies even after the blood
assays became available in 1970 because the stress of repeated blood taking can
affect the values. The more recent ultrasound, while adding an additional tool
for the study of ovulation, cannot replace urine, especially for long term studies.
Whether a healthy ovulation occurs or not is diagnosed by the
pregnandiol secretion. His definitions of cycle type are as follows:

Pregnandiol mg/24h

Cycle Type

<1.6

Anovulation

(7mol/24h)

Luteinized Unruptured Follicle

1.6 2 (7-9mol/24h)
(LUF)
2 3
13.5mol/24h)

(9-

Deficient luteal phase. (Peak

may or may not be recognised).
Infertile
Short luteal phase <10 days after
oestrogen peak. (Peak rule applies.)
Infertile

>3
(13.5mol/24h) in the 6
days after oestrogen peak (after
which any placental output will
confuse interpretation)

Fertile ovulatory cycle if followed by luteal

phase 11-17days long.

105

The peak oestrogen levels sufficient to release

LH and induce ovulation ranges from about
40g/24h (10th percentile) to about 100g/24h
(90th percentile). The related 40th pregandiol
percentile also indicates an inadequate
ovulation that causes a deficient or short luteal
phase. In his paper, Brown calculates the
luteal phase from the peak oestrogen rather
than from the LH surge which is within a day
later. He also cites his mucus score which
scores from -1 for dryness to 9 for wet,
slippery mucus of any amount, thus being suitable for combining with the BOM.
From the results, he described the normal continuum of 5 merging states of
ovarian activity in a womans life viz (i)no ovarian activity (ii)anovulatory
activity with constant, peaking or fluctuating oestrogen (and mucus) or with
regular cycling (iii)luteinized unruptured follicle (LUF) (iv)ovulation with
deficient or short luteal phase (v)fully fertile cycle. These exhibit variations of
FSH and LH with accompanying oestrogen and pregnandiol variations and are
found in states of reproductive life like childhood, menarche and puberty,
normal cycling, pregnancy and lactation, menopause as well as conditions
associated with stress, variations in body weight (higher in obese) and thyroid
function.
Puberty for example goes through these 5 states in that order as does the
recovery of fertility after childbirth. The waxing and waning of fertility along
these lines before and after intensive physical training was found in a study of 10
elite women rowers by Harvard U (Snow et al.,1989.). Stress of any kind during
reproductive life is the most important factor causing ovarian activity to change
from the fertile to infertile types. Removal of the stress usually allows fertility to
return. These states constitute a spectrum and have therefore been described by
Brown as a continuum.

106

Other than the normal

continuum,
pathological
states such as drastic weight
loss and obesity may also
affect the hormonal and
menstrual patterns, as do
diseases like the Polycystic
Ovary
Syndrome
and
Insulin Resistance.
A, B and C are 3 postpartum
charts. A shows the rise of
oestrogen at 5 months but
without
ovulation
(pregnandiol<2
mg/24h),
and bleeding 12 days later.
2 cycles later, ovulation
occurred
(pregnandiol>3
mg/24h) with a normal
luteal phase. She continued
to ovulate with increasing
lengths of luteal phase but
stopped charting and conceived 12 months after delivery. She was using LAM
and had reached fertility unusually early.

B resembles the pubertal rise in fertility but faster. First 4 bleeds from 5 months
were anovulatory but with increasing pregnandiol and luteal phases until the
14th month, when fertility was restored.
C was from a woman who did not breastfeed. Ovulation returned at 2 months
with normal pregnandiol but the next 4 luteal phases were short.

107

oestrogen and pregnandiol and then a bleed.

The 2nd example is the

decline of fertility in a
42 yo woman from 1972.
After a lifetime of
regular cycles she had a
delayed period with a
deficient luteal phases,
then regular cycles for 8
months although not all
had pregnandiol >3
mg/24h. Then came 3
deficient luteal phases,
after which she had
fluctuating
oestrogen
and mucus without
ovulation for 12 months.
The FSH and LH levels
were between normal
cycles and menopause.
She ovulated then but
had a luteal phase of 4
days.
She was then
amenorhoeic for a year
when she had mucus
again, a slight rise in

Oestrogen rises paralleled by mucus scores but without pregnandiol rises were
followed by bleeding. The FSH and LH were at postmenopausal levels.
Ovulation failed first before all the follicular activity.

108

Bleeding
after
distinct
oestrogen rise patterns but
without ovulation is illustrated
in 3 subjects. The first (21yo)
bled every 3 weeks about 5
days after the oestrogen peak
(oestrogen withdrawal bleed),
the second (13 yo) every 5 or 6
weeks and the third (42yo) had
a broad oestrogen pattern with
midcycle bleeding. The mucus
symptom was not recorded
but I expect that without
ovulation, the Progesterone
change would not have been
observed ie no Peak.
The
oestrogen peaks tend to be
higher than in ovulatory cycles which may mean that ovulation truncates the
rise.

109

Another pattern shown is in a

19 yo woman with constant
oestrogen levels between 12
and 20 g/24 h due to FSH
failing to rise to produce a
dominant follicle. Ovulation
fails
to
occur
and
breakthrough bleeding occurs
from time to time, usually
irregular
but
sometimes
monthly,
which
can
be
confusing.
The
mucus
symptom was not charted but
we can guess that it would not
have shown a definitive Peak.

A 26 yo woman also presented with a constant oestrogen level had breakthrough

bleeding which stopped as the oestrogen started to climb to fully fertile
ovulation with a secretory endometrium. The bleeding could thus be called midcycle bleeding.

110

Higher (double) constant

oestrogen levels in a 27 yo
woman, follicular cysts on
ultrasound
and
a
proliferative
endometrium
with
cystic
glandular
hyperplasia presented with
irregular bleeding over 3
years.

A 43 yo woman also with cystic glandular hyperplasia had a high and

fluctuating broad peak oestrogen rise associated with anovulatory cycles
interspersed randomly with ovulatory cycles.
The broad peaks indicate
oestrogen production 2 or 3 times that of a normal ovulatory cycle but are not
common in the general population.
Anovulatory cycles cause proliferative endometrial changes without secretory
conversion and may thus produce abnormal bleeding. But high constant and
high fluctuating oestrogen levels may also have different predilections. High
constant oestrogen often ends with irregular and often uncontrolled bleeding.
But high fluctuating anovulatory oestrogen levels may commonly cause bleeding
on the way down but also on the way up, constant or not at all; or as a oestrogen
withdrawal bleed later in the cycle. Thus we cannot judge by the bleeding what
kind of ovarian activity there was.

111

The fertile ovulatory cycle has

very denite characteristics.
Of 140 ovulatory cycles 114
(81%) had a single ovulatory
oestrogen peak and 26 (19%)
showed a composite peak
from more than 1 follicle.
Fifty-two (37%) also showed
early oestrogen peaks that did
not progress to ovulation, all
lower than the later ovulatory
peaks.
Oestrogens rose from 11.85
g/24 h to a peak of 6321
g/24 h. The fall after the
peak reached 0.410.12 of the
peak value. Thus the fall after
the peak is a very clear signal
dening the peak, being the
clearance of oestrogens no longer produced at ovulation.

However, it is possible to nd this type of oestrogen peak without ovulation; of

the 140 cycles, 10 were conception cycles, another 10 (7%) had decient luteal
phases. Raised progesterone values before ovulation reduce fertility (Baird et al.,
1999). Women in the daily work force have lower ovarian hormone production
than women at home minding children (Dennerstein et al. 1993) affecting
cervical mucus production and probably their fertility.

112

Brown collected all the

variations
of
the
continuum where either
the FSH or the LH
deficiencies may cause
problems in fertility
awareness in a single
stylized chart.
These
charts plot oestrogens as
nmol units rather than
g.
This summary
includes
charts
of
ovulatory inactivity (A)
through fluctuating (B)
or
constant
(C)
oestrogen activity, an
LUF (D), through a
deficient (E) or short (F)
luteal phase to a fertile
ovulatory cycle with 10%, 50% or 90% percentile oestrogen peaks (G) to (I).

Some take home points from the paper

The Billings Method correctly identies fertility and infertility in all stages of
the continuum. Infertility is recognized by absence of the mucus symptoms
of the fertile ovulatory cycle.
Fertility is marked with daily changes. Any pattern without changes denotes
infertility.
Only one ovulation may occur per cycle. Any two or more follicles are exactly
synchronized (Brown, 1978).
Ovulation is always followed later by bleeding whether the luteal phase is
normal, short or decient, in the absence of pregnancy or abnormality.
Pregnancy is proof that the cycle is fertile. Next best is the Peak Symptom
from the build-up in cervical mucus followed by a sudden change to minimal
mucus, due to progesterone and its anti-estrogenic effect on the cervix.
A continuing pregnancy can result only from a fertile ovulatory cycle with an
adequate luteal phase. The short luteal phase (<11 days from Peak) and the
deficient luteal phase are infertile. These are usually sporadic events from
stress and need removal of stress factors and reassurance of success
(Townsend et al., 1966). If the problem is persistent clomiphene or
gonadotrophins may be needed.
113

The Unitive Meaning.

The unitive meaning of NFP is more critical than the procreative meaning. It
seems however that all the focus has been on the procreative which is easily
understood, but what does unitive mean? I learned from Janet Smith that
contraception blocks the unitive meaning not just the procreative, as it disfigures
the sexuality of husband and wife and hinders the self-giving that characterises
love. Therefore contraception destroys love which reminds me of Mother
Teresas comment that abortion destroys love.
Although contraception initially meant anti-baby, its common theme or process
is to break both meanings of sex in order to have safe sex ie sex that is free of all
encumbrances, not just children.
So expansion into extramarital sex,
homosexuality, pornography, bestiality, paedophilia, incest and abortion for
heterosexual sex constitutes milestones of contraception, so to speak.
Accompanying this is a train of socio-political consequences that is derailing
civilization, as predicted in visionary comments by Paul VI in Humanae Vitae
(1968). The doctrinal account of marriage and condemnation of contraception
can be found in the Bible and in many Papal pronouncements eg
Mt 5:27-28; Mt 19:1-13; Mk 10:1-12; Lk 20:27-35; Jn 8:1-11; Mal 2:13-16; 1 Cor 7; 1
Cor 13 1-7, 13; Eph 5:22-33.Casti Connubii (Pope Pius XI) 54; Allocution to
Midwives (Pope Pius XII); Humanae Vitae (Pope Paul VI) 10, 16; Gaudium et
Spes (Second Vatican Council) 50.2; Catechism of the Catholic Church 2368
But all that does not tell us, What is unitive? Can we say that it is Spousal
Love? But then what is love? So I want to focus on Pope John Paul II because
he expounded heavily on the personalistic aspects ie the unitive meaning, the
focus of our investigation.
In his letter to families (1994)(18), John Paul II points out that Man is the only
creature on earth which God willed for itself and Man cannot fully find
himself except through a sincere gift of himself (GS 24, 1965), a paradox he
explained cryptically as truth in love, perhaps better understood as a truth in 2
dimensions, divine and earthly.
First, about the gift of self Love means self giving and spousal love on earth
(we are not married in heaven) is self-fulfilment by giving ourselves to our
spouse.
Second, about being willed by God for ourselves while we are on earth, we are
social beings and depend on others for our fulfilment. A doctor is nothing
114

without his patients, a teacher nothing without his pupils, a businessman

nothing without his customers, a speaker nothing without his audience. Yet we
are made in the image of God and are self sufficient in God.
And whether we marry or not, all forms of human love resonate with the eternal
love of the Divine. We are destined to live the life of the divine, though for now
our hearts are restless until we rest in God (St Augustine). This gives us some
realisation of our links to the divine and makes all the difference to how we
understand and practise love here on earth. (Please call my liberties with
Theology Poetic License, to allow me to understand some truths that are
beyond me.)
JP IIs elaboration of spousal love can be found in his book Love and
Responsibility (L&R), published in Polish in 1960 and in English in1981.(19)
Following are his insights on spousal love. Serving as backdrop to this book
were two world wars, nuclear arms use, the population explosion, the 1960s
sexual revolution and the invention of the Pill all leading to Vatican II from
1962-1965 and to the hotly contested papal commission on Humanae Vitae.
JP II could not attend the commission meeting in 1966 at which the dissenting
progressive majority presented their support for contraception. But he sent a
proposal in French from the Polish theologians to Paul VI, favouring a more
personalistic way of presenting the same truths in Humanae Vitae, which was
felt to be too legalistic.(20) L&R and later his Theology of the Body (TOB) from
1979-1984 reveal some of the ways JP II thinks. I think it is very relevant in the
present discussion in order to answer, What is Spousal Love?
And also, What is not love. Love is not to use others or to be used. Using is
the opposite of loving. And if I treat someone else as a means and a tool, I must
regard myself in the same light. The "original sin," JP II says, is to violate the
Law of the Gift built into us, to turn the other into an object, a thing to be used.
And, as JP II points out, it is not love even when we give pleasure to another just
to get pleasure ourselves.
Utilitarianisms real mistake is the recognition of pleasure in itself as the sole or
greatest good. JP II also dwells in TOB and in L&R on the entry of shame, which
is the fear of being used. And if we later become shameless, it is to get more
pleasure, without realising that we have become addicted and are being used.
Pornography is a good example of this addiction that is gripping the world.
Sexual matters are especially relevant because in Freuds view we are driven by
the pursuit of pleasure and sex is instant and powerful pleasure. It appears that
the fall of Adam plunged the world into a Freudian Vortex from which it is still
reeling, a civilization of use for pleasure, of things, and not of persons.
115

Pursuing pleasure alone leads to boredom, depression, addiction, and

aggression. And in this milieu, woman can become an object for man, children
a hindrance to parents, the family an institution obstructing the freedom of its
members. (Letter to Families).
Viktor Frankl rejected Freuds Pleasure Principle naming Man's search for
meaning as the principle drive, after he observed that inmates in the Auschwitz
death camp who gave meaning to their suffering were more likely to survive,
even without restricting meanings to only edifying ones.(21) He also rejected the
pursuit of happiness as the mere pursuit of pleasure, saying that happiness
cannot be pursued but must ensue as a side effect of a worthy cause. This is of
relevance to Bhutans proposal in July 2011, accepted by the United Nations and
several countries, to create the index of Gross National Happiness.
While Freud reduced love to the sexual instincts and the Pleasure Principle,
Frankl justified sex only as a way of expressing love; any inflation of sex is a
devaluation and a manifestation of a rampant sexual libido that is vicariously
compensating for the existential vacuum that marks the 20th century along with
the search for power.(21) His Search for Meaning specifically the Unitive
meaning in our context is the more constructive way.
Love on the other hand is the unification of persons. The foundation of love is an
objective common good that individual persons choose and subject themselves
to. Love is by nature creative and constructive. Spousal Love and procreation
are one, neither more important than the other. Spousal Love is fertile by both
the biological urge and physiology and its link with existence, including the task
of procreating children who, like us, are willed by God for themselves (we do not
own our children) while we give our likeness and personality to them.
There are many steps (and missteps) in the growing relationship between man
and woman from Attraction (skin-deep or inner beauty), to Desire (to use another
or to complete oneself), to Goodwill (selflessness), to Reciprocity (attention seeking
or unity as co-creators), to Sympathy (subjective evaluation of emotion not of the
person), to Comradeship (objective common interests, work, goals, concerns), to
Friendship (Goodwill together) and to Betrothal (surrender of the I; the gift of
self) exchanging the mutual gift of self as a common Task (Love is not ready made;
it is always becoming) with Limited Freedom (responsibility and commitment
limits ones freedom for the sake of love).
There are some psychological traps that may easily trip us up. These include
Sensuality (normal sexual attraction, not love), Sentiment (feelings, inward
looking, idealisation) and Tenderness (feelings only, need to balance with
firmness, self-denial, sacrifice)

116

There are also some ethical characteristics to remember in this development.

They are Love as virtue (vs love as experience), Affirmation of the Value of the Person
(including the possibility of becoming a parent), Objectivity (Joint Striving for
Good) and The will (Love is a creation of the Will).
JP II also dedicates some time to discuss Chastity, Concupiscence, and
Continence together with modesty and Shame and their integration in marriage.
Chastity is the virtue that clarifies loves objective profile ie building love by an
act of the will and quickness to affirm the value of the person in every situation.
This requires being always aware of how different men and women are in many
areas and adjusting to the different but legitimate needs of the spouse. In
particular, love means for the man to ensure that climax is reached in harmony
with both spouses involved, not for hedonistic but altruistic reasons. Chastity is
not Puritanism or Asceticism. It is not to blindly push sensuality and the values
of the body and of sex into the subconscious, where they wait to explode.
Sexual reactions develop more quickly than virtue and so deprive love of clarity.
So attaining Chastity is a difficult, long-term matter and one must wait patiently
for it to bear fruit.
Concupiscence is a consistent tendency to see persons of the other sex as objects of
sexual enjoyment. As soon as concupiscence achieves its ends, all interest in it
disappears. Still, the urge is natural and it is not a sin until we act on it. What
we do with it is spousal love or it is not. We should not marry to relieve
concupiscence. Modesty & Shame (Protected value of the person) are a natural
form of self-defence for the person against the danger of descending or being
pushed into the position of an object for sexual use.
Continence or Self Control. This is a kind of defence against the invasion of
concupiscence and deploying sensuality towards authentic love. Continence is
not an end in itself but aims at the perfection of the person who attempts to
achieve it in order to establish love. It turns a foe (concupiscence) into a friend
(love).

MARRIAGE
Finally L&R discusses the integration of all these components in the institution of
marriage. Marriage must provide first of all the means of continuing existence,
secondly a conjugal life for man and woman, and thirdly a legitimate orientation
for desire. These 3 are ontologically in that order. But they constitute a single
interdependent aim and we cannot say that any one supercedes another. And if
any of these 3 is missing, the marriage is at risk.
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For example, Love is a union of persons, a mutual gift, and a man and a woman
whose love has not yet so established itself should not marry. This principle is
fully compatible only with monogamy and the indissolubility of marriage. Any
other view of the matter puts the person in the position of an object for use and
endangers the marriage. For example, premarital and extramarital sexual
relations automatically put one person usually the woman in the position of
an object to be used by another even if the woman consents.
Marriage serves love more fully when it serves the cause of existence and
develops into a family. This is how the statement procreation is the principal
end of marriage should be understood. Contraception not only blocks
procreation, it also diverts union with the person to mere enjoyment: the person
as co-creator of love disappears. The mutual need of the two persons for each
other expresses itself also in the need for sexual intercourse. Yet periodic
continence is a condition of love, grounded as it is in affirmation of the value of
the person and not just in sexual attachment which is a utilitarian view.
A human being is a person, so that the fact of becoming a father or a mother has
a personal significance not merely a biological significance. If the possibility of
parenthood is deliberately excluded, the character of a sexual relationship
between the partners changes from unification in love to bilateral enjoyment,
leaving a sexual association without the full value of a personal relationship.
Willingness for parenthood is an indispensible condition of Love, even if we do
not want any more children for good reasons. However, intercourse is still
naturally ordered to pregnancy so when using NFP, we always say we are
postponing, never avoiding or preventing pregnancy. That would be using
NFP as a contraceptive and NFP is not a contraceptive.
This brings up the question, How many children should we have? JP II writes
in L&R (pp 242-243) that a family is a community and 2 children are not a
community they are just 2 children, one for each parent. Janet Smith, without
criticising those who for good reasons do not have a choice, went on to suggest
that the critical mass is three children who have to negotiate and share and
cannot each have a parent. She reported that Mothers also remark that after four,
it does not matter if there is one more, then one more etc.(22) Having many
children also reflects the absence of the contraceptive mentality and the ease with
which such parents accept their children.
Finally, we need Grace to Love. As JP II concludes, A believer...is also aware
that his own spiritual reserves alone are inadequate to the development of his
personality through love... The operations of Grace take man beyond the
confines of his personal life and bring him within the orbit of Gods activity...
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Every man must learn to integrate himself into the activity of God and respond
to His love. The Unitive meaning is not just of marriage but is a human quality.
While spousal love is one way, no one is married in heaven and whether married
or not, our eternal destiny depends on self-giving to God Himself.
References
(1) Humanae Vitae 12,
http://www.vatican.va/holy_father/paul_vi/encyclicals/documents/hf_pvi_enc_25071968_humanae-vitae_en.html
(2) NFP links, http://www.natural-family-planning.info/
(3) H.G. Burger, K.J. Catt and J.B. Brown (1968), "Relationship between plasma
luteinizing hormone and urinary estrogen excretion during the menstrual
cycle,", Journal of clin. Endocrin. and Metab. 28:1508-1512.
http://www.familynfp.com/main/page_dr_james_brown.html
(4) E.L. Billings, J.J. Billings, J.B. Brown and H.G. Burger (1972), "Symptoms and
hormonal changes accompanying ovulation.", Lancet 1:282-284.
(5) Odeblad, E. (1959). The physics of the cervical mucus. Acta Obstetricia et
Gynecologica Scandinavica, 38(S1), 44-58.
(6) Odeblad, E. (1960). Discussion: The physics of the cervical mucus. Acta
Obstetricia et Gynecologica Scandinavica, 39(S1), 126-127.
(7) Odeblad, E. (1968). The functional structure of human cervical mucus. Acta
Obstetricia et Gynecologica Scandinavica, 47(S1), 57-79.
(8) Odeblad, E. (1994). The discovery of different types of cervical mucus and the
Billings Ovulation Method. Bulletin of the Natural Family Planning Council of
Victoria, 21(3), 3-34
(9) Odeblad, E. The Cervix, World Organisation of the Ovulation Method
Billings; http://www.woomb.org/bom/cervix/
(10) Odeblad, E. (2002). Investigations on the physiological basis for fertility
awareness, Bulletin of the Ovulation Method Research and Reference Centre
of Australia, 29:1:2-11
(11) Odeblad, E. (2010). Contributions of Cervical Mucus and Vestibular
Factors to Peak Sensation. Bulletin of OMR&RCA, 37(2), 2-8.
(12) Odeblad; Evelyn L. Billings and John J. Billings The Behaviour of the
Cervix over the Phases of the Ovulatory Cycle, World Organisation of the
Ovulation Method Billings, Animation, Erik
http://www.woomb.org/bom/cervix/behaviour.html
(13) Odeblad, E. (2009). Some Additional Aspects of the Physiology of the
Mucus Symptom. Bulletin of OMR&RCA, 36(3), 2-7
(14) Bibliography of the BOM,
http://www.thebillingsovulationmethod.org/ourservices/bibliography.html
(15) Billings, E.L. & Westmore, A. (2011). The Billings Method (9th ed.).
Melbourne, Australia: Anne ODonovan Publishing.
119

(16) http://www.thebillingsovulationmethod.org/en/how-effective-is-thebillings-ovulation-method%E2%84%A2/success-in-achievingpregnancy.html
(17) Brown, J.B. (2011). Types of ovarian activity in women and their
significance: the continuum (a reinterpretation of early findings). Human
Reproduction Update, 17(2), 141-158.
http://humupd.oxfordjournals.org/content/17/2/141.full.pdf+html
(18) John Paul II (1994), Letter to families
http://www.vatican.va/holy_father//john_paul_ii/letters/documents/hf_j
p-ii_let_02021994_families_en.html
(19) John Paul II (1960), Love and Responsibility,
http://www.catholicculture.com/jp2_on_l&r.html
(20) George Weigel The Humanae Vitae controversy,
http://www.viastuas.net.au/bc/WeigelHV.html
(21) Viktor E Frankl (1946), Mans Search for Meaning
(22) Janet Smith, The Moral Use of Natural Family Planning
Acknowledgements: This account would not have been possible if
not for the strong shoulders of the giants I have stood on. They
are too many to list but I have attempted to name as many as I
could. I am very grateful to them for the knowledge they have
provided to educate those, like myself, who yearn for wisdom.
Dr Ian Snodgrass

Note:
Paper of Sister Arlene I-Ren Te M.D and Victor Chen Kun Chang M.D was not available.

120

Session 5 : Controversy in the use of condom in HIV prevention (Panel Discussion)

The effectiveness of the use of condom in HIV

prevention: view from medical perspective
Dr Peter Au-Yeung BSc MRCP FRCA MA

Condoms have been promoted as the way to prevent HIV spread. Consistent in
its opposition to condom use and promoting instead a strategy based on chastity,
the Catholic Church has come under attack for placing ideology over the need to
tackle a global medical crisis. Yet despite the widespread promotion of condoms
and safe sex, the spread of HIV/AIDS has continued unabated. Is condom use
really effective in protecting against AIDS? Is safe sex really safe?

There are a number of factors which limit the effectiveness of the use of condom
in preventing the spread of HIV/AIDS. Condoms address the sexual (and the
main) mode of transmission of HIV, hence the disease should properly be
considered as a sexually transmitted disease (STD). Before looking at condoms
and their problems one has to realize that the philosophy underlying the
containment of HIV spread is in itself problematic. HIV exceptionalism virtually
denies its STD status and stops the application of measures normally used
against STDs to prevent its spread. The development of the concept of safe sex
also runs contrary to the ideas behind infection control in an epidemic, which
would include reducing contact between the pathogen carrier and the vulnerable
host.
Condoms can leak, slip off as well as rupture and these will impact on its
effectiveness in HIV prevention. Apart from these problems, safe sex can also
lead to risk compensation and an increase in risk taking behaviour. This paper
will consider all these elements in an examination of condom use for HIV
prevention and how behavioural modification according to principles of
infection control, which actually amounts to a chastity-based approach, can lead
to better control of HIV spread.
121

The failure of condoms to contain HIV/AIDS

Although many countries have been promoting condoms as a means of stopping
the spread of HIV/AIDS, there has been no corresponding fall in HIV infection.
In sub-Saharan Africa where AIDS has been exactly a grace toll, only Uganda
experienced a fall in HIV rates, but that is not due to the wholesale promotion of
condom use and safe sex, but rather through the ABC programme, which
includes condom as a means of last resort in a programme involving partner
reduction as well reducing premarital sex. With such a programme, HIV rates
fell from 18% in 1992 to 5% in 2001. This outcome has been compared with what
can be achieved with universal vaccination using a vaccine of 80% effectiveness.
What is also notable is that in this particular instance, condom was not
universally promo9ted, but only to certain high risk groups in Uganda, such as
HIV discordant couples as well as sex workers.
The ineffectiveness of a condoms promotion only programme was also
illustrated when the situation in Thailand was compared with the Philippines.
Both countries had their first HIV/AIDS case recorded in 1984, and they had
recorded 112 and 135 cases up to 1987 respectively. The WHO estimated in 1991
that based on their respective populations Thailand and the Philippines would
have 70,000 and 80,000 cases in 1999. Both countries launched a condom
promotion campaign in 1991, but there was also a chastity based AIDS
prevention programme launched with the aid of the Church in the Philippines in
1992. The results were startling: Thailand had accummu7lated 780,000 cases of
HIV/AIDS in 1999, whilst the Philippines AIDS registry had only recorded
around 1-2000 cases (actual figure say around 5000). The latest figures from
UNAIDs (2009) showed that there are 530,000 people living with HIV/AIDS in
Thailand, whilst the corresponding figure is 8700 in the Philippines.

The transmission of HIV/AIDS

Although there are many ways the HIV virus can be transmitted from one
person to another, such as contaminated blood transfusions and hypodermic
needles, and from mother to child during pregnancy, delivery, or breastfeeding,
the sexual means of transmission remains one of the most important ways of
spreading HIV/AIDS. Of particular note is the fact that men who have sex with
men (MSM) are most at risk of contracting the disease. This, together with the
fact that condoms are promoted as an important means of containment, really
122

confirms the reality that HIV/AIDS should be considered a sexually transmitted

disease (STD).
STDs are really a special form of infectious disease, and as such considerations
applicable to infectious diseases are also applicable to STDs, including AIDS.
Traditionally one of the means of combating infectious disease would involve
prevention of contact between infecting agent and susceptible host. There may
also be a need to eliminate or control the vector where applicable. Examples
would include culling chickens during avian influenza, centralized slaughtering
to prevent it, anti-mosquito campaigns to stop the spread of malaria, dengue
fever and Japanese encephalitis, isolation for SARS and human swine flu etc.
Whatever one does to contain a disease, few would advocate unlimited contact,
albeit with protective gear! But that is what is really behind a condom campaign
as regards to HIV/AIDS.
Condom failure
Although studies have shown that condoms do not develop significant pores to
let the HIV virus through in laboratory studies, they do however slip and break
in real life. In a summary of 15 studies presented in Dr Brain Clowes The Case
Against Condoms: Death by Latex, it was noted that the average slippage rate
was 3.44%, whilst the average breakage rate was 4.64%, giving an average
overall failure rate of 8.08%. In another study presented in the same work, it was
found that for a couple always using condoms, the pregnancy rate rose from 15%
in the first year, to 556% by 5 years to a startling 80% by the 10 year. That is for
pregnancy. It is salutary to note that it is easier to be infected with HIV than to
get pregnant for the following reasons: (i) the sperm is between 25 to 50 bigger
than the HIV virus; (ii) a woman is fertile only some 25% of the time, but (iii) a
person is susceptible to HIV infection 100% of the time.

The additional problem of risk compensation.

Risk compensation is an observed effect whereby people tend to adjust their

behaviour in response to perceived level of risk, behaving less cautiously where
they feel more protected and more cautiously where they feel a higher level of
risk. First described in road transport, examples of risk compensation can be

123

found in other areas such as sports and perhaps may explain why condoms fail
to prevent the spread of HIV/AIDS.

In road transport, risk compensation can explain why the expected benefits have
not accrued or have accrued to a lesser extent when safety measures are
introduced. ABS anti-lock brakes have not reduced accident rates because drivers
have compensated by driving faster, following closer to the car in front and
braking later, negating the benefits of anti-lock brakes. Sate belts have also been
found to little impact on road traffic accident deaths, with drivers having been
found to drive faster and less carefully when belted. Some studies have also
found a corresponding increase in deaths outside the vehicle, cancelling the
increased safety of seat belt to vehicle occupants. Sometimes the compensation is
by other parties. Drivers tend to drive closer to helmeted cyclists, which makes
accidents more likely.

In sports, the availability of safer parachute equipment has not been

accompanied a drop in fatalities, due to the increased popularity of faster
canopies, as well as more parachutists doing more complicated manoeuvres
closer to the ground. Likewise, ski helmets have not reduced fatalities, with
evidence showing that skiers tend to go faster when helmeted.

Is there risk compensation in sex? There is evidence that increased condom usage
can lead to reduced avoidance of casual sex, thus increasing overall partner
numbers. AS the treatment of HIV/AIDS advanced, there was reduced anxiety
over AIDS amongst gay men resulting in more unprotected sex. One study even
showed that with the availability of post exposure anti-retroviral, 3% of men at a
Gay Pride event in 1997 had already made use of such prophylaxis and 26% of
them would consider using it if exposed.

An alternative to condom to prevent HIV/AIDS

124

If we practise quarantine and isolation for other infectious diseases, why can this
not apply to HIV/AIDS? HIV exceptionalism would consider this too much to
interfere with sexual activity; too much an assault on todays secular liberalism.
They would also claim that this is old-fashioned and would not work. But that is
not supported by the data. With the Ugandan ABC programme, a reduction in
premarital sex was recorded from 1989-1995, with rates falling from 60% to 23%
in males and from 53% to 16% in females. There was a similar fall in sexual
partners over the same period: with males > 1 casual partner falling from 35% to
15% and females > 1 casual partner fell from 16% to 6%. Just as importantly, at
the other end of the spectrum, the percentage of males > 3 casual partners fell
from 15% to 3%. Away from HIV/AIDS, the TeenSTAR programme pioneered
by Dr Hanna Klaus has found secondary abstinence amongst programme
participants, showing that sexual behaviour can be changed and that chastity is
possible.

Although chastity seem such an outlandish concept these days, it is worthy to

remember that it is no more than a lifestyle modification for health. We are
constantly being urged to adopt these lifestyles modification for health, such a
quitting smoking, eating healthily, doing more exercise, etc. Sometimes
legislation is drafted in to force matters, such as anti-smoking legislation, transfat and even soft drinks legislation. Since this is the case with other health issues
such as heart and lung disease, secondary harm from others smoking habits and
obesity, is there any reason not to promote chastity?

AIDS exceptionalism however argues that it is a different infectious disease, a

different STD to which normal contact tracing or quarantine cannot be applied. It
also argues that there is no need to reduce contact, promoting barriers of limited
efficacy whilst at the same time denying the effectiveness of chastity based
approaches. But in fact, some African countries are promoting partner reduction
in their fight against HIV/AIDS.
In conclusion, the reasons why condoms are limited in their effectiveness has
been presented, as has the case for lifestyle modification to limit the spread of
AIDS. Condom promotion flies against the traditional approach in limiting the
spread of infectious disease, and this together with risk compensation exp0lains
why it is ineffective in stopping the spread of HIV/AIDS.
125

Bibliography
The Case Against Condoms: Death by Latex, Dr Brain Clowes, HLI
http://www.hli.org/index.php/condoms/320-case-against-condoms-death-bylatex
UNAIDS Country-by-country HIV/AIDS statistics
http://www.unaids.org/en/Regions_Countries/Countries/default.asp
Cassell MM, Halperin DT, Shelton JD, and Stanton D. Risk compensation: the
Achilles heel of innovations in HIV prevention? BMJ (2006) 332:605-7
Richens J, Imrie J and Copas A. Condoms and seat belts: The parallels and the
lessons Lancet (2000) 355: 400-3
Shelton JD, Halperin DT, Nantulya V, Potts M, Gayle HD and Holmes KK.
Partner reduction is crucial for balanced "ABC" approach to HIV prevention. BMJ
(2004) 328:891-3.

Note:
Paper of Fr David Garcia and of Prof Wirawan were not available.

126

FREE PAPER SESSION

Session 6.1a

Does Fertility Awareness Impact Teens Sexual

Behaviour?
Hanna Klaus, MMS, MD. FACOG
Natural Family Planning Center of Washington, D.C. and Teen STAR
Program
4400 East West Highway
Bethesda, MD 20814-4510 USA
http://www.teenstarprogram.org
While everyone tries to reduce or eliminate teen pregnancy, most
approaches either teach abstinence or provide contraceptives in pursuit of the
goal. To this end, the World Health Organization described prevention of
violence, early marriage and pregnancy and sexually transmitted infections as
means to achieve healthy teen sexuality in a policy brief this year.73 Research lists
include stable family structure, education and healthy peers as important assets
to achieve delay of intercourse, and provision of contraceptives to prevent
conception 74, but understanding and valuing ones bodys fertility was absent. A
healthy body was simply the instrument to satisfy desires, and could be
manipulated without qualm for the achievement of a desired end, including
gender reassignment, reflecting our culture which has separated sex not only
from procreation but from relationship. Yet the body is integral to sexual
intercourse.
Biological capacity for parenthood begins at puberty, while emotional
and personal readiness for this task lags far behind. Longitudinal brain imaging
studies show that the frontal lobes, the locus of rational thought and decision
making are not fully mature until the middle 20s, while during childhood and
1 Expanding adolescent access to contraceptive services. WHO policy brief accessed September 9, 2012
http://apps.who.int/iris/bitstream/10665/75160/1/WHO_RHR_HRP_12.21_eng.pdf
74
SEARCH Institute: what kids need to succeed. 40 Developmental Assets. http://www.searchinstitute.org/developmental-assets. Accessed September 9, 2012

127

adolescence the limbic system, which mediates impulsive behavior, dominates. 75

yet our culture invites teens to begin sexual relations when you feel ready
with disastrous physical and emotional results. 76
Since all sexually transmitted diseases as well as pregnancy are
transmitted by bodily action it is obvious that the only way to prevent undesired
outcomes is to change behavior. After HIV/AIDS began in Uganda in the late
1980s 30% of expectant mothers were infected. A massive government effort
which stressed premarital abstinence and marital fidelity as well as condom use
brought the incidence down to 5%. With the advent of ARVs and the inflow of
commodities people began to be complacent and the incidence rose to 7%.
Studies in several African countries found that the HIV incidence rise paralleled
condom distribution in low risk populations. The rise was attributed to risk
compensation. 77
Another approach was clearly needed beyond preaching about abstinence
and teaching about the very real consequences of sexual behavior, because teens
are at the stage of the personal fable ( Erikson) in their psychosexual
development. They live only in the present moment and believe themselves to
be invulnerable. Talking about consequences is meaningless, since only the
meaning of their acts is important to them. Teens psychic energies are absorbed
by their developmental tasks: development of their personal identity which
includes gender identity, vocational goals, ethical stance and the need to
separate from their parents. No wonder that solely focusing on teaching about
or providing contraception has had little impact on behaviour. Chlamydia, HPV
and herpes genitalis are epidemic. 78
The physical and hormonal components of the teens emerging sexuality
require a great deal of psychic energy. To become adult both sexes must
integrate the sexuality with their procreative capacity, their parental capabilities.
The fact that sexually active girls usually worry about pregnancy shows that they
are aware of its possibility, even if the risks of contracting an STI are 30 times
higher. This validate the common understanding of the link between sex and
procreation.
75

Giedd JN. The Teen Brain: Insights from Neuroimaging. J Adol Health (2008)42:335-343.April.

76

Grossman M Sense and Sexuality. The college girls guide to protection in a hooked up world. Clare
Luce Policy Institute. 2009 Avail. at http://wwwcblpi.org
77
Cassell MM, Halperin DT, Shelton JD, Stanton D. Risk compensation: the Achilles heel of innovations in
HIV prevention? BMJ 2006; 332: 60507.
78
http://www.cdc.gov/std/stats10/figures/49.htm accessed September 9, 2012

128

Contraceptives are designed to remove procreation from the sexual act but
at the level of the emotions contraception is usually seen as disvaluing
procreation even when it is rationally chosen. On the other hand placing a high
value on fertility as is done with fertility awareness methods introduces another
dynamic. We found that teen girls who came to understand and value their
fertility patterns via the Billings Ovulation Method not only maintained
virginity to a large extent, but pulled away from the peer pressure which is
typically dominant in early adolescence, and began to make their own decisions.
Here is one randomized control study:
Behavioral outcomes, Chile

Study

Controls

N males

251

195

N females

147

147

% transitions virgin non-virgin

Males
Females

Discontinuation of intercourse *
Resumption of intercourse

sig

8.8
3.4

17.6
12.4

p =<.004
p=<.001

20

p=<0.03

11

p=<0.04

* No intercourse within the last three months of the program

Vigil P et al. J Ped & Adol. Gyn 2005:212

Even though males do not have a fertility cycle, male teenagers need to
understand and accept their sexuality and powers. Witness the behavioral
outcomes above, which are similar to our experience in many countries.
Adolescence is a difficult time not only for the teen, but for their parents.
Parents are the most important persons in a teens life, although teens seldom
want to admit it. In the process of separating from parents they disvalue them,
often consider them old fashioned or tyrannical. But parents are very necessary
for a teen as they are the ones not only to provide love, nurture and support but
also set the boundaries needed for security, We respect parents natural right to
be the primary educators of their children in all areas, including sexuality by
129

requiring parental permission as an entry requirement for Teen STAR program

participation.
Prior to approaching the teens we meet with parents and explain the
program. To assure a free decision, we ask teens to sign their consent form before
asking one parent to countersign it.
Courses are geared to early, mid or late adolescents, all give the body a
central role situated within the emotional, social, intellectual and spiritual
aspects of their sexuality. Parent-teen dialogue is necessary to complete several
of the assignments, especially about gender roles, the way media portray men
and women, etc.
Changes in their childrens attitudes as well as behavior is reported by
parents at later meetings, who are often pleased that their children have a
beginning perception that the parents are sexual persons.
Understanding and valuing the physical signs of the womans cyclic and
the mans constant fertility supports primary and secondary sexual abstinence.
The physical advantages are clear: prevention of premarital pregnancy
and STIs.
The emotional advantages include waiting until maturity to marry and
start family building, having presumably completed ones formal education
beforehand.
Blessed John Paul II devoted four years of his Wednesday catechetical
audiences to exploring the spiritual implications, in his Theology of the Body,
more properly translated as the Theology of Conjugal Love (Bishop Jean Lafitte,
Pontifical Council for the Family ). Too may health care professionals in the
western world scoff at the notion that sexual continence is possible outside of
marriage. Our data show otherwise, as do data on HIV prevalence from Africa.
Why are we professionals so slow to believe?

130

References:
1 Expanding adolescent access to contraceptive services. WHO policy brief accessed September 9, 2012
http://apps.who.int/iris/bitstream/10665/75160/1/WHO_RHR_HRP_12.21_eng.pdf
1
SEARCH Institute: what kids need to succeed. 40 Developmental Assets. http://www.searchinstitute.org/developmental-assets. Accessed September 9, 2012
1

Giedd JN. The Teen Brain: Insights from Neuroimaging. J Adol Health (2008)42:335-343.April.

Grossman M Sense and Sexuality. The college girls guide to protection in a hooked up world. Clare
Luce Policy Institute. 2009 Avail. at http://wwwcblpi.org
1
Cassell MM, Halperin DT, Shelton JD, Stanton D. Risk compensation: the Achilles heel of innovations
in HIV prevention? BMJ 2006; 332: 60507.
1
http://www.cdc.gov/std/stats10/figures/49.htm accessed September 9, 2012

131

WHAT CAN CATHOLIC DOCTORS AND CATHOLIC FLOCKS

DO TO SUPPORT RETIRED PRIESTS AND NUNS?
S.Hitomi & B.Ishijima
S1) The aged priests and nuns are increasing dramatically in Japan, recently. It is
becoming a serious problem. We have studied the quality of life of retired priests
and nuns, and have found that their living conditions leave much to be desired.
The purpose of this investigation is to clarify their situation more and to let the
people realize the facts and to find out the best supporting system for them.
S2) We have investigated the age distribution of priests and nuns, medical and
economic conditions, and their wishes how to spend the end of life, and the
numbers and the actual situation of the private-care-houses for retired priests
or nuns, and also Catholic nursing homes which are founded and administered
by Catholic groups and Non-Catholic public nursing homes. We are trying to
make a system with which Catholic doctors and flocks can support the aged
priests, monks and nuns medically, economically and spiritually.
S3) This slide shows the age distribution of 1,515 priests in Japan in 2012. The
green curve shows the age distribution of the total priests in Japan and the blue
curve shows that of Japanese priests. The red curve shows that of non-Japanese
priests came from foreign countries. The average year is almost same in 3 groups,
around 63 years old.
S4) This shows the ratio of priests over 65 years old. It is 49 % in total priests,
and 47 % in Japanese and 51 % in non-Japanese priests.
S5) I would like to explain the meaning of the ratio of population over 65 years
old. According to the demographic study, if, in some village, the ratio of
population over the age of 65 exceeds 50% , this village has a danger of
disappearing. because there will be no younger people to sustain the community.
Such a village is called as Genkai Shuraku in Japanese, limited village or
marginal village in English.
S6) This is the distribution of age of priests and monks in Osaka in 2012. The
number of priests and monks over 65 years old is 108 in total 205. So, its ratio is
53 %.
132

S7) This is the age distribution of nuns of 6 convents in Osaka in 2012.

Total number of nuns is 431. The number of nuns over 65 years old is 372, of
which ratio is 87 %. So, we can say that they are typical limited villages, and are
standing at the edge of a cliff.

S8) We distributed questionnaires to 86 priests & monks and got responses from
51% of them.
The questionnaires are as follows:
1 ) What are the important things in your living?
2) Where and how do you want to live, when you come to need the nursing
care or therapy?
3) Do you have anything to worry, when you come to need the health care?
4) What do you know about the social security system?
5) Do you have good communications with Catholic medical persons?
S9) This slide shows the answers to Q1. What are the important things in your
living? The answers are; prayer 23%, missionary 29 %, sacramental 28 %, action
in public 11 %, others 8 % and no answer 1 %.
S10) This is the answers to Q2: Where and how do you want to live, when you
come to need the nursing care or therapy? 50 % of them want to live in Catholic
nursing home or hospital, 7 % want to live in public nursing home or hospital,
and 14 % want to live in Private-care-house for retired priests. 9 % want to live in
priests house or dormitory in the parish where they have been working. 16 %
persons are thinking nothing and 4 % didnt understand the question.
S11) Here is the answers to Q3: Do you have anything to worry, when you come
to need the health care? Economy is 4 %, decrease of missionary activity is 17 %,
Health difficulty is 27%, Circumstances of life is 17 %, Social security is 7 %,
Nothing is 20 % and Others is 7 %.
S12) The answers to Q4: What do you know about the social security system?
I know well is 14 %, I dont know very much is 66 %, I have no interest is 9
% and I dont know anything at all is 11 %.
S13) The answers to Q5: Do you have good communications with Catholic
medical persons?
133

Yes, enough is 11 %, I want a little more is 27 %, I want much more is 30 %

and Not at all is 32 %.
S14) This slide shows the cost of living with a nursing care or medical therapy,
and their income.
The cost is different depending on where they spend the end of life and on their
health condition.
The followings are the cost of four types of living in the bedridden state.
1Private-care-houses, which is specially made only for retired priests, monks
or nuns:
The cost of residence is about $5,000 monthly. It is very expensive, because they
are closed to the public and are not covered by the public insurance. So, it is
impossible for retired priests to pay the fee by themselves. As a result, this
type of house is limited to the special groups. For example, some monastic
order pays about $ 100,000 per year to support its care-house in Tokyo, where
25 retired priests and monks are living.
2Catholic nursing homes or hospitals which are founded and administered by
Catholic groups:
A residence fee is about $1,750 per month which is less expensive than the
private-care-house, because they are opened to public and can be fully
supported by public insurance
3) Non-Catholic( public ) nursing homes or hospitals: The cost is as same as
Catholic nursing homes.
4) Living in the priests house in his parish or in his dormitory:
It is lowest-price, because there is no room charge.
In this case, however, voluntary support of flocks is needed.
As to their income, the salary of priests and nuns in Osaka is about $1,300, and
the pension is about $700 monthly. So that the total is about $2,000 a month.
S15) The next 4 slides show the merits and demerits of 4 types of living place.

134

First, the merits of the Private-care-house for retired priests, monks or nuns are
that there is a Chapel, and they can offer Sacrament, Mass and Prayer. Priests can
enjoy their hobbies and can talk with other priests.
As demerits, first of all, we must say that the fee is expensive. They need
economical support from dioceses or the monastic order.
The number of such houses is very few. There are only 5 in Japan.
The retired priests, monks or nuns may have to leave their parish houses,
dormitory or convent and lose contact with old friends.
They may lose the chance of missionary.

S16) Catholic nursing-homes, which are administered by Catholic groups, and

are opened to the public:
Merits are,
1) Cost is low by use of public insurance.
2) There is a Chapel and they can pray and offer Mass.
3) They can keep the communications with old friends or acquaintances.
4) Missionary to non-catholic persons is possible.
Demerits are,
1) The number is very few. There are only 125 Catholic Nursing-homes, 13
hospitals and 8 hospices in
Japan. They are not enough.
2) More money is needed to build new homes and hospices.

S17) Non-Catholic (public) Nursing-homes:

Merits are,
1) Cost is low by use of public insurance.

135

2) They can keep the communications with old friends or acquaintances.

3) Missionary to non catholic persons is possible.
4) More homes are there than Catholic homes
Demerits are,
1No affiliation to the Catholic church.
No chapel nor mass.
They have to make an effort to accustom themselves to the environment.
S18) This shows the merits and demerits of living in priests house or in the
dormitory or convent.
Merits are,
1) It is convenient to live in the same place, where they have lived for long
time.
2) Cost is low because of no-room-charge and they can use the public
insurance fully.
3) Old communities can be continued.
Demerit is .
1) The mutual support by those who live together, and the support by flocks
are essential. But, an actual situation in some convent is, in fact, olds are
taking care of very olds.
There is no good supporting system by flocks yet.

S19) This slide shows the proposed plans which we can do.
1) Serve priests who live alone with well balanced food & nutrition.
Raise money to hire cooks in priests house.
2) Make system which Catholic doctors can work for priests, monks or nuns.
3) Make system in which flocks can support priests, monks or nuns in
priests parish house or in dormitory
or in convents.

136

4) Donate money to build private-care-homes for retired priests, monks or

nuns.
5) Build more Catholic nursing homes.
6) Donate money for the fee of hospitals or hospices.

S20) Conclusion
In order to keep the aged priests, monks or nuns healthy and active as long as
possible, we have to start the followings right away.
1) Build up donations.
2) Establish the supporting system for the aged priests, monks and nuns.

Note:
Papers of Fransisco A Woo, MD, Joon-Ki Kang M.D and Prof W Maramis were not available

137

Session 6.1b

Medical Mission at Philippines, Rural Agriculture

District of 25Years Activities Japanese Catholic
Medical Association
Fumihiko

Shinozaki,

Buichi Ishijima

Masaya

Takeuchi

Around 1970s, many local people were suffering from poverty and sickness at
Philippines. Bishop Purganan, Isabela State,Ilagan Parish needed to break off this
bad relations. To improve these bad relation, he requested Sisters of Visitation,
Japanese nunnery sisters, who had doctor or nurse license. They worked and
educated to local women about hygiene, measurements of the parasite and
infection control at Guibang Village, Isabela.
At 1984 NovemberAsian Catholic Medical Association
ConferenceAFCMA hold on Manila. Dr.Annopresident our society and
some doctors attended this meeting. After this conference, several doctors visited
Guibang and inspected sisters activities. And then Bishop requested to send
Japanese doctors and have the clinics. Dr.Takeuchi, former president Japanese
society, he begun the fund raising for to construct new reference center and clinic
At 1986 January, new reference center opened and then new style community
health workers education started. And then every year we are attending medical
services in summer season. It is continuing over twenty five years.
Last year, seven doctors, six dentists, two pharmacists, six nurses, two dental
hygienist and four other staff attended. And four local doctors join had medical
examinations.
Over one thousand patients had come only two days clinic, to put it concretely,
367 patients internal medicine,128 pediatric patients,43 patients operated,302
dental treatments,93 patients ophthalmological and ENT and 80 patients
acupuncture had treatments.

138

They are much better off now than twenty five years ago.The transportation
facilities improved. People are going rich and it is not difficult to get the medical
care in local province.
It is now crossroad to continue or finish this medical mission.

139

THE IMPORTANCE OF SPIRITUALITY AND RELIGION IN

CLINICAL PRACTICE
Mariola Zofia Stawasz, D.Min.
Cardinal Tien Hospital, Pastoral Care Department,
Taiwan R.O.C.

INTRUDUCTION
In many years of my work experience in Cardinal Tien Hospital
(hereafter: CTH) in Taiwan as the pastoral care worker whose profession is to
take spiritual care for patients, their families and our employees, I have realized
that the patients desire and like spiritual talks and discussions with health-care
professionals. Besides, I believe that spiritual health is very important for
physical health. However, most patients reported that spiritual discussions took
place relatively rarely. In the research area of the correlation between body and
spirit among patients, advanced studies were done in the USA over the past
decades, particularly in the discussion of ones spiritual history within his / her
medical records. I have found that this topic is unknown in the Eastern part of
the world, notably in Taiwan, where I have been working for more than 10 years.
In Asia, and not only in Taiwan, there are rich spiritual and religious traditions
to look at. Christianity as such enjoys there only a small percentage of followers.
Generally speaking in the West, spirituality has become an
increasingly relevant topic in current models of health care. In the USA more
than 75 percent of medical schools teach topics related to spirituality and health,
and hospitals are beginning to develop spirituality programs to increase the
delivery of compassionate care. 79 I am convinced that at present both in the West
and East, health-care professionals can no longer ignore the spiritual aspects of
health care. Nor are they able to ignore the spiritual aspects of delivering care.

79

Puchalski CM. Spirituality and medicine: curricula in medical education. J Cancer Educ.
2066;21(1):14-18.
140

Thus, humane caring about the patient is (or at least: should be) also what
gives joy and fulfillment to health-care professionals and it is why many of them
have chosen this profession. At present, especially in this pressured health care
environment, there is a lack of personnel; instead there are many protocols and
other formalized ways of conduct which can rapidly lead to dissatisfaction,
emotional exhaustion, and burnout. The active practice of whole-person
medicine with its most profound spiritual or religious dimensions is the best
health care both for those who receive it and those who give it.
This study was undertaken to determine relations among patients and
health-care professionals (physicians and nurses) in view of their spirituality and
religious faith as relevant in medical treatment and documented in patients
spiritual history and medical records. The survey was conducted in Catholic
CTH in Taipei, Taiwan in June 2012.

SPIRITUALITY AND RELIGION

Spirituality and religion are related but conceptually different. The word
spirituality, etymologically speaking, comes from the Latin spirare, which means
breath. 80 It is a broader concept than religion and is primarily a dynamic,
personal, and experiential process. There is no one, clear comprehensive
definition of spirituality in the literature. Spirituality implies that there is a
deeper dimension to human life, an inner world of the soul. It assumes that
humans are fundamentally spiritual beings living in a spiritual, as well as
physical, universe. 81 Features of spirituality include quest for meaning and
purpose, transcendence (eg., the sense that being human is more than simple
material existence), connectedness (eg., with others, nature, or the divine), and
values (eg., love, compassion, and justice). 82 Its the name we give to the
dimension of seeing and living that goes far beyond the material world to deeper
truths and eternal values.

80

Gove PB. Merriam-Webster Editorial Staff. Websters Third New International Dictionary of
the English Language, Unabridged. Springfield, Mass: G & C Merriam Co; 1961.
81
Elkins DN, Hedstrom LJ, Hughtes LL, Leaf JA, Saunders C. Toward a humanisticphenomenological spirituality: definition, description and measurement. Journal of Humanistic
Psychology. 1999; 28:9.
82
Emblen JD. Religion and spirituality defined according to current use in nursing literature. J
Prof Nurs. 1992;8:41-47.
141

Even though some people who regard themselves as spiritual do not

endorse a formal religion, religious involvement and spirituality are overlapping
concepts. 83 The word religion, etymologically speaking, comes from the Latin
religio, which means to bind together. 84 Historically, the word religion was
used in ways that were indistinguishable from what we now call spiritually.
Now, the term religion is increasingly used by scholars in the narrow or even
pejorative sense of institutionally based dogma, rituals, traditions, beliefs and
practices of an organized religion.85 Here we want to conceive religion broader,
that is, as religiosity, religious faith or even religious beliefs.
Experientially, religious dimension may involve a search for meaning and
purpose, transcendence, connectedness, and values. In this light, religious
involvement is similar to spirituality. For the reason that of this overlap, religious
involvement and spirituality are considered together in this article.
According to the statistics, there is growing numbers of Americans who
consider themselves spiritual but not religious. 86 It is important to note that
those who consider themselves spiritual but not religious will also have genuine
spiritual needs. Those phenomena is also seen in Asia where it can be find a
tremendous gap between South and East Asia when we compare the percentages
of people who, when consider themselves spiritual but not religious.The
percentage of the population of South Asia who profess no religious identity is
essentially zero. In East Asia the percentage of people with no religious
affiliation, but consider spiritual ranges: Taiwan 24.1%, Korea 43.1%, Japan 60.1%
and over 70 per cent in China and Hong Kong. 87 And it goes without saying
that all over the world plenty of people who are religious but not spiritual, for
whom religious practice does not foster a genuine relationship with the
transcendent, may still need to grow spiritually within their faith traditions.
Generally speaking, religious beliefs and practices are common among
patients seeking medical care, and even those who indicate that they are not
83

Holland JC, Kash KM, Passik S, et al. A brief spiritual beliefs inventory for use in quality of
life research in life-threatening illness. Psychooncology. 1998;7:460-469.
84

Websters Third New International Dictionary of the English Language, Unabridged.

Springfield, Mass: G & C Merriam Co; 1961.
85
Crawford R. What is Religion? London and New York, Routledge, 2002.
86
Kosmin BA, Mayer E. American religious identification survey, 2001. Available at:
http://www.gc.cuny.edu/faculty/research_briefs/aris.pdf. Accessed January 26, 2009.
87 Reed SR. Analyzing Secularization and Religiosity in Asia. Faculty of Policy Studies Chuo
University Tokyo, Japan, 2004.
142

religious often identify themselves as being spiritual in some way. 88 The primary
spiritual questions that illness raises are about meaning, value, and relationship.
Questions about meaning include the Why me?, that is, the questions about the
meaning of suffering, life, death, purpose, and afterlife. Questions about value
encompass those that illness raises regarding a persons worth; the value one has
(or may not have) when disfigured, dependent, unproductive, or otherwise
afflicted in ways that undermine what society typically values. 89 These questions
arise for both patients of all religious persuasions and those who profess no
religious beliefs. And these questions are inevitably occasioned by a persons
confrontation with serious illness or injury and the looming possibility of death.

DISCUSSING SPIRITUALITY WITH PATIENTS

1.

Description and Explanation of the Questionnaire

Two kinds of questionnaires with the total number one hundred twenty
were distributed to in-patients (t=70), physicians (t=25) and nurses (t=25) in
Cardinal Tien Hospital (CTH). One hundred eighteen surveys were returned
within the period stipulated for the response which is a valid response rate of 99
percent: patients 100%, nurses 100% and physicians 98%. The sample survey was
randomly selected from the total patients, physicians and nurses. The
questionnaires included close and open-questions around the topic of
spirituality, religion in medical treatment and regardless of whether religious
should be eliciting a spiritual history from a patient for the proper spiritual care.
2.

Result

The preferred course of action among respondents, they wanted their

health-care professionals to know about spiritual beliefs center around
understanding (Table1).

88

Koenig HG, George LK, Titus P. Religion, spirituality and health in medically ill hospitalized
older patients. J Am Geriatr Assoc. 52:554562.
89
Sulmasy DP. Spiritual issues in the care of dying patients: . . . its OK between me and God.
JAMA 2006; 296:13851392.
143

Table 1. Respondents about add the religious belief/spirituality into

medical history

Positon

No. Yes

Patients

15

Nurses

14

Physicians

15

No. No

Percent
65.
2
56
65.
2

Percent

Neither
Yesor
No

Percent

____

__

21.7

20

24

21.7

13

Of those patients who want to add their religious beliefs, 65.2% wanted
their health-care professionals know more about them and provide some kind of
spiritual support, but they do not express why it is important. Among 65.2%
physicians the most answer to this question was that the religious identity in the
medical history can help others to better understand patients, relive pain and
suffering, give the psychological and mentally comfort. 56% nurses who
answered this question emphasis, that to know and understand patients
religious belief can provide more respect and give the patients the best holistic
care which include the spiritual and religious needs. On the other hand, the most
common answer in survey among patients who does not want add their religious
beliefs into medical treatment were that patients do not want to border healthcare professionals and others about this issues, and many of them did not think
about it. So, their explanation is not against but just open for the future to
explore.
The most common answers of 21.7% physicians and 20% nurses (Table 1)
who were not in favor to add religious believe into medical history were that
religious believe and health-care professionals duty must be separated,
otherwise can influence the nurse-physician-patient relationship, and that if
there is different religious beliefs among patients and the medical professionals
then can be some burden during the medical treatment.
The result of the open-ended questions about if the patients religious
belief will be admitted to the medical history what kind of prayer/rituals and
activity they would like to be offered (Table 2). The four highest number of the
religious activities as exorcism 100%, sprinkling the holy water 97.1%,
144

opportunity to talk with people from the same religious community and
religious ritual 92.9% shows that patients are want to have the different kind of
spiritual and religious support not only from health-care professionals but form
others as well.
Table 2. What kind of prayer/rituals activity you would like to be done
Characteristic

No.

Pray

53

75.7

Blessings

22

31.4

Religious dedication

52

74.3

Religious rituals

65

92.9

Exorcism

70

100

Anointment

45

63

Sprinkling the holy water

68

97.1

Confession

44

62.8

69

98.6

Talk with the person from

your religious community

Percent

Even those patients who do not have any religious beliefs would like to
have some spiritual care provide by the hospital or others as prayer, blessings,
talk etc., (Table 3). The 34.3% of those patients admitted that prayer and spiritual
care specially needs it in the time of illness give strengths and hope.
Nevertheless, the 48.6% of those patient who do not give neither answer must be
take in account as open possibilities to understanding this phenomena.
Table 3. Even if you do not have any religious believe, would you like that
the hospital provides for you some forms of spiritual care?
No.

Percent

Yes

24

34.3

No

12

17.1

Neither Yes or No

34

48.6

145

Other worthy to notice result is that 67% physicians and 61% nurses even
they do not have any religious affiliation (Table 4) are willing to pray with
patients if they will be asked (Table 5). The 30% of health-care professionals will
refer the patient to the pastoral care department to fulfill the patients spiritual
needs.
Table 4. Religious affiliation of medicalhealth professionals
Position

No. Yes

Percent

No. No

Percent

Physicians

13

56.5

10

43.5

Nurses

12

48

13

52

Table 5. Will you pray with a patient even you do not have a religious
belief?
Position

Fulfilled the patients needs

(pray/blessings etc)

Refer to hospitals pastoral care

dept.

Physicians

Nurses

67%

30%

61%

30%

The survey for physician and nurses ask also the questions about learning
more about patients spiritual needs (Table 6). Most of the answers among nurses
were to advise the nursing department of the hospital to arrange classes and
course to enrich nurses knowledge in this field, and ask hospitals pastoral care
department for guidance and support how to comfort patients in their spiritual
needs. Physicians answers of this question expressed that they by themselves
will enrich their knowledge by reading books or just humbly way pray and
comfort patients by its own.

146

Table 6. Would you like to learn about how to help patients in their
spiritual needs?
Position

Nurses

Physicians

3.

Variable

No.

Advise the hospital nursing department to provide some

classes and courses to enrich nurses knowledge about
patients spiritual needs.

13

52

Ask the hospitals pastoral care department for support and

guidance.

12

48

I will comfort patients in my own way; do not need to learn

about it.

13

56.5

Enrich once own knowledge about patients spiritual, religious

needs and desire in the different religious beliefs.

10

43.5

Discussion

The results of this study evidentially show the close correlation among
patients, nurses and physicians which should be taken into account for deeper
understanding and possible discussions on the importance of spirituality and
religion in medical treatment (cf. Figure 1).
First, the correlation between patients and physicians is very significant and
shows that there is even an increased and enhanced need for spiritual and
religion dimension in the patient during his or her illness. This calls for more
functioning listening and dialogue on the side of the physician. Secondly, the
correlation between patients and nurses draws attention to more active and full care
in view of patients spiritual and religion needs. There is the need for a more
holistic view of health care on the side of nurses. Thirdly, the importance of the
physician-and-nurse correlation shows a space for more awareness, willingness,
and even cooperation to expand their knowledge about the importance of
spirituality and religion in medical treatment. There is a profound calling for
more active and practical steps in this field. Fourthly, the correlation among
patients, physicians, and nurses reveals possibilities of building more hope and
trust among health-care professionals and patients through mutual and deeper
understanding, respect and sharing personal spirituality and religious faith or
humane spirituality in the process of medical treatment.
147

Figure 1. The mutual correlation between patients, physicians and nurses

Those significant mutual correlations among patients, physicians and
nurses brought some foremost fruits. The major contribution of this study is
helping to clarify that people/patients have their spiritual needs which have to
be taken seriously in account during the medical treatment. There is hidden
needs of the patients to be understood by health-care professional in the wider
sense and cultural context. For instance, the patients do not want to boarder
medical health-care professionals. The cultural politeness and fear of power have
to be overcome. In all this patients are looking for understanding, compassion,
and hope. This finding is consistent with Scheurichs call for attention to patient
values, Pulchalskis use of understanding in designing clinical assessments, and
Koenings theoretical perspective concerning patient centeredness and the
provision of holistic care for someone whose being has physical, emotional and
spiritual dimensions. 90 Providing understanding, compassion, and hope are
hallmarks of a good physician/nurse in any culture and are not necessarily and
faith dependent. To bridge the gap between medicine and spirituality, the
physician and nurse (health-care professionals) must identify, coordinate, and
utilize referral sources for patient-generated requests. 91

90

Koenig HG. Religion, spirituality, and medicine: application to clinical practice.JAMA. 2000;
284:1708; Scheurich N. Reconsidering spirituality and medicine. Acad Med.2003;78:356-360;
Puchalski C, Romer AL. Taking a spiritual history allows clinicians to understand patients more
fully. J Palliative Med. 2000;3:129-137.
91
Astrow AB, Puchalski CM, Sulmasy DP. Religion, spirituality, and health care: social, ethical
and practical considerations. Am J Med. 2001;110:283-287.
148

Another contribution of this study is the examination of possibilities and

willingness of the health-care professional to support patients in their spiritual
needs. They should identify referral sources and use them when appropriate.
The culturally-sensitive physicians and nurses foster communication by
encouraging exploration of the patients beliefs and values. They can also
facilitate the patients integration of the particular medical decisions into the
patients worldview. As Koenig stresses, the physician/nurse treats the whole
person, not simply the patients disease. 92
WHY SHOULD HEALTHCARE PROFESSIONALS ATTEND TO THE
SPIRITUAL CONCERNS OF PATIENTS?
The results of the survey and the studies in this topic the author reviewed
suggest that acknowledging and supporting patient spirituality may enhance
patient care. Indeed, William Osler 93 called faith an unfailing stream of energy,
whereas William Mayo 94 said, [T]here is a spiritual as well as a material quality
in the care of sick people, and too great efficiency in material details may hamper
progress. The patient care is much more than disease management; it involves
addressing the needs of the whole person.
The nature of the conditions treated by pulmonary and critical care
physicians seems to raise spiritual questions in a particularly sensitive way. 95
Some clinicians, however, might acknowledge that the spiritual concerns of
patients are important but question whether physicians, nurses, or other healthcare professionals have any duty to attend to these concerns. Why not leave
spirituality to families, clergy, and chaplains?
For several reasons, I would argue that health-care professionals have a
moral obligation to attend to their patients spiritual needs. First, patients regard
their spiritual health and physical health as equally important. 96 Second, if
physicians and other health-care professionals have sworn to treat patients to the
best of their ability and judgment, and the best care to treats patients as whole
92

Koenig HG. Religion, spirituality, and medicine: application to clinical practice. JAMA. 2000;
284:1708.
93
Osler W. The faith that heals. Br Med J. 1910;2:1470-1472.
94
Mayo WJ. Minutes from a faculty meeting of the Mayo Clinic staff, November 21, 1932.
95

Ehman JW, Ott B, Short TH, et al. Do patients want physicians to inquire about their spiritual
or religious beliefs if they become gravely ill? Arch Intern Med 1999; 159:18031806.
96

King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and
prayer. J Fam Pract. 1999;39:349-352.
149

persons, then to treat patients in a way that ignores the fundamental meaning
that patient sees in suffering, healing, life and death. 97 The encounter between
health-care professionals and patients is imbued with an interpersonal
significance that is itself, in many religious traditions, an encounter with sacred.
Third, acknowledging and addressing a patients spirituality may enhance
cultural sensitivity. 98 Sometimes clinicians are in the best position to elicit the
most serious spiritual and religious concerns of patients. Many patients are
frightened by their condition and its meaning. An astute clinician might discover
that the patient is in a serious spiritual crisis and make the appropriate referrals.
Forth, sometimes spiritual issues may be interfering with treatment and patients
may not be readily forthcoming about the reasons. 99 Fifth, supporting a patients
spirituality may enrich the patient-physician relationship. Finally, because the
goals of medicine are to cure disease when possible and to relieve suffering
always, including spirituality in clinical practice should be within the purview of
the physician. 100
For these reasons, health-care professionals, regardless of whether they
are themselves religious, ought to be able to bring out a spiritual history from a
patient and make proper referrals to clergy or others who are experts in the
delivery of spiritual care.

SPIRITUALITY, RELIGION AND ETHICS

Ethical issues are raised when one includes patient religion and
spirituality in clinical practice. Non-maleficence (the principle: do no harm)
requires that physicians do not proselytize and of course religious and spiritual
practices should not replace effective allopathic treatments. 101

97

Post SG, Puchalski CM, Larson DB. Physicians and patient spirituality: professional
boundaries, competency, and ethics. Ann Intern Med. 2000;132:578-583.

98

Post SG, Puchalski CM, Larson DB. Physicians and patient spirituality: professional
boundaries, competency, and ethics.
99
King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and
prayer.
100
Cassell EJ. The nature of suffering and the goals of medicine. N Engl J Med. 1982;306:639645.
101

Koenig HG. Religion, spirituality, and medicine: application to clinical practice. JAMA.
2000;284:1708.
150

On the other hand, the beneficent health-care professional acknowledges

and supports a patient spirituality. Some authors, however, claim that the
religious and spiritual concerns of patients are private and that physicians
should not inquire about them. 102 Though a similar case could be made regarding
inquiries about patient sexuality, substance abuse, and other sensitive matters.
These matters, formerly shunned by physicians, are now discussed openly
because of their potential effect on health. The physicians duty is not to judge a
patients private attitudes and behaviors but to understand their clinical
importance. 103 Hence, physicians should inquire about and support a patients
spiritual beliefs and needs, especially during severe and terminal illnesses, when
they are most likely to affect clinical decisions. Religions do tend to prescribe and
proscribe many behaviors, including, importantly, many medically related
behaviors. Spirituality does provide a motivation to act morally, a context for
cultivating a life of virtue, and a perspective by which to view the affective and
interpersonal contours of a moral life. 104 Indeed, lack of appropriate spiritual
care may constitute a form of negligence.
Some authors suggest that physicians ignore patient spirituality because
they may not have the knowledge or skills to engage religiously diverse patients
in meaningful discussions about their spiritual needs without offending them. 105
Autonomy, however, requires that physicians respect the decisions of competent
patients, which are often based on religious and spiritual beliefs. Furthermore,
unrelated to medical decisions, patients often spontaneously raise spiritual issues
and concerns with their physicians. Therefore it is difficult for physicians to
ignore or avoid patient spirituality.

PATIENTS SPIRITUAL NEEDS

It is not always certain what the precise spiritual needs of a patient might
be. Some might want help with specific religious rituals. Some might want to talk
to members of their own faith communities about the meaning of suffering. Still
102

Sloan RP, Bagiella E, VandeCreek L, et al. Should physicians prescribe religious activities? N
Engl J Med. 2000;342:1913-1916.
103
Koenig HG, Idler E, Kasl S, et al. Religion, spirituality, and medicine: a rebuttal to skeptics.
Int J Psychiatry Med. 1999;29:123-131.
104

Post SG, Puchalski CM, Larson DB. Physicians and patient spirituality: professional
boundaries, competency, and ethics. Ann Intern Med. 2005;132:578-583.
105
Sloan RP, Bagiella E, VandeCreek L, et al. Should physicians prescribe religious activities?
151

others might want pastoral counseling regarding their fear of death. Defining the
spiritual needs of patients is a matter that is being investigated empirically, but
there are, at present, no well-validated research instruments for this purpose.
Several early studies have demonstrated that large numbers of patients report a
wide spectrum of spiritual needs, and that meeting spiritual needs is correlated
with patient satisfaction with care and their ratings of the quality of medical
care. 106
According to the survey done among the Americans some religious
patients actually desire that their physicians pray with them. Interest in this
practice varies significantly from 19% for routine office visits in one study to 95%
before ophthalmologic surgery in another. 107The clinicians response to a patient
request for prayer generally depends on the religious and spiritual beliefs,
practices, and circumstances of both the clinician and the patient.
Result of the sample survey in regard of which was recently done among
patient in Catholic Cardinal Tien Hospital in Taiwan also showed that 75.5% of
patients are willing to accept prayer and 98.6 % talk about their spiritual needs
with health-care professionals and others (Table 2). The 56.5% of clinicians and
46% nurses who has religious belief response that they support the patients
spiritual or religion request (Table 3). Even 43.5% of clinicians and 52% nurses
those who do not admit any religious affiliation is willing to support patients in
their spiritual need (Table 3, 4). Moreover, in the future they are willing to learn
more about patients spirituals and religious needs and refer pastoral care
department for the help (Table 4). It is observable that if the patient and the
physician are both religious (and especially if they are of the same religion), the
request can be met with a simple prayer. Even if they are of different religions
this may be possible. However, some clinicians are uncomfortable praying with
patients. 108
TAKING A SPIRITUAL HISTORY
Discerning the spiritual needs of patients can be done by taking a spiritual
history. Similar to the social history, the spiritual history informs the physician of
106

Clark PA, Drain M, Malone MP. Addressing patients emotional and spiritual needs. Jt Comm
J Qual Saf 2003; 29:659670.
107

MacLean CD, Phifer SB, Schultz L, et al. Patient preference for physician discussion and
practice of spirituality. J Gen Intern Med 2003; 18:3843; King DE, Bushwick B. Beliefs and
attitudes of hospital inpatients about faith healing and prayer. J Fam Pract 1994; 39:349352.

108

Lo B, Kates LW, Ruston D, et al. Responding to requests regarding prayer and religious
ceremonies by patients near the end of life and their families. J Palliat Med 2003; 6:409415.
152

the importance of spiritual matters in the life of the patient and how the patients
spirituality can be used as a source of strength and coping. For terminally ill
patients, the spiritual history is regarded as a crucial component of palliative
medicine. 109
Several formal assessments exist to help physicians address the
spiritual needs of their patients. These tools are designed to help physicians
approach the topic of spirituality using open-ended questions in order to obtain
important information about patients views of health care and faith. It is already
few years of observance that several acronyms have been developed to help
clinicians to do so, and two are presented in Table 7. 110,33 These serve as
reminders of the kinds of spiritual issues that clinicians ought to be able to
address with patients. Like many such phrases, they are often most useful for
novice learners and simply and quickly way eliciting the same information.
Table 7: Useful acronyms for obtaining a spiritual history
FICA
F:
I:
C:
A:

(Puchalski)
Faith and beliefs
Importance of spirituality in the patients life
Spiritual community of support
How does the patient wish spiritual issues to be addressed in his or her care?

SPIRIT
S:
P:
I:
R:
I:
T:

(Maugans)
Spiritual belief system
Personal spirituality
Integration with a spiritual community
Ritualized practices and restrictions
Implications for medical care
Terminal events planning

HOPE 111
H:
O:

Sources of hope, meaning, comfort, strength, peace, love and connection

Organized religion

P:
E:

Effects on medical care and end-of-life issues

Personal spirituality and practice

109

Bruce R. Spirituality and Palliative Care: Social and Pastoral Perspectives. Oxford
University Press, USA; 2004.
110
Puchalski CM. Spirituality and end-of-life care: a time for listening and caring. J Palliat Med
2002; 5:289294; Maugans TA. The spiritual history. Arch Fam Med 1996; 5:1116.
111
Anandarajah G and Hight E. Spirituality and Medical Practice: Using the HOPE Questions as a
Practical Tool for Spiritual Assessment. Am Fam Physician 2001; 63(1): 81-89.
http://www.aafp.org/afp/2001/0101/p81.html
153

According to Dr. Christina Puchalski the FICA model are already widely
used in the many medical courses at medical schools in United States. However,
it is hard to make an exact estimate how many people have been trained so far to
use the spiritual history. 112Those FICA as SPIRIT model has general principles,
which must be taken in the cross-cultural dimension and understanding. Mere
cultural sensitivity and competence requires that patients and families be
welcomed and respected in expressing themselves in the terms that are most
comfortable for them rather than have to translate or reframe their thinking in
the idiom of the hospital.
Furthermore, Harold G. Koenig well known in this field strongly
emphases that first and foremost, physician should take the brief history and
document this in the medical record. Questions asked during a spiritual history
include the following (Table 8): 113
Table 8: Sample of questions which can be asked during a spiritual history
Questions
(1) Are religious beliefs a source of comfort or a cause of stress?
(2) Are religious beliefs in conflict with medical care?
(3) Are there religious beliefs that might influence medical decisions (and how)?
(4) Is there a supportive faith community likely to check on and monitor the patients
recovery?
(5) Are there any other spiritual needs that need to be addressed?
This information may be collected over several visits or all at one time as
part of the social history. The best times are at the time of hospital admission,
during a new patient evaluation, or as part of a well-person check up. Studies
have shown that a brief spiritual history adds only 1 or 2 minutes to the visit. 114
The spiritual assessment brings us back to those compassionate, caregiving roots

112

Puchalski, CM , Romer AL. Taking a Spiritual History allows clinicians to understand patients
more fully. J Palliat Med 200; 3:129137.
113
Koenig, Harold G. Religion, Spirituality, and Medicine: Research Findings and Implications
for Clinical Practice. Southern Medical Association 2004; 1194-1200.
114

Koenig HG. Spirituality in Patient Care: Why, How, When, and What. Philadelphia, PA,
Templeton Foundation Press, 2002.
154

of the doctor-patient relationship. 115 Moreover, the resulting information learned

and the effect on the, in terms of building trust, make this extra time well spent.
Doing the spiritual history also helps health care providers understand the role
that spirituality plays in the patient-health care professionals itself. Without
asking, one might not recognize the spiritual needs of such patients and be
unable to assist them in a time of extraordinary need. It is also according to the
physician what he/she will do with that information, what they learned about it?
CONCLUSION
In this contribution, with help of my survey, I have briefly touched on a
wide range of religious and spiritual concerns in health care. Of course, this is
not the end of the study of this topic as such. Much more needs to be done, not
only theoretically, but especially practically. However, the most conspicuous
insight into mine surveyed is the fact that there is the desire of taking much
seriously spiritual and religious aspects of human life into medical treatment.
It is obvious that not always openly expressed spiritual and religious
needs of patients must be brought as important information into their ward.
However, the knowledge of patients' spiritual history can support the
physicians and nurses work for the good of the patient and help him or her
better during hospitalization. Through this, the health-care professionals can be
probably able to get some new insights helpful for recovery of health, or at least
stabilize the condition of the patient.
I am aware that the survey here presented by me is a very simple one.
There is still a need for much deeper studies than my survey with questionnaire.
Especially in Taiwanese context (and we can extend it to Asian context) where
there is a plethora of religious beliefs, the aspects of how and when and which kind
of spirituality or religion is the most significant and difficult one. However, one
thing is sure, and it is that the patients needs which begin with seeking physical
health, but always go beyond it, are the focus of the process of medical care. By
sharing and understanding the patient life experience with its spiritual and
religious dimensions, the health-care professionals can bring themselves into the
dialogue with the patient and build more humane bridge into their scientific
and medical world of daily medical practice. We have to be more aware of that

115

Puchalski, CM , Romer AL. Taking a Spiritual History allows clinicians to understand patients
more fully.
155

fact that, simply treating a medical diagnosis or a disease, without considering

the person with such a disease, is no longer acceptable. The time has passed
when the spiritual concerns of patients could be ignored as irrelevant to good
medical care. Patients are individuals with life stories, emotional reactions to
illness, and social and family relationships that effect and are affected by illness.
It is also interesting and important that the results of this survey are
similar to many advanced studies within this field done in the USA in the past
decades. Nevertheless, I believe that some future studies in Asia conducted in
various areas will bring more contextual differences which can enrich this topic.

156

Catholic Medical Association Events As A Collaboration

Between Catholic Medical Doctors, Paramedics, and
Medical Students
Eko Budidharmaja, FX Awal Prasetyo, FX Sukendar
Catholic Medical Association (for example: Indonesian Catholic Medical
Community ICMC) has various profession of its member:

Medical Doctors and Dentists as regular members.

Paramedics (Nurses, Pharmacists, Analyst and Medical Students) as

extraordinary members.

(Anggaran dasar KMKI)

ICMC Semarang has done several events by involving medical doctors, nurses,
pharmacists, analyst and medical students:
1.

Public Circumcision
Date

: July 3rd 2011 and July 1st 2012

Place

: St. Paul Catholic Church, Sendangguwo, Semarang

In these events, ICMC Semarang has done a collaboration between medical

doctors, nurses, and medical students. To achieve collaboration, ICMC
Semarang have some strategies in organizing these events :

Job job distribution between doctors, medical students, and nurses:

Steering Comittee

: Medical Doctors

Fund Raising

: Medical Doctors

Experts

: Residents of Surgery, Nurses, Co-assistant

Organizing Comittee : Medical Student

Routine meeting between Steering Comittee and Organizing

Comittee
157

In these events ICMC Semarang also done a transfer of knowledge between

clinicians and medical students in the Circumcision Station:

2.

Supervisor

: Surgeon

Operator

: Resident of Surgery

Assistant 1

: Co-assistant

Assistant 2

: Nurse

Observer

: Medical student

Blood Donor and Health Service

Date

: September 30th 2012

Place

: Holy Mary Cathedral Church, Randusari, Semarang

In this event we also done a collaboration between medical doctors, nurses,

pharmacists, analyst and medical students in organizing this events :

Patient Registration : Medical student

Vital Sign

Consulting Doctor : Medical Doctor, Co-assistant under supervision

Assistant

: Medical Student or Nurse

Pharmacy

: Pharmacist, Medical Student

Laboratory Test

: Lab analyst

: Medical Student, Nurse Academy Student

Objectives of ICMC Semarang Events

1. As an opportunity of togetherness and fraternity (decrease comunication
gap between senior and junior)
2. As an update of science, medical ethics, and catholic medical ethics.
3. As a social service and social responsibility.
4. As a continous regeneration and caderisation process of CMA.
5. Transfer of knowledge from clinicians to medical students.
158

Why we need to focus in regeneration process?

Nowadays medical students are guided to be a five stars doctor (or seven star
doctor ini some region),
5 Stars Doctor
Care provider
Decision-maker
Communicator
Community leader
Manager
+ Religious
+ Researcher
Details of 5 Stars doctors are given below
Care-provider. Besides giving individual treatment five-star doctorsmust
take into account the total (physical, mental and social) needs of the patient.
They must ensure that a full range of treatment - curative, preventive or
rehabilitative - will be dispensed in ways that are complementary, integrated
and continuous. And they must ensure that the treatment is of the highest
quality.
Decision-maker.In a climate of transparency five-star doctors will have to
take decisions that can be justified in terms of efficacy and cost. From all the
possible ways of treating a given health condition, the one that seems most
appropriate in the given situation must be chosen. As regards expenditure, the
limited resources available for health must be shared out fairly to the benefit
of every individual in the community.
Communicator. Lifestyle aspects suchas a balanced diet, safety measures at
work, type of leisure pursuits, respect for the environment and so on all have
a determining influence on health. The involvement of the individual
159

inprotecting and restoring his or her own health is therefore vital, since
exposure to a healthrisk is largely determined by ones behaviour. The doctors
of tomorrow must be excellent communicators in order to persuade
individuals, families and the communitiesin their charge to adopt healthy
lifestyles and become partners in the health effort.
Community leader. The needs and problems of the whole community - in a
suburb or a district - must not be forgotten. By understanding the
determinants of health inherent in the physical and social environment and by
appreciating the breadth of each problem or health risk five-star doctors will
not simply be treating individuals who seek help but will also take a positive
interest in community health activities which will benefit large numbers of
people.
Manager. To carry out all these functions, it will be essential for five-star
doctors to acquire managerial skills. This will enable them to initiate
exchanges of information in order to make better decisions, and to work
within a multidisciplinary team in close association with other partnersfor
health and social development. Both old and new methods of dispensing care
will have to be integrated with the totality of health and social services,
whether destined for the individual or for the community.
(Boelen C. Frontline doctors of tomorrow. World Health, 1994, 47:45)
We need to focus in regeneration process because of :
1. Regular medical education are insufficient to prepare a catholic doctor.
(Because Catholics are minority in most Asian countries)
2. ICMC (CMA) need a continous regeneration process
Good comunication and interpersonal relation are the beginning of
regeneration process of CMA. Collaboration in CMA events can train
leadership and managerial skill to its participant

160

Conclusion
1. CMA have to remember the need of regeneration function in CMA events
2. Advantages of involving paramedics and medical students in CMA Events :

As a continous regeneration process of CMA

Build communication and interpersonal relation between seniors and

juniors.

Transfer of knowledge between seniors and juniors.

Job distribution between medical doctors, paramedics, and medical

students.

Note
Paper of Peter J. Manoppo, MD, FINACS, FICS and CP Chen, RN, MSc were not available

161

Session 6.2a

THE ROLE OF THE CATHOLIC DOCTOR IN

HUMANITARIAN AID
Fr JH (Gino) Henriques CSsR

Introduction:
This short paper presupposes certain important aspects in the ministry of
a Catholic Doctor. I shall briefly enumerate them now.
1.
A Catholic doctor is not a mere professional. He continues in his
professional work the healing ministry of Christ.
2.
As in all Catholic ministries a doctor's faith in God, and a belief that
God works through him/her is important.
3.

A patient is treated in a holistic manner.

The word 'humanitarian' in a broad sense refers to a concern with needs

towards an alleviation of suffering. In this paper I refer to the alleviation of
suffering of the poor and the deprived.
I

A few examples

(i) A Catholic doctor, Mrs. Leonilda Dias was widowed early in her
marriage. She felt a call to reach out to the poor. Graduating in medicine, she
went to a remote poor village with a paramedic. Diligently, she ministered to the
poor for thirty years. Her prayerful life, her trust in God and love for the poor
was a source of much edification. If there was a surplus of money, it was given to
orphanages, to the seminary for the education of priests or some charity for the
poor. She lived and died living a frugal but happy Christian life.

(ii) Another Catholic doctor, Mr. Chico, was moved to care for the poor.
He had observed how the poor could barely pay for their medical expenses. For
162

the last thirty years he drives to a far away village to treat the poor in a village. It
is only in the evening for three hours that he offers his services to both the poor
and the middle class people in the city where he lives. He is not afraid to remind
his patients that God is the healer. Whenever possible, he recommends prayer
together with medication to them.
These are individuals who spend lives in humanitarian aid through a
motivation that comes from their faith. Money does have a role to play in their
medical practice. But it is not the dominant factor or guiding motive for their
medical service.
(iii)
Dr. Devi Shetty, a heart surgeon who worked in Calcutta was
inspired to make his service available to the poor. He was Mother Theresa's heart
doctor. He was inspired by her dedication to the poorest of the poor. Today he is
world renown for his work towards establishing an equitable distribution of
world class, affordable healthcare for the masses. He relentlessly pursues this
goal through the Narayana Hrudyala Institute of Cardiac Sciences that he has
founded in Bangalore, India. His foundation strives to go beyond cardiac to other
health treatments. He believes that specialist healthcare should be available to
both rich and poor.
A

Reflection:

A
similar commitment and dedication was witnessed to by many in the
medical healthcare offered by the Church through Religious institutions in the
past (perhaps, even today). But Dr. Shetty has developed his cardiac healthcare
to large proportions that would make him the biggest in the world, reaching out
to the poor and to others.
A deeply religious person, God must certainly be the heart of his
motivation in his work. In all his institutions, he has a prayer chapel for the
different faiths for those who may want to pray.

(iv). It is known that Catholic doctors in many Asian countries have

formed groups that offer medical and health care to the poor. These groups liaise
with Priests and Religious in poorer countries and indulge in medical outreach
over short periods (a few weeks). To cite just one example : Singapore Doctors
have chaplains with a number of the laity who are motivated for mission and
outreach in missionary witness and social uplift in the countries like the
163

Philippines, Myanmar and Cambodia. This is holistic evangelization where

witness, healing and social development are done together. In this process, not
only are the recipients of humanitarian aid evangelized. The evangelized in turn
evangelize the evangelizers. Those offering humanitarian aid are evangelized by
the humility, the receptiveness, the gratitude and love of the poor. This latter
fruit of evangelization motivates the doctors and their team to want to go more
often to these countries.
Holistic evangelization is outreach towards the whole person, both the
physical and the spiritual.

II.

The Role of the Catholic Doctor

I once read an article in a news paper (The Sunday Times, December 7,

2008 Singapore). It was entitled: "Medicine is not a career, but a calling". The
author, Lee Wei Ling, is a neurologist. A significant percentage of patients seen
cannot be cured. Yet the best that one can do is offered to the patient. A
humanitarian approach is recommended in such neurological cases: to cure,
sometimes; to relieve, often; to comfort, always. This doctor has striven to do this
for the last 30 years with remarkable success.
This doctor deplores a practice that has developed over the years. Despite
the advances in the medical sciences, the medical community has drifted away
from this humanitarian approach. Yearning and working for monkey is widely
and openly practiced; and sometimes perceived as acceptable behavior. One's
moral instinct is needed to right the wrong that benefits from the patient any
unfair monetary gain.
An important trait in Jesus the healer was empathy and compassion. Such
an attitude is necessary towards the sick while one seeks the right monetary
compensation for one's work. Hence, the challenge often to doctors is to choose
between two incentives: the humanitarian, ethical, compassionate approach to do
the best to all patients versus the calculating attitude that seeks to profit from as
many patients as possible. In a Catholic doctor, the first should triumph.

164

III.

Jesus, the Model

Jesus has been and will always be the model to a doctor of humanitarian
aid. With the important emphasis on the spiritual, Jesus did not neglect the
human aspect of human life. In compassion he strove to educate the masses with
his teachings and preaching. Moved to pity, he fed the hungry, counselled the
broken hearted and healed the sick. His humanitarian outreach was broad and
expansive: a model for every Christian, especially the medical personnel.

165

AWARENESS OF CHURCH TEACHING ON IVF AMONG CATHOLIC DOCTORS

AND YOUNG COUPLES IN JAKARTA AND SURABAYA
R. E. Nadres, PhD

Abstract:
Description: As with anything that is destined to become part of life and culture,
everything related to respect for human life--the Gospel of Life--has to take root first in the
awareness of the people before it becomes a governing principle of behavior. The great
obstacle to the awareness of what is good are all the counter- influences that are present in
the environment. In Indonesia, concretely, in vitro fertilization (IVF) has become a widely
acceptable product within its target market. Couples who are unable to have a child,
including Catholic couples, are almost certain to at least think about IVF as an alternative
to achieve the much desired dream of having children. Why is this so? Theoretically, we
can envision two possible root causes: (1) the lack of awareness among Catholic pastors
that this is an issue and the lack of preparedness of the sacred ministers to catechize the
faithful on this matter; and/or (2) the lack of awareness among Catholic doctors on this
Church teaching and their consequent inability to advise Catholic patients correctly.
Objective: This study aims to test the second hypothesis: that the lack of awareness
of the morality of IVF among Catholic Indonesian doctors is greatly contributory to the
confusion on the moral acceptability of IVF.
Method: Through a survey, it intends to gather empirical data on the presence or absence of
such awareness. It is hoped that the results of this study can guide bishops on what
actions could be taken to address this area of Church Magisterium that is
becoming more and more relevant today, especially in Indonesia.
Results and Conclusions: The survey shows that there is a lack of true knowledge of the
teachings of the Catholic Church on the morality of IVF. Although 52.54% of the doctors
surveyed said that they knew that the Church has taught something about the morality of
IVF, only seven have correctly mentioned titles of documents of the Church that are
more directly related to the topic. 18.64% honestly say that they do not know if the
Church has said something about this, and the rest said that they think the Church did
not teach anything about it. In spite of the fact that the majority said they know that the
Church has taught something about it, 47.46% of the doctors believe that IVF may be used
in certain cases and 26.27% say that it is actually morally acceptable.
166

The survey made on the young Catholic couples likewise reflects a lack of
knowledge of the teachings of the Catholic Church on the morality of IVF. This just goes
to show that the teachings of the Catholic Church on this matter have not yet trickled
down effectively to the Christian faithful. There is ignorance rather than outright
rejection.
There are three main points of doctrine that have to be established well in the minds of
the ordinary Catholics: (1) that human life starts at conception and this is the reason why
the place of conception and gestation of the human child is very morally relevant; (2) we do
not have an absolute right to have a childa child is a gift, not a possession, not a
commodity; and (3) that IVF itself is immoral and not only because of the collateral aspects
of its procedure. We think that from these two basic pointswhich are found in the
teaching of the Catholic Church on the morality of IVFit will be possible to establish
clearly in the eyes of the Catholic faithful the immorality of this procedure.
Catholic doctors have to be formed and educated directly on the morality of IVF by
qualified pastors and/or lay experts chosen by the Church. Due to the basic requirements
of competence in their profession, we expect the doctors to have the intellectual
capability and fitting background to be good vehicles of this doctrine to the people
of God. Of course, the priests do have to have some training on this, but it seems to
us that spreading the doctrine through the doctors is an effective way. Besides, it is
logical for a Catholic couple to seek the advice of a Catholic doctor on the morality and
advisability of IVF. It may also happen that a priest who considers himself insufficiently
informed about the procedure direct Catholic couples to Catholic doctors in order to
consult on this issue.
Category: ii. Challenges of Catholic Doctors at the beginning of Human life

167

AWARENESS OF CHURCH TEACHING ON IVF AMONG CATHOLIC DOCTORS

AND YOUNG COUPLES IN JAKARTA AND SURABAYA
Ramon E. Nadres, Ph.D.

Introduction
As with anything that is destined to become part of life and culture,
everything related to respect for human life--the Gospel of Life--has to take root first in the
awareness of the people before it becomes a governing principle of behavior. The great
obstacle to the awareness of what is good are all the counter- influences that are present in
the environment. In Indonesia, concretely, in vitro fertilization

(IVF)

has

become

widely acceptable product within its target market. Couples who are unable to have
children, including Catholic couples, are almost certain to at least think about IVF as an
alternative to achieve the much desired dream of having children. Why is this so?
Theoretically, we can envision two possible root causes: (1) the lack of awareness among
Catholic pastors that this is an issue and the lack of preparedness of the sacred ministers
to catechize the faithful on this matter; and/or (2) the lack of awareness among Catholic
doctors on this Church teaching and their consequent inability to advise Catholic patients
correctly.
This study is divided into the following sections:
1. A Review of the Official Church Teaching on IVF
2. A Description of the Survey Method
3. The Results of the Survey Made on the Catholic Doctors
4. The Results of the Survey Made on the Young Catholic Couples
5. A Discussion on Doctors as Vehicles for Spreading the Correct Doctrine
168

6. On the Bioethical Education of Catholic Medical Students

7. Suggestions on Achieving a Greater Acceptability of Church Doctine
8. Conclusions and Recommendations

A Review of Official Church Teaching on IVF

The Catholic Churchs teachings on the morality of in vitro fertilization can be
found in the following documents (arranged according to year of publication):
1965: SECOND VATICAN COUNCIL, Pastoral Constitution Gaudium et Spes, 7
December 1965, 51. This document defines the two aspects of a morally upright
conjugal act: the procreative and the unitive aspects. These, based on the nature of
the human person and his acts, preserve the full sense of mutual self-giving and
human procreation in the context of true love. [no. 51, the italics are ours]
1987: Congregation for the Doctrine of the Faith, Instruction Donum Vitae (On Respect for
Human Life in its Origin and on the Dignity of Procreation: Replies to Certain Questions of
the Day), Rome, 22 February 1987.
1995: Pontifical Council for Pastoral Assistance to Health Care Workers, The
Charter for Health Care Workers, Vatican City, 1 January 1995.
1995: JOHN PAUL II, Encyclical Evangelium Vitae, Rome, 25 March 1995.
2008: Congregation for the Doctrine of the Faith, Instruction Dignitas Personae, Rome, 8
September 2008.

Among these documents, the most comprehensive discussion of the morality of in vitro
fertilization to date can be found in Donum Vitae. As regards this issue Donum Vitae answers
the following specific questions:
How is one to evaluate morally the use for research purposes of embryos obtained
by fertilization in vitro?
What judgment should be made on other procedures of manipulating embryos
169

connected with the techniques of human reproduction?

What

connection

is

required

from

the

moral

point

of

view

between

procreation and the conjugal act?

Is homologous in vitro fertilization morally licit? 1
But as early as 1995, with the document Charter for Health Care Workers (nos. 24-26),
the Church had already clearly defined the central notions involved in the determining the
morality of in vitro fertilization, to wit:
In vitro fertilization is immoral because it does not respect the unitive aspect of
the

conjugal act. According to this requirement, sexual union should occur

between husband and wife for the conception to occur in accordance with human
dignity. 2
In vitro fertilization is immoral because it take the baby as something
someonethat one has a right to have and not as a gift. 3

We are also morally obliged to reject in vitro fertilization is because its

procedure up to now has immoral consequences: abortion (extra zygotes that are
not implanted as done away with); it allows the freezing of extra embryos for later
implantationan action that is not respectful of the human being; it opens the
possibility for post mortem insemination, which brings a baby into the world even
though his father is no longer around. 4
1 It is this question, actually, that goes to the heart of the matter as regards the morality of fertilization in

vitro. The document, however, has decided to save the best for last and chose to tackle the consequences of in
vitro fertilization first before asking whether the act in itself is immoral.

2 Cfr. Charter for Health Care Workers, no. 24. Together with the required occurrence of the conjugal act, we
shall see later on that the dignity of the human being requires that he or she be conceived develop completely
inside his or her mothers womb until it will be possible for him or her to survive outside it. Bringing any
stage from conception to the time that the baby is viable outside the womb is not in accordance with human
dignity.

3 Cfr. Charter for Health Care Workers, nos. 24-25.

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The Charter for Health Care Workers further clarifies that although in vitro
fertilization can be rejected even with just the consideration of these
accompanying

moral circumstances, Catholics have to note that in vitro

fertilization is immoral in itself because of the destruction of the unitive aspect

of the conjugal act and the treatment of child as a right and not as a gift.
The latest document that explicitly and directly refers to the morality of in vitro
fertilization is Dignitas Personae (2008). IVF is specifically tackled in nos.
14-16. Dignitas Personae aims to assess the morality of the new technologies that
have come up since Donum Vitae and Evangelium Vitae. From the point of view of IVF
itself, the document largely reiterates the principles already stated in the two
previous documents. It sustains the moral unacceptability of IVF for the same
reasons stated in the two previous documents.

4 Cfr. Charter for Health Care Workers, no. 26. Some people may find something romantic about this, but
we must admit that it has its bizarre side. Children also have a natural need for their father when it
comes to their education. It is one thing for a father not to be around because he died after his child
was born and quite another to bring a child into the world with the full certainty that he will grow up
without the care of his father.

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Survey Method
A total of 118 Catholic Indonesian doctors 5

and 109 Catholic Indonesian young

couples 6 in Jakarta and Surabaya and from their surrounding areas were surveyed. There
were separate questionnaires for the doctors and for the couples (see Annexes 1 and 2).
The two cities were chosen primarily because they are considered places where there is a
high probability that couples will resort to in vitro fertilization methods should they
encounter problems in having children. These cities are populated with persons who
could afford to pay for such procedures. Also, the subjects level of education makes
them more open to understanding the gist of the medical procedure. Cosmopolitan
education, attitude and lifestyle of city people can also allow them to more easily
overcome cultural and religious barriers that prevent others from even considering the use
of such methods. Where the market is, there is where we should also find the doctors
who are willing to provide assisted reproductive techniques (ART). 7 Of course, cities are
also the first places where this technology could be more easily available.

5 The 2008 list of the Catholic Doctors Association in Surabaya accounts for 237 Catholic doctors. Our data

collection limitations may have skewed the results of the survey towards Surabaya, but still a good
14.41% of the doctors surveyed are from Jakarta. Place of practice: 17 in Jakarta; 1 in Karawang; 1 in Manila; 1
in Medan; 1 in Samarinda; 98 in Surabaya. University: Airlangga = 42; Atma Jaya = 4; Brawijaya , Malang =
14; Diponegoro = 2; Universitas Kristen Djaya = 1; Freie Universitaet Berlin = 1; Gadjah Mada = 4; Hang
Tua = 8; Jember = 4; Johanes Gutenberg University = 1; Justus Liebig Universitas Gieben = 1;
Melbourne = 1; Samratulayi = 1; Sebelas Maret = 1; Tarumanagara = 1; Trisakti
= 4; Udayana, Bali = 8; Undip = 1; Unej = 1; Unissula = 1; Universitas Indonesia = 4; Universitas
Methodist Indonesia = 1; Wijaya Kusuma = 14. Sex: 66 male doctors and 52 female doctors. Age range:
20-29 years old = 22; 30-39 years old 43; 40-49 years old = 18; 50-59 years old = 16; 60-69 years old =
13; 70-79 years old = 5; 80-89 years old = 1. Specialization: 63 are General Practitioners, the rest are of very
varied specializations. Two (2) are Andrologists.

Twelve pairs were marriages of persons of different religions, one of the spouse being Catholic. 20 of
them live in Jakarta and other Western Javanese cities and 89 of them live in Surabaya and other Eastern
Javanese cities. The number of children range from 0-3. The husbands ages range from 23-44 years old; the
wives from 20-52 years old.

This author actually does not agree with the use of the term assisted reproductive technology. The
Catholic Church distinguishes between assistance and replacement. Assisting the martial act in the
genesis of new human life is actually ethical. Replacing the marital act with a technological procedure is
considered not in accordance with human dignity and does not respect the rights of the newborn child nor
the rights of God. Cfr. Dignitatis Personae, no. 13.

172

Young couples were defined as those who had been married for 10 years or less.
This limit was chosen with the assumption that such couples would most probably think
of using in vitro fertilization methods should they encounter difficulties in having
children. The results of the survey were subjected to cross- tabulation and association ChiSquare testing, the results of which are found in Annex 3.
This researcher first became aware of the possible lack of knowledge about the
morality of IVF among Catholic doctors due to discussions with these doctors and Catholic
couples in the course of teaching Bioethics in the university. An article in one of the
local dailies also made this author realize that IVF is more readily available and
considered more generally acceptable in Indonesia than in the Philippines 8 . Significant,
too, are: (1) the art exhibit on IVF entitled Art of ART organized by Dr. Aucky Hinting
from 16-20 November 2011 in the city of Surabaya; and (2) the convocation of the First
Congress of [the] Indonesian Association for In Vitro Fertilization (IA-IVF), held last 1315 February 2012 at the Grand Melia Hotel in Jakarta.
It should be clarified to that the field of expertise of this researcher is
Philosophy. 9 Though this paper counts on a survey as the starting point, the aim really is
to address an ethical issue. We are more inclined to base ethical decisions on
universal and essential moral laws based on basic human nature (i.e., human natural law
as philosophically considered) rather than determining them on the basis of statistical
data.
8 See for example the article in Kompas, Sunday, 30 October 2011. A cursory search over the Internet reveals
that there are 30 IVF clinics in Indonesia compared to the 3 that are found in the Philippines. One can also see
that the ones in the Philippines are relatively new, while the ones in Indonesia seem to have been around for
already a considerably long time.

9 This researcher, however, also has a bachelors degree in Zoology from the University of the Philippines and
has done the first year of Medicine at the University of the Philippines, Philippine General Hospital during
the school year 1982-1983. During his high school years (1974-1978), he was part of a team that tested the
effectiveness of lecithin in the improvement of memory retention in white mice and did a comparative study
of the effects of Cimetidine and Ranitidine on secondary sex characteristics of roosters in 1983. This is the
reason for his desire to have at least some empirical data as the basis for even philosophical conclusions.

173

From the philosophical point of view, a few significant cases can be the basis of valid ethical
conclusions if human reason can see that the ethical principles involved are rooted in and
essential to the nature of man.
The survey questions were designed so that they can be answered even without
an interviewer. The interviewees were asked to reply quickly with what they immediately
knew at the moment of filling up the form. This was done to preclude answering the
questions on the basis of what can be researched or searched on the Internet, and not on
what they presently know. 10

Results of the Survey among Catholic Doctors

Almost half (47.46%) of the doctors surveyed think that the use of IVF is morally
acceptable in certain cases, to wit, when the couple has tried everything else and still they
are unable to have a child. Many of these doctors presume that the right to have a child is
absolute, that is, that a couple without a child can never feel complete. By the insistence
on which this reason is cited as warranting the use of IVF, this researcher also tends to
think that the doctorsand young couplesin general tend to conclude that a couple can
never be complete without
having at least one child.
MORALITY OF IVF
Immoral
Morally Acceptable
It depends

NO. OF RESPONSES
30
31
56

10

PERCENTAGE
25.42%
26.27%
47.46%

One weakness of the survey question design is that the participants tend to get confused as they move from the
question on whether they know that there is some document of the Catholic Church declaring the morality of IVF to the
question on whether they agree with that teaching. But the accompanying strength of the survey design is that the
request for a short explanation of what they mean by their answer actually corrects any miscorrelation between these two
questions. The explanations also reveal what they do not know or fail to grasp in the Churchs teaching about IVF.

174

This may sound logical from a certain point of view. After all, even the Church
says that one of the primary ends of marriage is procreation. If the couple are unable to
procreate, would that not mean that they are unable to fulfill the natural end of their
union? Would not IVF pave the way to the achievement of this frustrated natural end?
And if it fulfills a natural end, wouldnt that be perfectly ethical?
It can be seen, though, that some doctors proceed with caution in the granting of
legitimacy to some cases of IVF. These are especially those who already know that the
Church has already said something about IVF and would like to uphold that statement.
Thus, these doctors take the effort to state the conditions that warrant an exception and
they say that IVF can only be ethically allowable: (1) only if all the natural methods have
been tried for a sufficiently long period of time; (2) only if there is mutual agreement
between the spouses as regards the use of IVF; (3) only if all the fertilized ova are implanted
and none are frozen or thrown away; (4) only if the ovum comes from the wife and the
sperm from the husband; etc.
There is therefore no desire to sever ties with the moral teaching of the Church but
there are clear attempts to justify exceptions which the Church herself does not make.
Of course, this may be because of mistaken information or ignorance.
26.27% of the doctors interviewed said that IVF is morally acceptable. This, of
course, goes completely opposite the teaching of the Catholic Church. If we add those
who make exceptions to this, then we could probably legitimately say that 73.73% of
Catholic doctors in Jakarta and Surabaya do not agree with the teaching of the Catholic
Church either deliberately or out of ignorance. This is a very big percentage.

175

Only one-fourth of the doctors (25.42%) agreedwhether consciously or

not consciouslywith the teaching of the Catholic Church and clearly stated that
IVF is immoral.
52.54% of the Catholic doctors said that they knew beforehand that the
Catholic Church has taught something about the morality of in vitro fertilization.
This is high, especially considering the fact, as we said above, that 73.73% of them
actually do not agree with this teaching. But this knowledge means that they
have once heard about it and have a vague remembrance of having received
information about it. Even among those who admitted that they knew that the
Catholic Church has taught something about the morality of IVF, only seven (7)
could correctly cite a document of the Catholic Church that indeed imparts this
teaching.

IF CHURCH HAS TAUGHT

Yes, the Church has taught something
No, the Church has not taught anything
I do not know

NO. OF
RESPONSES
62
34
22

PERCENTAGE
52.54%
28.81%
18.64%

Among the 62 who knew that the Church had taught something about the
morality of IVF, one-third (33.87%) still choose to disagree with the Churchs
teaching. This is also quite big, and serious. It just goes to show that there is a
significant gap in the Bioethical formation of Catholic doctors, at least from the
point of view of coaxing them to accept the teachings of the Catholic faith on the
morality of IVF.
DO YOU AGREE?
I agree
I do not agree
No response

NO. OF RESPONSES
37
21
4

176

PERCENTAGE
59.68%
33.87%
6.45%

Knowledge of Young Catholic Couples about the Morality of IVF

While in the case of the doctors, the majority tend towards allowing
exceptions to the Catholic teaching of the immorality of IVF, among the Catholic
couples

the

opinions are

evenly

distributed

between

immoral,

morally

acceptable and it depends. Even so, the conclusion that we can draw from this is
that 64.22% of Catholic couples do not know the teaching of the Church on
IVF.
MORALITY OF IVF
Morally Acceptable
Immoral
It Depends
I dont know

NO. OF RESPONSES
34
39
35
1

PERCENTAGE
31.19%
35.78%
32.11%
0.92%

Like the doctors, a good percentage of the Catholic couples (57.80%)

already know that the Catholic Church has taught something about in vitro
fertilization. Only nine (9) could correctly identify a Church document that
contains this teaching.
HAS THE CHURCH
TAUGHT?
Yes.
No.
I do not know.

NO. OF RESPONSES

PERCENTAGE

63
29
16

57.80%
26.60%
14.68%

Like the doctors again, one-third of these Catholic couples (34.92%) who know
that they Church has taught something about IVF do not agree with
Catholic teaching.
DO YOU AGREE?
Yes.
No.

NO. OF RESPONSES
41
22
177

PERCENTAGE
65.08%
34.92%

Doctor Teachers or Priest Preachers?

There are two easily conceivable ways by which a couple may be catechized on the
morality of the use of in vitro fertilization: (1) catechesis through the parish or through a
priest; and (2) through the advice given by a Catholic doctor. Catechesis through the parish
or through a priest is not the object of this study. It is possible that the priests in Indonesia in
general have not had sufficient training on giving advice on the use of IVF, but we have not
tried to ascertain this in this study.
Besides, one can also imagine the hesitation of a parish priest to explain the ins
and outs of in vitro fertilization. He may feel overwhelmed by the technology and
thus prefer to refer the faithful to someone whom he considers to be a good, ethical and
knowledgeable

Catholic doctor. Of course, we are speculating here. The case of the

readiness of the parish priests to give advice on the morality of in vitro fertilization can be
the subject of another study. In the meantime, it is good to look into the possibility of
having the Catholic doctors equipped to explain the real Catholic teaching on in vitro
fertilization to all Catholic couples who consult them.
Our theory is that the one of the best ways to convey the teaching on morality of
in vitro fertilization is through the Catholic doctor (with no prejudice against the
effectiveness of spreading the same teaching through the priests). With the great weight
that is put on scientific discoveries nowadays, it is not uncommon that what a scientist
or a doctor says can very well challenge what a priest says. The attitude is not new. In
medieval University of Paris, some Averroist professors were ready to take the line
that, if there were a conflict between the teaching of a Father of the Church and
Aristotle, the default according to themshould be Aristotle. With this comment we
are not saying that the default should be the opposite: that if there is a conflict between
the teaching of the Church and science, the Church automatically prevails de fide. No.
Rather, we should strive a little bit harder to seek the possible compatibility and, although
178

we are all now science-minded in this millennium, we might want to try to harder to be
open to the fact that the Church may have a point.
Besides, when it comes to in vitro fertilization, we all have to realize that the
Church is not arguing on the basis of the Bible, of Sacred Scripture. No. Rather, all Her
argumentation stems from human nature, which is something that even the philosophers
like Socrates, Plato and Aristotle could achieve even without the help of Sacred Revelation.
That said, we go back again to our point that the best defense of the Churchs
teaching on IVF and one of the best ways of conveying this teaching to the faithful is
through the Catholic doctor, in the same way that they best way, for example, to convey the
teaching on Catholic feminism is through a good, faithful, intelligent and well-accomplished
Catholic woman.

Bioethical Education of Catholic Medical Students

If indeed it is imperative for the Church to attend to the ethical formation of our
Catholic doctors, then we must identify the different fronts through which this ethical
formation could be achieved. Now, if we want to be practical about it, we must realize
that much of the ethical education of a Catholic doctor in Indonesia nowadays is
through his own university. We still have to hear of a Church institution that dedicates
itself to bioethical formation of Catholic doctors. Rather, what we have right now are
organizations that help Catholic couples to learn the Catholic teachings related to married
life: e.g., the morality of contraception, abortion, etc.
Many of these organizations are dedicated to the formation of the Catholic family
and, if ever they touch on this issue, it would be in the context of preparation for
marriage, that is, the set of seminars given the couples who are preparing for their
179

wedding. Who are often called to give the seminars on the morality of contraception
and of abortion? The Catholic doctors themselves. Again, we have to ask whether these
same doctors in turn get sufficient training in the teachings of the Catholic faith in this
regard. Perhaps, indeed, those specific doctors who give seminars for the preparation
for marriage may be sufficiently equipped. But, what about the others? And what about
those who are asked about the morality of in vitro fertilization during a medical
consultation? 11
Again, the doctor often gets the bulk of his ethical training from his medical
faculty. Note, however, that not all the medical faculties in Indonesia are Catholic or have
ethical orientations that are similar to that of the Catholic orientation. Furthermore, a
good number of these non-Catholic universities are considered to have higher academic
standards from the scientific side of the discipline. For this reason, the Catholics who
can make it to those universities often have no qualms and do not hesitate to enroll
in

such

universities considering the great advantage this would have for their future

professional life.

11

I once asked around for a doctor who could explain the Billings Ovulation Method to couples who see
the need to use it. It seems like a worldwide phenomenon that the Calendar Method (merely counting the
days without heeding the bodily signs) is often taken to be the natural way. But that Calendar Method
has a higher failure rate and that is why to assuage the fear of distressed Catholic couples, someone has
to be ready to teach them the Billings Ovulation Method or some other of similar effectiveness.
However, it was not easy to find such a doctor. Although this may be anecdotic (of course, a survey can be
done on this as well), I have once heard a medical student say that he hesitates to specialize in
Obstetrics-Gynecology because it will be difficult for a Catholic doctor not to prescribe contraceptives.
There have been commentaries here and there also from doctors expressing some similar idea and
possibly implying that, in the end, there may be nothing wrong in prescribing these in extreme
situations. We dont want to make any conclusions here, but these little accounts just goes to show that
there is a need to look into the ethical formation of Catholic doctors in Indonesia.
I also recently heard that in Airlangga University, they had decided that the semester during which Bioethics
is taught, instead of separating the different religions during the religions class, they will be lumped
together and the Bioethics classes will be taught by lecturers of different religious backgrounds,
the goal being to have the future doctors have a well-rounded view of the different ways at look at
bioethical problems. While this may indeed give the students an overview of the different stances as regards
bioethical issues, it is of no advantage to any one of them who would like to know the Catholic stand first
before venturing into the study of the other views.

180

But what type of ethical training do these Catholic students get from non- Catholic
faculties? Certainly, he will not receive a complete Catholic orientation on bioethics.
What most people call multiculturalism, in these cases, becomes a principle that
overrides a more thorough Catholic bioethical training. 12

By rule and unwritten

agreement, such teachings should be ecumenical, i.e., partly Catholic, partly

other. It does not matter if there is no coherence or even if there is some slight
contradiction. The higher value is the acceptance of the teachings of all sides, with an
attempt not to leave out any.
This, of course, is understandable in a non-Catholic university. What
about the

Catholic universities? Having to make a review of the different

bioethical syllabi of the Catholic universities in Indonesia exceeds the scope of this
paper. However, we think that we can find some hint of the material used in the
teaching of Bioethics in the Catholic universities through the books used for this
purpose. From the bookstores, we can most easily obtain the following list:
1. Gregory C. Higgins, 8 Dilema Moral Zaman Ini Di Pihak Manakah
Anda?, Kanisius, Yogyakarta, 2006.
2. Willaim Chang, Bioetika Sebuah Pengantar, Kanisius, Yogyakarta,
2009.
3. K. Bertens, Etika Biomedis, Kanisius, Yogyakarta, 2011.
The book of Gergory Higgins is a translation of the book published in New
Jersey, U.S.A., in 1995 entitled Where Do You Stand?
12

As we have said before, the basis of Catholic bioethical teaching is largely human nature,
which is within the reach of any human mind, even by those who have not received any Revelation.
By focusing on the correct bioethical formation of the Catholic medical students, we are not saying
that Catholic biomedical teaching is applicable only for Catholics. The truth is, the Bioethical
teachings of the Catholic Church are also true for and apply to everyone else, since everyone bears
the same human nature.

181

There is no indication as to whether this book is currently being used by any Medical
faculty. But it is cited as a reference in the
book of William Chang, and the book of William Chang is the fruit of his teaching at
the Theological School for Higher Learning Pastor Bonus.
Higgins openly discusses the Christian view of the biomedical issues that he
writes about in his book. He also directly quotes Catholic sources, which means
that a Catholic reader will have a good glimpse of official Catholic teaching plus
possible Catholic and non-Catholic debate on the corresponding issues. His writing
style, however, still gives a sense of openness to contrary opinions. While stating the
Catholic stand, he still invites the reader to weigh her own position as regards the
matter in question. This is why he adds the subtitle Di Pihak Manakah Anda?
(Where do you stand?).
Higgins book, however, does not have a bibliography. From the just the book
itself, we would not know what his main sources are. However, his footnotes are full of
citations from Catholic documents.
William Chang does not hide his religions condition and adds the
abbreviation of his Order at the end of his name. He also clearly states in his
introduction that his book is the fruit of his teaching at STT Pastor Bonus. Chang calls
his book Sebuah Pengantar (An Introduction). The reason for the qualification
becomes clear to the reader as he finds a good number of the ethical discussions a bit
truncated. With the parts related to IVF, for example, a conclusion is given (i.e.,
IVF is intrinsically immoral 13 ) but the argumentation that arrives at that conclusion
is not systematically elucidated. The conclusion also taken seems to apply
indiscriminately to all the subsidiary issues related to IVF: the problem of sperm
and egg donation from a third party, surrogate motherhood, all the different
types of procedures, etc. However, we think that each of the subsidiary issues
require a separate type of argumentation because they are not immoral in the same
182

way. With a severely shortened bioethical discussion, it would be difficult for the
reader to enter into an informed debate or exchange of ideas with persons who may
think differently.

Perhaps, the advantage of Changs book is that the readers willlike in the book of
Higginsget a general idea of the Churchs stand on the different bioethical
problems.

However,

Chang

does

not

usually

directly

cite

official Church

documents and his bibliography at the end of the book does not list down any official
Church document but rather many manuals written by Catholic moral theologians.
Whenever he cites a Church document in the footnote, it seems that his knowledge of
the content of the Church document came from the Bioethics manual.

Hot off the press is the book of K. Bertens, Etika Biomedis. It is a delight from
the point of view of the amount of work that went into it and its advanced
completeness compared to the other two books. The cases presented and the
inclusion of relevant laws from the Indonesian juridical code are admirable.

13 Cfr. Chang, Bioetika, p. 112.

183

Bertens Etika Biomedis, however, from the point of view of the text, is less clearly
Catholic in orientation. There are three indications that may make us conclude that the
author intended the book to be useable by a Catholic readership: (1) it is the text
book of Universitas Katolik Atma Jaya; (2) it is published by Penerbit Kanisius, a Catholic
publishing house; and (3) K. Bertens is actually a Roman Catholic priest. 14

The

bibliography, however, does not cite any official Church document, but rather cites the
different manuals available, just like Chang.
Bertens, however, might be deliberately doing this so that both his classes and his
books can be used by Catholics and non-Catholics alike. This approach has its advantages in
multi-faith and multi-cultural Indonesia. He also refrains from stating a very strong and
definitive stand about the morality of the different issues. Rather, he tends to guide the
readers towards making their own conclusions as, for example, with the guide
questions that he abundantly provides at the end of each chapter.
Given the three books available to Indonesian Catholic medical students for the study of
bioethics, it is understandable that the knowledge of the Catholic doctors about the morality
of in vitro fertilization is not as deep as the Church might want it to be. The most readily
available literature in Bahasa Indonesia is good but maybe no purposeful enough in
conveying clear Catholic teaching on this. This is a wake up call for Church leaders to
address this lack of sufficient moral orientation on IVF (and on other bioethical issues that
Catholics in the medical sciences need to know).
A review of the Bioethics syllabi of the different Catholics universities would be
helpful to better understand and address the problem, but this is beyond the scope
and the capability of the present investigation. It could be reserved for a future study.

14 He celebrated the 50th anniversary of his priestly ordination in 2010.

184

Towards a Greater Acceptability of Church Teaching on IVF

The two main conclusions of this study are:
(1) Catholic doctors and Catholic couples are not sufficiently aware of the
Catholic teaching on the morality of in vitro fertilization; and
(2) (one-third of those Catholic doctors and couples who do know that the
Catholic Church has taught something about the morality of IVF
actually do not agree with this teaching.
The first recommendation we have for the Catholic Church and for the
Catholic doctors association is to provide clear and unequivocal instruction on the
morality of IVF.
The second recommendation, which is like a more concrete objective
within the first recommendation, is to clarify three main ideas within this
teaching that have probably not taken root in the minds of the doctors and
Catholic couples, to wit:
(1) that human life begins when the egg is fertilized by the sperm;
(2) the right of parents to have a baby is not an absolute right and value:
some other rights and values may be found to be above this right; and
(3) IVF is immoral in itself and not only in its circumstances.
The way of carrying out the first recommendation now depends on the
Catholic

Church and the Catholic doctors associations. As for the second

recommendation, we would like to elaborate further.

Human life begins at fertilization. Not very many doctorsand Catholic
couplesseem to be aware that the in vitro fertilization procedure involves
abortion. The explanation for this might be that: (1) it is not clear to them that the
185

procedure involves the wasting of fertilized ova; and (2) that fertilized ova are
actually already complete human beings whose full array of human rights should be
respected.
The problem of knowledge of the IVF procedure is easy to resolve: all the IVF
clinic websites admit that a selection of the fertilized ova is made. Not all websites
explain what happens to the extra fertilized ova once one of them successfully
implants. But we suppose any competent Catholic doctor, after having this
pointed out to him, will be able to conclude that they are either wasted or kept
frozen for future use or donation or turned over to other groups doing scientific
research. All these possibilities would exact no moral qualms if the doctor does not
think that what is actually being wasted, frozen, donated or used for research is
already a human person.
Chang says that embryological studies already support the moment of
conceptionthe meeting of the sperm and the eggas the moment when human life
begins. 15 We think that this teaching is very readily acceptable to Catholics. But if
that is so, why is it that such a high number of Catholic doctors and couples still
recommend the use of in vitro fertilization? It may also be because, even if the
zygote is already considered a human person, it suffers fewer disadvantages when
lost compared to when an adult human being dies or suffer. In a sense, it is like saying
yes the zygote is a human person but it is less human than an adult.
These are, in fact, the two things that a couple considering the use of IVF have
to choose from: (1) to get rid of several human beings who are zygotes in exchange
for satisfying the deep emotional longing of one or two adults; or (2) not to even
open the possibility of the death of human zygote and be simply ready to suffer like an
adult the unfulfilled longing to have a child. In the first case, the adult can be happy
but the children in the extra zygotes are gone; in the second case, the adult freely
decides to suffer in order not to make the big mistake of killing a person who is a
zygote. And yet, many doctors and couples recommend the first. This can only be
explained if the zygote possesses a low type dignity in their eyes, an attitude that
186

may have rubbed off onto them from the current general attitude in medical
science.
Are zygotes already complete human beings? The Catholic Church clearly
states that they are. 16 We can also find scientific data and scientist who support this
reality, which means that it is not merely taught by the Catholic Church and for
Catholics only. It is a human reality that must be accepted and respected by all.
Act and potency. The fact that the complete individual human being is already in the
zygote is supported by the Aristotelian analysis according to the metaphysical
principles of potency and act. A potency is the ability to become something and an
act is that something which that potency has the ability to become. Each potency is
essentially linked with its corresponding act. The corn seed, for example, is in
potency to become a corn plant (its corresponding act) but it is not in potency to
become a rose bush. The potency in the corn seed is essentially linked to the corn
plant in act. Potency is not an undetermined possibility but a possibility that is
already directed towards its corresponding perfect act.

15
16

Chang, Bioetika, p. 37.

Donum vitae, I, 1 and III, a; Holy See, Charter of the Rights of the Family, 4: LOsservatore Romano,
25 November 1983.

187

With concepts of act and potency, we now understand why the zygote of
Albert Einstein is Einstein himself, and why the zygote which was Mother
Theresa of Calcutta was Mother Theresa herself and not someone else. Left to
develop and take its natural course of growth the zygote of Einstein will
necessarily become Einstein and the zygote of Mother Theresa will necessarily
become Mother Theresa. From this point of view, their corresponding zygotes will
have to be given the same respect and the same rights as the grown up persons
themselves. A concrete human life begins at fertilization and not at a later time.
The Right to Have a Child is Not Absolute. The most common reason given by
the doctors and couples interviewed why childless couples should be allowed to
use IVF to have a child is what they consider the inherent right of couples to have
a child. This value is so high up in the hierarchy of values, especially in
Indonesian

society, that it seems to overrule any other

consideration. But is this presumption true?

In this day and time, it is very difficult to find and justify a case when a
person has a right over another person. Many years ago, there were countries that
defended the right for white people to have African slaves. Slavery is actually one
clear instance in which people are considered to have a right over other people.
Having a right over another person essentially means ownership of that person.
Having a right over a person is different from having a right to receive
something from another person. A wife, for example, has the right to received love
from her husband; a husband has the right to be cared for by his wife. But the wife
does not own the person of the husband nor does the husband own the person of the
wife.
Having a right over a child is basically a concept of ownership. The
question is: Do parents own their children?
188

The desire to be a mother or a father does not justify any "right to

children", whereas the rights of the unborn child are evident. The unborn
child must be guaranteed the best possible conditions of existence through the
stability of a family founded on marriage, through the complementarities
of the two persons, father and mother. The rapid development of
research and its technological application in the area of reproduction poses
new and delicate questions that involve society and the norms that regulate
human social life.
[] Unacceptable are methods that separate the unitive act from the
procreative act by making use of laboratory techniques, such as
homologous
artificial insemination or fertilization, such that the child comes about more as
the result of an act of technology than as the natural fruit of a human act in
which there is a full and total giving of the couple. 17
If children can be owned, then parents have a natural right over the child. If
children cannot be owned, then the zygote has all the right not be treated in the way
that it is treated in an IVF procedure. Parents have no right to do this to their child
even though he is still a zygote.
From the point of view of our relationship with God, the child is a gift from
God. A gift is freely given by the giver. He is the one who chooses: (a) whether to
give a gift or not; (b) what gift to give; and (c) when the gift is to be given. The
receiver of the gift is not entitled to go to the house of this given without being
asked, to pick from among the things that this prospective gift-giver has and then to
take that gift himself and bring it home. A receiver cannot give the gift to himself.
A true gift is freely received from another.

17 Compendium of the Social Doctrine of the Catholic Church, n. 235.

189

If that analysis of gift-giving is correct and the child is really a gift from God, then
IVF is really a wrong attitude towards the rights of the Creator as Gift- giver.
Therefore, not having a child is not bad in itself; it is not a sign of the non- fulfillment
of the goal of marriage. It is not an absolute must be. To test this, we only need to ask: If
my spouse cannot give me a child, would it be reason enough for me not to love him or her?
Is it absolutely impossible for a couple to love one another if they dont have a child? If
a couple thinks that having a child is imperative for a marriage to be good, was the
child a condition for them to get married? If they could not pay for an IVF procedure,
should they divorce and marry someone else who could give them a child?
We have to realize that the strong external pressure to have a child is not correctly
rooted in human nature. And the supposed personal and deep emotional need to
have a child in order to be fulfilled is more of a personal preference than a real natural
human need. It is the self that takes becomes the center of the question in these cases, not
God nor the child that is to come.
IVF in itself is immoral. In order to dissuade couples from using IVF, both doctors and
lay people cite the immorality of certain aspects of the procedure (e.g., its abortive side,
the use of sperm or egg donors, the hiring of surrogate mothers, etc.) or the inconvenient
corollary effects (e.g., the physiological and psychological stress on the mother, the cost
of the procedure, the high rate of failure, the social stigma, etc.).
Several of the doctors and couples who are open to the use of IVF ask for these
conditions: as long as the egg is from the mother and the sperm is from the father; as
long as all the fertilized eggs are introduced into the womb of the mother 18 ;

18 The question that arises with this qualification is: Does this justify the procedure? Knowing that some of the
fertilized ova will not implant, would this not be the same as allowing a foreseeable abortion of a zygote?

190

as long as only one egg is fertilized andintroduced into the womb each time 19 ;
as long as the family foresees the expense and the required physical and psychological
effort; etc., etc., etc. But the question is: Is IVF immoral in itself? If we can avoid the
abortion and the technological adultery (i.e., using donor sperm and eggs) will the
IVF then become morally acceptable?
The Church points out that the IVF procedure is immoral in itself because it takes
out the unitive aspect of the conjugal act. To make the sexual act really human and really
an expression of the love of spouses for one another, they must do it. In order to give
maximum respect to the dignity of the baby to be born, he or she should be conceived in
the womb (fallopian tube, actually) of his mother and his entire process of development
should take place in that human and loving place.
In sum, IVF is immoral in itself and not only because of its accompanying immoral
circumstances. Some might argue that IVF is less immoral than abortion. That is
probably true. But one act being more evil than the other does not erase the evil of the
lesser act. The fact that killing an unarmed thief is less bad than killing your unarmed
parents does not make killing an unarmed thief a good action. Killing an unarmed thief
remains bad and should not be done. So, too, homologous IVF should not be done, even
though it may be possible that it is less bad than asking for a sperm donor and having a
baby even when one does not intend to get married.

19 The difficulty with this is what the IVF practitioners themselves point out: low success rate. Fertilizing
and introducing one fertilized ovum at a time lessens the probability of implantation for each try, probably
increase the expense and probably exacts more grueling effort from the mother.

191

Conclusions
From the survey results, we can see that the Indonesian Catholic doctors
and Catholic young couples are largely unaware of the Churchs teaching on the
morality of IVF or at least their knowledge is not deep enough to cause a change
of behavior in the right direction towards IVF.
We realize that the Church needs to address the formation of Catholic
doctors on this teaching, especially explaining to them and convincing them of
three points of this doctrine: (a) that human life begins at fertilization; (b) that
couples do not have an absolute right to have a child, i.e., the principle is not to
have a child no matter what the procedure; and (c) that IVF is immoral in itself
and not only in its accompanying circumstances.
We recommend maximizing the involvement of the Catholic doctors in
the spread of the correct doctrine since it seems to be one of the most effective
and practical ways of doing so.

BIBLIOGRAPHY:
BENEDICT XVI, Address to the General Assembly of the Pontifical Academy for Life and
International Congress on The Human Embryo in the Pre- implantation Phase (27
February 2006): AAS 98 (2006), 264.
BERTENS, K., Etika Biomedis, Kanisius, Yogyakarta 2011.
Catechism of the Catholic Church, Word & Life Publications with CBCP/ECCCE, Manila, 1994.
Copy right of the original Latin text belongs to the Libreria Editrice Vaticana, Citt del
Vaticano, 1994.
CHANG, William, Bioetika Sebuah Pengantar, Kanisius, Yogyakarta, 2009. PONTIFICAL
COUNCIL FOR JUSTICE AND PEACE, Compendium of the Social
Doctrine of the Church, Libreria Editrice Vaticana and Word & Life
Publications, Manila, 2004.
CONGREGATION FOR THE DOCTRINE OF THE FAITH, Instruction "Dignitas
Personae", 8 September 2008.

CONGREGATION FOR THE DOCTRINE OF THE FAITH, Instruction Donum Vitae (On

192

Respect for Human Life in its Origin and on the Dignity of Procreation: Replies to Certain
Questions of the Day), Rome, 22 February
1987.
HIGGINS, Gregory C., 8 Dilema Moral Zaman Ini Di Pihak Manakah Anda?, Kanisius,
Yogyakarta, 2006.
JOHN PAUL II, Encyclical Evangelium Vitae, Rome, 25 March 1995.
, Familiaris Consortio, Rome, 22 November 1981.
, Discourse to priests participating in a seminar on "Responsible
Procreation", 17 September 1983, Insegnamenti di Giovanni Paolo II, VI,
2 (1983).
MONGE, Michael A., Ethical Practices in Health & Disease, Sinag-tala
Publishers, Inc., Manila, 1994.
PARDO SENZ, Jos Mara, The Unknown Face of In Vitro Fertilization, Medicina e
Morale, 2012/1.
PAUL VI, Encyclical Humanae Vitae, Rome, 25 July 1968.
PONTIFICAL COUNCIL FOR PASTORAL ASSISTANCE TO HEALTH CARE WORKERS,
The Charter for Health Care Workers, Vatican City, 1 January
1995.
SACRED CONGREGATION FOR THE DOCTRINE OF THE FAITH, Declaration on Procured
Abortion, 12-13: AAS 66 (1974) 738.
SECOND VATICAN COUNCIL, Pastoral Constitution Gaudium et Spes, 7
December 1965, 51.

193

Annex 1

SURVEI UNTUK DOKTER

DATA:
Universitas tempat Anda mempelajari Ilmu Kedokteran:
Kewarganegaraan anda:
Tahun lulus dari Fakultas Kedokteran:
Agama:

Usia:

Jenis kelamin: [ ] L

Spesialisasi:

Kota tempat praktik Anda:

[ ]P

Jawablah pertanyaan-pertanyaan berikut ini dengan apa yang pertama kali

muncul dalam pikiran Anda. Tidak perlu melakukan pengkajian literatur atau
riset lebih lanjut.
1. Pilihlah salah satu: In vitro fertilization saat ini:
[ ] A. dapat diterima secara moral.
[ ] B. imoral.
[ ] C. dapat diterima secara moral dalam situasi tertentu. [Sebutkan situasi
situasi tersebut pada tempat yang tersedia di bawah ini.]

2. Gereja Katolik mengajarkan sesuatu tentang moralitas in vitro fertilization:

194

Ya. [Tuliskan judul dokumen Gereja yang menyampaikan hal tersebut di

bawah ini, jika Anda ingat.]
Judul dokumen:
[ ] Tidak.

3. Setujukah Anda dengan ajaran Gereja Katolik mengenai in vitro fertilization?

Mengapa setuju atau mengapa tidak?
[ ] Saya setuju. [ ] Saya tidak setuju Berikan penjelasan singkat:

4. Jika seseorang meminta nasihat Anda untuk menggunakan in vitro

fertilization, nasihat apakah yang akan Anda berikan dan mengapa demikian?
Silakan berikan penjelasan singkat.

195

--o0o

Terima kasih atas partisipasi Anda dalam survey kami. Semua jawaban Anda
dijamin kerahasiaannya dan hanya akan digunakan dalam rangka mengetahui
tren umum in vitro fertilization di Indonesia.

196

Annex 2

SURVEI UNTUK PASANGAN MUDA

DATA:
Kota tempat tinggal:
Agama suami:
Usia suami:

Kewarganegaraan:
Agama istri:
Usia istri:

Jumlah anak:

Usia perkawinan:

Jawablah pertanyaan-pertanyaan berikut ini dengan apa yang pertama kali

muncul dalam pikiran Anda. Tidak perlu melakukan pengkajian atau riset lebih
lanjut. Pada dasarnya, suami dan istri harus menjawab kuesioner ini secara
bersama-sama. Jika Anda dan pasangan Anda mempunyai opini yang
berbeda, sebaiknya isilah lembar ini secara terpisah dan isilah keterangan
untuk menandainya pada akhir kuesioner. Terima kasih.
5. Pilihlah salah satu: In vitro fertilization saat ini:
[ ] A. dapat diterima secara moral.
[ ] B. imoral.
[ ] C. dapat diterima secara moral dalam situasi tertentu. [Sebutkan situasi
situasi tersebut pada tempat yang tersedia di bawah ini.]

6. Gereja Katolik mengajarkan sesuatu tentang moralitas in vitro fertilization:

[ ] Ya. [Tuliskan judul dokumen Gereja yang menyampaikan hal tersebut di
bawah ini, jika Anda ingat.]
197

Judul dokumen:
[ ] Tidak.
7. Setujukah Anda dengan ajaran Gereja Katolik mengenai in vitro fertilization?
Mengapa setuju atau mengapa tidak?
[ ] Saya setuju. [ ] Saya tidak setuju. Berikan penjelasan singkat:

8. Jika seseorang meminta nasihat Anda untuk menggunakan in vitro

fertilization, nasihat apakah yang akan Anda berikan dan mengapa demikian?
Silakan berikan penjelasan singkat.

--o0o-Jika Anda dan pasangan Anda mempunyai opini yang berbeda tentang in vitro
fertilization, silakan berikan tanda cek () pada kotak yang sesuai di bawah ini:
198

Jenis kelamin: [ ] Pria [ ] Wanita;

Pasangan saya mengisi lembar tersendiri: [ ] Ya

[ ] Tidak

--o0o-Terima kasih atas partisipasi Anda dalam survey kami. Semua jawaban Anda dijamin
kerahasiaannya dan hanya akan digunakan dalam rangka mengetahui tren umum in
vitro fertilization di Indonesia.

199

Annex 3: Chi-Square Testing

RESULTS (DOCTORS)
Has the Church taught something on IVF? * opinion on IVF Cross-tabulation
Count
opinion on IVF
Morally
acceptable
Has the Church taught
something?

Immoral

Total

the church has taught

14

23

25

62

the church has not taught

11

17

34

14

22

31

30

56

118

does not know

Total

Chi-Square Tests
Asymp. Sig. (2Value
Pearson Chi-Square
Likelihood Ratio
Linear-by-Linear Association
N of Valid Cases

It depends Does not know

df

sided)

.020

15.549

.016

1.301

.254

15.001

118

a. 3 cells (25.0%) have expected count less than 5. The minimum expected
count is .19.

200

opinion of IVF * advice or suggestion Crosstabulation

Count
advice or suggestion
Does not give
any advice or
allow IVF
opinion on IVF morally acceptable

do not allow IVF rethink using IVF

Total

suggestion

10

18

31

immoral

14

30

depends

27

18

56

41

16

50

11

118

does not know

Total

Chi-Square Tests
Asymp. Sig. (2Value
Pearson Chi-Square
Likelihood Ratio
Linear-by-Linear Association
N of Valid Cases

sided)

df
a

.006

21.694

.010

2.816

.093

23.212

118

a. 8 cells (50.0%) have expected count less than 5. The

minimum expected count is .09.

The statistical analysis of 118 doctors shows a significant association between

the doctors knowledge of the Church teaching related to IVF and their opinion
regarding IVF. When doctors know that the Church has taught something related to
IVF, they are more likely to judge IVF as immoral. When they do not know about the
teaching of the Church, they tend to judge IVF as morally acceptable. On the other
hand, whether the doctors know or do not know the teaching about IVF, more
doctors tend to think that there are cases when IVF can be morally acceptable. The
professional orientation of doctors in generalwhether Catholic or notmight
explain this.
Whether they think IVF morally acceptable or not doctors, in general, tend to ask
the couples to reconsider their decision to use IVF. The reason for this advice seems
to be more because of the physical and emotional tediousness of the procedure
rather than moral considerations. Non-andrologists would recommend that the
patients seek the advice of specialists. Because of the social repercussions of IVF,
several doctors havesuggested that the couple carefully seek the advice of family
members, or try to look for other solutions aside from IVF.
201

RESULT (COUPLES)

Has the Church taught something on IVF? * opinion on IVF Crosstabulation

Count
opinion on IVF
morally
immoral

acceptable
Has the Church taught
something?

depends

yes

21

27

15

63

no

11

12

30

14

18

35

39

36

111

does not know

Total

Chi-Square Tests
Asymp. Sig. (2Value
Pearson Chi-Square
Likelihood Ratio
Linear-by-Linear Association
N of Valid Cases

Total

does not know

df

sided)

.000

29.916

.000

9.562

.002

27.962

111

a. 3 cells (25.0%) have expected count less than 5. The minimum

expected count is .16.

202

Has the Church taught something on IVF? * giving advices related to IVF Cross-tabulation
Count
advice on IVF
not

Has the Church

taught?

recommend

recommend

IVF

IVF

no advice or
rethink the use of IVF

Total

suggestion

yes

15

28

15

63

no

16

30

12

18

21

20

38

32

111

does not know

Total

Chi-Square Tests
Asymp. Sig. (2Value
Pearson Chi-Square
Likelihood Ratio
Linear-by-Linear Association
N of Valid Cases

df

sided)

.000

37.706

.000

9.381

.002

43.926

111

a. 2 cells (16.7%) have expected count less than 5. The minimum

expected count is 3.24.

203

opinion on IVF * giving advice on IVF Crosstabulation

Count
giving advice on IVF
does not give any
advice or

not recommend
IVF

recommend IVF
opinion on
IVF

rethink use of IVF

Total

suggestion

morally acceptable

17

35

immoral

13

11

15

39

12

10

36

21

20

38

32

111

it depends
Ddoes not know
Total

Chi-Square Tests
Asymp. Sig. (2Value

sided)

df
a

.001

37.203

.000

Linear-by-Linear Association

.770

.380

N of Valid Cases

111

Pearson Chi-Square
Likelihood Ratio

29.421

a. 4 cells (25.0%) have expected count less than 5. The minimum

expected count is .18.

The analysis of 111 couples also shows a significant association between

knowledge of the Churchs teaching regarding IVF and their opinion about IVF.
Most of the Catholic couples (63) know that the Church has taught something
related to IVF and would tend to advise other couples to seriously rethink
using IVF because they think it is immoral. Couples who do not know the
Churchs teaching (18) are more likely to think that IVF can be used in some
cases (14).

204

ACKNOWLEDGEMENTS

I would like to thank Dr. Willy Maramis, Ph. D. for encouraging me to submit
this paper and participate in the 15th Congress of the Asian Federation of Catholic
Medical Associations. He also endorsed the carrying out of the survey in the Faculty of
Medicine of the Catholic University of Widya Mandala in Surabaya as well as in other
medical institutions.
I would also like to thank my dean, Dr. Agustinus Ryadi, for supporting this
research and providing an endorsement letter for the various medical institutions
where this survey was carried out.
My gratitude goes also to the Dr. Sulung Budianto, Business Development Officer
of Premier Hospital at Surabaya, and Dr. Sugiharto Tanto, director of St. Vincent de
Paul Hospital at Surabaya, for facilitating the survey at their respective hospitals.
Special thanks to Dr.Benedictus Triagung Ruddy P. for helping us out in the
distribution and collection of the survey forms at St. Vincent de Paul Hospital at
Surabaya. We also enjoyed the exchange of ideas with him on this subject matter.
I am grateful to Widhawan Aryo Pradhita for having helped me with the
statistics, and to my students Stevanus Findi Arianto, Kristoforus Sri Ratulayn, and
Yohanes Robertus Tedjokusumo for helping me carry out the survey among doctors
and young couples that they knew.
I have also received the help of various individuals who, in their own little way,
contributed some surveys to this investigation. Though each one may have gotten a
few surveys each, taken together, they have made it possible for this research to reach
over a hundred doctors and over a hundred young couples. To these individuals, I am
extremely grateful.

Note

Papers of Dr. Nicholas Hung, Dr Kristina Ulob Ma and Dr Shigeyuki Kano were not available

205

Session 6.2b

First Introduction in Japan

of Creighton Model System and Napro Technology
(Creighton & Napro)
and
its Practice with Japanese Young Couples
Y. Takei M.D

[Prologue]

Reproductive Health As we all know, this term was first introduced in 1994 at Cairo
International Conference on Population and Development. This UN initiative after several
International conferences in Bucharest and Mexico is an effort to slow the population
explosion, especially in Asian and African countries.
The Cairo Conference also introduced an idea that a couple, husband and wife, should
make a Family Planning decision not the government. The ultimate goal of the Family
Planning should be to create a happy family.

I strongly believe that all couples are free to choose any humane Family Planning method
based on their marital status, economical status, number of children they already have, and
their physical and health conditions.

I believe you all agree that every couple in the world should be able to choose a Family
Planning method of their choice. From my experience in Africa in 2009, women were given
an artificial Family Planning method such as Provera Depo or implant, after the delivery,
without a proper informed consent. As a result, some women developed anemia due to
206

severe uterus bleeding because of a side effect of artificial progesterone. These women
ended up going to a clinic for treatment.

So, what do you think was given to the women to stop bleeding? It was a contraceptive
pill. Even worse, some of the women suffered nausea and vomiting because of the side
effect of Contraceptive Pill.

One of my students who did an internship at Palestinian refugee camps in Jordan reported
that most women are inserted with an IUD without their husbands being told about the
IUD.

[Beginning of the New NFP method in Japan]

Let me get back to my main subject, the current situation in Japan.

It was just 4 years ago at this AFMCA conference in Hong Kong, I first met Sr. Arlene who
has just made a presentation on NFP yesterday. In Hong Kong, we discussed common
issues that Catholic clinicians often encounter every day practicing medicine. She strongly
suggested that I should visit the Pope Paul VI institution, in Omaha, the US, to study about
Creighton Model System NaproTechnology and I followed her advice and visited the Pope
Paul VI institution in 2009.

After coming back from Omaha, I started teaching Creighton & Napro to my clients at my
hospital in Sendai. Just within 8 months, 9 women started pursuing the follow-up sessions
until I had to leave the hospital to do a volunteer work in Africa. After coming back from
Africa I started teaching in Tokyo. Now the number of my clients has increased to 31 in
total in Tokyo. They are married or unmarried couples and single..

Slides
All the numbers are those who pursued at least 4 Fups.

207

Numbers of single women correspond to ones of whom use Creighton to moniter womans
health.
In Tokyo, unmarried couples who came for Fups are to avoid pregnancy and are still using
condom.
All married couple do not use condom.
All Creighton babies were born to married couples

[Many young couples having conservative ideas in Japan]

One of the major issues is that couples who want to avoid pregnancy still are sticking to
using a barrier method. They believe that without using a barrier method, they will
possibly become pregnant even I repeatedly told them that although men are almost
always fertile women become fertile only during a certain period in her menstrual cycle.

Regarding a barrier method which is the most popular method of Family Planning in
Japan, although a failure rate of condoms for contraception can be as high as 15% , young
generations are taught in school how to use condoms to avoid unwanted pregnancy in the
sex education class as early as in 5th or 6th grade. Of course most schools start teaching
about using of condoms at junior or high school.

The problem is that they are taught only how to avoid pregnancy. They are not given
education on proper and right ideas of where the life comes from, how the single cell
develops to embryo, how many fertilized cells fail to survive in the process of developing
to a fetus, how many obstacles that the human life has to overcome until a baby is born, just
for a few examples. These are a true secret of the life.

So, if such young students are taught that using condoms is the most acceptable method
of birth control, how can they learn and realize that there is a better method, NFP, that is
consistent and cooperative with womans natural cycle, and also how can they learn about
the method that respects woman and enhances human bonding? We have to be patient. It
will take time for us to start recognizing and reconsidering what has been
taught.

208

[New movement]

However I have noticed that a little changes are coming. Let me share my surprising
experiences which may encourage some of you who are interested in teaching NFP but
somehow hesitate to introduce NFP to the public.

Before I started teaching this new NFP, I was a little bit concerned that young generations
might not like the ideas such as self- control, abstinence, and chastity for single women
which are essential for NFP.

However, as our follow up sessions move on further and the basic ideas are taught, my
clients have shown interests in the idea of SPICE. I will tell you shortly what SPICE stands
for and what it means. This is characteristic for Creighton and Napro that can eventually
lead to a respect of dignity of woman and marriage.

Let me explain about SPICE. When practicing NFP, abstinence is essential as I said.
Abstinence usually needs self-control by a couple during womans fertility period. Yet, as
you know the fertility period sometimes lasts longer than one week depending on her
observation of mucus. So, even a strong minded young couple may not be able to maintain
self-control.

Now in order to keep abstinence Creighton Method, we need to bring a conception that
separates a sexual contact from a genital contact. Both of these words may sound similar,
but they are quite different. A genital contact implies all the contact which can potentially
result in pregnancy. That is why the avoidance of genital contact is a primary mechanism
through this NFP to avoid pregnancy.

On the other hand, sexual contact (activity) is the relations and collaborations of two
human beings. I have five key words that describe these multidimensional aspects of
relations between two human beings. They are Spiritual, Physical, Intellectual, Creative
and Emotional. Taking the first letter of each word we call this SPICE.

209

While genital contact is to be avoided during the days of fertility, sexual contact(activity)
should never be avoided. A wife should not just ask her husband to sleep in a sofa away
from her or outside of their bedroom during the period of fertility. The couple should still
sleep together showing their affection to each other in a different way.

When I introduced this SPICE concept to my young client this concept was totally new to
her. Nobody ever told her about these important aspect of sexual activity, and she started
showing an interest and liking. She felt that SPICE concept expressed womens dignity. She
went back home and told her boyfriend about this concept but she came back to me
complaining that her boyfriend was not certain of this very new idea. So, I asked her to
bring him in. They came together at the next follow up meeting and I gave them a brief
lecture on Creighton & Napro and answered their questions. At the next follow up meeting,
she thanked me as her boyfriend had gradually changed his behaviors. For instance when
he wanted during her fertile days he listened to her and refrained. He may still wanted to
use a barrier method, but he does only when she is not fertile. (Of course they do not need
to use it as far as she is infertile)

As some of my clients become happy with SPICE, they have started talking about this
SPICE to other friends and they also become interested in attending the Introductory
Session of Creighton & Napro sessions.
This is my unexpected experience with young generations through Creighton & Napro.

When I was at the medical school I was not properly taught on NFP. Our professor told us
that this method was neither accurate nor reliable so we did not need to study hard. Almost
all gynecological textbooks treat very little on NFP. However the Creighton method is
based on concrete scientific studies and researches.

[Japanese catholic is very minority]

Catholic population in Japan has never been over 0.4% of the population since Japan
opened its country nearly 150 years ago. Catholic population in Indonesia is 2.7%. Almost

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all my clients are non- Christian (0.47% of my clients are Christian) Yet, if you present NFP
with your passion, it can eventually be accepted more widely.

[About Creighton beside SPICE]

Examining mucus is not difficult thing to do although at the beginning women may not like
to handle it because it is sticky. But they gradually recognize how their menstrual cycles
change correspondently to their physical and mental conditions, using several bio-markers
such as nature of mucus, length of mucus cycles and pre-ovulatory and post-ovulatory
phases etc. It is well known that physical and mental stress affect the menstrual cycles by
suppressing hypothalamus-pituitary-ovary axis hormone production which appears
clearly on everyday charting very well. So eventually they get used to using their fingers
for handling mucus.

[Epilogue]

30 years ago when Dr. Hillgers, a founder of Creighton & Napro started a center in Omaha
to teach Creighton & Narpo, there were only 27 Creighton Napro centers in the US. But
now the number has increased to nearly 300. There are many others outside the US,
spreading an idea of preciousness of natural fertility and mutual relationship of a couple.
In Japan this initiative has just started.. My role is to a set a groundwork for this cause, and
I am hoping that a new generation becomes widely aware of the Fertility based on NFP.

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BIOETHICAL ISSUES IN PLACEMENT OF THE ELDERLY IN PANTI WREDHA :

INDONESIAN (CATHOLIC)S PERSPECTIVE.
Kris Pranarka
Geriatric Division, Dept. of Internal Med
Medical Faculty Diponegoro University
Semarang, Indonesia.
INTRODUCTION
With the rapid increase of the older population in Indonesia, the need for elderly homes
placement is also expected to increase.
Placement issues surrounding the elderly are complex and often emotional for both the
person and family members.
The elderly population is still very much a deprived or at least an under privileged group
in many developing countries
Decisions regarding placement may not involve the elderly themselves
The elderly at risk of placement in an institution, like Goverments Elderly Home are those
with lack of a social support system, and physical-mental-functional disabilities.
Semarang is the capital of Central Java Province, estimated population 1.468.292 ; and
79.521 (5.24%) are the elderly.
The social condition of the elderly in urban area, according to the States Statistic (Social
Welfare Dept, RI. 2009) are : a. Good 56.85%, Poor 29.73% and Neglected 13.42%.
In Semarang city, about 1089 (male 500, female
elderly

589). supposed belong to the neglected

Dr. Kariadi General Hospital is the largest State Hospital in Central Java Province with 804
beds. The Geriatric Department started to operate at 1993 and its facilities / services are :
Out Patient Unit, Geriatric Assesment Team, Acute Ward with 40 beds, Rehabilitation
Unit, Day Hospital, Respite Care and Home Care.
The core members of the team are : Geriatricians, Psychiatrist, Rehabilitation doctors,
Geriatric Medicine Trained Nurses, Social Workers, Pharmacist, Nutritionist, etc.

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Panti Wredha Wening Wardoyo, is one of Goverment Elderly Homes for the poor elderly,
with capacity of 110 clients.
OBJECTIVE
To get informations concerned
Wardoyo).

the elderly being placed in Panti Wredha (Wening

SETTING
The study took place in Panti Wredha (= elderly home) Wening Wardoyo Ungaran District,
Semarang City

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METHODS
We use a simple questionaire form as followed, and invited all the residents to be
interviewed.

PANTI WREDHA PERCONTOHAN

WENING WARDOYO
KABUPATEN SEMARANG

1.

NAMA LENGKAP

: BAPAK / IBU : ...........................................................................................

2.

JENIS KELAMIN

: LAKI LAKI

3.

UMUR

: ...........................................................................................TAHUN

4.

STATUS

: MENIKAH
JANDA

5.

6.

AGAMA

PEKERJAAN

: ISLAM

DUDA
CERAI
NASRANI

BUDHA

KONGHUCU

LAIN LAIN

: ................................................................

: SWASTA
LAIN LAIN

7.

PEREMPUAN

PEG.NEGERI
: ................................................................

ALAMAT SEBELUM MASUK PANTI WREDHA ................................................................

: .........................................................................................................

8.

JUMLAH ANAK

: ......................, SEMUA MANDIRI

/ BELUM

9.

JUMLAH CUCU

: ......................, SEMUA MANDIRI

/ BELUM

10. ANGGOTA KELUARGA LAIN : ADA

/ TIDAK ADA

11. CARA MASUK PANTI WREDHA

A. KEHENDAK SENDIRI :
B. KELUARGA

C. LAIN LAIN

: .............................................................................................

12. TAHUN MASUK PANTI WREDHA

: .................................................................................

13. PERASAAN HATI

A. LEBIH SENANG DIRUMAH SENDIRI
ALASAN : ...................................................................................................................................
B. LEBIH SENANG DI PANTI WREDHA :
ALASAN : ...................................................................................................................................

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RESULTS
There were 93 respondents, 31 (33,3%) male and 62 (66,7%) female. Most of them 85(91,3%)
were married, and 48 (51,6%) were childless,
51 (54,8%) still have family members. The mode of entering Panti Wredha was his / her
own choice 53 (56,9%) and 40 (43,1%) for other reasons.
Almost all of the resident 82 (88,1%), feel happy dwelling in Panti Wredha and 90 (96,7%)
had stay for more than ten years.
As for the religion, 79 (84,9%) Moslem,12 (12,9%) Christianity, while 2 (2,2 %) are others.
DISCUSSION
The elderly population is still very much a deprived or at least an under privileged group
in many developing countries.
The appropiate placement of elderly people into elderly home become an essential issue.
If decisions regarding their placement into elderly home do not involve the elderly
themselves, they will have been deprived of their rights.
Professionals of various disciplines should assist elderly people in exercising their rights to
determine where they should spend the rest of their lives
Ethics is a fundamental part of geriatrics, and the dependent nature of the elderly raised
special concerns.
Major ethical principles are
1. Autonomy
Duty to respect persons
Right to independent - self - determination
2. Beneficence
Obligation to do good
3. Non-Maleficence
Obligation to avoid harm
4. Justice
Nondiscrimination, duty to treat individuals fairly
Discussions of ethics and aging seem to focus on the roles of autonomy and rationing.
Persons whose aged and low income level, place them at risk for placement in elderly
home.

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An important feature in determining an older persons ability to live in the community is

the extent of support available.The family is the heart of this support. The difference
between needing and not needing an elderly home can depend on the availability of such
suppot.
The most influential people in making the decision were the children(the family) of the
elderly person.
In general, the familys inability to care is the reason most frequently given for placing an
elderly person in an elderly home.
The incidence of belief and the importance of religion increase as people aged. Nearly all
the respondents have spiritual lives, and stated that religion was very important in their
lives
According to the late Pope, John Paul II, the elderly should stay in their own home,
surrounding by their beloved ones as long as possible. Their needs should be support by
their children, family members, the community or the goverment. Elderly person should
not deprived of their rights as humans and citizens.
Elderly person should not lose their rights to full consideration of options and participation
in the decisions that affect their placement in elderly home. For many of them The Elderly
Home will be their final Home.
Surprisingly, in our study most of the residents (88,1%) feel happy and comfortable in Panti
Wredha Wening Wardoyo, although in the beginning some of them (43 %) entered Wening
Wardoyo not by their own wish.
References
1.
2.
3.
4.
5.

Lai, CKY;Lau, LKP:

Placement appropriateness for seniors. Asian J. Gerontol Geriatr. 2008; 3: 34 39.
Kris-Pranarka : Bioethical Issues in Geriatric Medicine.
National Conggress in Bioethics, Patra Jasa, Semarang 2010.
Witham, P :
Elderly home life : Activities and their importance.
Pope John Paul II : The Dignity of Older People and Their Mission in the Church and in the World,
Pontifical Council for the Laity, Vatican, 1998.
Pope John Paul II : Letter of His Holliness Pope John Paul II to the Elderly, Vatican, 1999

Note
Papers of Sr Ann Lou and Dr Nobuaki Sakai, D.D.S., D.D.Sc were not available

216

Congress Committee
Patron
Archbischop Antonio G. Filipazzi,
Apostolic Nuncio for Infdonesia
Mgr. Martinus D. Situmorang, OFM Cap,
President of the Catholic Bishops Conference of Indonesia
Mgr. Silvester San, Pr,
Bishop of Denpasar
Mgr. Florentinus Sului, MSF,
Delegate for Catholic Health Services
Advisor
DR. dr. Ign Harjadi Widjaja, PA
DR. Dr. E. Widyastuti Wibisana, MSc(PH)
Dr. Stephanus Indradjaja, MSc, PhD
Prof. Dr. A.N. Kurniawan, SpPA(K)
Prof. DR. T. Santoso, MD, FACP, FESC
Prof. Dr. W.F. Maramis, SpKJ(K)
Chairman
Dr, Albert Hendarta, MPH
Scientific Committee
Dr. Felix Gunawan
DR. Dr. F. Joedajana, SpPK
Fr. DR. C.B. Kusmaryanto, SCJ
Organizing Committee
Dr. Angela N. Abidin, MARS, SpMK
Sr. Johanni, CB, SKM
Dr. Ika Belinda
Dr. Freddy Ciptono
Dr. Benny Handoyo Raharjo
Dr. Irene Setiadi
Fund-raising Committee
DR. Med. Dr. Lukas Jusuf
Dr. Hasan Haris Mutiara, MKK
Dr. Elisa
Dr. Liwina Tasman
Secretary
Dr. Veronica Wiwing, SpMK
Dr. Lenny Tan
Treasurer
DR. Dr. Robert Gandasentana, MS
Dr. Liliana Kurniawan, MSc, MHA, DTMH

217

Congress Committee
Bali Local Committee
o Lead Coordinator
: Dr. Hensen, SpPD
o Ass. Lead Coordinator
: Dr. Aloysius Tony Gozal
o Treasurer
: Dr. Anna MG Sinardja, SpS(K)
Dr. Gabriella Tantular
o Secretary
: Dr Natasha Lay
Dr. Yoanes Gondowardaja
Catholic Medical Student Team
o Event
: dr Nisa Setiati (Coordinator)
Catholic Medical Student Team
o Liturgy & Protocol
: Sr. Magdeline CB (Coordinator)
Ibu Paulina Suharti
o Measl & Refreshment
: Dr. Yetie (Coordinator)
Dr. Yulita Cundawan
o Transportation
: Dr. Dinny Arinaty Zailani (Coordinator)
Dr. Salikur Kartono
o Additional Equipment : Dr. Freddy AP Winarto (Coordinator)
Dr. Martina Eva Tanusiska
Catholic Medical Student Team

Host

Co-host

Bali, 21 October 2012

Scientific Committee
218