Bishop Sgreccia on an End-of-Life Issue
ROME, 24 APRIL 2004 (ZENIT).Here is the text of an address delivered by
Bishop Elio Sgreccia, vice president of the Pontifical Academy of Life, at
the international congress "Life-Sustaining Treatments and Vegetative
State: Scientific Advances and Ethical Dilemmas," held here last month.
* * *
"The Subject in Vegetative State: For a Personalistic View"
Bishop Elio Sgreccia
Vice President of the Pontifical Academy of Life
Emeritus Professor of Bioethics
Catholic University Medical School
Member of the National Bioethics Committee of Italy
Premise
The aim of my paper is to outline the condition of the persistent
vegetative state beginning with the analysis specific to philosophical
anthropology and, more precisely, beginning with the concept of the human
person.
The underlying question, and the one to which this paper seeks to give an
answer, is the following: Is the human subject who is in a persistent
vegetative state a living human person or a corpse?
In simpler terms: Is this subject, who is able to receive nourishment and
to breathe but is incapable of having mentally connoted conscious
relationships, still a body animated by a spirit? Can an organic,
vegetative life exist in the human subject without there being the
presence of the spirit as well?
In order to be able to engage in this analysis more effectively it is
necessary, in my opinion, to address three assertions:
a) Man is a unitary but at the same time a compound being; his components
are the spiritual soul and the material body and as such he is defined as
a "person."
In classical, medieval and also modern philosophy, reference is made to
the material body and the spiritual soul, but today in the biomedical
sciences, and in particular in the neurosciences, the terms "mind" and
"brain" are more frequently employed.
These two modalities are not equivalent because whereas the phrase
"body-soul" refers to the concreteness of the individual being, to
substance, to being, the phrase "mind-body" refers to function and is thus
reductive. One can think that the mind does not express its function in
the fetus or in the child or in the sleeping person, but this does not
mean that these individuals do not have a spiritual soul.
b) The unity of the spiritual soul with the body is of a substantial (and
not accidental) character, and is such that whereas the soul is able to
live and to operate separately from the body as well, the body receives
existence, that is to say life, from the soul. In relation to the
spiritual soul the body does not have its own existence. The unity of the
person lies in this fact: There is a single existence for these two
components.
c) In the living human being there are not different kinds of souls: one
vegetative, one sensory, and one rational; instead, the rational soul is
responsible for all the functions. Thus the personal being is unitary in
the sense that the self invests the whole of the corporeal existence. Even
when rationality is impeded this does not mean that the rational soul is
not present in a person who is still biologically alive.
In setting out these steps I follow the anthropological approach which,
beginning with Albert the Great and Thomas Aquinas,1 and going beyond the
Aristotelian vision and especially the vision connected with the
Aristotelian philosophy of Arab culture (Averroës), was adopted both in
the field of Catholic theological anthropology and in the field of
ontologically based personalism.2
Such personalism rejects both the dualism of a Platonic kind and the
dualism of a Cartesian kind, and also rejects Marxism, which expresses
itself today primarily in materialist approaches.
In contrary fashion, personalism emphasizes the unity of the person as
regards the relationship between the spiritual soul and the body by
affirming that in the person there is a "dual unity" because the body
receives "being," "subsisting," from the spiritual soul.
The body has the poverty of not being able to exist on its own; instead,
it exists as a human body because of the existing that is conferred upon
it by the spiritual soul. It is precisely this step that is the first step
in my analysis.
The human person in his or her living unity
In order to adequately understand the anthropological structure of the
human person we need to refer to two kinds of relationships that are
defined and used in classical and medieval philosophy: the relationship
between matter and form (the ilemorphic [hylomorphic] approach) and the
relationship between essence and existence ("essentia et esse").
Experience offers us the first fact that enables us to know that the
individual man has a material body, capable of development and decay like
every other living organism, the outcome of different organs and
apparatuses and marvelously structured according to what the biological
sciences have analyzed with their increasing knowledge.
In this body a spiritual soul shows that it is present and operative;
differently from what happens in the organisms of other living species,
this spiritual soul is capable of immaterial operations: the intellect,
freedom and moral conscience.
From this observation of such operations according to the principle "operari
sequitur esse et huic proportionatur" [activity follows from being and is
proportioned to it] we may conclude that the spiritual soul is immaterial,
although it uses the body, and is thus immortal. The spiritual soul is not
only the principle of "animation" of the body but also has an activity
that is higher than the body and which transcends the organism and
materiality.
The presence in man of the intellect, both as "passive" intellect
(understood as a capacity to receive the result of the process of
abstraction) and as "active" intellect (understood as a capacity to
formulate a concept by abstraction), is a sufficient proof to demonstrate,
following Thomas Aquinas, that in the spiritual soul there are activities
"cui non communicat corpus" [in which the body does not share] that are
higher than the dynamisms of the brain and the senses.
This conclusion, which acts to complete Aristotelian thought,3 leads us to
conclude that the spiritual soul is an immaterial and subsistent
substance. It is united to the body from the outset as its animating
principle, but its capacity does not stop at this task of animation.
Indeed, being spiritual, it continues to exist after the death of the body
as well.
From this we may derive the following assertion. As the spiritual soul is
called to subsist it cannot come from the bodies of the parents because it
cannot come from a biological element; instead, it receives its existence
("esse") from God the Creator, because only the Subsistent Being (God) has
existence because of his own being.
For this reason, the "esse" of the spiritual soul, since it cannot come
from material corporeity (because what is spiritual cannot come from what
is material), can only be created by God. At the same time the soul is
created to be united to the body and to communicate existence to the body.
Just as every form defines the matter, the structure, of a body, so the
spiritual soul defines and structures the body and makes it human.
The simultaneousness of the creation of the soul with the conception of
the body is a consequence that St. Thomas did not directly affirm
—
believing as he did that a certain development of the body was necessary
for the infusion of the soul
— but
this truth (today recognized by specialists) is more consistent in the
context of his thought and his metaphysical principles.4
Above all else it is required by the knowledge of biology and genetics
that demonstrate a very specific organizational "form" of the embryo from
the first moment of conception. Compared to other forms, the human soul
has specific to it the fact of being subsistent in its being and of
communicating to the body the being that is specific to the body.5
This "poverty" of the body, which receives existence ("esse") from the
spiritual soul, ends up by being wealth because human corporeity is thus
realized as an epiphany and language of the spirit. And in every one of
its acts it becomes the bearer of a higher meaning, it reveals the dignity
that comes to it from a spiritual and immortal soul. Here, medicine has a
point that is one of the fundamental cardinal points of its
epistemological and ethical status.
The union of the spiritual soul with the body
The spiritual soul has a dual tie with the body: one belonging to the
order of essence and one belonging to the order of existence.
In the order of essence, according to classical language the soul is
"forma corporis" [the form of the body], that is to say it (the human
soul) makes of the body human corporeity, which is a corporeity different
from that of any other living thing.
To employ more modern language, one would say that the spiritual soul is a
"self" together with the body, which reveals all the richness of
spirituality, and such spirituality is expressed in every one of its
actions: in movement, in smiling, in pain and in speech.
That this essential value is recognized as a substantial form from the
moment of conception is the logical consequence of the fact that the human
individual is constituted as an "unum" [unit], indeed as an "unus" [one],
from that moment, and during development conserves his organic unity and
his unity as an organism throughout the whole of that development. "That
self," in "that body," maintains that unity inside, outside, and
diachronically in, the same individual from conception to death.6
One single soul for the functions of life and thought
This assertion is an uncontested cardinal point in Thomistic
anthropological thought starting from the heritage received from Albert
the Great.7
In Question 76 of the "Summa Theologiae," Part I, St. Thomas addresses the
question in two separate articles (III and IV) on the uniqueness of the
soul in man and the uniqueness of form.
The two questions are not identical. He thought that the uniqueness of the
spiritual soul also subsists in the (successive) plurality of forms.
Aristotle had stated in relation to the development of the embryo that the
human embryo lives first a vegetative life, then a sensory life, and that
finally the intellect of divine origin enters (by the door
— "thürathen").
Many contemporaries of St. Thomas even argued in favor of the co-presence
of different "forms of animation" in man after the development of the
rational soul as well.8
Among the ancient Greek Fathers, there had been, on the other hand, the
well-known doctrinal point of St. Gregory of Nyssa according to which the
rational soul, with all its perfections is present from the first moment
of generation, and with the advance of the formation of the body the
various activities of the spirit are gradually manifested.
St. Albert the Great had concluded that in the human being there is a
succession of forms and vital principles and that the most perfect
spiritual soul, when it arrives, absorbs and takes the place of the
inferior forms.
However, St. Thomas,9 who remains receptive to the Aristotelian position
and requires the advent of the spiritual soul prior to the formation of
the organism, asserts that:
a) the soul is a unique substance that has different (intellectual,
sensory and vegetative) powers, and that as a substantial form it
constitutes a single entity. If there were more than one soul there would
be more than one form and thus more than one entity within the same
individual-man;
b) The spiritual soul, as a substantial form, does not absorb the
vegetative and sensory soul, but because it is already, as "actus corporis"
[the "act" of the body], supplied with the capacity to express vegetative
and sensory life, on its arrival, once it is present in the body of the
embryo, it transforms its total essence and makes it human.
With this position St. Thomas aims to uphold the unity of the person. One
should not think (and this may be said in parentheses) that he thereby
admits the lawfulness of abortion, because in destroying the preparatory
material moment in the creative design of God, one always commits a grave
offense against God.10
Conclusions as regards the persistent vegetative state
Thomistic thought on the unity of the form of the human body, and thus on
the unity of soul, which was opposed at the outset, was adopted by
Catholic anthropology as regards its strong affirmation of the unity of
the person, which excludes any form of dualism.
Such thought shares the same ground as ontological personalism, which is
founded, that is to say, on the essence of the human individual and on his
or her unitary reality.
The conclusion that is offered by such thought, which has remained
characteristic of, and specific to, the philosophical anthropology of
Christian personalism, can be formulated in the following way employing
the words of S. Vanni Rovighi: "The human soul, which is an intellective
soul, is thus the soul that gives to man his being a body
—
specifically in this way and made in this way
—
which is living, feeling and rational."11
To come to our question and our case, if we adopt this unitary
anthropology the body in a persistent vegetative state, which has vitality
at the level of an organism, albeit of a merely vegetative nature, is
united to the rational soul, the only soul that makes the body living.
There cannot be a vegetative vitality that is separate from the unique
vital principle exercised by the only soul that exists in man, the
intellectual or spiritual soul, whichever term one chooses.
Only the loss of the vital unity of the organism can be taken as the sign
of death.
The conclusion that has been arrived at involves a brief reflection on the
concept of the death of the human individual.
Given as known the distinction between ontological death (the separation
of the soul from the body), a reality that cannot be observed directly,
and clinical death as a set of signs that provide the moral certainty that
death has really taken place in an individual, when it come to the signs
that allow the ascertaining of death from a clinical point of view three
different positions must be recorded:
1) A minority position that in specific terms wants to argue that clinical
death coincides with the irreversible cessation of the higher functions of
the brain and thus with the loss of relational life, a fact connected
neurologically with the compromising of relational life, for which reason
it is often designated "cortical death."12
2) On the basis of this position the patient in a persistent vegetative
state, whose possible recovery is excluded, should be held to be dead.
This is the position that we excluded with the clarifications presented
above.
A second position that is diametrically opposed requires for a definition
of clinical death so-called biological death, the cessation of every
internal biological activity in the body of the individual and in
particular the cessation of the circulation of the blood (cardiological
death).
In definitive terms, this position is encountered implicitly in those who
argue that the so-called death of the whole encephalon, also known wrongly
as "brain death,"13 is insufficient.
However, in practical terms this criterion should involve a definitive
cessation of the heartbeat. This empirical observation used in cases of
deaths in the home, in the street, and outside the context of intensive
care, is certainly valid for the ascertaining of death, but it does not
allow the transplant of organs.
The possibility and the need to use resuscitation has made possible a
third approach which is that known as "brain death," but which should more
properly be known as "encephalic death" because it refers to the whole
encephalon.
Today, this line is followed not only by the Italian law on transplants
(18.8.1993) but by almost all laws and also by the practice followed in
relation to transplants.
This criterion is explained not in the sense that one wants to identify
the part (the encephalon) with the whole (the body separate from the soul)
but in the sense that once the functions of the entire encephalon have
been irreversibly lost, including those of the encephalic trunk, which as
one knows governs the cardio-respiratory function, the whole living
organism loses a unifying principal of life that defines it as a living
organism, even though with the help of machines which substitute
spontaneous breathing and use the residual vitality of the heart muscle
one can maintain artificial circulation for a certain time in order to
keep an organ to be transplanted undamaged.
During the address of the Holy Father to those taking part in the congress
on organ transplants of 29 August 2000 this criterion was accepted with
the following words:
"It is a well-known fact that for some time certain scientific approaches
to ascertaining death have shifted the emphasis from the traditional
cardio-respiratory signs to the so-called 'neurological' criterion.
"Specifically, this consists in establishing, according to clearly
determined parameters commonly held by the international scientific
community, the complete and irreversible cessation of all brain activity
(in the cerebrum, cerebellum and brain stem). This is then considered the
sign that the individual organism has lost its integrative capacity. With
regard to the parameters used today for ascertaining death
—
whether the 'encephalic' signs or the more traditional cardio-respiratory
signs —
the Church does not make technical decisions. She limits herself to the
Gospel duty of comparing the data offered by medical science with the
Christian understanding of the unity of the person, bringing out the
similarities and the possible conflicts capable of endangering respect for
human dignity.
"Here it can be said that the criterion adopted in more recent times for
ascertaining the fact of death, namely the complete and irreversible
cessation of all brain activity, if rigorously applied, does not seem to
conflict with the essential elements of a sound anthropology.
"Therefore a health-worker professionally responsible for ascertaining
death can use these criteria in each individual case as the basis for
arriving at that degree of assurance in ethical judgment which moral
teaching describes as 'moral certainty.' This moral certainty is
considered the necessary and sufficient basis for an ethically correct
course of action. Only where such certainty exists, and where informed
consent has already been given by the donor or the donor's legitimate
representatives, is it morally right to initiate the technical procedures
required for the removal of organs for transplant."14
The Charter for Health Care Workers had for that matter adopted this
criterion, which makes the transplant of organs something that can be
practiced.15
The persistent vegetative state and the ascertainment of the
neurological death of the whole encephalon
It seems to me, however, that the difference that exists between so-called
cortical death and encephalic death is clear. In the first case the
organism demonstrates the persistence of a unitary organic life, albeit of
a vegetative kind
— it
is able to breathe autonomously as well, it maintains cardio-circulatory
activity, and it is able to be nourished if fed artificially.
In the second case none of these functions is carried out autonomously,
respiratory activity is replaced by machines, and as a result
cardio-circulatory activity cannot maintain itself except for a short
period of time after its autonomous charge of energy has been exhausted.
From the point of view of the personalistic approach, the discriminating
criterion between the life and non-life of the human individual is not in
itself the function of the encephalon but the unifying principle that
vivifies the organism (the soul). This principle of life unity in the
adult is ultimately linked to the function of the encephalic trunk and can
be controlled with appropriate neurological methods, the control of the
evoked potentials or the cerebral flow; whereas in the embryo during the
first stages of its development the unity of the organism is activated and
maintained by the genome which governs the construction itself of the
brain.
For this reason, the ill-founded objection that argues that when one holds
the criterion of "encephalic death" to be valid, embryos that do not yet
have even a rudimentary form of the cerebral system should be seen as
lacking life, has no basis. In the embryo the principle of life (the soul)
that defines it as an individualized organism is observable in the unity
and the biological function of the genome that governs the progressive
development16 of the individual and the formation itself of the central
nervous system.
In adults the physiology itself of the nervous system demonstrates that
this system has a function of coordination in relation to the other organs
and the functions of the whole organism, whereas the respiratory and
cardio-circulatory system has the function of transporting the elements
needed for nutrition.
All the other systems, such as the endocrinological system, the immunity
system, etc., that cooperate and contribute to the vitality and the unity
of the organism come anyway in the adult to depend on the central nervous
system.
Personally I am convinced that despite the criticisms leveled against the
neurological criterion for the ascertaining of death, if observed
scrupulously it merits our trust and should not be abandoned in the field
of transplants to rely upon the criterion of "cortical death" or to
ignore, as some argue, the rigorous observations that it requires because
the carrying out of the transplant is said to be a sufficient and
proportionate reason for going ahead even in a state of uncertainty.17
Indeed, it should be stressed that in the final analysis the person
carrying out the transplant and the specialists of the committees who
preside over the ascertaining of death should, when faced with a concrete
doubt in an individual concrete case, abstain from declaring the person
dead and wait for such certainty to be well founded and morally valid.
* * *
NOTES
1 Thomas Aquinas, "Summa Theologiae," I, 75-76; "Quaestio De Anima," Art.
1, Art. 2, Art. 6; "Contra Gentes," Chap. 68 and Chap. 69; "De Unitate
Intellectus," 83-84.
2 S. Vanni-Rovighi, "Alberto Magno e l'unità della forma sostanziale
nell'uomo, in Medioevo e Rinascimento. Studi in onore di Bruno Nardi"
(Florence, 1955), pp. 755-778; E. Gilson, "L'ame reaisonable chez Albert
Le Grand"; S. Vanni-Rovighi, "Introduzione a S. Tommaso D'Aquino" (Laterza,
Bari, 2002); "L'antropologia filosofica di S. Tommaso D'Aquino" (Vita e
Pensiero, Milan, 1965); E. Sgreccia, "Manuale di Bioetica," I, 3rd
edition, (Vita e Pensiero Milan, 2003), pp. 105-137.
3 In Aristotle the assertion that the "active" intellect was specific to
each single individual was not clear. As held by the Aristotelian Arabs,
it was believed that there was a single (divine) intellect that impressed
abstract concepts in individual subjects (passive intellects). The thesis
of Thomas Aquinas is expounded in the "Summa Theologiae," Q. 75, Art. 1
and in "De Anima," Book II, lectio I, nn. 219-221. See also S.
Vanni-Rovighi, "L'antropologia filosofica di S. Tommaso D'Aquino," op.
cit., pp. 23-34.
4 "Contra Gentes," Chaps. 86-87; "Summa Theologiae," I, p. 118, Art. 2.
5 S. Vanni-Rovighi, "L'Antropologia filosofica," op. cit., p. 34.
6 J. Vial Correa and E. Sgreccia (eds.), "Identità e Statuto dell'embrione
umano" (Libreria Editrice Vaticana, Vatican, 1998).
7 S. Vanni-Rovighi, "Introduzione a Tommaso D'Aquino" (Laterza, Rome,
2002) pp. 83-96.
8 S. Vanni-Rovighi, "L'Antropologia filosofica," op. cit., pp. 48-53.
9 Ibid., pp. 53-57.
10 G. Cottier, "Scritti di etica" (Piemme, Casale Monferrato, 1994), pp.
295-8.
11 S. Vanni-Rovighi, "L'Antropologia filosofica," op. cit., p. 57.
12 C.A. De Fanti, "I concetti di morte dell'organismo, morte cerebrale,
morte corticale, in A. Ferroni" (ed.), "Atti del II Incontro di
aggiornamento in neurologia. attualità in tema di morte cerebrale" (Perugina,
Feb. 20, 2003), published in Annali di Neurologia e Psichiatria, 1993, 87,
I,II, III, pp. 21-29. It is known that the thought of H.T. Engelhardt, who
defines such subjects as "no longer persons," shares the same approach.
13 A. Shewmon, "Brain Death: a Valid Theme with Invalid Variations,
Blurred by Semantic Ambiguity," pp. 23-51 in R. Whito, Angstwurm, and
Carrasco De Paula (eds.), "Working Group on the Determination of Brain
Death and Its Relationship to Human Death" (Vatican City, 1992); J.
Seifert, "Is Brain Death Actually Death?," Ibid., pp. 95-143.
14 John Paul II, Address to the 18th International Congress of the
Transplantation Society, Aug. 29, 2000, in L'Osservatore Romano, Aug. 30,
2000.
15 Pontifical Council for Health Care Workers, Charter for Health Care
Workers, No. 87, 1995.
16 A. Rodriguez Luño, "Rapporti tra il concetto filosofico e il concetto
clinico di morte," Acta Philosofica, 1992, 1,I, pp. 58-68; E. Sgreccia,
"La persona e la vita," Dolentium Hominum, 1986, 2, pp. 38-41.
17 R.D. Trhog, "Is it Time to Abandon Brain Death?" Hastings Center
Report, 1997, 27, pp. 29-37.
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