THE PHILOSOPHICAL DISEASES OF MEDICINE AND THEIR CURE

Philosophy and Medicine

VOLUME 82

Founding Co-Editor
Stuart F. Spieker

Editor

H. Tristram Engelhardt, Jr., Department of Philosophy, Rice University, and Baylor

College ofMedicine, Houston, Texas

Associate Editor

Kevin Wm. Wildes, S.J., Department of Philosophy and Kennedy Institute of Ethics,
Georgetown University, Washington, D. C.

Editorial Board

George J. Agieh, Department of Bioethics, The Cleveland Clinic Foundation,

Cleveland, Ohio
Nicholas Capaldi, Department of Philosophy, University of Tulsa, Tulsa,
Oklahoma
Edmund Erde, University ofMedicine and Dentistry of New Jersey, Stratford,
New Jersey
Eric T. Juengst, Center for Biomedical Ethics, Case Western Reserve University,
Cleveland, Ohio
Christopher Tollefsen, Department of Philosophy, University of South Carolina,
Columbia, South Carolina
Becky White, Department of Philosophy, California State University, Chico,
California

The titles published in this series are listed at the end of this volume
 THE PHILOSOPHICAL
DISEASES OF MEDICINE
AND THEIR CURE
PHILOSOPHY AND ETHICS OF MEDICINE,
VOL. 1: FOUNDATIONS

by

JOSEF SEIFERT
International Academy of Philosophy in the Principality of Liechtenstein (lAP) and Chile (lAP-PUC)
and
Pontificia Universidad Cat6lica de Chile, Santiago

~ Springer Science+Business Media, LLC

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A C.I.P. Catalogue record for this book is available from the Library of Congress.

ISBN 978-90-481-6736-4 ISBN 978-1-4020-2871-7 (eBook)

DOI 10.1007/978-1-4020-2871-7

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 Dedicated to
My beloved children
Maria Michaela Seifert,
who is dedicating her life to philosophy and wrote her first work on
the nature and inviolable dignity of each human being,
and
Gabriel Joseph Seifert,
who intends to work as a philosophically healthy physician for the
high goods entrusted to medicine;

and to my many dear friends in medicine - professors of medicine

and medical ethics, physicians, and nurses in all the world, who serve
the great ends ofmedicine with an unwavering commitment,
including:
Jerome Lejeune t
in commemoration of the tenth anniversary of his death (1994)
Madame Jerome Lejeune
and to
Michael and Charlotte Barthel, Anna Barthel, John and Evelyn Billings,
Johannes Bonelli, Judie Brown, Sr. Anna Cappella, Fr. Fernando Chomali,
Fr. John Fleming, Petr Hach, Gonzales Herranz, Roy Joseph and
Elizabeth Heyne, Joseph Dietrich and Cynthia Heyne, Nicholas Heyne,
Thomas Hilgers, Paulina Johnson, Gudrun Lang, Birthe Lejeune,
Josef Lingenhole, DetlefLinke, Lorena Mosso, Jorge Neira, Luis Jensen,
Antun Lisee, Manfred Lutz, Marcelo Munoz, Tamas Csaky-Pallavicini,
Soledad Perez, Wanda Pohawska, M. Loreto Rodriguez, Alberto Rojas,
Pedro Rosso, Gottfried Roth, Joseph Santamaria, Philippe Schepen,
Beatriz Paulina Shand, Alejandro and Maritza Serani, Daniel Serrao,
Alan Shewmon, Anton Svajger t,William F. Sullivan, Paulina Taboada,
Nicholas Tonti-Filippini, Sergio Valenzuela and Pamela del Carmen
Silva Crespo, Patricio Ventura, Raul Ventura, Dieter Walch, Albert Wick,
Tom Watts, Nikolaus Zwicky-Aeberhard
 TABLE OF CONTENTS

PREFACE AND ACKNOWLEDGMENTS xvii

INTRODUCTION xxvii
CHAPTER 1
THE NATURE AND THE SEVEN GOALS OF MEDICINE AS OBJECTS OF A
DRAMATIC FREE CHOICE OF THE PHYSICIAN TODAY

1. On the Nature of Medicine and the Physician. The Physician as

Scientifically Trained Healer, as Practitioner ofthe 'Art of
Medicine', as Ethicist, and as Moral Subject
1.1. The Physician as Scientifically Trained Healer, the Essence of
Medicine as Empirical Inductive Science, and Its a priori
Foundations
1.1.1. The Physician and the Role of Empirical Scientific Training
1.1.2. A Justification of Medicine as an Empirical Science against Hume's
and Popper's Objections Raised against Induction 2
1.1.3. Immense Progress in Medicine as Experimental Science and as
Scientifically Supported Medical Practice 25
1.1.4. Medicine as Practical or 'Pragmatic' Science and the Respective
Values of Theoretical versus Practical Sciences 32
1.2. The Physician as 'Practical Artist' and Craftsman-and Progress in
Medicine 36
1.3. On the Constitutive Role of a Philosophical Understanding of Man
and Morality for Medicine as Science, and of Moral Commitments
for the Physician as Practitioner 38
2. The Physician-Philosopher: Theoretical and Practical Philosophical
and Ethical Aspects of Medicine 39
2.1. The Goods Medicine Is Called to Serve and the Indispensable Moral
Choice of the Physician 39
2.2. The Seven Goods or 'Seven Ends' the Physician Should Serve and
Respect 44
2.2.1. Medical Service to Human Life in Its Uniqueness and Specifically
Personal Nature as well as in Its Right Place in the Whole Order of
Goods 45
2.3. 'Health' as a Fundamental Goal of Medicine and as Disputed
Question 52
2.3.1. The Question "What Is Human Health?" as a Philosophical and as
Disputed Question 52

Vll
viii TABLE OF CONTENTS

The Nature of Health and Reductionism 54

Utopian Notions of Health 54
Objectivity or Subjectivity of Concepts of Health? 56
2.3.2. The Question "To Which Extent Should Health Be Promoted in
Medicine?" as a Disputed Question 57
2.3.3. The Question "What Is the Place of Health in the Hierarchy of
Human Goods?" as a Disputed Question 57
2.4. The Fight against Pain (Suffering) and for Pleasure and Physical and
Mental Relief: Preventing, Alleviating, or Freeing from Suffering
(Palliative Medicine)-Promoting Well-Being and Feeling Well 58
2.5. The Conscious Life of Man as Such and Personal Dignity 61
2.6. Integrity of the Human Bodily Form and Aesthetic Values 68
2.7. The General and Spiritual Good of Man and of His Vocation as
Transcendent Goal and Guideline for Medicine 69
2.7.l. General Remarks on the Ways in Which This Transcendent Good of
the Human Person Obliges the Physician 69
2.7.2. The Different Ways in Which This Transcendent Good of the
Human Person Obliges the Physician 71
2.8. The Special Relationship between the Physician and the Absolute
Good (God) 72
2.9. The Religious Transformation of the Image of the Physician and the
Goods Medicine Should Serve 76
2.10. The Remarkable World Wide Consensus on the Goods Medicine
Should Serve 79
2.11. The Physician-Philosopher and the Nature of the 'Practical'
Philosophy in Medicine with Respect to the Seven Goods 80
2.12. Conclusion of Our Reflections on the Goods Medicine Should Serve,
and Theophrastus Paracelsus on the Transcendent Ends of Medicine 81
3. The Physician as Moral Agent and Further Hints at the Philosophical
Diseases of Medicine and Their Cure 82
3.l. Importance of the Subject of Medicine and His Inalienable Rights as
Person: Physicians, Nurses, and Other Health Professionals Are Not
Mere Technicians or Instruments in the Service of Health and ofthe
Other Goods of Medicine or of Patient Wishes but Acting Persons 82
3.2. Finding Anew Its Roots? A Word on the History and the Essential
Ethical Dimension of Medicine-the Hippocratic Oath as More than
an Ornament of the Medical Profession 84
3.3. Progress or Decline of Medicine with Respect to Its Value-Base and
Third Philosophical-Ethical Dimension: Modem Medicine-
Immense Progress or Regress behind the Age of the Medicine Man? 85
 TABLE OF CONTENTS ix

CHAPTER 2
THE DIGNITY OF THE HUMAN PERSON AS A 'UNIVERSAL OF MEDICAL ETHICS' 89
1. Prolegomena 89
1.1. The Theoretical and Practical Significance of Understanding Human
Dignity 90
1.2. Can Human Dignity Be Known to Be an Objective, Universal and
Simultaneously Uniquely Individual Value? 93
1.3. Can Consensus Be Reached about Human Dignity and Can It
Function as a Common Ground for Medical Ethics-as a 'Medical
Ethical Universal '? 94
1.4. The Role of Realist Phenomenological Philosophy in Showing
Human Dignity to Be Truly a 'Medical Ethical Universal' 96
1.5. The Main Theses to Be Defended in This Chapter 99
1.6. Two Ways to Know What It Is to Be a Person: Immediate
Phenomenological Experience of Persons, and Intuition into the
Ontological Ground that Intelligibly Underlies Experience 99
2. What Is a Person? Ontological and Axiological Understanding
of the Person 100
2.1. The Person as Ultimate Individual Subject of Rational Nature 100
2.1.1. Person as a Substance 101
2.1.2. The Person as 'Thing in Itself 102
2.1.3. The Person as a Living Substance 103
2.1.4. Personal Individuality (Uniqueness) 104
2.1.5. The Person as a Spiritual Substance and the Human Soul 104
Arguments for the Existence of the Soul 105
2.1.6. The Person as an Individual Spiritual Substance in Relation to Other
Persons 113
2.2. A Definition of the Person by Her 'Inviolable' Dignity 114
3. The Four Sources and Dimensions of Human Dignity and Their
Characteristics 115
3.1. Ontological Dignity of the Human Person as Such and from the Very
Beginning of Her Existence 115
3.2. Dignity of the Conscious and Rational Person and Its Levels 121
3.3. Third Source and Sort of Dignity: 'Acquired Dignity' and Moral
Dignity 126
3.4. Fourth SourcelDimension of Dignity-Dignity as GiftlBestowed
Dignity 128
3.5. Relations between the Different Sources and Dimensions of Personal
Dignity 132
x TABLE OF CONTENTS

4. Dignity as Object of Rational Knowledge and Answer to Some

Objections against the Rational Knowability of Human Dignity 134
5. Human Dignity as a Unifying Bond among Men and Medical
Professionals Worldwide 136
CHAPTER 3
FROM THE MORALLY RELEVANT GOALS OF MEDICINE TO MEDICAL Enncs
On the Superiority of Moral Values over All Extramoral Goals of Medicine 139
1. Introductory Notes on Ethics in Its Relation to Medicine 139
2. The Ambiguity of the Notion of the Good: On the Totally New
Quality of Moral Goodness and Evil in Comparison with all Other
Goods and Evils 149
3. The Nature of Moral Goodness 151
3.1. Moral Values Are Objectively Good 151
3.2. Intrinsic Goodness 01alue) Rather Than Being Merely Agreeable or
Even Only Objectively Goodfor Me 152
3.3. Moral Values Are Necessarily Linked to Freedom 153
3.4. Moral Values Presuppose a Certain Morally Relevant Object or
Matter (Which Can Be Grave or Light) 153
3.5. Moral Values Imply a New Type of Ought Which Elucidates the
'Absolute Sense' in Which They Are Good 155
3.6. Moral Values Are Dependent on the Knowledge of Morally Relevant
and of Moral Goods and Evils 156
3.7. Moral Values Involve Responsibility 157
3.8. Moral Conscience 158
3.9. Moral Values Deserve Praise or Blame in a New Sense 160
3.10. Moral Goodness Alone Can Constitute a Certain 'Worthiness of
Happiness', Moral Evil a 'Deserving of Pain' 160
3.11. Also Guilt and Merit, Reward and Punishment Are Essentially
Related to Moral Good and Evil, and to It Alone 161
3.12. Moral Goodness Expresses in an Essentially New and Higher Sense
the Idea of Value as Such (Good in a New and More Proper Sense to
Which Extramoral Senses of 'Goodness' Are Merely Analogous) 162
3.13. Moral Goodness, As Long As It Really Exists, Cannot Be Abused
Like Intellectual, Aesthetic, Temperamental and Other Values 164
3.14. Moral Values Are Absolutely Speaking Good in that They Never
Must Be Sacrificed for Any Other Value, because They Are (a)
Incomparably Higher and (b) Should Absolutely and 'First' Be
Sought F o r · 165
 TABLE OF CONTENTS xi

3.15. Moral Goodness as a Source of the Value of the Person as Such:

Only the Person Herself Can Be the Primary Bearer of Moral Values,
Never Impersonal Beings, and also Personal Acts Can Be Morally
Good Only in a Derivative Sense 166
3.15.1. Only Persons as Opposed to All Impersonal Beings Can Be Morally
Good 166
3.15.2. Only the Person Herself Can Be the Primary Bearer of Moral
Values-Personal Acts Can Be Morally Good Only in an Analogous
Sense 167
3.15.3. Moral Goodness Makes the Person as Such Good in a Deeper Sense
Compared with Which all Other Meanings of the Goodness of the
Person Are Just Analogous 167
3.16. Moral Values Are the Absolute and Highest Good for the Person:
Moral Values Belong to the Unum Necessarium and the 'Three
Modes of Participation in Values' Account for Three Ways in Which
Moral Values Are the Highest Objective Goods for Persons 169
3.17. Moral Values Are Goods 'in the Unrestricted Sense' by Being Pure
Perfections 172
a. Transcendentals 173
b. Pure Perfections 174
3.18. Moral Values Are Unconditionally Good because They Are Never
Just 'Means' towards Ends (Happiness). They Are Dominated by a
Principle of Dueness and Appropriateness and Arise 'on the Back' of
Acts (a Critique ofEudemonism) 176
3.19. Link of Morality to Religion and to God 177
3.20. Moral Values Constitute the Most Direct Link between Morality and
Religious Spirituality: Distinction between Philosophical and
Theological Assertions 178
3.21. The Unity of Moral Values 180
3.21.1. 'One Moral Value'-Goodness 180
3.21.2. 'No Division of Labor' in the Moral Life 180
3.21.3. 'Existential Moral Unity' 181
3.21.4. The Unity ofthe 'Root' of All Moral Goodness: the 'Oneness of
Virtue' 181
3.22. The Superiority of Moral Values over All Others and the Crucial
Importance of This Insight Expounded in This Chapter for Medical
Ethics 181
3.23. Moral Values Are Characterized as 'Goodness without
Qualification' -Its Relationship to Happiness and to the Supreme
Good 182
4. Concluding Remarks 185
xii TABLE OF CONTENTS

CHAPTER 4
THE FREEDOM OF CHOICE FOR OR AGAINST THE BASIC GooDS AND ENDS OF
MEDICINE
Physicians, Nurses, and Other Health Professionals as Agents in the Drama
ofFreedom 187
1. Towards a Metaphysics and Epistemology of Freedom 188
1.1. Freedom in the Strong Metaphysical Sense Is Absolutely Inseparable
from Personhood 189
1.2. A Metaphysical Detour for Those Readers Who Are Interested in the
Ultimate Foundations of Medical Ethics: Some Elements of a
Metaphysics of Human Freedom and Answers to Objections against
the Existence of Human Freedom 192
1.3. The Nature and Real Existence of Human Freedom Can Be Known
with Indubitable Certitude 196
1.4. Some Metaphysical Difficulties and Apories in Admitting Human
Freedom and Another Metaphysical Side-Trip to Support Additional
Evidence of the Truth of Our Knowledge that We Are Free 198
1.5. Did Neurological Evidence Refute Freedom? 203
1.6. Is Freedom Self-Creation? 210
1.7. Freedom and Its Conditions: Individual Being, Cognition, and Value 211
2. Ethics, Freedom, and Motivation: the Drama of the Physician's
Freedom Can Only Be Understood in the Light of the Free Choice of
the End and Not Only of the Means 213
2.1. Categories of the 'Good' 213
2.2. The Drama of Human Freedom Can Only Be Understood in the
Light of the Free Choice of the End and Not Only of the Means:
Categories of the 'Good' as Explanation of This Choice 215
3. Being Free Is Not Restricted to the Sphere of Action but
Encompasses Many Spheres of Human Willing 223
3.1. Different Levels of Human Freedom-Actual and Superactual,
Direct and Indirect Freedom, Affective Responses, Other Gifts and
Cooperative Freedom 223
4. Cooperative Freedom and the Affective Dimension of the Gift of
Self as an Important Element of Medical Ethics 233
5. Concluding Remarks on the Fundamental Moral Choices in
Medicine 236
 TABLE OF CONTENTS xiii

CHAPTER 5
RATIONAL JUSTIFICATION OF AN OBJECTIVE AND PUBLICLY ACCEPTABLE
BIOETIllCS
A Critique ofEthical Relativism, Skepticism, and Nihilism and an Answer to
Engelhardt 237
1. Short Summary of the Results Gained in the Preceding Chapters and
of the Problems to Be Treated in Chapter 5 237
2. The Philosophical Plague and Aids of Medicine to Be Discussed in
this Chapter and Their Cure 239
3. Are Truth and Goodness Relative? 243
3.1. Relativism, Skepticism, and Their Consequences-a Radical
Philosophical Plague of Medicine 243
3.2. The Evident Falsity and the Internal Contradictions of General
Relativism and Skepticism 247
3.3. Critique of Ethical Relativism and Skepticism 251
3.3.1. Actual Contradictions of Ethical Relativism and Skepticism 251
3.3.2. Inevitable and Inherent Contradiction in Ethical Relativism and
Skepticism 252
3.3.3. Critique ofEmotivist Ethical Relativism 252
3.3.4. Critique of Positivist Forms of Ethical Agnosticism 253
3.3.5. Immediate Evidence of Morally Good and Evil and of Other
Values-Value-Seeing (Wertsehen) as a Method of Ethics 255
3.3.6. Refutation ofthe Argument for Ethical Skepticism or Relativism
from a Lack of Ethical Consensus-Broad Ethical Consensus Also
with Atheists 257
3.3.7. Arguments against Ethical Relativism from the Observation that
Many Apparently Moral Disagreements Are Disagreements on Facts,
Not on Values 259
3.3.8. Two Arguments against Ethical Agnosticism and Relativism Which
Are Insufficient in Themselves but Constitute Additional Reasons
against Ethical Subjectivism: Evaluation of Desires and Coherence 260
3.3.9. Is There a Conflict between Intuitive Ethical Knowledge and Ethical
Argumentation? 262
3.3.10. Some Excellent Arguments against Purely Consequentialist Ethics
Based on a Purely Intersubjective Hermeneutical Objectivism,
Which Cannot Overcome Ethical Relativism 262
3.3.11. Arguments against an Ethical Relativism Based on the Alleged
Relative and Relational Character of All Values-A New Use of the
Distinction between Three Categories of Goodness (of Positive
Importance) 263
3.3.12. Intrinsic Value and Affirmability of the Person 264
xiv TABLE OF CONTENTS

4. Is an Objective Rational Bioethics Possible in Our Pluralistic

Society? Engelhardt's Negative Reply to the Second and Third
Questions Posed Above and the Need to Return to Things
Themselves 264
4.1. The First Reason of Engelhardt's Allegation of the Incapacity of
Philosophical Moral Reasoning: the 'Private Character' of Moral
Commitments and the Ambiguity of This Claim 265
4.2. Does Every Claim of Rational Ethical Knowledge either Beg the
Question or Lead to an Infinite Regress?-Critique of Engelhardt's
Second Reason to Reject Philosophical Ethical Objectivism 268
4.3. Natural Ethical Knowledge or Total Value Blindness of Secular
Society 275
4.4. Does Engelhardt Have any Theory of Error? On the Inner Distinction
between Ethical Knowledge and Ethical Errors, and between Ethical
Theories and Immediate Ethical Cognitions as Ground of Rejecting
Skeptical Conclusions from Ethical Dissent in Society 277
5. Is There a Publicly Acceptable Content-full Bioethics? 278
5.1. Ambiguities in the Term 'Canonical' and the Distinction between
Epistemological and Metaphysical Ethical Skepticism 280
5.2. Ambiguities Regarding the 'Political Ethics' and the Relationship
between Truth, Private Morality, and Public Ethics 283
5.3. The Need for Phenomenology in the Clarification and Objective
Foundation of Content-full Ethical Intuitions 289
5.4. Critique of Engelhardt's Christian 'Fideism' and of His Divorcing
Religion from Reason-Ambiguities in His Use of the Term
'Rationalism' and Some Reflections on the Relations between
Reason and Faith in Ethics 291
5.5. On the Indispensability of Looking for the Foundation ofBioethics
in Objective Values 297
5.6. Can We Derive an Ought From an Is? Another Objection against an
Objective Bioethics in a Pluralistic Society 299
5.7. Does a Publicly Acceptable Bioethics Today Require a Utilitarian
Basis? On the Irreducibility of Moral Values to Means for the
Morally Relevant Values Which Are the Results of Moral Actions 301
5.8. Does a Modem Bioethics in a Pluralist Society Require the
Abandonment of' Speciecism', as Singer Postulates? On the Dignity
of the Human Person as a Unique Objective Value-the Untenability
of Regarding the Insistence on Human Dignity as a Mere
'Speciecism' 303
 TABLE OF CONTENTS xv

CHAPTER 6
ARE THERE ABSOLUTE MORAL OBLIGATIONS TOWARDS FINITE GOODS? A
CRITIQUE OF 'TELEOLOGICAL ETHICS' AND OF THE DESTRUCTION OF
BIOETHICS THROUGH CONSEQUENTIALISM
On The Invertebratitis ofMedical Ethics and Its Cure 305
1. Introduction 305
1.1. The Denial of Intrinsically Wrong and Evil Acts as Ethical
Invertebratitis 305
1.2. Some Bearing of Our Previous Discussion on the Morally Intrinsic
Character of Right and Wrong Actions-Beyond the False
Alternative: Kant or Utilitarian Consequentialism 308
2. The Main Theses of a 'Teleological' Foundation of Moral Norms 310
3. Immanent Critique of' Consequentialist Ethics': Its Contents and
Implications, Contradictions, and Silent Admissions 312
3.1. The General and Specific Consequences of Consequentialist Ethics
(Giiterabwiigungsethik) for Medical Ethics 313
3.2. Immanent Critique Properly Speaking of the Position of
'Teleological Ethics' 321
4. Transcendent Critique of a 'Purely Teleological' Ethics 325
4.1. Positive Insights Contained in Purely Teleological Ethics 325
4.1.1. Serious Difficulties for an Ethics of Moral Absolutes, Which Seem
to Speak for Purely Teleological Ethics 325
4.1.2. Is There a Legitimate 'Personalistic Teleologism' Which Is
Opposed to 'Teleological' Consequentialism? 326
4.2. Critique of the Central Thesis that No Finite Good Could Ground
Absolute Imperatives in the Moral Sense of the Term 327
4.2.1. Absolutely Required Inner Responses to Non-Absolute Goods 328
4.2.2. A Radical Equivocation of 'Absolute' at the Root of the Chief
Argument of Teleological Ethics 329
4.3. Are There Intrinsically Good or Evil Acts? 331
4.4. On the Possible More Moderate (Third) Thesis of Consequentialist
Teleologism: Only External Actions Which Are Directed towards
Finite Goods Are Not Intrinsically Good or Evil 332
4.4.1. The Third Possible Thesis of Consequentialist Teleologism Denies
the Unity of Man 333
4.4.2. Teleological Ethics Must Admit at Least One Important Exception to
Its Principles: Moral Values. An Internal Contradiction and the
Denial of Moral Facts 335
4.4.3. The Abuse of the Distinctions 'Moral-Premoral' and 'Ontic versus
Moral' Goods and Evils 337
xvi TABLE OF CONTENTS

4.5. Critique of the Depersonalization of Morality Implied in the

Allegedly Personalistic Ethical Teleologism 345
EPILOGUE 349
BIBLIOGRAPHY 355
INDEX OF PERSONAL NAMES 375
SUBJECT INDEX 381
 PREFACE AND ACKNOWLEDGMENTS

At the beginning of this work I wish to explain briefly its basic argument and goal. 1
This book does not only seek to develop a philosophy and ethics of medicine but in-
tends to show that an at least implicit ethics and philosophy of man are integral
parts of medical knowledge and of the medical profession which, divorced from an
understanding of, and commitment to, its goals and the goods which it has to serve,
ceases to be medicine and becomes anti-medicine. Moreover, knowledge of these
goods and ends of medicine lies entirely beyond the reach of experimental natural
science and can be clarified only through philosophy, which thus is a foundational
part of medical science. In other words, besides biological and experimental knowl-
edge pertaining to medical science and underlying medical care of all sorts, and be-
sides the diagnostic and practical arts and manifold techniques required for the car-
rying out of medical actions, the theoretical and practical aspects of medicine de-
pend essentially and constitutively on an understanding of the human person and of

I also wish to explain in a footnote the policy adopted in the present work regarding inclusive lan-
guage. In keeping with present usage, as often as it seems reasonably acceptable, I replace the inclu-
sive use of the term 'man' by other terms (such as 'human person'). I do not abandon and replace the
word 'man' entirely and always, however-for every language needs (and most often possesses) a
single word for human being (human person). In German this word (Mensch) is fortunately distinct
from man in the sense of a masculine human adult (Mann). And this sense of the word 'man'
(Mensch), which cannot be entirely replaced by 'human person', 'human being', etc., happens to be
the English word 'man' (as homo in Latin). Therefore, it is in my mind a childish abuse of the English
language to introduce the term 'woman' as equivalent to 'man' (Mensch) because, as the German
Frau, or the Frenchfemme, there is simply no linguistic sensibility which permits such a use of the
word 'woman'. When continuing at times to use the word 'man' for human being, I will also keep
using the masculine personal pronouns to stand for 'man' (human being), as well as keep using the
masculine pronouns for physicians, scientists, etc., while using the feminine pronoun for 'nurse' even
though there are also more and more male nurses.
There is no sexism contained in this use of language. Just as I, a man, feel perfectly included in
the feminine pronoun used for persons (in German and in this book also in English), I expect my
women readers to be perfectly included in the notion of 'man' (Mensch) and in the masculine pronoun
in English. To call such a use oflanguage 'sexist', is plainly silly. Just as no German will take the pro-
noun 'sie' ('she') for Person as a sign that persons are considered feminine in German and men are
excluded, no normal user of the English pronoun 'he' for man (Mensch) will have a 'sexist' meaning
in mind. Much rather, Thomas ofErfurt (or Duns Scotus) seem to be right here who distinguished in
the Grammatica speculativa four kinds of gender, insisting on the 'inclusive' or 'common' one where
masculine or feminine forms and pronouns include both male and female members. Besides the mas-
culinum,femininum, and neutrum, there is, according to them, a fourth 'common' gender (sexus com-
mune): There is, namely, as the author of the Grammatica speculativa points out quite well (and to
recognize this would in my opinion avoid the sexist interpretation of male or female inclusive pro-
nouns) a special discretio sexus, namely the genus commune, which in its linguistic form is either
masculine or feminine (quod nec differt a masculino nec a feminino) but in its meaning comprises
both sexes within itself, such as in homo (man) when this term signifies human persons as such.
In spite of all this and the fact, however, that the pronoun for 'person' in English used to be 'he',
and today often is 'it', I will neither use the masculine nor the impersonal pronoun in reference to
'person', but will sometimes use 'he or she' and, because this is too cumbersome, most times simply
use the feminine pronoun for person (in the inclusive sense), as this is customary in many contempo-
rary texts and in many other languages.

xvii
xviii PREFACE AND ACKNOWLEDGMENTS

values and goals that have crucial ethical implications and inform the entire activity
and essence of medicine.
At least a pre-philosophical understanding of, and a commitment to, these ends
and goals of medicine is not some type of 'luxury' for physicians graced with a phil-
osophical mind-set, but is indispensable for any physician and nurse in order to ac-
tually be a physician or nurse, instead of turning into a mere medically trained tech-
nician or even criminal. The same is true for all other health professionals.
The book also argues that we experience a great progress of medicine in those
aspects of the discipline that pertain to experimental natural science and diagnostic
and practical art, but an unprecedented crisis of the very core of medicine that is
constituted by its ends and inseparable from philosophical and ethical dimensions.
Insufficient or wrong answers to the questions about the nature of medicine and
the goods physicians ought to serve, about knowledge, human nature, and ethical is-
sues are among the chief causes of a profound philosophical crisis of medicine.
Indeed, as we shall see, the term 'crisis' in its ordinary usage is insufficient to refer
to what actually are various life-threatening philosophical diseases that plague medi-
cine today. We do not just speak of normal developmental crises such as they occur
in the age of puberty, but ofa 'critical medical condition'. Following the meaning of
the original Greek words krisis and krinein, which can mean 'to separate' or to 'put
asunder', but also 'to decide', a medical crisis in the most serious sense of the term
indicates that turning point and critical moment in the development of a disease after
which either a sudden change for the better will occur, signaling the imminent or al-
ready incipient, but still threatened, cure of the patient, or a decisive change for the
worse, heading towards death. 2 Faced with the present philosophical 'crisis' ofmedi-
cine, we will remain entirely open as to the positive or negative outcome of the cri-
sis, without hiding from the reader our impression that the forces of the philosophi-
cal diseases of medicine threaten to prevail over those of a cure of these diseases.
We will at any rate not only diagnose some deadly philosophical diseases in contem-
porary medical theory and praxis, but also indicate ways and methods of their cure.
Questions of value theory, ethics and philosophy of man are obviously intimately
tied up with medicine. In a similar way, and this becomes specifically relevant in the
discussions of chapter 5, questions of epistemology are of crucial importance for
bioethics and ethics in general, and the underlying crisis of philosophical epistemo-
logy becomes a major reason for the crisis of medicine and medical ethics. No ra-
tionally justified ethics is possible if we cannot or do not know the objective nature
of things and above all the value of the human person and of many domains of hu-
man life. While I cannot in this work present extensive epistemological Prolegom-
ena, I will repeatedly refer to the epistemological foundations of ethics and also ex-
pound some ofthem. 3

2 See also Balduin Schwarz, Wahrheit, [rrtum und Verirrungen. Die sechs grofJen Krisen und sieben
Ausfahrten der abendliindischen Philosophie, herausgegeben von Paola Premoli und Josef Seifert
(Heidelberg: C. Winter, 1996), chs. 4 and 12.
3 For a more detailed discussion of the nature of knowledge and of value knowledge see Dietrich von
Hildebrand, Sittlichkeit und ethische Werterkenntnis. Eine Untersuchung iiber ethische Strukturpro-
bleme, 3. durchgesehene Auflage (Vallendar/SchOnstatt: Patris Verlag, 1982); Fritz Wenisch, Die Ob-
jektivitiit der Werle (Regensburg: J. Habbel, 1973); Josef Seifert, Erkenntnis objektiver Wahrheit. Die
 PREFACE AND ACKNOWLEDGMENTS xix

The present work also intends to identify the causes of the deep philosophical
crisis of medicine that originates in various dangerous philosophical diseases that
risk to turn out deadly for medicine, transforming it into its very opposite, a sort of
anti-medicine.
This book undertakes a full-scale effort to lead the way to a correct diagnosis and
an efficient cure of various philosophical diseases that touch the foundations ofmed-
icine and medical ethics. Some of these may be cured by simple philosophical anti-
biotics, others require stronger philosophical drugs which attack viruses hidden
deeply in the blood and vital organs of the minds of physicians and of the spirit of
our age. The profound philosophical crisis of medicine is chiefly a consequence of
an underlying and much wider crisis of contemporary philosophy itself, which is due
to the most dangerous diseases that ever have afflicted the science and art of medi-
cine throughout its long history.
The first volume of this work is dedicated to the foundations of a philosophy and
ethics of medicine, while the second one will treat in detail such central anthropo-
logical and ethical questions as those which pertain to life and death issues and to
health, and will enlarge and deepen the study of each single one of the seven goods
medicine should serve, discussed in chapter 1 of this volume: such as the notions,
definition, and interpretations of life and death including a critical review of 'brain
death', the biological and personalistic concepts of health, of pleasure, suffering, and
pain-relief, of the integrity of the human body and aesthetic goods. Besides and
above all, volume II will deal with many concrete issues of medical ethics concern-
ing the practical application of the theoretical understanding of the goods medicine
should serve in medical actions concerning life and death, health and pain, human
procreation, organ transplantation, the aesthetic integrity and form of the human
body, etc.
The present volume on the foundations of philosophy and ethics of medicine will
treat, after an introduction, the general nature of medical science, three most general
parts of medicine, i.e. three aspects of the physician, and the seven high goods which
are the objective goals of medical care, and which to understand is a condition for
grasping properly medicine itself as well as the moral drama in the choice for· or
against the ends of medicine, a drama which Aristotle was unable to admit-
because of certain limits inherent in his eudemonistic ethics-but which we ex-
perience painfully today (chapter 1).
The foundation of any ethics, but quite particularly of medical ethics, requires a
careful and in-depth study of the central value with which most medical actions are
concerned and which is centrally present in some ·way in all the seven goods dis-
cussed in chapter 1: I refer to the dignity of the human person. The reason why an
understanding of this exalted value in which also the fundamental human rights are
grounded, on which, since the Universal Declaration of Human Rights in 1946, well
over 90% of all nations have expressed agreement, is particularly important for phy-
sicians, nurses and other medical professional groups, lies in the fact that they deal
daily with human beings of all ages and in all kinds of physical and mental con-

Transzendenz des Menschen in der Erkenntnis, 2. Aufl (Salzburg: A. Pustet, 1976); the same author,
Back to Things in Themselves. A Phenomenological Foundation/or Classical Realism (London: Rout-
ledge, 1987); and Paola Premoli De Marchi, Etica dell'assenso (Milano: Franco Angeli, 2002).
xx PREFACE AND ACKNOWLEDGMENTS

ditions. Moreover, an ethics pertaining not only to how we ought to treat hwnan per-
sons in their fully experienced and developed being and social presence, i.e., mature
and healthy adults and developing normal children, but to how we should treat the
unborn, the handicapped, the aged, the terminally ill patients, and even gametes and
other cells or tissues that are somehow related to hwnan persons, requires a lucid un-
derstanding of the nature of personal dignity and of its radically different sources
and dimensions.
While we reserve a fuller treatment of hwnan life to volwne II, already volwne I
requires a brief examination of the nature of hwnan life and of the person herself,
the bearer of hwnan dignity. In this context, the outlines of a philosophy of man ap-
propriate for medicine are developed: particularly the existence of the mind and its
irreducibility to the body, the irreducibility of the body to a machine, and the phe-
nomenon of the 'lived body', as well as the irreducibility of the hwnan person to any
level of his or her consciousness and actions.
All of these anthropological considerations will prove indispensable for any bio-
ethics, secular, Christian, Jewish, Muslim, or other, particularly for supplying the
theoretical foundations for avoiding the errors of actualistic and functionalistic con-
cepts of the person with their devastating effects on bioethics. Regarding these onto-
logical and anthropological issues that touch the nature of personhood (discussed
and to be clarified only by philosophy but presupposed in medical ethics and in any
psychology or religious creed), the mentioned forms of reductionism (of persons to
bodies or to conscious experiences) will have to be refuted. They have equally seri-
ous consequences for a secular as for a religiously oriented ethics of abortion, brain
death, euthanasia, etc. For however much the contents of one's religious faith
change her worldview, any person's positions on these fundamentally philosophical
issues (the substantiality of the soul, of the person, as well as her reducibility or irre-
ducibility to conscious acts) will have the same consequences regardless of any reli-
gious positions the respective author may embrace. For depending on which ontolo-
gy of the person, of the embryo, of the dying or 'brain dead' she holds true, any per-
son and ethicist, whether Christian or not, will decide ethical issues differently.
In fact, in many cases of the lack of consensus in ethics, which motivates some
forms of moral relativism and which, in his The Foundations of Bioethics, stands in
the forefront of H. T. Engelhardt's attention, we find in reality different opinions
about ontology and facts, not about values. Max Scheler and Dietrich von Hilde-
brand have shown that ethical relativism often falsely rests on the asswnption of a
divergence of ethical positions when in fact we find the same ethical positions ap-
plied to different opinions about facts. 4 For this reason it is evident that questions of

4 Cf. Max Scheler, Der Formalismus in der Ethik und die materiale Wertethik. Neuer Versuch der
Grundlegung eines ethischen Personalismus, 5. AutI. (Bern und Miinchen: Francke, 1966), ch. 5.3;
Formalism in Ethics and Non-Formal Ethics of Values. A New attempt toward the Foundation of an
Ethical Personalism, trans. by Manfred S. Frings and Roger 1. Funk (Evanston: Northwestern Uni-
versity Press, 1973), ch. 5.3, "The Meaning of the Thesis of the 'Relativity' and 'Subjectivity' of Val-
ues," pp. 265-269. See also Dietrich von Hildebrand, Ethics, 2nd ed. (Chicago: Franciscan Herald
Press, 1978), ch. 9.
 PREFACE AND ACKNOWLEDGMENTS XXI

philosophical anthropology and ontology play a crucial role for bioethics (chap-
ter 2). 5
The disquisition will then turn to the question which-among the many moral
systems in our pluralistic society--ethics the physician should choose and to the out-
lines of the foundations of a rational ethics and bioethics, as well as to an ABC of
the terminology, epistemology, and objective discoveries of a rigorous ethics. The
distinctive essence of specifically moral values, which to understand is a necessary
requirement in order to move from a theory of goods that are morally relevant for
the medical staff to a theory of the moral life itself and thereby to medical ethics
properly speaking, will be elaborated. In this context, the pressing question of a spe-
cific novum found in various religiously motivated ethical medical codes and specif-
ically in Christian morality and bioethics, and of the place of religiously motivated
ethics with respect to a purely philosophical secular ethics, will be briefly discussed
(chapter 3).
Because of the crucial and absolutely indispensable role of the reality of freedom
for morality, and inasmuch as consequently any bioethics without a clear recognition
of freedom would be no ethics at all, a relatively detailed analysis of freedom is of-
fered as part of the general ethical foundation of bioethics. Such an analysis of free-
dom and in particular of the scope of the freedom of choice regarding the ultimate
ends of human actions is also necessary in order to justifY the central thesis of this
work that the physician and health worker is faced today with a dramatic free choice
for the goods medicine ought to serve (chapter 4).
Special consideration will be given to a justification of a binding and content-full
rational ethics in our pluralistic democratic society, discussing in this context criti-
cally the prevailing ethical skepticism, agnosticism, and value relativism. Particular
attention will be given to the positions H. T. Engelhardt, Jr., the editor of this series,
has expounded in his The Foundations of Bioethics. 6 The very different and mostly
contrary positions I am defending here I shall explicate in a critical dialogue with the
ideas expressed by Engelhardt (chapter 5).
Another foundational issue of all ethics, but quite particularly of bioethics and
medical ethics, needs to be taken up: are there acts which are intrinsically wrong or
can any medical act be justified depending on its results and consequences? Utilitar-
ianism, pragmatism, and consequentialism in ethics claim the latter to be the case,
while other ethical positions admit that there are a great number of actions that never
ought to be done, as is clearly stated in the Hippocratic Oath. It is clear that the an-

5 See for example John F. Crosby, "Evolutionism and the Ontology of the Human Person," Review of
Politics, 38 (April, 1976): 208-243; see also by the same author, The Selfhood of the Human Person
(Washington, D.C.: The Catholic University of America Press, 1996), and Personalist Papers (Wash-
ington, D.C.: The Catholic University of America Press, 2004); see likewise Josef Seifert, Leib und
Seele. Ein Beitrag zur philosophischen Anthropologie (Salzburg: A. Pustet, 1973); and Josef Seifert,
Essere e persona. Verso una fondazione fenomenologica di una metafisica classica e personalistica
(Milano: Vita e Pensiero, 1989).
6 See H. T. Engelhardt, Jr., The Foundations of Bioethics (New York and Oxford: Oxford University
Press, 1986), and the substantially different version of the work: H. T. Engelhardt, Jr., The Foundation
of Bioethics, 2nd ed. (New York and Oxford: Oxford University Press, 1996); see also Brendan P.
Minogue, Gabriel Palmer-Fernandez, James E. Reagan (eds.), Reading Engelhardt. Essays on the
Thought ofH T. Engelhardt, Jr. (Dordrecht, Netherlands: Kluwer Academic Publishers, 1997).
xxii PREFACE AND ACKNOWLEDGMENTS

swer to this foundational ethical question has immense consequences for medical
ethics: are such acts as torture, human experimentation by killing or mutilating hu-
man patients, abortion, infanticide, or euthanasia always wrong or not? Depending
on the reply to this question, almost every chapter of medical ethics will have to be
written differently. Therefore, the discussion of this issue very much belongs to a
work on the foundations of philosophy and ethics of medicine. I will defend the Hip-
pocratic view of this question and of medical ethics against a great number of very
serious objections difficult to deal with (chapter 6).
In a second part, to be published a year later, the present work will proceed to
examine, at greater length and in more detail, some of the most important morally
relevant (seven) goals of medicine, justifying the objectivity of their morally rele-
vant character and value (most extensively human life and the health of persons).
Their anthropological character as well as the ethical dimensions involved by the
seven goills of medicine expounded in volume I will be discussed with reference to
concrete examples and questions concerning these goods and particular aspects of
the objective ends of medical action. In this second volume, I will treat separately
and in greater detail some concrete 'issues of bioethics' such as the role of 'brain
death' in transplantation medicine, as well as the issues of abortion, assisted suicide,
euthanasia, restriction of access to medical care in ICUs, various forms of contracep-
tion and In vitro Fertilization, cloning, prenatal screening, genetic engineering, and
others. In conclusion, I will treat the specific problems of a 'Christian Bioethics'.
Some of the following texts were originally lectures delivered orally, in English,
as the first cycle of The Claude Bernard Lectures on Philosophy and Medicine, held
at the Unidad Bioetica of the Medical Faculty of the Pontifical Catholic University
of Chile in Santiago from August to September 1990. I herewith thank Prof. Juan de
Dios Vial Correa, then Rector of the University, and Prorector Professor Pedro Mo-
randlS for their invitation. A special word of thanks I address to Professor Carlos
Quintana, at the time of my visit Director of the Unidad Bioetica, whose gentle hos-
pitality during my stay in Santiago remains unforgettable for me. To him in particu-
lar as well as to the former Professors Alejandro Serrani and Manuel Lavados of the
Pontifical Catholic University of Chile lowe the honor of this invitation. I am fur-
ther greatly indebted to Dr. Pedro Rosso, then Dean of the Medical School, who re-
cently became Rector of the Pontifical Catholic University of Chile, and to the
whole medical faculty of this University, not only for the opportunity and distinction
of having been invited to deliver these lectures but also for the undeserved honor,
bestowed on me later, of having been named an honorary member of the Medical
Faculty of that same University. A greater gift than the honor they bestowed upon
me, however, was their intellectual seriousness and integrity as well as their personal
amiability and gracious hospitality. Their and their colleagues' and students' pene-
trating questions were and, in view of my recently closer ties to this University, are
presently a source of personal and theoretical inspiration for me.
In 2001, I received an invitation, for which lowe thanks to Rector Rosso and to
Professor Patricio Ventura, now Head of the Unidad Bioetica of the University, to
teach the first philosophy course in a newly established Masters program of bioeth-
ics at PUC. Especially the second chapter of the present book on human dignity was
preceded by vivid discussions with the excellent students of this program and with
 PREFACE AND ACKNOWLEDGMENTS xxiii

colleagues and students in Liechtenstein, Germany, Belgium, Italy, and in other

countries where I have lectured on the foundations of human dignity.
The text of my Claude Bernard Lectures, as printed here, 7 and of some of the
chapters of volume II, has been revised repeatedly and essentially, most extensively
in connection with a two year research program into the philosophical aspects of the
definition of health carried out at the International Academy of Philosophy in the
Principality of Liechtenstein,8 with the support of the Schweizerischer Nationalfonds
zur Fiirderung wissenschaftlicher Forschung (Swiss National Science Foundation),
whose assistance towards the realization of this research and publication project I
hereby gratefully acknowledge. 9 Other papers on medicine and philosophy which I
have written since 1990, in particular the text of some lectures which I held at the
same University in 1993, have been added in this two-volume work to the revised
texts of the Claude Bernard Lectures so as to form a more comprehensive treatment
of a philosophy and ethics of medicine, and of vital issues of bioethics.
lowe profound gratitude regarding the issues treated here, and the knowledge
gained about them, to many persons. The first of them in rank and dignity is His
Holiness Pope John Paul II, who, through his profound work both as philosopherlO
and as teacher of the Church, II gave me invaluable inspirations. By nominating me
as member of the Pontifical Academy pro Vita, he gave me a precious opportunity
and duty to deepen my philosophical reflections on ethical issues regarding human
life and death. In this context, lowe special thanks also to Prof. Juan de Dios Vial
Correa, President of the Pontifical Academy pro Vita, and to His Excellency, Mon-
signore Elio Sgreccia, who as Vice-President of that same Academy and as author of
important works on bioethics, inspired my bioethical reflection in so many ways,
and to all members and colleagues in the Academy. Needless to say, the responsibil-
ity for this text is entirely mine and not of the Pontifical Academy whose member I
have the honor to be. Moreover, I wish to insist on the fact that this book is a purely

7 Some of them have been published in their original form in which they were held (i.e., in Spanish
translations). See Josef Seifert: "Acerca de la posibilidad de una bioetica publicamente aceptable en
nuestra sociedad contempoflinea pluralista," in Educacion Medica 12 (Septembre 1994), Etitada por 1a
Facu1tad de Medicina de 1a Pontificia Universidad Cat6lica de Chile (Santiago), pp. 205-217; "Con-
sideraciones filos6ficas acerca del impacto social de la legalizaci6n del aborto," in ibid., pp. 234-240;
"Pensamiento cristiano y los problemas de la bioetica," in Educacion Medica 11/93 (Santiago, Chile:
Facultad de Medicina de la Pontificia Universidad Cat6lica de Chile, 1993), pp. 66--71.
8 During the years 1994-1996.
9 See the published results of this research, "Bedeutung der 'allgemeinen Systemtheorie' in der heuti-
gen Debatte tiber den Gesundheitsbegriff," in Paulina Taboada, Kateryna Fedoryka Cuddeback, and
Patricia Donohue-White (eds.), Person, Society and Value. Towards a Personalist Concept o/Health
(DordrechtIBostonlLondon: Kluwer Academic Publishers, 2002). Having offered the Claude Bernard
Lectures in 1997 as a course at the Austrian Campus of an American University and at the Internation-
al Academy of Philosophy in the Principality of Liechtenstein, I had a further opportunity to rework
the manuscript. Other chapters I have reworked while preparing a paper on ethics for the 20th World
Congress of Philosophy in Boston, and during work for papers given at various symposia and Univer-
sities.
10 See Karol Wojtyia, The Acting Person (Boston: Reidel, 1979); see also by the same author, Love and
Responsibility (San Francisco: Ignatius Press, 1993). See likewise Josef Seifert, "Karol Cardinal Woj-
tyia (pope John Paul II) as Philosopher and the CracowlLublin School of Philosophy," in Aletheia II
(1981).
II See especially his Salvifici Doloris on pain and suffering, and Uomo e donna 10 credo
xxiv PREFACE AND ACKNOWLEDGMENTS

philosophical one quite apart from the fact that membership of the Pontificia Acade-
mia pro Vita does not entail any ecclesiastic authority.12 At this point, I should also
express my gratitude to the Secretary of the Pontifical Academy of the Sciences (of
which I am not a member but by which I was invited), Monsignore Ing. Renato Dar-
dozzi, whose invitation to participate, as expert in philosophy, in an Academy ses-
sion on brain death, and in another one on chaotic and non-chaotic systems and on
life,13 greatly enhanced my knowledge and inspired my philosophical reflection on
medicine. My gratitude extends quite especially to my former main teacher, Dietrich
von Hildebrand, without whose What Is Philosophy? and large ethical work this
book could not have been written,14 to Professor Balduin Schwarz who has made me
deeply aware of the great crises in the history ofphilosophy,t5 and to many classical
philosophers, colleagues, friends and students at different schools, especially at the
International Academy of Philosophy in the Principality of Liechtenstein.
Acknowledging the help I have received from all those many philosopher friends
and students who inspired me to rethink the issues treated in this text and from all
the doctors and professors of medicine with whom I discussed these subjects in vari-
ous Academies and Universities, I wish to thank in particular a few persons to whom
lowe a special debt of gratitude besides those already mentioned. First, I have to
thank my very close friend and colleague Professor Rocco Buttiglione, now his Ex-

12 I stress this obvious point because recent articles and publications show that there is a widespread
misunderstanding as if the Pontifical Academy of Sciences possessed any magisterial role or repre-
sented the Vatican position. This is in no way the case. The members of the Pontifical Academy of
Sciences are to a large measure not Catholics, differ often radically from the Magisterium's positions
regarding population control etc., and lack any official magisterial authority. They are a purely scien-
tific community, a free group of scholars who are meant to be useful in informing the Church's Mag-
isterium of the opinions, developments, findings, etc., in the sciences and disciplines, or in treating
such issues as defmitions of death or the origins of life. In spite of the very different 'idea' of the Pon-
tificia Academia pro Vita, neither the Pontificia Academia pro Vita as a whole nor (and even less) its
single members can make any claims to their utterances possessing 'ecclesiastic authority' or being
.the official positions of the Catholic Church.
13 See as record of this my paper, whose content strongly differed from all other Pontifical Academy-
members' opinion: Josef Seifert, "Is 'Brain Death' actually Death? A Critique of Redefining Man's
Death in Terms of 'Brain Death' ," in R. J. White, H. Angstwurm, I. Carasco de Paola (eds.), Working
Group on the Determination of Brain Death and Its Relationship to Human Death (Vatican City:
Pontifical Academy of the Sciences, 1992), pp. 95-143. See also Josef Seifert, "What is Life? On the
Irreducibility of Life to Chaotic and Non-Chaotic Physical Systems," Proceedings of the 1993 Gener-
al Assembly Meeting, Pontifical Academy of the Sciences (Vatican City, 1994); and Josef Seifert,
What is Life? The Originality, Irreducibility, and Value ofLife (New York/Amsterdam/Atlanta, GA:
RodopiNalue Inquiry Book Series, 1997).
14 Dietrich von Hildebrand, What Is Philosophy? (Milwaukee: Bruce, 1960; 2nd ed. Chicago: Franciscan
Herald Press, 1973; 3rd ed., with a new introductory essay by Josef Seifert, London: Routledge,
1991); EthiCS; Die Idee der sittlichen Handlung, phil. Diss. vom 6. November 1912, in JahrbuchjUr
Philosophie und phiinomenologische Forschung, 3. Band (Halle: Niemeyer, 1916), pp. 126-251; Sitt-
lichkeit und ethische Werterkenntnis; Moralia. Nachgelassenes Werk, Gesammelte Werke V (Regens-
burg: JosefHabbel, 1980). Dietrich von Hildebrand and Alice von Hildebrand, True Morality and Sit-
uation Ethics (New York: David McKay Company; Toronto: Musson. 1955; 2nd ed. entitled Morality
and Situation Ethics. With an introduction by Bernhard Hliring and an epilogue by Alice von Hilde-
brand. Franciscan Herald Press, 1966); Graven Images. Substitutes for True Morality (New York:
David McKay Company, 1957; 2nd ed. Chicago: Franciscan Herald Press, 1976).
15 See Balduin Schwarz, Wahrheit, Irrtum und Verirrungen. Die sechs grofJen Krisen und sieben Aus-
fahrten der abendliindischen Philosophie; Ewige Philosophie.
 PREFACE AND ACKNOWLEDGMENTS xxv

cellency, Italian Minister for European Integration, for many ideas and inspirations
for the present work, particularly regarding the ethical dimension as constitutive of
the essence of medicine, and whose former Full Professorship and continuous and
faithful support of the International Academy of Philosophy in the Principality of
Liechtenstein and of this project on bioethics and philosophy of medicine became
one of its more significant origins.
Special gratitude lowe also to Professor D. Alan Shewmon, a pediatric neurol-
ogist and expert on surgical treatment of children's epilepsy in California; since his
contributions refer to the topics of the second volume of this work, I will acknowl-
edge my debt to him in the introduction to volume II.
Another person to whom lowe special gratitude with respect to this publication
is my former student and dear friend, Dr. med. Dr. phil. Paulina Taboada (who is
now directing the Masters Program in the Unidad Bioetica at the Catholic University
of Chile in Santiago and teaching ethics and medicine) for having repeatedly pro-
vided me, during and after my various lectures in Santiago, with a series of construc-
tively critical remarks which helped to improve this text. I appreciate also deeply the
precious gift of her friendship and encouragement in the pursuit of knowledge re-
garding the crucial matters here discussed.
In the summer and fall of 1997, finally, I had the great opportunity to co-teach
with Professor H. T. Engelhardt, Jr. a research and discussion seminar on bioethics
at the International Academy of Philosophy in the Principality of Liechtenstein
(lAP), in which we held dialogues with each other and with students of the Acade-
my about his Foundations of Bioethies, about a new text he was preparing at that
time on Christian Bioethies and which since then was published, and about portions
of the manuscript preceding the present work. Also this opportunity was a precious
help towards completing this text and I wish to express my vivid thanks to H. T. En-
gelhardt, Jr. for his personal gentleness, despite our profound philosophic disagree-
ments, for sharing his vast knowledge with us and for spending several months of
his sabbatical year (1997) in Liechtenstein where we discussed some matters con-
tained in this text. I also took part in a two-year research project on "Limiting Ac-
cess to Medical Resources in Intensive Care Units" which helped me to understand
better many issues discussed in volume II of this book. I express my thanks also to
my parents who besides life and all other gifts they bestowed on me, made my
studies possible and also accompanied my philosophical work always with extreme
interest and competence in philosophy and ethics, and to my wife Mary Katherine
who suffered my being absorbed by this work for countless hours and who is a very
fme philosopher herself. A special word of gratitude I also owe to Mrs. Veronika AI-
bicker who prepared this manuscript for print and contributed much to its form and
to certain scholarly aspects of it. I include in my thanks many other persons who are
here not mentioned by name but to whom I am greatly indebted.

July 20,2001
Gaflei, TriesenbergIVaduz, Principality of Liechtenstein
Josef Seifert
 INTRODUCTION

At all times physicians were bound to pursue not only medical tasks, but to reflect
also on the many anthropological and metaphysical aspects of their discipline, such
as on the nature of life and death, of health and sickness, and above all on the vital
ethical dimensions of their practice. For centuries, almost for two millennia, how-
ever, those who practiced medicine lived in a relatively clearly defined ethical and
implicitly philosophical or religious 'world-order' within which they could safely
turn to medical practice, knowing right from wrong, or at least being told what to do
and what not to do. Today, however, the situation has radically changed, mainly due
to three quite different reasons: First and most obviously, physicians today are faced
with a tremendous development of new possibilities and techniques which allow
previously unheard of medical interventions (such as cloning, cryo-conservation, ge-
netic interference, etc.) which call out for ethical reflection and wise judgment but
regarding which there is no legal and medical ethical tradition. Traditional medical
education did not prepare physicians for coping with this new brave world of mod-
em medicine. Secondly, there are the deep philosophical crises and the philosophical
diseases of medicine mentioned in the preface that lead to a break-down of firm and
formative legal and ethical norms for medical actions. And thirdly, in our postmod-
em world there are neither the commonly shared religious ethical norms on which
medieval medicine could rely nor the rational codes of the enlightenment or of the
Universal Declaration of Human Rights on which society and the medical profession
used to rely.
Consequently, in our pluralistic and rapidly changing society, medical profes-
sionals frequently remain without any adequate training in medical ethics and with-
out any publicly or universally accepted solutions to even the most basic ethical
questions in their field, such as: "Is it ethically justified to assist suicide, to kill the
elderly, to abort babies, even up to birth?" They are likewise left without orientation
regarding such elementary theoretical and ultimately philosophical problems as lie at
the foundations of their discipline, such as: "What is human death?" and "What is
human life?" and, more practically, "When does life begin, when end?"
But not only in the public life, also in the private consciousness of medical per-
sonnel, the type of clarity of concepts, thoughts, and solutions to the philosophical
questions of medical practice still found after World War II, especially under the im-
pact of the shock over the Nazi horror and its horrendous effects on medicine, has
long since disappeared. After the 'Niirnberger ProzeB' had brought to light the cor-
ruption of many Nazi doctors, the whole medical world woke up to the evils of eu-
genic euthanasia and collaboration of physicians with abortion and euthanasia for
racist and political reasons, ruthless medical experimentation on humans, and other
Nazi crimes in the field of bioethics. A universal declaration on human rights was
signed by many nations in 1946, and similar documents were internationally sanc-
tioned thereafter. The forms of human experimentation conducted in Ravensbruck,
for example, would shock us even if animals had been used for experiments instead
of women. But today the wholesome effect of reflecting on those philosophical and
xxvii
xxviii INTRODUCTION

moral truths which were gravely violated by Nazi doctors such as Dr. Mengele who,
in the concentration camp of Auschwitz and others, used men and women for medi-
cal tests in ruthless ways, has long passed. I Weare back into a deep and universal
crisis ofbioethics and of the recognition of the very values that lie at its foundations.
Behind this crisis in medical ethics we find a much wider and almost universal
crisis of philosophy and ethics, a crisis of which one can safely claim that it surpas-
ses any of the preceding great crises of philosophy in the history of occidental
thought and extends especially to the very foundations of values, of ethics, of moral
obligations, of intrinsically good and wrong acts, and of religion. This crisis has also
thrown medical ethics into an emergency situation that could well be regarded as a
specially revealing concrete appearance of the sixth great crisis of philosophy in the
midst of which we find ourselves today.2 The objectivity and the very notions ofhu-
man rights and of moral obligations have become doubtful.
Bioethics today stands in desperate need of a new voyage, of a new beginning
and new foundation of philosophical ethics, which both rediscovers the perennial
foundations of ethics and lays its foundations more deeply than any previous ethical
system had ever laid them, in accordance with new philosophical discoveries and
new challenges and with entirely new practical possibilities of medical action.
The picture of philosophy and ethics today is not all gloomy, however. One
could apply here Hegel's word according to which Minerva's owl flies at the time of
dusk. 3 We encounter today new and better ways of founding ethics than in the past.
These new contributions to ethics belong already to the pure air of a new foundation
and new beginning of philosophy (the seventh great voyage of philosophy in its his-
tory) which philosophy and medical ethics, building on previous philosophical con-
tributions, are called to undertake and have begun to undertake today. This greater
clarity of some philosophers of the 20th century regarding the true foundations of
ethics and bioethics may be precisely due to the gravity of the present crisis which
forces us to look for ultimate answers because insufficient and superficial answers
will no longer do.
A conspicuous absence of commonly accepted public guidelines of medical ac-
tion, and of privately achieved clarity about them, is found not only with respect to
almost all great traditional problems of medical ethics but also, and even more, with

On the horrors of those experiments see Wanda P6ltawska, Und ichft1rchte meine Triiume, 2. Auflage
(Avensberg: Maria aktuell, 1994).
On the notion of the six major crises and seven 'voyages' of occidental philosophy, see Balduin
Schwarz, Wahrheit, Irrtum und Verirrungen. See also Josef Seifert, "Die 'Siebte Ausfahrt' als Aufga-
be der Intemationalen Akademie fUr Philosophie im FUrstentum Liechtenstein (1986--1996)," in Mar-
iano Crespo (ed.), Menschenwiirde: Metaphysik und Ethik (Heidelberg: Universitatsverlag C. Winter,
1998), pp. 19-56/3.
See Gottfried Wilhelm Friedrich Hegel, Einleitung zur Rechtsphilosophie:
Urn noch fiber das Belehren, wie die Welt sein soli, ein Wort zu sagen, so kommt
dazu ohnehin die Philosophie immer zu spat. Als der Gedanke der Welt erscheint sie
erst in der Zeit, nachdem die Wirklichkeit ihren Bildungs-ProzeB vollendet und sich
fertig gemacht hat. ... Mit Grau in Grau laBt sie (eine Gestalt des Lebens) sich nicht
verjUngen, sondem nur erkennen; die Eule der Minerva beginnt erst mit der einbre-
chenden Dammerung ihren Flug. (G. W. F. Hegel, Werke, Bd. 7 [Frankfurt a. M.:
Suhrkamp, 1970], pp. 27-28).
 INTRODUCTION XXIX

respect to the enonnous number of stunning ethical and anthropological problems

which are posed by modem medical technology and which by their very nature do
not allow solutions by a return to traditions of medical ethics which in these cases do
not and cannot exist.
This leads us to a further reason why medical ethics and bioethics need to be de-
veloped anew with all seriousness: the fact that objectively, and wholly independent-
ly of any decline in ethical thinking, countless new problems arise in medicine due
to medical development. Artificial life-support systems and the unavoidable limits to
medical efforts of prolongation of life pose such ethical problems as: "What are the
criteria according to which one should allocate extraordinary means of life-support
to patients?" "How should we handle modem reanimation technologies and when is
it licit to turn respirators off?" "In which ways may we or ought we limit access to
medical treatment?,,4 Organ explantations and transplantation medicine, which in-
volve a new concept of human death, likewise pose radically new problems regard-
ing the definition of life and death, and regarding the beginning and end of human
personal life. The moral aspects of organ donation and harvesting of organs need to
be investigated anew because these technologies never existed before and yet touch
classical issues such as sacrifice, donation, bodily and personal integrity, as well as
mutilation. The possibilities of changing one's sex, IVF (in vitro fertilization),
spenn- and egg-donations, GIFT (gamete intrafallopian transfer) in its many fonns,
'cloning', and many other new medical procedures pose crucial moral questions re-
garding the origins of human life and the nature of human parenthood as well as re-
garding the difference between aid to the marital act and its substitution through the
operations of medical teams. New fonns of human reproduction now replace the
'old methods' by 'making babies' from egg-cells collected from women who sell or
donate them, and from spenn obtained by masturbation of males - both having been
deposited at egg and spenn banks - in processes reminiscent almost of a cook's
cooking foods from various ingredients. Modem knowledge of genetics and the abil-
ity to alter genetic codes similarly pose multiple new and pressing ethical questions
and dilemmas as to whether 'genetic engineering' can ever be right and, if so,
whether it is licit only for strictly therapeutic ends. Research on human embryos and
countless other new aspects of a rapidly evolving medical science pose a world of
ethical, legal, social, and philosophical problems which cannot be solved by mere
reliance on tradition, not only for the reasons of the collapse of this tradition under
the jolt of the present great philosophical crisis hinted at above, but also because the
classical authors were unaware of them.
But notwithstanding all the neutral reasons to renew bioethical reflections in re-
sponse to an incredibly growing medical science and technology, the most important
source of the need to redevelop bioethics lies in the universal crisis of philosophy
and ethics today. And this general philosophical and ethical crisis that grew over two
or more centuries but had not altered medicine for a long time, has finally reached
medicine as well as health care law. The world of professional medical practice and

4 In September 1997, the International Academy of Philosophy in the Principality of Liechtenstein

hosted a first meeting of a two-year research project on "Limiting Access to Medical Treatment in an
Age of Medical Progress: A Roman Catholic Perspective," directed by Professor H. T. Engelhardt, Jr.
xxx INTRODUCTION

the laws of most states no longer provide even minimally fIrm and solid, let alone
unchanging standards and codes of medical ethics within which the practice of med-
icine could confIdently be performed. Acts such as killing unborn babies, which still
during my high-school years were illegal and recognized as criminal in my home-
land Austria, are now - almost world-wide - virtually forced upon medical students
and medical doctors.
I had the occasion to discuss such questions for many hours with the director of a
department of gynecology and obstetrics in Western Europe, a noble doctor who
lives the tragedy of practicing medicine that now has been deprived of a compass
and standard for right action. The performance of abortions - as it now, according to
his opinion, "belongs to his practice," and which he reserves to himself in order to
limit the number of killed babies and to prevent that his assistant doctors handle
abortion more 'liberally' - has put on the mind of this doctor the heavy burden of
torments of conscience to the point of his hating his own profession. But nowadays a
physician like him, who restricts as far as possible committing actions that were rec-
ognized before quite generally as murder of the innocent, is even regarded as still
too 'restrictive'. This physician, who only a few years ago would have been expelled
from his country or gone to prison for his actions, appears today, and perhaps per-
sonally feels, almost like a martyr of conscience who stands up against the common
trend towards a far more liberal 'handling' of abortion.
Consider that students of midwifery presently are not even accepted, for example
in Zurich, Switzerland, for professional training if they refuse to declare that they
will assist in abortions - a symptom of a radical change of public ethics in a very
short time, and a clear and striking case of violation of the fundamental human right
to the freedom of conscience. 5 Consider the depth of the public's change of judg-
ment on abortion by contemplating the following facts: such a liberal mind as Jo-
hann Wolfgang von Goethe during the years of his political career still signed death
sentences for abortions (which were recognized as murder of children); a liberal
Jewish-Austrian poet such as Joseph Roth wrote that "every civilized society ought
to punish abortion as a crime"; and even the world-famous atheist fIlm producer, Pa-
solini, in the 20th century wrote: "the very thought oflegalization of abortion shocks
me, because I, with many others, regard abortion as murder.,,6
If unborn babies are human persons, abortion is objectively a grave crime and
any participation in it is a form of participating in mass murder to which today not
only in China but also in most Western countries many more millions of human
persons are victims than died in the Nazi holocaust. How much the times changed in
this regard even within the last decades often escapes our consciousness. Consider,
for example, that after having committed abortions, some thirty years ago, the father
of a schoolmate of my brother was expelled by the Austrian Medical Association; he
was constrained to flee from indictment and imprisonment in Austria and to practice

In response to this intolerable situation, the association "Betroffenes Spital" ("Concern: Hospital")
was formed in Switzerland on May 18, 1996, to protect the freedom of conscience and of religion, and
to unite 15,000 medical professionals in the commitment for human life in the face of the estimated
15,000 abortions performed every year in Switzerland.
See Karin Struck, Ich sehe mein Kind im Traum. Pliidoyer gegen die Abtreibung (BeriinIFrankfurt
a. M.: Verlag Ullstein, 1992), p. 62.
 INTRODUCTION xxxi

medicine in Africa in order to avoid serving a jail term. Today, the very opposite is
happening: a physician in Austria was expelled from the official medical association
for having said and written that - despite their legalization - abortion and other
forms of killing the innocent, of which many medical colleagues are guilty, are
crimes. This remark (which was in full harmony with what virtually all medical
codes of the world had held till recently) was taken as an attack on the moral
integrity of the medical profession, and this doctor was threatened with expulsion
from the medical association and supposed to pay a severe fme (though he was later
acquitted by the public courts and did not use any polemic language). Similar turns
of the tide of prevailing opinion are found in almost all fields of medical ethics: re-
garding euthanasia, genetic engineering, sterilization, contraception, assisted suicide,
homosexuality, use of deadly abortifacient drugs such as RU 486 (Mifegyne), etc.
Until now we have spoken of the public world of the law and of secular medical
ethical standards, but this is not all that is in crisis in bioethics. In a thoroughly secu-
lar society in which religion lost long ago its strong formative influence, physicians
frequently do not even fmd any personally binding religious answers to the pressing
philosophical and ethical problems that confront them daily. Also moral theologians
in great number, Jewish, Catholic, Protestant, and Orthodox alike, defend - based
chiefly on some variety of ethical consequentialism (or 'teleological ethics') - by
theological arguments almost all the practices which the pagan Hippocrates, at least
as far as we can infer from the text of the Hippocratic Oath/ had regarded as crimes
against the goals of the medical profession. Thus we witness today not only a col-
lapse of the unity and traditional value commitments of secular ethics and of state
law but also a large-scale collapse of traditional moral theology, of the moral and so-
cial order dominant in religiously inspired hospitals, and of their medical ethical
codes. Some authors have spoken of a deep crisis of the Hippocratic medical tradi-
tion,s a crisis and break that also can be seen in the ethical guidelines and policy
statements of Catholic Hospitals. (I am thinking, for example, of a specific Catholic

It is true that both in Plato's Republic and in a number oftexts of the Hippocratic tradition these grand
ideals were not upheld, as described and defended by Darrel W. Amundsen, "The Physician'S Obliga-
tion to Prolong Life: A Medical Duty without Classical Roots," Hastings Center Rep (Aug 1978), 8:
23-30.
See for example Nigel M. de S. Cameron, "The Seamless Dress of Hippocratic Medicine," Ethics Med
(Autumn 1991): 43-50. Summary in Philosopher's Index (Fall 1998) In the excellent summary in the
Philosopher's Index (Fall 1998), the author summarizes his results:
The Hippocratic medical tradition, the originally pagan cornerstone of Westem med-
icine, is in crisis. What is the nature of the distinctive Hippocratic medical values?
They have been constitutive not only of medicine as a profession, but of the idea of
a profession, as a self-regulating institution with inherent moral as well as technical
components. Hippocratic medicine was from the start medicine as moral commit-
ment, enshrined in a covenantal context (God-physician, physician-patient, physi-
cian-master/profession), based on a twofold obligation (sanctity of life and philan-
thropy), and with a single commitment to heal. (Article extracted from the author's
The New Medicine [Crossway Books, 19921 ).
See also the interesting description of the integration of the Hippocratic tradition of medical eth-
ics into the Islamic medical traditions in Azim A. Nanji, "Medical Ethics and the Islamic Tradition,"
J Med Phil (Aug 1988), 13: 257-275.
xxxii INTRODUCTION

Hospital in the United States known to me. 9 ) In such medical guidelines hardly a
trace of the clarity of ethical positions and distinctions that characterized hospital
ethics of the past is left intact.
In such a confused time as ours, an honest attempt at clarifying - through care-
fully conducted and at the same time intelligible philosophical analyses accessible to
a wider readership - the important interdisciplinary questions which concern both
philosophers and physicians might prove helpful to doctors who are searching eager-
ly for the truth about the meaning and theoretical foundations of their noble art.
Even those who object against any rational philosophical solution to these prob-
lems, while holding that a religious answer to them is possible, cannot avoid offer-
ing philosophical opinions and analyses, using philosophical arguments to ground
their skepticism regarding the capacity of reason to solve ethical issues; and they
keep presupposing philosophical terms, insights, and principles along every step of
their religious discussion. \0
Some of these adherents of the position that a content-full ethics is only possible
on religious grounds have, apart from their skepticism and despair of reason, another
argument for their position, namely the obvious moral preconditions of moral
knowledge: rarely do thieves see stealing, murderers assassination, tax-swindlers
cheating as wrong.
While I fully agree with the conviction that a comprehensive and pure objective
knowledge in ethics requires virtue and can be reached fully only by a total conver-
sion and not by philosophical analysis and argument alone, I am fIrmly convinced
that philosophical reasoning and argumentation never have been more needed than
today. These are indeed indispensable if the world-wide crisis of medical ethics, in
which false philosophies of all sorts play an enormous role and in whose genesis
philosophers have a great share of responsibility, should be overcome and physi-
cians should again find a reliable guide for medical action.
Some bioethicists, perhaps the majority, hold this to be impossible, drawing from
this opinion various consequences: The fIrst consequence is a reduction of public
ethics to the contents of general consensus or agreement (or to the mere object of
tolerance and acceptance), and of private ethics to a fIdeistic ethics whose adoption
is judged to be a mere private matter of the conscience of "moral strangers in a pub-
lic world." Some authors hold both of these opinions at the same time. The stand-

This hospital has recently been sold to a non-sectarian, non-Catholic health organization. It developed
guidelines that allow withdrawal of fluids (with starvation as consequence) even from patients who
were still conscious and pleaded for fluids. The argument for such a shocking stance has been that
those patients before had signed some living will or similar written agreement no longer to be tube-fed
when being in certain physical conditions.
\0 In the new and interesting Journal Christian Bioethics. Non-Ecumenical Studies in Medical Morality
(started in 1995) many articles, for example by H. T. Engelhardt, Jr. and Fr. George Eber, seem to im-
ply that philosophy can contribute virtually nothing to the solution of problems related to actual con-
tents of medical ethics. They regard this, in the tradition of parts of the Orthodox Church, as a vain ef-
fort of a secular mode of thinking to solve problems that can only be solved by spiritual religious con-
version and liturgical celebration in the faith. Other authors in the 'non-ecumenical' Journal, like Rus-
sell E. Smith, Darrell W. Amundsen, and Otto W. Mandahl, Jr., take other positions on these ques-
tions. See Christian Bioethics 1 (1995), pp. 128-152; 161-181; 182-199; 213-255.
 INTRODUCTION xxxiii

points of H. T. Engelhardt, Jr." or Fr. George Eber l2 go in this direction and are
based on a general view of the eclipse of reason in modernity and its incapacity to
reach objective truth. Engelhardt argues that there is no publicly binding reason or
ethics today (except some watered-down formal tenets which meet with political
consensus or assent in a libertarian democracy). Instead there would only exist ethi-
cal systems binding for closed groups, the "moral strangers in a public world.,,1J To
these groups the Journal Christian Bioethics. Non-Ecumenical Studies in Medical
Morality lends a voice. 14
Two other responses to a similar opinion that all contents of moral judgments are
subjective are the attempt to develop some kind of 'objective ethics' based on the
evaluation of conflicting subjective desires,15 and a reduction of ethics to a mere
'logic of norms', to an ideal of ethical consistency. In chapter 5 of this volume, we
will return to a critical examination of all these views which imply different forms of
ethical agnosticism and relativism and which we deem to be a major philosophical
disease of medicine.
The following reflections are based on the very different conviction, which to
elucidate and to establish is the purpose of the subsequent reflections, that philoso-
phy as an objective knowledge of reality, of objective values and oughts, not only in
the sense of a purely ontological and religious objectivisml6 but also in the sense of
an epistemological objectivism, possesses also today a rational justification and
foundation. In the face of the profound subjectivist and relativist crisis of philosophy
today - the sixth great crisis in the history of occidental philosophy -, such a philo-
sophical position is rationally justified only if there exists what could be called the
'seventh voyage' in the history of Westem philosophy. 17 What is needed, in order to
grant philosophy an important role in overcoming the huge skeptical and ultimately
nihilistic crisis of medical ethics today and to reinstate philosophical knowledge in
its rightful place, is a new beginning in philosophy and a new justification of its

11 H. T. Engelhardt, Jr., "Christian Bioethics as Non-Ecumenical," Christian Bioethies, vol. 1, no. 2

(1995): 182-199.
12 Christian Bioethics 1 (1995): 128-152.
13 H. T. Engelhardt, Jr., The Foundations ofBioethics.
14 Though inasmuch as this non-ecumenical journal is partly ecumenical after all, by aiming at fmding
points of consensus among various Christian and Jewish groups, and by tolerating opinions differing
from those of the editors, it includes also other voices such as mine.
15 See Julian Nida-Riimelin, "Wert des Lebens," in Angewandte Ethik. Die Bereichsethiken und ihre
theoretische Fundierung. Ein Handbuch herausgegeben von Julian Nida-Rilmelin (Stuttgart: Alfred
Kroner Verlag, 1996), pp. 832-861, especially pp. 834 ff., 841 ff. Cf. for example, p. 841: "Die ent-
scheidungstheoretischen Kohtirenzbedingungen markieren eine Form des Uberganges von subjektiven
zu objektiven Wiinschen bzw. Interessen." Nida-Riimelin defends the position that the theory of deci-
sion, based on the principle of the coherence necessary among an individual's different decisions, can
provide objective standards of the logic of decision excluding certain contradictions and incoherences
within the sphere of subjective value-decisions.
16 H. T. Engelhardt, Jr. considers himself a metaphysical objectivist (on religious grounds) and an epis-
temological skeptic.
17 See on this Balduin Schwarz, Wahrheit, Irrtum und Verirrungen Die sechs grofJen Krisen und sieben
Ausfahrten der abendliindischen Philosophie, particularly "Die sechs groBen Krisen der abendllindi-
schen Philosophie," in ibid., pp. 1-21; Josef Seifert, "Vorwort," in ibid., pp. XXIX-LXXI.
xxxiv INTRODUCTION

methods, which preserves all discoveries of the philosophia perennis but copes with
the challenges of the present time. Such a seventh voyage, which cannot simply con-
sist in a naive textbook-like going back to earlier philosophies, gives rise to new dis-
coveries and brings once again to evidence the fundamental capacity of human rea-
son to reach an objective knowledge of reality.
This fundamental capacity has no doubt moral preconditions!8 but cannot be sub-
stituted by religion or morality, already because these always and necessarily pre-
suppose rational insights without which religion becomes superstition and sheer in-
tolerable abdication of reason and loses its own presuppositions. The love of truth
requires not only the love of religious truth but of all truth, including that part of it
which is accessible to human reason, and only to reason, and which any meaningful
religious faith but also any ordered democratic state in which fundamental human
rights are recognized presuppose.
Moreover, any bioethics today needs to proceed by means of a carefully worked
out method that overcomes three deadly opponents of objectivist philosophy:
(I) a radical skepticism or cognitive nihilism and irrationalism which identifies
philosophy with mere constructions, games, or inventions in which everything is
permitted and truth never attained;
(2) German idealism, with the many forms of subjectivist explanations of the 'a
priori' implied in Kant's, Hegel's and other positions, and partly following there-
from: such as historicism or the reduction of philosophy to historically changing per-
spectives of hermeneutics of changing ideas and texts, Marxism, and many others;
(3) any form of empiricism and reduction of philosophy to language analysis, so-
ciological or psychological factors, and in particular the emotivist ethical relativism!9
or a purely linguistic and conceptual objectivism of values, such as Mackie's, which
entails an epistemological skepticism and metaphysical nihilism of values.
I am convinced that the basic outlines of the necessary seventh voyage of philos-
ophy, which overcomes all of the 'suicides' and abdications of philosophy, were al-
ready procured - even if the work of those who undertook the first part of the sev-
enth voyage is still recognized only by a few.
In view of the preceding brief remarks it is clear that the metaphysical and at
least the epistemologicafO subjectivism and skepticism prevalent in many contempo-

18 These moral preconditions of knowledge in general and ethical knowledge in particular lie in the love
of truth and in many other attitudes without which value blindness or errors can easily result. Cf. Diet-
rich von Hildebrand, Sittlichkeit und ethische Werterkenntnis.
Also regarding the mentioned positions of Engelhardt and Eber I agree with the thesis that-as al-
ready Plato suggests in the Myth of the Cave in his Politeia- only a metanoia, a moral or religious
conversion, can fully overcome the moral obstacles to true knowledge. But in philosophy, more and
other conditions are required and often very religious people hold catastrophic philosophical errors
such as fideism or general skepticism. Hence the relationship between ethical (at least philosophical
ethical) knowledge and religious spiritual life is far more complex than suggested by the main authors
of Christian Bioethics.
19 See on the emotivist relativism in ethics-besides David Hume, Enquiry Concerning the Principles of
Morals-Charles L. Stevenson, Ethics and Language (New Haven: Yale University Press, 1976); see
an excellent critique of these positions in John Barger, "The Meaningful Character of Value-Lan-
guage: A Critique of the Linguistic Foundations of Emotivism," J Value Inquiry 14 (1980): 77-91.
20 See H. T. Engelhardt, Jr., The Foundation of Bioethics; see also the same author, "Towards a Chris-
tian Bioethics," Christian Bioethics, vol. 1, no. 1 (1995): 1-10.
 INTRODUCTION xxxv

rary philosophies of medicine21 are far from me. I do not think that philosophy "must
no longer dream the rationalistic dream" of discovering universally intelligible and
rational foundations of ethics (which was and remains the task of philosophy), nor
that there are today no content-full ethics and legal knowledge as basis of the public
life. I reject wholeheartedly the idea that the ethics of the 'public world' has no other
cognitive basis except mere democratic tolerance and acceptance, and that a content-
full ethics belongs solely to "moral strangers in a public world," i.e. amounts to
nothing but a personally adopted ethical viewpoint in a world in which neither faith
nor reason can provide an objectively knowable, true, and universally valid founda-
tion of ethics. No, medical ethics does have objective and intelligible foundations,
some accessible only to believers, but many accessible to every intellect open to
truth.
Thus the viewpoint recently expressed in the 'non-ecumenical' Journal Christian
Bioethics (according to whose general guidelines neither in the world nor in reli-
gious communities a universally valid and defensible ethics can be reached but only
'sectarian' standpoints can be taken) seems to be based on a failure to recognize the
universality of truth in itself and its accessibility to humans, partly through reason,
partly through faith. The new epistemological skepticism in bioethics seems to adopt
a new fide ism that separates religious faith, far more radically than Protestantism in
general,22 from reason.
In reality, ethics based on authentic and 'rational' religious faith (i.e. a faith that
follows the Pauline saying "scio cui credidi," "I know in whom I put faith") is not
only itself rational but shares innumerable truths which also unaided human reason
can get to know. A religiously motivated Jewish or Christian bioethics, while it can
go far beyond what philosophy or pure reason can establish, cannot ever substitute
for reason, nor dispense of reason. Also Islamic, Buddhist, or other forms of 'reli-
gious ethics' stand in need to clarify concrete ethical contents by means of reason.
Moreover, any fideist attempt to replace philosophy by personal private faith, as pro-
posed in the guidelines of the Journal Christian Bioethics. Non-Ecumenical Studies
in Medical Morality,23 cannot avoid appealing to philosophical and rational evi-
dences.
Philosophy as a rational knowledge of ethical norms which appeals to all persons
of good will and to every human person who loves truth, has its indispensable role in
ethics today, a role as significant as ever before, and even more so in a world in
which the religious unity of the Middle Ages has disappeared. Closed communities

21 See Lennart Nordenfelt, On the Nature ofHealth (Dordrecht: Reidel Publishing Company, 1987); see
likewise Nordenfelt, "Health and Disease: Two Philosophical Perspectives," Journal ofEpidemiology
and Community Health, 41 (1986): 281-284. See the critique of these views in Kateryna Fedoryka,
Understanding Health: The Foundations of Its Normativity and Its Foundational Normativity for
Medicine (Schaan, FL: International Academy of Philosophy in the Principality of Liechtenstein, un-
published doctoral dissertation, 1996).
22 See on this the excellent critique of Eber's and Engelhardt's fideistic views in Darrell W. Amundsen
and Otto W. Mandahl, Jr., "Ecumenical in Spite of Ourselves: A Protestant Assessment of Roman
Catholic, Eastern Orthodox, and Anglican Catholic Approaches to Bioethics," Christian Bioethies,
vol. 1, no. 2 (1995): 213-145.
23 See H. T. Engelhardt, Jr., ''Towards a Christian Bioethics."
XXXVl INTRODUCTION

united in the Christian, Islamic, or other religions, which provide firm moral founda-
tions for whole states, cease to exist more and more. And no single religion, whether
it makes justified or unjustified claims to being the true religion, can claim dominion
over the convictions of society at large, at least not in our modem Western states. In
today's secular and pluralistic society not the whole truth (that ideally speaking
should in/act bind all societies) but only that 'part of truth' which is open in princi-
ple to any human reason can be that truth that provides the foundations of modem
civil society - independently of religious creed. And to clarify this common basis so
desperately needed as foundation of medical ethics in a secular world, is precisely
the task of a philosophy and philosophical ethics of medicine.
The following work is based, at any rate, on the firm conviction that philosophy
can be established as a rational and rigorous science, which uses methods that allow
it to grasp the objective nature and existence of things,24 especially the necessary
essences of things, as well as the objective values founded on the natures of things,
many of which give rise to moral imperatives. In other words, the following reflec-
tions are based on previous works of various thinkers who attempted to establish in
the midst of the sixth and greatest crisis in the history of occidental philosophy that
an objective and true philosophical knowledge is possible and is of decisive impor-
tance for the world and for philosophy today. I can here only refer the reader to
some of the works in which this task has been carried out, but not develop extensive-
ly the epistemological foundations of such a philosophy, except to the extent to
which they will inevitably be touched and elucidated in the course of the following
bioethical reflections. 25

24 See D. von Hildebrand, "Das Cogito und die Erkenntnis der realen Welt. Teilveroffentlichung der
Salzburger Vorlesungen Hildebrands: 'Wesen und Wert menschlicher Erkenntnis'," in Aletheia
VI/1993-1994 (1994), pp. 2-27. See also Josef Seifert, Sein und Wesen (Heidelberg: Universitats-
verlag C. Winter, 1996), chs. 1-2; or the earlier English work of mine, "Essence and Existence. A
New Foundation of Classical Metaphysics on the Basis of 'Phenomenological Realism', and a Critical
Investigation of 'Existentialist Thomism'," in Aletheia I (1977), pp. 17-157; 1,2 (1977), pp. 371-459.
25 See AdolfReinach, "Uber Phanomenologie," in Adolf Reinach, Siimtliche Werke. Kritische Ausgabe
mit Kommentar, Bd. I: Die Werke, Teil I: Kritische Neuausgabe (1905-1914), Teil II: Nachgelassene
Texte (1906-1917); Bd. II: Kommentar und Textkritik, hrsg. v. Barry Smith und Karl Schuhmann.
(Mlinchen und Wien: Philosophia Verlag, 1989), Bd. I, pp. 531-550; Dietrich von Hildebrand, What
Is philosophy?; Fritz Wenisch, Die Philosophie und ihre Methode (Salzburg: A. Pustet, 1976); Josef
Seifert, Erkenntnis objektiver Wahrheit; the same author, Back to Things in Themselves; "Philoso-
phie als strenge Wissenschaft. Zur Grundlegung einer realistischen phanomenologischen Methode -
in kritischem Dialog mit Edmund Husserls Ideen liber die Philosophie als strenge Wissenschaft" (in
Lithuanian), Logos (1988/13-14),19-39. In Czech and German: in Filosofie, Pravda, Nesmrtlenost.
TN praiske prednd§kyIPhilosophie, Wahrheit, Unsterblichkeit. Drei Prager Vorlesungen pp. 14-50.
Preklad, uvod a bibliografi Martin Cajthaml. Prague: Vydala Ki'estanska akademie Rim, svazek,
edice Studium, 1998. In Russian: "Philosophy as a Rigorous Science. Towards the Foundations ofa
Realist Phenomenological Method-in Critical Dialogue with Edmund Husserl's Ideas about Philos-
ophy as a Rigorous Science," Logos 74, 9 (1997), 54-76. In Czech: "Filosofie jako prisna veda.
Prispevek k zalozeni realisticke fenomenologicke metody v kritickem dialogu s Husserlovou ideou
filosofie jako pfisne vedy," in Filosoficky Casopis 6, 44 (1996), pp. 903-922.
 CHAPTER 1

THE NATURE AND THE SEVEN GOALS OF

MEDICINE AS OBJECTS OF A DRAMATIC FREE
CHOICE OF THE PHYSICIAN TODAY

1. ON THE NATURE OF MEDICINE AND THE PHYSICIAN

The Physician as Scientifically Trained Healer, as Practitioner of the 'Art of
Medicine', as Ethicist and as Moral Subject

Before the rise of the idea and reality of the physician, of the medicus, and partly
alongside with it, we find the idea of the magician or 'medicine man', of the medi-
cally knowledgeable person. Three elements or factors chiefly! characterize the phy-
sician and distinguish him from the medicine man and the medical practitioner who
is not a physician:
1. science (a scientific- base of medical interventions),
2. systematic technique or art of medicine, and
3. an ethical dimension which involves both a personal moral commitment of
the physician and a philosophical vision of man; this third element can also
include a further religious dimension?
Let us turn to examine these three elements more deeply.

1.1. The Physician as Scientifically Trained Healer, the Essence ofMedicine as

Empirical Inductive Science, and Its a priori Foundations
1.1.1. The Physician and the Role ofEmpirical Scientific Training
The first respect in which the physician in the strict sense differs from the premedi-
cal, paramedical or perimedicae healer is a higher degree of empirical knowledge-

1 I should acknowledge here my great indebtedness to my friend and colleague, the Italian philosopher
Rocco Buttiglione, of the International Academy of Philosophy in the Principality of Liechtenstein
who has developed these three aspects of the Arzt in an ingenious lecture to Liechtensteinian and
Swiss physicians held in Schaan in 1989. In the meantime, Professor Buttiglione has become a politi-
cian and, in 2001, Minister in the Italian Government.
2 When speaking of the physician as philosopher, I do not mean that the physician necessarily has to
study philosophy or to pursue it thematically and systematically (though this is to be recommended,
and medical education should, especially today, include a basic philosophical and ethical formation).
Instead, I mean that the medical profession involves an understanding of man as person and a clear
ethical commitment as distinguishing marks of medicine, as we shall see.
3 I distinguish 'perimedical' from 'pararnedical'-which refers to medical services and activities per-
formed by medical professionals of a less than complete medical education. By the term 'perimedi-
1
2 CHAPTER 1

in keeping with the cultural and historical stage of development of medical and sci-
entifically established empirical knowledge. From this last moment follows a certain
relativity of the distinction between the physician and the perimedical healer. A me-
dieval physician, if he were to practice today, would not be a physician according to
our standards.
While the physician is not necessarily a medical scientist, the nature of medical
science and the kind of knowledge it gains must be understood in order to compre-
hend the nature of the physician, whose activity is informed by the results of med-
ical science. To say this is not the same as to say that medicine can be reduced to its
character of a science. Rather, medicine aims at achieving purposes that lie outside
scientific research and even largely consists in practical activities. This accounts for
the fact that medicine is not exclusively interested in scientific knowledge per se.
But its practical ends, since their medical pursuit is built upon scientific knowledge,
in no way prevents that the knowledge that underlies medical practice is properly
scientific.

1.1.2. A Justification o/Medicine as an Empirical Science against Hume's and

Popper's Objections Raised against Induction
In the light of this result, the position expressed by Ronald G. Munson and various
authors that medicine, because of its pragmatic aspects, and for some additional and
related reasons, is no science, is incorrect, even though they are quite correct in say-
ing that medicine is not exclusively or even primarily a science. At the most, how-
ever, their argument could prove that also the experimental science of medicine is
not a 'pure science' but a pragmatically narrowed science.
Some amount of the narrowing of interest characteristic of the pragmatic point of
view, however, belongs to all natural sciences, as Max Scheler and others have
shown. Any trace of a pragmatic narrowing of the point of view of scientific investi-
gation is only overcome in philosophy; and even here we find applied philosophy
with a limited scope of interest dictated by some practical purpose, such as business
ethics. 4
What kind of knowledge is then gained by medicine as a science? In this regard
we find a striking circumstance. On the one hand, medical knowledge is almost ex-
clusively based on the experience of facts, which we have to observe empirically.
For example, Stanley B. Prusiner won the Nobel prize for medicine in 1997 after 25
years of empirical observation and testing which led him to discover prions (which

cal', I understand here methods which lie in, or in proximity to, the properly medical field, but are
used by persons of limited medical knowledge and of lower standards of medical professionalism, or
by persons who use methods of healing which may be perfectly sound and better than those propa-
gated by school medicine, though scientifically less explored and less understood, or simply rejected
by members of school medicine because of some prejudices.
4 See Max Scheler, "Vom Wesen der Philosophie. Der philosophische Aufschwung und die morali-
schen Vorbedingungen," in Max Scheler, Yom Ewigen im Menschen (Erkenntnislehre und Metaphy-
sik), Schriften aus dem Nachlass Band II, herausgegeben mit einem Anhang von Manfred S. Frings
(Bern: Francke Verlag, 1979), pp. 61-99. Certainly, 'pure physics' is freer of pragmatically narrow
points of view than applied physics, etc.; nevertheless, the whole science of physics does not purely
look into the ultimate essence of its subject of investigation but looks into it not much farther than can
be operated with.
 NATURE AND GOALS OF MEDICINE 3

have no genetic information) as a distinct class of causes of disease (besides viruses,

bacteria, and others such as fungus), which give rise to Mad Cow Disease and
Creutzfeldt-Jakob disease (CJD). Medicine examines contingent empirical facts, of-
ten unexpected ones, and does not investigate essentially necessary data and essen-
tiallaws as philosophy, mathematics, and other disciplines do. It does not even have,
with the exception of psychiatry, a priori parts, as physics and psychology do. These
disciplines, besides including empirical studies, which demand simple observation
and description offacts, also embrace a priori fields of study, which call for entirely
different methods of rational insight, analysis, or for applied mathematical methods
and deduction.
I understand 'a priori' here not in a Kantian subjectivist sense as the conditions
and necessary elements in the subject, of which Kant says that they "lie ready in the
Gemiite" (the heart, or mind)5 as mere subjective forms of perception or of thought.
Rather, I understand the a priori here in a completely realist and objectivist sense: as
absolutely necessary, highly intelligible essences and truths which are entirely inde-
pendent of the subject and can be known to apply not only to the world of our expe-
rience, but also to the real world as it is in itself and to any possible world. 6 Often,
one single example or even a merely imagined one suffices to gain insight into es-
sentially necessary states of affairs, although sometimes empirical methods are also
required when faced with laws or states of affairs which objectively are a priori but
which we cannot comprehend immediately, as in certain aspects of number or chess
theory.7

5 Immanuel Kant, Kritik der reinen Vernunft, B 34:

Da das, worinnen sich die Empfmdungen allein ordnen und in gewisse Form gestel-
let werden k<innen, nicht selbst wiederum Empfindung sein kann, so ist uns zwar die
Materie aller Erscheinung nur a posteriori gegeben, die Form derselben aber muB zu
ihnen insgesamt im Gemiite a priori bereit liegen und dahero abgesondert von aller
Empfindung k<innen betrachtet werden.
Kant uses the term 'Gemiit' 70 times in the Critique of Pure Reason, only three times in other
works. The term means in the above text primarily the part of the mind which contains the a priori
conditions of sensibility (sense perception), but can also possess a broader meaning indicating also the
a priori forms of thinking in the mind inasmuch as it contains-according to Kant's subjectivism-all
a priori conditions of knowledge, for example in ibid., B 75:
Unsre Erkenntnis entspringt aus zwei Grundquellen des Gemiits, deren die erste ist,
die Vorstellungen zu empfangen (die Rezeptivitiit der Eindriicke), die zweite das
Verm<igen, durch diese Vorstellungen einen Gegenstand zu erkennen (Spontaneitiit
der Begriffe); durch die erstere wird uns ein Gegenstand gegeben, durch die zweite
wird dieser im Verhiiltnis aufjene Vorstellung (als bloBe Bestimmung des Gemiits)
gedacht. Anschauung und Begriffe machen also die Elemente aller unsrer Erkennt-
nis aus, so daB weder Begriffe, ohne ihnen auf einige Art korrespondierende An-
schauung, noch Anschauung ohne Begriffe ein Erkenntnis abgeben k<innen.
6 On this notion of the a priori see Adolf Reinach, "Concerning Phenomenology," trans. from the Ger-
man "Uber Phiinomenologie." See also Dietrich von Hildebrand, What Is Philosophy?, ch. 4. See also
Fritz Wenisch, Die Philosophie und ihre Methode. See likewise Josef Seifert, Back to Things in Them-
selves; the same author, "Essence and Existence"; Sein lind Wesen, ch. 1.
7 See on such empirical methods for the exploration of a priori laws in mathematics, Gregory J. Chaitin,
"Zahlen und Zufall-Algorithmische Informationstheorie. Neueste Resultate iiber die Grundlagen der
Mathematik," in H.-C. Reichel, E. Prat de la Riba (eds.), Naturwissenschaft und Weltbild (Wien:
H<ilderlPichlerlTempsky, 1992), pp. 3044. See also, on a similar case in chess theory, the discussion
4 CHAPTER 1

Let us return to the peculiar situation of medicine in its relationship to the con-
trast between empirical and a priori knowledge: On the one hand, as was just stated,
medicine seems to be the most purely empirical science. We will see later that this is
not only untrue for significant parts of psychotherapy and psychiatry, but also entire-
ly false for the ultimate goals and purposes of medicine, which contribute decisively
to constitute its essence. At a superficial consideration of medicine, and ignoring its
essential determination through its goals, however, one could think that medicine is
exclusively a natural science and, with biology and zoology, the most empirical one
of them. If one restricts medical science to pure natural science, then it is indeed im-
possible to name one single content, diagnosis, cure, method of surgery, etc., in
medicine proper, as part of specifically medical knowledge, which could be said to
be open to a priori methods of knowledge or which would have essentially necessary
objects.
On the other hand, medical empirical knowledge rests, more than physics or
chess theory (in spite of the fact that the latter is almost exclusively a priori), 8 on a
foundation of philosophical, non-empirical knowledge-and this not only, as all dis-
ciplines, about knowledge and method in general, logic and being, but also about the
essences of the human person, of health, life and death, of medicine itself and its
goals, as well as of morality. In this respect, medicine is far more essentially and
more deeply connected with a priori and specifically philosophical knowledge than
those disciplines that contain more a priori elements. 9
To have overlooked this, constitutes one of the most serious and fateful errors of
Claude Bernard and others who have handed down to us the wrong positivist idea
that medicine is nothing but an empirical natural science. 10
As long as we prescind, however, from the knowledge of the essence and goals
of medical practice and from the nature of persons and patients, the properly medical

and references presented in my Schachphilosophie (Darmstadt: Wissenschaftliche Buchgesellschaft,

1989).
8 See my Schachphilosophie, chs. 1-3.
9 We will return to this in chapter 5. See also the critique ofnon-cognitivist bioethics in Elio Sgreccia,
Manuale di bioetica, I. Fondamenti ed etica biomedicale, II. Aspetti medico-sociali (Milano: Vita e
Pensiero, 1988-1991; 2nd ed. 1994, 3rd ed. 2002), vol. I, pp. 75 if.
10 See Claude Bernard, Introduction to the Study of Experimental Medicine (1865), (New York: Dover
Publications, 1957), pp. 5 if., especially p. 31: "Experimental reasoning is the only reasoning that
naturalists and physicians can use seeking the truth and approaching it as nearly as possible."
Although he did not include it in his theory of medicine, Claude Bernard has a keen moral sense,
thus admitting the importance of a non-experimental science of ethics for medicine, as can be seen,
for example, from his discussion of vivisection in medical research, ibid., p. 101.
Claude Bernard was born on July 12, 1813. He received a humanistic rather than a scientific edu-
cation, writing some music and some drama. In 1834 Claude Bernard began to study medicine in
Paris. The physiologist Fran~ois Magendie was among his teachers.
Bernard soon became one of the leading men of his time in science. A chair of general physiology
was created for him at the Sorbonne (1854). In 1868, after the Emperor had a laboratory built for him
at the Jardin des Plantes, Bernard left the Sorbonne and published the results of his scientific investi-
gations in public lectures and writings (17 volumes). Among his publications are: Introduction to the
Study ofExperimental Medicine (1865) and General Physiology (1872). Bernard died in Paris on Feb-
ruary 10, 1878, and had become so famous that he was accorded a State funeral, an honor never be-
fore bestowed by France on a man of science. See also Compton's Interactive Encyclopedia (1996),
article "Bernard, Claude."
 NATURE AND GOALS OF MEDICINE 5

contents of knowledge (excepting here psychiatry) are indeed almost exclusively

known by empirical methods.
Nonetheless, even medicine as an experimental science, with any other empirical
science, not only possesses logical and methodological foundations a priori, but also
rests on philosophical presuppositions by implying an understanding of the essence
of its own subject-matter inasmuch as it is highly intelligible and more an object of
philosophy than of the respective empirical sciences. And this connection to a priori
knowledge is even more present in medicine than in other disciplines.
We shall even see that a decisive part of medical theory and knowledge consists
in, or at least should consist in, cognitions gained by other sciences, chiefly by phi-
losophy. In this consideration, when we understand medicine in a wider sense and
not only as the empirical field normally called so, medicine not only presupposes but
contains philosophy as part ofa comprehensive knowledge of its subject-matter, i.e.,
of human life and htunim health. Any real understanding of these requires knowl-
edge of the human person.
Therefore, I strongly argue for an inclusion of philosophical and related disci-
plines as indispensable parts of a curriculum of studies of future medical profession-
als. The need for this will become particularly clear when we will see that all of
those seven goods whose protection and service form the final goal of medicine, and
which constitute the guiding principles for all medical actions, are not matters of
empirical science but of philosophical (or pre-philosophical) knowledge. The same
applies as well to the ethical aspects of the medical actions geared at the realization
of these goods.
The empirical side of medical knowledge seems to prevail, however, not only in
the curricula of medical studies but objectively with regard to that which is strictly
and narrowly medical. Medicine properly speaking is to a large extent a typical ex-
ample of an empirical science, or of a variety of empirical sciences. It deals with
contingent and yet general facts (unlike historiography which is also an empirical
discipline but deals almost exclusively with individual particular or cultural, polit-
ical and social phenomena). The empirical data medicine studies concern the human
body and man himself, with respect to his health and sickness, and to life and death.
While we can to some degree understand the structure and 'logic' of these facts,
they could still be otherwise. Therefore, medicine and most of the sciences founding
it, such as chemistry or anatomy, are empirical sciences (Tatsachenwissenschaften)
and not a priori sciences such as logic, philosophy, or mathematics. 11
To repeat and to develop further an important point made before: We do not
mean here by 'a priori sciences' sciences which would have no reference to experi-
ence at all and even less sciences based on inborn ideas or subjective forms of per-
ception and thought, as Kant conceived of them. Instead, a priori sciences go back to
incomparably intelligible and strictly necessary essences and essential laws of things
that do not require confirmation by the experience of matters of fact. In view of this

11 See on this Husserl's distinction between Tatsachenwissenschaften and Wesenswissenschaften in his

Ideas Pertaining to a Pure Phenomenology and to a Phenomenological Philosophy, in Edmund Hus-
serl, Collected Works, vol. ill (DordrechtIBostonlLondon: K1uwer Academic Publishers, 1989); and
AdolfReinach, Was ist Phanomen%gie?, in Adolf Reinach, Samtfiche Werke. Kritische Ausgabe mit
Kommentar. See likewise Dietrich von Hildebrand, What Is Philosophy?, ch. 4.
6 CHAPTER 1

objective foundation of a priori knowledge in things themselves, we could also say

that the 'matters of fact', which we grasp in a priori knowledge, are so necessary and
absolute that they are much more strictly speaking and much higher facts than mere
contingent 'matters of fact' .
The object of empirical Tatsachenwissenschaften, on the other hand, is not char-
acterized by an intrinsic and absolute essential necessity but is contingent not only in
its existence but also regarding the unity of elements, which constitute its essence.
Therefore, medicine as well as its branches and sub-sciences rely on the observation
of 'facts' such as the astonishing complexity and structure of the blood, its circula-
tion and function, or the exact workings of the different body systems, for example
of the nervous or the digestive system, the functions of the single organs, the opera-
tions of the brain, etc. Medical science further observes various types of anomalies
and diseases, it studies their causes such as bacteria or viruses, the symptoms of dis-
eases and their synchronous and diachronous 12 dynamic patterns, the effects which
certain medicines or other cures and operations have on medical disorders, the fac-
tual origins and developmental stages of human life and the causes and signs of
death, as well as many other questions related to the goals of medicine (to be discus-
sed below).
In a physician, we expect a more sophisticated and complex medical knowledge
and also a vaster experience than in a natural healer or medicine man. This experi-
ence is not only the individual medical scientist's or physician's own experience (ir-
replaceable as this might be), but also an experience of scientific results of research
that are shared by an international community of researchers and health profession-
als and by many generations of physicians. These objective results are then com-
municated to the scientific and medical communities through oral descriptions, trad-
itions, and writings. But given the empirical character of medical knowledge, med-
ical theory must never emancipate itself from a constant reexamination of experi-
enced facts. As Paracelsus and Claude Bernard note, when medicine divorces itself
from experience as teacher, confining itself only to its own theories or to medical
authorities of the past, it becomes closed, stubborn, and even what we now call 'ide-
ological' ,\3 excluding new discoveries by a false clinging to its traditions and even
persecuting and ridiculing those who make new discoveries.
From medicine as a science we expect more than just a higher level and com-
plexity of experience, however; we expect a methodologically well-founded knowl-
edge. Whatever the exact methods of medical science are in detail, we expect from
the science of medicine procedures by which the results of a scientific investigation
are obtained and examined in a critical and systematic way. Moreover, the theories
based on such observations are tested as to whether or not they adequately explain
the facts. {We leave it open here in which sense medical explanations are always 'in-

12 With these terms we mean here the simultaneous or the consecutive occurrence and sequence of
symptoms.
13 See on the many meanings of 'ideological' and on the meaning of the term relevant here and opposed
to the openness of scientific experimental knowledge, Josef Seifert, "Ideologie und Philosophie. Kriti-
sche Reflexionen tiber Marx-Engels 'Deutsche Ideologie' - Vom allgemeinen Ideologieverdacht zu
unzweifelbarer Wahrheitserkenntnis," in Prima Philosophia, Bd. 3, HI, 1990.
 NATURE AND GOALS OF MEDICINE 7

complete explanations', often to rest not solely on observation and experiment but
on models, chaos theory, hypothetico-deductive procedures, and other methods. 14)
Also medical practice needs to be based, as far as possible, on some systemati-
cally tested and obtained evidence. The foundation of medical practice in a syste-
matically examined evidence expresses itself today also in the call for an 'evidence-
based medicine'. This call has (a) a purely epistemological side that concerns the na-
ture of medical knowledge as SUCh,15 but also possesses (b) an ethical aspect which
demands that the basis of medical practice must lie in evidence for the moral reason
that only if this condition is fulfilled we can speak of virtuous medical behavior. 16

14 The role of 'incomplete explanations' was investigated carefully by Volker Gadenne, in his "Unvoll-
stfuldige Erklarungen," in M. Sukale, ed., Sprache. Theorie und Wirklichkeit (Bern: P. Lang, 1990),
pp.263-287. Certainly, medical explanations are necessarily incomplete inasmuch as this income-
pleteness results from the limits of natural inductive science and of its formal object; but are they are
also necessarily incomplete within the context of that science? Furthermore, is this incompleteness of
the essence of medicine, or only imposed by the limits of each particular context of explanation? See
also Rudolf Grass and Markus Loeffler, Prinzipien der Medizin. Eine Ubersicht ihrer Grundlagen und
Methoden (BerlinlHeidelberglNew York, etc.: Springer 1998).
15 See John Worrall, "What Evidence in Evidence-Based Medicine?" Philosophy of Science (2002), 69
(3 Supplement): 316-330. It understands 'evidence-based medicine' (EBM) as a (relatively new)
movement that seeks to put clinical medicine on a firmer scientific footing. The author argues that it is
uncontroversial that medical practice should be based on the best evidence it can obtain but then dis-
cusses interesting questions concerning a more detailed understanding and application of this prin-
ciple, moving towards a more coherent and unified account of best evidence in medicine, by exploring
in particular the question of what 'randomized controlled trials' contribute to the evidence of medical
knowledge. I would suggest that only if inductive empirical knowledge stands on firm grounds, evi-
dence-based medicine in this epistemological sense can be defended.
See also Ross E. G. Upshur, "The Ethics of Alpha: Reflections on Statistics, Evidence and Values
in Medicine," Theoretical Medicine and Bioethics (2001), 22 (6): 565-576. See likewise H. Neder-
bragt, "The Biomedical Disciplines and the Structure of Biomedical and Clinical Knowledge,"
Theoretical Medicine and Bioethics (2000), 21 (6): 553-566. The author argues that the structure of
clinical knowledge involves knowledge of the patient who has a disease. Therefore, the notion of evi-
dence-based medicine should realize that not only biomedical knowledge contributes to this knowl-
edge but that it also entails knowledge regarding economic and social relations, ethics and personal
experience. He argues that the interaction between each of the participating 'knowledges' in clinical
knowledge is different from biomedical knowledge, and based on a competition and partial exclusion
rather than on mutual dependency and accumulation of different arguments from each. The difference
of the structure of biomedical knowledge from that of clinical knowledge is linked with a discussion
of the place of technology, evidence-based medicine, and the gap between scientific and clinical
knowledge. See also the application of Gadamer's theory of hermeneutics in R. E. G. Upshur, "Priors
and Prejudice," Theoretical Medicine and Bioethics (Aug 99),20 (4): 319-327. I will argue that the
basis of medical evidence has to lie in certain ontological and not only in hermeneutical presupposi-
tions which will easily lead to the types of scientific and ethical relativism and skepticism discussed in
chapter 5.
See also Derrick K. S. Au, "Constructing Options for Health Care Reform in Hong Kong," Jour-
nal of Medicine and Philosophy (D 99), 24 (6): 607-623. This paper seeks to show that the Harvard
Report, published in April 1999 for public consultation in Hong Kong, which proposes a fundamental
restructuring in health care delivery and financing systems in Hong Kong, while it claims to be evi-
dence-based in its approach and to rely on surveys, consultations and focus groups, the recommenda-
tions put forth express clear ideological preferences and contain questionable value assumptions.
16 Cf. Ross E. G. Upshur, Erica Zarkovich, "The Virtues of Evidence," Theoretical Medicine and Bio-
ethics (2002), 23 (4-5): 403-412. The authors proceed from a definition of evidence-based medicine
as "the conscientious and judicious use of current best evidence in making clinical decisions." The pa-
per goes on to show that the terms 'conscientious' and 'judicious' represent terms derived from virtue
8 CHAPTER 1

'Evidence-based medicine' in its epistemological sense (that also underlies its

practical sense) can mean many things, however. Its proper understanding and a so-
lution to the question of its real attainability require a careful investigation into the
kinds of scientific evidence open to medicine, and also into the evidence of philo-
sophical and other types of knowledge that are presupposed by medical and clinical
disciplines. Whereas the sources of ontological, anthropological, and ethical evi-
dence relevant for medicine are chiefly discussed in chapters 2 to 5, we will now in-
vestigate first the question which kind of evidence medicine can obtain and then the
problem to which extent the practical and normative aspects of medical knowledge
and praxis rest on theoretical evidence.
It is clear that we should strive in medicine to obtain the best attainable evidence
and to test this evidence as far as possible. Not all medical knowledge and theory
can be tested directly, however; often methods of indirect confirmation or refutation
through experience are needed. The reason for this is that most empirical knowledge
is not 'purely empirical' but, as Karl Popper has shown (which constitutes a certain
measure of overcoming pure positivism and empiricism), is rendered more fruitful
by unverifiable and not even directly falsifiable ingenious ideas and hypotheses
regarding the explanation of empirical facts. In medicine, some of these hypotheses
and theories also lead to new ways of preventive measures or to new cures. While
they are not the direct fruit of the empirical observation of facts, they may fmd
indirect empirical confirmation, for example, when the preventive steps or cures
based on these hypotheses 'work'.
Theories that go beyond what can be directly verified through observations are
tested as far as possible by empirical findings that confirm (or at least accord with)
or refute medical assumptions by some trial-and-error method. 17 In medical scientif-
ic theories also elements that cannot directly be tested empirically, such as hypo-
theses and paradigms in different senses, certainly playa big role. For, unlike many
facts which are directly observed or described, such as the characteristics of species
of animals investigated in descriptive zoology, or the list of symptoms of a certain
disease, other medical 'facts'-such as the operations of the brain-are largely not
directly observable. They have to be 'figured out' by complicated and predomi-
nantly hypothetical theories, such as those developed in bionics and cybernetics, 18

ethics and virtue epistemology. The identification of explicit virtue components in the defmition and
conception of evidence-based medicine presents an important starting point in the connection between
virtue theories and medicine.
17 Medical ethical codes and the law wisely require that such experiments be first performed on animals,
although this should not be misconstrued as defending a license for ruthless experimentation and
exploitation of animals without respect for the ethical requirements and conditions of such research.
Cf. Julian Nida-Riimelin, Angewandte Ethik. Die Bereichsethiken und ihre theoretische Fundierung.
Ein Handbuch herausgegeben von Julian Nida-Rumelin (Stuttgart: Alfred Kr6ner Verlag, 1996).
18 Bionics is described in the Encyclopaedia Britannica in the following way:
science of constructing artificial systems that have some of the characteristics of liv-
ing systems. Bionics is not a specialized science but an interscience discipline; it
may be compared with cybernetics. Bionics and cybernetics have been called the
two sides of the same coin. Both use models of living systems, bionics in order to
find new ideas for useful artificial machines and systems, cybernetics to seek the ex-
planation ofliving beings' behaviour.
 NATURE AND GOALS OF MEDICINE 9

the 'general systems theory' of Bertalanfi)r,19 Sir John Eccles's theories relating to
the "liaison between mind and brain,,,20 the "modular theory of the brain," the "ionic
theory of memory,,,21 or the theories regarding the exact physical causes or reasons
of the state of sleep and of dreams. 22
Nevertheless, we expect some (direct or indirect) empirical confirmation of all
medical theories. In a strict sense, all assertions about the observable structures and
systems of the body, their fimctions and parts, or the effects of chemicals and of sur-
gical interventions, etc., need to be confirmed empirically and directly. Of course,
we can observe directly and empirically, through our senses, only one or many sin-
gle cases that correspond to a general statement, not the general state of affairs itself.
Nevertheless, the observation of many single cases exemplifYing a general fact re-
garding the human body, for example that the human hand normally has five fingers,
in some real sense and based on conditions which we will have to study more close-
ly, directly 'confirms' the truth of that general assertion. The situation is very differ-
ent when we are faced with more speculative general claims of medicine and with
theories that cannot directly be confirmed empirically such as the states of affairs
asserted in the modular theory of the brain. Nonetheless, once we clarified the
grounds and validity of inductive knowledge, we see that even such speculative
medical theories are capable and in need of some indirect support through the obser-

19 See Ludwig von Bertalanffy, General Systems Theory (New York, 4th ed. 1972). See also Paulina Ta-
boada, "Bedeutung der 'allgemeinen Systemtheorie' in der heutigen Debatte iiber den Gesundheits-
begriff." The key notion of the influential "general systems theory," namely the concept of an 'organ-
ized whole', or 'organized totality', has also much to do with entelechy although it rejects vehemently
the notion of entelechy. One problem with this theory, which was shown by Conrad-Martius and
Paulina Taboada to amount to a subtle reductionism, is that it fails to account for the inner finality,
and above all to the dynamically self1"orming character of this organization. Cf. Hedwig Conrad-
Martius, "Praformismus in der Natur," in H. Conrad-Martius, Schriften zur Philosophie, edited by
Eberhard Ave-Lallement (Munich: Kosel, 1964), vol. 2, pp. 153-173, p. 160:
[Fiir] die nicht mehr fortzu1eugnenden transphysischen Phanomene [bleibt] nur der
mathematische Symbolismus iibrig-wenn man nicht zu mechanistischen Analogien
und Figmenten oder aber, was der Biologie naherliegt, zu psychologistischen greifen
will.
See also ibid., p. 159.
This theory also fails to recognize the metaphysical necessity that only life itself and soul can
explain the specific irreducible essence of the effects and activities of living organisms. See my What
is Life? This is very understandable given the origins ofBertalanffy's thought (1952) in the circle of
disciples of Moritz Schlick and of the Vienna Circle of Neopositivism to whose descendants he as-
cribes himself. See T. Purola, "A Systems Approach to Health and Health Policy," Medical Care,
10:5 (1972). Other names of contemporary defenders of some version of general systems theory today
include H. Noack, R. Anderson, and A. Kaplun.
20 See Karl R. Popper/John C. Eccles, The Self and Its Brain (BerlinlHeidelbergILondonlNew York:
Springer-Verlag International, 1977; corrected printing 1981).
21 See on these Sir John Eccles, Facing Reality. Philosophical Adventures by a Brain Scientist (Ber-
linlHeidelberglNew York, 1970).
22 Cf. Sir John Eccles, The Human Psyche. The Gifford Lectures, University of Edinburgh, 1978-1979
(New YorklHeidelberglBeriin Springer Verlag International, 1980), pp. 22 ff., 31 ff., 44 ff., 85 ff.,
98 ff., 147 ff., 153-155. See also Karl R. Popper/John C. Eccles, The Self and Its Brain; Sir John
Eccles, Facing Reality; The Human Mystery. The Gifford Lectures, University of Edinburgh, 1977-
1978 (BerlinlHeidelberglNew York: Springer Verlag International, 1979); Sir John Eccles and D. N.
Robinson, The Wonder ofBeing Human. Our Brain and Our Mind (New YorkiLondon, 1984).
10 CHAPTER 1

vation of empirical facts. For example, the observation of certain temporal sequen-
ces of brain events in limited groups of ca. 10,000 cells, and related observations,
must make the modular theory of the brain plausible; otherwise, it cannot count as a
genuinely scientific theory.
Some empirical medical facts are discovered without developed preceding theo-
ries or assumptions being necessary, as for example the count of the average number
of white blood cells in healthy adults. In other cases conjectures or hypotheses pre-
cede further findings and empirical confirmations of hypotheses. Assuming, for ex-
ample, that Jerome Lejeune, before discovering the cause of Down Syndrome, had
an inkling of this syndrome possibly being caused by an abnormality in the chromo-
somes, he nevertheless had to confirm this theory by investigating various persons
with Down syndrome to find whether they actually had such an anomaly, which he
later found and identified as a trisomy (an extra chromosome) in the 21 st pair of
chromosomes. Such a procedure of combining assumptions, hypotheses, and various
falsifying and verifying techniques through observation of facts can lead to discov-
eries such as Lejeune's mentioned breakthrough or the finding that Edwards's syn-
drome, and the serious mental retardation that goes hand in hand with it, is due to
trisomy 18 or Patau's syndrome to trisomy 13, etc.
Such empirical testing of medical hypotheses and theories is not restricted to tak-
ing the form of the (successful or unsuccessful) 'falsification' by trial and error, and
of related methods of attempts at falsification proposed by Karl Popper, but may al-
so consist in a positive inductive verification through experiment.
Claude Bernard, who gave the name to the lectures out of which this text was
born, has been a champion of the empirical methods to be used in medicine. He was
a great defender of experimental inductive scientific methods in medicine, which
have lately fallen in discredit in philosophical circles inspired by Hume and Pop-
per-all the more reason to defend the inductive empirical methods in medical sci-
ence.
Indeed, in order to ascertain the character of biology and medicine as sciences,
inductive knowledge needs to be firmly grounded and freed from the suspicion of its
invalidity that David Hume and Sir Karl Popper have thrown on all inductive knowl-
edge by declaring that it is a mere consequence of 'customs of experience' or mere
guesswork. According to them, no general claims of scientists ever are the result of a
verification of scientific judgments but at best have the character of hypotheses open
to falsification, or are even just 'constructs' relative to changing 'paradigms'. In oth-
er words, according to these theoreticians, it is never possible to verify inductive
claims to knowledge of the general natures ofthings. 23

23 Since medicine uses far less 'paradigms' and is a stricter experimental science than, for example,
physics, I do not think it is necessary here to deal with the ultimately skeptical theory of science pro-
pounded by Thomas Kuhn with which I am dealing elsewhere. Thomas S. Kuhn, The Structure ofSci-
entific Revolutions, 3rd ed. (Chicago & London: The University of Cicago Press, 1964). See also
Thomas S. Kuhn, The Essential Tension. Selected Studies in Scientific Tradition and Change (Chica-
go & London: The University of Chicago Press, 1977). For a critique of Thomas S. Kuhn's theory see
my ''Nachwort des Herausgebers", in Giovanni Reale, Zu einer neuen Interpretation Platons. Eine
Auslegung der Metaphysik der grojJen Dialoge im Lichte der "ungeschriebenen Lehren, " fibers. v.
L. Holscher, mit einer Einleitung von H. Kramer, hrsg. und mit einem Nachwort von 1. Seifert (Pader-
born: SchOningh, 1993), pp. 541-558; and my "Wissen und Wahrheit in Naturwissenschafien, Philo-
 NATURE AND GOALS OF MEDICINE 11

While we cannot here explore in greater detail the conditions of an epistemologi-

cal justification of inductive knowledge facing all the vigorous Popperian objections
against induction,24 we need to say a few words in defense of the validity of the em-
pirical scientific methods of medicine, methods which Claude Bernard, and before
him Paracelsus, have insisted on so strongly and which nowadays widely dominate
medical science.
Certainly, it cannot be our task here to discuss the historical question in which
respects Bernard's underlying theory of science was a realist, empiricist and Pre-
Popperian, or a nominalist one,zs but nevertheless the respect for the great mind and
physician who inspired these lectures demands that we defend his discoveries, as
well as answer possible postmodern objections as chiefly Karl Popper has launched
them against the type of inductive knowledge Bernard has emphasized.
With D. Hume, Popper distinguishes between a logical and a psychological
problem of induction. 26 The logical problem consists in the epistemological justifi-
cation of the transition from the observation of single facts to justified universal
claims. Popper agrees with Hume that such a transition is not logically justified-
neither in the form of rationally justified assertoric nor in the form of apodictic as-
sertions about the general nature ·of things. Popper even denies any rational justifica-
tion of making problematic general judgments, in which we assert only weakly that
some general state of affairs obtains. He likewise denies that inductive knowledge as
used in medicine can reach any probability for its claims.27
The psychological problem of induction, however, which Hume wants to resolve
through the thesis that a 'habit' or 'custom of experience' underlies our scientific be-
liefs,28 consists in the question what actually motivates and prompts human beings to
make (logically unjustified) general assertions, for example about the functions of
the healthy human body or about the way in which diseases affect these functions. It
is not necessary here to analyze Popper's position on this psychological question in
detail because our interest lies in the logical and epistemological side of the problem

sophie und Glauben", in Naturwissenschaft und We/thild (Hrsg. R-C. Reichel, E. Prat de la Riba),
(Wien: Holder-Pichler-Tempsky, 1992).
24 We refer the reader to a more detailed defense of the method of induction against Popper's well-
known critique of it, offered elsewhere. Cf. Josef Seifert, "Objektivismus in der Wissenschaft und
Grundlagen philosophischer Rationalitat. Kritische Uberlegungen zu Karl Poppers Wissenschafts-, Er-
kenntnis- und Wahrheitstheorie," in N. Leser, 1. Seifert, K. Plitmer (eds.), Die Gedankenwelt Sir Karl
Poppers: Kritischer Rationalismus im Dialog (Heidelberg: Universitatsverlag C. Winter, 1991),
pp. 31-74; and "Diskussion," ibid., pp. 75-82.
25 See on this question a paper that argues that in regard to the empirical science of the observable Ber-
nard was a realist, but with respect to the apriori or in general to the unobservable a nominalist: Luiz
Henrique Dutra, "0 Realismo Cientifico de Claude Bernard," Cad Hist FilosofCie 6 (1), (1996): 29-
44. With respect to his conception of the empirical methods of medicine, he could also be regarded as
a forerunner of Popperi an fallibilism, as is argued in J. F. Malherbe, "Karl Popper et Claude Bernard,"
Dialectica 35, (1981): 373-388. On the general epistemological views of Claude Bernard cf. J. M. D.
Olmsted, E. Harris Olmsted, Claude Bernard and the Experimental Method in Medicine (New York:
Schuman, 1952).
26 Sir Karl Popper, Objective Knowledge. An Evolutionary Approach (Oxford, Clarendon Press, 1972),
pp. 3 ff.
27 Ibid, p. 7.
28 Ibid, p. 4.
12 CHAPTER 1

of induction. (popper fails to see that the purely logical problems of the structure of
inductive inferences and of their formal-logical validity or invalidity is wholly dif-
ferent from the epistemological problem of whether and how we can know the vali-
dity or invalidity of inductive reasoning and the truth of its underlying assumptions.)
Regarding medical science, very much depends on how we resolve this question.
Russell rightly observed, in his critique of Hume, that a radical skepticism about sci-
ence results as consequence from Hume's empiricism, because according to Hume
there are only psychological customs of experience but no objectively, logically, and
methodologically justified procedures that would explain any cognitive value of in-
duction.
This position would, if true, have tremendous consequences for medical science.
For, as Russell notes, if there were no logical and methodological justification in an
empirical science such as medicine, it would become impossible to distinguish mad
scientific assumptions from normal ones or even to have recourse to any criterion of
reasonability of scientific assumptions-because there would be no longer any ra-
tional ground for assumptions29 about the general nature of synthetic a posteriori (or
a priori) judgments. 3o
After having rejected a logical and, without distinguishing them, implicitly also
epistemological justification, of general scientific assertions, Popper basically offers
unconvincing and even quite irrational grounds for the making any universal claims
in science:
1. purely biological causes and 'inborn dispositions' ,31
2. purely cultural and historical reasons,32
3. an irrational psychological inclination to hold dogmatic views observed by
him in children and adults. 33
I do not see any possible rational justification for making general scientific as-
sumptions in line with Popper's answer to the logical problem of induction.
Popper holds about the logical problem of induction, i.e. about whether induction
can logically warrant a verification of general theses (as Carnap and the Vienna
Circle had held), that it has to be answered negatively. In contrast, the disjunctive
question whether the truth or falsity of general hypotheses can be demonstrated em-

29 We do not study here the reasons why Popper disputes this eminently apt observation of Bertrand
Russell. See Sir Karl Popper, ibid., p. 5 ff. Though he rejects Russell's observation, Popper holds
nonetheless, for somehow mysterious reasons, that there is an "isomorphy between logic and psychol-
ogy" and a ''principle of transference, " which says: "What has validity in logic, is also valid for psy-
chology. " See Sir Karl Popper, Objektive Erkenntnis. Ein evolutioniirer Entwurf, 3rd ed. (ZUrich:
Buchclub ex Libris, 1985), German translation (offourth English ed.), p. 6. I fail to see how this re-
mark can make sense inside Popper's theory.
30 We mean synthetic propositions here not in the Kantian (idealist) sense but simply in the sense of in-
formative, non-analytical, non-tautological judgments (propositions), in which the predicate concept
of the proposition adds something that was not yet contained in the subject-concept by definition. Cf.
Dietrich von Hildebrand, What Is Philosophy?; Fritz Wenisch, "Insight and Objective Necessity. A
Demonstration of Propositions Which Are Simultaneously Informative and Necessarily True," in
Aletheia IV (1988), pp. 107-197.
31 Sir Karl Popper, Objektive Erkenntnis, pp. 67, 71 (note), 72 f., etc.
32 Ibid., pp. 126-144.
33 Ibid., p. 24.
 NATURE AND GOALS OF MEDICINE 13

pirically through observation can be answered affirmatively, because-while empir-

ical verification of general propositions is not viable-empirical falsification of gen-
eral claims remains possible. 34
Popper's purely negative solution of the problem of induction, and the reduction
of scientific knowledge to a falsification of scientific theories through experience,
would not only deprive medical science of any certainty of knowledge, but even of
any probability of its general claims about the objects of medical science. 35 Medical
empirical scientific knowledge would then be nothing but "not yet refuted hypo-
theses, which withstood all attempts at their falsification hitherto made."
While therefore universal positive affirmations of science would have no justifi-
cation, Popper still grants them some merit but reduces the value of positive general
hypotheses in sciences such as medicine to three roles:
(1) They are heuristic fictions or models, which help in the finding and predic-
tion of individual empirical facts.
(2) They motivate attempts at falsification and thus inspire science as an aggres-
sive attempt at seeking to identify "the survival of the fittest scientific conjectures,"
i.e., those that keep surviving all past and present attempts at their refutation.
(3) General claims made in science might reach some verisimilitude or purely
'logical probability'-a hotly disputed conclusion for which Popper offers no ration-
al grounds. 36
His own assistant Miiller, in this regard more logical than his master, sharply
criticized Popper's retaining verisimilitude (approximation to the truth) as a category
in his philosophy of science. Based on his general position, Popper would have had
to reject anything like that. 37 Yet he holds that there is a numerical-quantitative ap-
proximation to the truth38 in the sense that theories such as Einstein's, which allow
the prediction of greater numbers of empirically given facts, approximate them-
selves more to the truth than other scientific theories.
Popper rejects not solely induction but any other attempt, such as intuition or in-
sight into essences and essential necessities, to reach knowledge, let alone certainty,
regarding universal states of affairs. 39
Now Popper obviously cannot hold this position without serious contradiction.
For he presupposes the truth of his own numerous general assumptions without
which he could never advance his critique of induction. He also presupposes knowl-
edge of the nature of truth, oflogical consistency and it's being an element of truth,

34 Ibid., p. 7 fT.
35 Popper cannot avoid to reintroduce some verisimilitude which he seeks to distinguish from probabili-
ty.
36 See Sir Karl Popper, Objektive Erkenntnis, pp. 58 fT., 44 fT..
37 Ibid., pp. 47 fT., 52 fT. See Karl R. Popper, "A Note on Tarski's Definition ofTruth", Mind(1955), 64:
388-391. See also Luis Fernandez Moreno, "Tarskian Truth and the Correspondence Theory", Syn-
these, (2001) January; 126 (1-2): 123-147.
38 I cannot here deal with the new version of the Tarskian truth theory which serves Popper to justify this
inconsistent claim.
39 See Popper, Objektive Erkenntnis, pp. 47; 63 fT.; 68 fT., 134, 143 fT. See also D. Hume, A Treatise of
Human Nature, bk. 1, pt. 3, sec. 2; Selby-Bigge edition, pp. 90 fT.
 14 CHAPTER 1

and many other non-tautological logical as well as epistemological principles. 40 Pop-

per's critique of pragmatist and other truth theories and his and his school's defense
of the correspondence theory of truth likewise imply many such certainties concern-
ing the universal natures ofthings,41 though Popper fails to even notice this problem.
He is so deeply locked into an empiricist epistemology that he is not even raising
such questions as to how he knows the nature of knowledge, truth, evidence, logical
validity, etc., and how he gains the rational intuition into their essences and neces-
sary laws grounded in them. He evidently presupposes such insights into the general
and necessary nature of the mentioned things all along in his critique of inductive in-
ferences, some elements of which are undoubtedly quite sharp and well-taken, for
example his critique of 'incomplete induction' as a (formal-)logically justified infer-
ence.
In an incomplete induction, not all individual members to whom a general asser-
tion refers are empirically observed, but only some. It differs from a complete induc-
tion, in which one infers the truth of general propositions, for instance, about a
group such as "all persons in the village Ruggell" or "all mountains of Chile," but
only after having observed each single member of the group.
Now, we agree with Hume and Popper (who fails to distinguish these two kinds
of induction) and also with Pfander,42 when they reject the logical validity of incom-
plete inductive inferences performed on purely formal logical grounds. For from the
mere fact that many individuals of a species show certain characteristics we cannot,
on the basis of a purely formal-logical reasoning, validly infer anything for the un-
observed ones. Popper rightly points out that we can, for example, not infer that a
certain species will survive based on the observation that it has survived for so many
millennia and under so many varying types of weather.
Even the classical conditions of valid inductive knowledge such as the variation
of the circumstances under which facts are observed are in no way sufficient to jus-
tify incomplete induction as a formally valid inference. PHinder demonstrates this
very well in his Logik, referring also to well-known older studies. 43 Thus, Paul
Feyerabend is quite correct when he notes that Popper's position regarding the
formal-logical invalidity of inductive inferences is in no way original with Popper. 44
We also agree with Popper that a falsification of a general assertion by reference
to a single empirical observation is possible, if the fact observed contradicts the gen-
eral thesis. If I say "All men are black" or "All crows are black," for example, the
observation of a single white man or a single white crow is sufficient to refute these
claims.

40 See Popper, Objektive Erkenntnis, pp. 55, 310; see likewise Josef Seifert, Back to Things in Them-
selves.
41 See Karl R. Popper, Conjectures and Refutations The Growth ofScientific Knowledge (London: Rout-
ledge and Kegan Paul, 1963), pp. 16,27.
42 A. Pfander, Logik, 4th ed., edited by Mariano Crespo (Heidelberg: Universitatsverlag C. Winter,
2000), pp. 341 ff.
43 See A. Pfander, "Die Lehre von den SchIUssen," in ibid., pp. 246-354.
44 See P. Feyerabend, "In Defence of Aristotle: Conunents on the Condition of Content Increase," in
G. Radnitzky and G. Andersson (eds.), Progress and Rationality in Science (Dordrecht: Reidel, 1978),
pp. 143-180,esp. 174-175,note8.
 NATURE AND GOALS OF MEDICINE 15

Not only long before Popper, but also before Pfander, Pascal stated both this fact
and the truth that even the highest mnnber of single observations as such is insuffi-
cient to prove a general thesis. 45
We need, however, to make several comments, very relevant for medicine, on
these Popperian insights into the falsification of general claims.
(1) Not all universal judgments can be refuted or falsified by single observations,
a fact that is of particular importance for medical science: For, unlike the assertions
about empty space which Pascal considered, there are many universal judgments
which do not make a claim to strict or absolute universality. They speak of how
things are 'in general' (ut in pluribus, as the scholastics used to say), and not absolu-
tely in all instances (ut in omnibus). Such universal propositions, which mean that
things are 'in general' such and such, admit the possibility of exceptions in their im-
plicit meaning. For example, the assertion that the human hand has five fingers, or
that the human organism has one heart and two kidneys, cannot be refuted by fmd-
ing one six-fingered man or some human beings who have two hearts and others
who lack one of the two kidneys. For these are precisely exceptions that, being ex-
ceptions, do not refute but confirm the rule, as one rightly says with regard to this
type of universal judgments. These judgments are, of course, in a rigorous logical
sense, particular and not universal judgments even if they speak about the general
nature of something and about the vast majority of cases. In terms of pure formal
logic, they should actually be rendered as "Some (many, most) S are P," or "in gen-
eral S's are P," or "most of the time S is P ... ,,46
(The distinction between strictly universal and exceptionless laws, and judg-
ments referring to them, and pseudo-universals or 'loose universals' which tolerate

45 With reference to the question as to whether an empty space exists, he insists that a single experiment
suffices to refute even the most venerable opinions of the ancients, and formulates:
Aussi dans Ie jugement qu'ils ont fait que la nature ne souffrait point de vide, ils
n'ont entendu parler de la nature qu'en l'etat ou its la connaissaient; puisque, pour Ie
dire genc!ralement, ce ne serait assez de l'avoir vu constamment en cent rencontres,
ni en mille, ni en tout autre nombre, que1que grand qu'it soit; puisque s'it restait un
seul cas a examiner, ce seul suffirait pour empecher la definition generale, et si un
seul etait contraire, ce seul ... Car dans toutes les matieres dont la preuve consiste
en experiences et non en demonstrations, on ne peut faire aucune assertion univer-
selle que par la generate enumeration de toutes les parties ou de tous les cas diffe-
rents. (Bl. Pascal, Preface sur Ie Traite du Vide, in "Opuscules," CEuvres completes
de Pascal [Librairie Gallimard, 1954], p. 232)
Applying this also to the assertion that diamonds are the hardest form of matter, Pascal is right to
say that all our experience only suffices to state this of the sorts of matter we knew by a certain time.
Uranium later refuted the hypothesis of the physicists of Pascal's times that diamond is absolutely
speaking the hardest kind of matter (a refutation the possibility of which by means of a single observa-
tion Pascal affirms). If Pascal, however, held that also the general assertion that diamond is harder
than all those other forms of matter known by his time could not be sustained empirically, he would
have overlooked the epistemological and logical justification of another type of incomplete inductive
knowledge of which we will speak in a moment.
46 See also P. Feyerabend, "In Defence of Aristotle."
16 CHAPTER 1

exceptions also contributes significantly to overcoming the errors and antinomies of

Whitehead-Russell's "theory oftypes.,,)47
We need to repeat: the type of refutation of universal claims in terms of a single
counter-example, of which Popper speaks, does precisely not apply to medical sci-
ence, though he applies it to medicine. In other words, the meaningful, but contin-
gent, natures with which medicine deals, and the empirical-inductive knowledge of
universals it seeks, are such that many of Popper's examples of falsification taken
from medicine are no falsifications at all.
(2) Popper's critique commits still another confusion: between the real species of
a thing and a merely apparently same species, which really is wholly different.
Popper gives the example of the death of human persons in France after they had
eaten a badly baked bread or a bread made from a bad dough, and the death of others
after they had drunken 'heavy water'. He uses these examples to prove that we can-
not make general medical claims about the effect of eating bread or drinking water,
but such alleged falsifications of inductively gained universal judgments are really
no falsifications at all, as Aristotle had seen and stated clearly.48 Assertions about
the general nature of water, the specific weight of oxygen or hydrogen, or the ali-
mentary value of bread, etc., are in no way 'falsified' because there are exceptional
cases of bad bread or of 'heavy water' that lead to death upon consumption. Asser-
tions about the specific nature and effects of eating bread are even less falsified by
cases in which different substances have been mixed into a dough that results, upon
consumption of the bread baked with bad dough, in death. This is no case of an ex-
ception of a general inductively known proposition at all. The death of many
Frenchmen after they had eaten bad bread is not due to an exceptional effect of
bread that had the same nature as normal bread but rather a consequence of the fact
that some poisonous and harmful substances had been mingled into the dough of the
bread. And these substances will have similarly harmful effects whenever they are
consumed and thus confirm and do not challenge the justification of general claims
of highest probability and almost complete certainty in science.
A real exception from the empirical medical findings about the effect of poison
would be present if, as the movie Princess Bride presents in a funny way, a man can
get so used to a deadly poison, which kills anyone who takes it for the first time, that
he can drink the same quantity, deadly for others, without suffering harm. Even in
this case, however, when regularly consumed small doses of a poison build up a re-
sistance to it, we find a general law which medicine uses in many forms of immuni-
zation.
(3) Very different would be an empirical claim meant as an exception-less truth,
such as the previously mentioned claim: "All human beings are white" or "No one is
pleased with the way his face looks." For as soon as such a claim is made apodicti-
cally and in the sense of a universal judgment true without exception about things of
a certain nature, one single exception refutes and falsifies such a judgment. Children

47 See Bertrand Russell, Principles of Mathematics, 2nd ed. (London, 1937); see also Josef Seifert,
Vberwindung des Skandals der reinen Vernunft. Die Widerspruchsfreiheit der Wirklichkeit-trotz
Kant (Freiburg/Miinchen: Karl Alber, 2001).
48 See Aristotle, Nichomachean Ethics 1,1; 1094 d 23 ff.
 NATURE AND GOALS OF MEDICINE 17

very often use such a refutation of general claims. A funny example of this correct
Popperian intuition into falsification of a universal claim (often made about things
which objectively, by their nature, do not admit such strictly universal assertions)
through a single observation is the following: A small boy (well known to me) over-
heard his elder sister, looking into the mirror, saying: "0 Mom, I h~te the way my
face looks," and her mother answering: "Never mind, you know, nobody is pleased
with the looks of his face." The boy replied: "All wrong! I for one, am perfectly
pleased with the way my face is looking."
(4) The possibility of such a falsification by a single counter-evidence is even
more clearly present in the case of assertions which, unlike judgments about the col-
or of the human skin or the dislike of one's face, claim, by the nature of their sub-
ject-matter, some strict universality, such as the dated theory of physics, to which
Pascal refers, that: "no empty space is possible in nature." This judgment made the
claim to express a rigid law of physics, but, as Pascal states, can be refuted by a sin-
gle example to the contrary.
Any universal judgment that asserts a state of affairs as absolutely general (as
many philosophical and mathematical assertions do), can indeed be falsified by a
single counter-example, precisely because it makes a claim to strict universality, and
does so often apodictically (logically speaking) and frequently also (epistemologi-
cally speaking) with a claim to apodictic certainty of knowledge.
Similarly and for the same reason, pointing out a single case to the contrary can
refute a philosophical thesis such as that "no truth can be known," or that "no free-
dom can exist." A single evident truth that contradicts such assertions, for example
the evident truth of the inner contradiction of the thesis itself that there is no truth or
a single evident case of free acts, falsifies such general claims. 49
(5) We need to make a further comment, however. Some philosophical and ethi-
cal judgments, which we will discuss in this work, namely true propositions a
priori, do not require empirical verification and can also not be falsified empirically
in the way Popper demands for the very meaningfUlness of an assertion. so The rea-
son for this lies neither in their lack of strict universality nor in their alleged mean-
inglessness, but in the absolute inner necessity of their object, on the one hand, and
in the evident self-givenness of the universal nature, on the other hand. For this rea-
son an assertion such as ''the quality of the color 'orange' lies, in the order of simi-
larity, between 'yellow' and 'red'," or: "moral responsibility presupposes freedom,"
or: "the dignity of the person morally requires respect," or "no pair of contradictory
states of affairs can coexist" can never be falsified because they are necessarily true
and for this reason do not depend on contingent experiences. The respective states of
affairs asserted in these propositions are quite different from those that admit empiri-
cal falsification. In fact, the experiences that might contradict these laws, if they ex-

49 See Martin Cajthaml, Kritik des Relativismus (Heidelberg: Universitatsverlag Winter, 2003); see also
John F. Crosby, "Refutation of Skepticism and General Relativism", in D. von Hildebrand (ed.),
Rehabilitierung der Philosophie (Regensburg, 1974), pp. 103-123.
50 See Popper, Conjectures and Refotations.
18 CHAPTER 1

isted, would have to be declared dreams of madmen or simply intrinsically contra-

dictory if absolutely necessary states of affairs would appear not to apply to them. 51
None of the mentioned propositions is analytical or tautological, but they still are
absolutely necessary. Any knowledge of these truths presupposes that the things
themselves, the respective essences, in which these necessary states of affairs are
grounded, be understood. A mere analysis of the concepts involved and of their defi-
nitions never suffices here, as it does in the case oftautologies, to know their truth. 52
That the mentioned universal synthetic propositions a priori are necessarily true
does not mean that nobody ever contradicts them. Not only do many persons contra-
dict them (for example, Calvin denied that freedom is a condition for personal guilt,
and Hegel claimed that within higher reasoniVernunft the principle of contradiction
is suspended) but also any stating their necessary truth is wholly different from
claiming: "everybody recognizes or presupposes them."
What we have said also does not exclude thatfalse synthetic propositions a priori
can be refuted through single observations or through rational insights and demon-
strations based on these.
(6) In our discussion of medical ethics, however, we also have to make another
important distinction: universal propositions about what ought to be can never be
falsified by reference to what actually is the case. Here, the facts contrary to ought-
ness are only seeming exceptions, but they in no way really refute the universal ethi-
cal truth that concerns what ought (or ought not) to be done. For the observations of
facts opposite to oUghtness do not refer to the contradictory opposite of the state of
affairs that something ought to be done (such a contradictory state of affairs would
rather be that "it is not the case that X ought to be done").
In spite of the absolute evidence that this attempt to refute ethical propositions is
untenable, many authors commit this grievous logical mistake. 53 This misunder-
standing of the principle of falsification constitutes a 'naturalistic fallacy' in the
sense ofG. E. Moore. 54 It confuses a universal proposition about what ought to be or
about what never ought to be done with a universal proposition about actual human
or animal behavior. That most human beings kill others or engage in certain kinds of
sexual behavior is absolutely no objection to, or refutation of, the claim of a strict

51 Therefore, logical paradoxes can usually be refuted by showing that the conflict with the principle of
contradiction does not arise from the nature of things or from a possible case but from an intrinsically
incoherent and contradictory absurd assumption such as a liar who, in lying, informs us truly about his
lying. See Josef Seifert, "Das Antinomienproblem als ein Grundproblem aller Metaphysik: Kritik der
Kritik der reinen Vernunft," in Prima Philosophia, Bd. 2, H 2,1989.
52 See Adolf Reinach, "Concerning Phenomenology," trans!. from the German ("Ober Phanomenolo-
gie") by Dallas Willard, The Personalist 50 (Spring 1969), pp. 194-221 (reprinted in Perspectives in
Philosophy, ed. Robert N. Beck (New York: Holt, Reinhart, & Winston, 1961 and 1969)."Ober Phli-
nomenologie" (Was ist Phanomenologie?); and the same author, Die apriorischen Grundlagen des
Biirgerlichen Rechts, in Adolf Reinach, Samtliche Werke, pp. 141-278; Dietrich von Hildebrand,
What Is Philosophy?; J. Seifert, Erkenntnis objektiver Wahrheit and Back to Things in Themselves.
53 Wolfgang Wickler for example regards mere factual conflicts with laws governing moral oUghtness
and even 'deviations' from moral oughtness in the animal kingdom as refutation of moral obligations
for human persons! See Wolfgang Wickler, Sind wir Siinder? Naturgesetze der Ehe. Einfiihrung Kon-
rad Lorenz (Droerner Knaur 1969), pp. 83 if., 222 ff.
54 G. E. Moore, Principia Ethica, 14th ed. (London: Oxford University Press, 1971).
 NATURE AND GOALS OF MEDICINE 19

and universal obligation not to kill or not to engage in certain kinds of sexual com-
portment.
(7) Still different are cases of real or of merely seeming exceptions in ethics,
which also do not constitute a falsification of a general claim. For example, we may
assert that a certain act is ethically required (such as to keep one's promises) or mor-
ally wrong (to break one's promises), and then refer to a case in which this ought-
ness does not exist or is suppressed: For example, immoral promises ought not to be
kept; or when coming across a person in desperate need of immediate help we must
abandon keeping our promise to meet our son in town at a certain time.
Here we are confronted with the distinctions that will be further explained in
chapter 6: namely between absolutely universal oughts applying to any circum-
stances and prima facie obligations which may be suppressed by higher ones in
cases of 'collisions' of various obligations. We will later see that we must not, with
Ross, universalize or misinterpret this case of prima facie obligations so as if all
moral obligations could be suspended in certain situations. 55 But such kinds of ex-
ceptions in no way refute the universal truths at stake but only show that their con-
crete application depends on the presence of some additional conditions.
(8) Popper's critique of induction, which, if applied to medicine, would lead to a
sort of skeptical disease of empirical medical knowledge, commits another crucial
mistake. It fails to distinguish between induction as a formal inference (merely
based on a series of observations; Sl is P, S2 is P, etc., and on the logically unwar-
ranted conclusion: 'S is P, 'or 'All S's are P') and induction as a 'material inference'
that rests on other foundations besides formal logical ones. The critique of induction
offered by Hume and Popper is correct only when it is directed against a defense of
induction as a form of purely 'formal-logical inference' but not of induction as an
entirely different form of inference: a 'material inference', that is a form of inference
which does not prescind from the contents with which we are dealing and from cer-
tain general features and aspects of them. Pfander has shown that induction belongs
to these entirely different "content-based ('material') inferences' .,,56
For induction rests on a world in which there are not just accidental facts but also
genuine general (though not absolutely necessary) natures, and on the knowledge
that there is such a world. Popper presupposes a sort of Humean world of mere se-
quences of chaotic sense-impressions. He does not distinguish mere 'habits of expe-
rience', which stem from repeated observation of similar events, which could never
justify a valid inductive reasoning, from the repeated observation of such features of
a thing ofwhich we have good reasons to assume that they are rooted in the very na-
ture or species in question.
Empirical natural science necessarily presupposes a world in which there are
genuine species. Therefore, Popper's justified critique of induction as a mere formal
logical inference fails to see that induction does not abstract from the contents and
from the fact that it is natures of some species to which the observed facts belong,

55 See chapter 6, below. See also Sir David Ross, Foundations of Ethics, 4th ed. (Oxford: Oxford Uni-
versity Press, 1960). See as wen Dietrich and Alice von Hildebrand, Morality and Situation Ethics.
With a Preface of Bernhard Hiiring and an Epilogue by Alice von Hildebrand (Chicago: Franciscan
Herald Press, 1966).
56 Vgl. Alexander Pfander, Logik, "Die Lehre von den Schliissen."
20 CHAPTER I

and precisely this assumption or knowledge is the basis of a valid inductive infer-
ence.
Moreover, there are many good criteria to recognize the difference between
those cases where we observe in a given experiment something that merely acciden-
tally belongs to the individual example we observe (for example, some characteris-
tics of blood are found only in blood of a high temperature) and those cases where
we observe some features that we have good reasons to take as characteristic of the
observed species itself and not as merely due to accidental aspects of individual
samples or groups. Even if also this knowledge is not infallible, it is rationally justi-
fied.
In all results of empirical experimental science, and in the use of technology
based on empirical science, we presuppose precisely this distinction. And so does
every court of law. Therefore, a judge will never accept that a physician caught in
malpractice excuses himself by saying: "From my and many other physicians' re-
peated observation that the type of medical procedure I applied to patient Y led (in
previous experiences gained by me and by generations of physicians over millennia)
to the death of countless other patients, it in no way followed, or was even rendered
probable, that this same treatment would lead to the death of my present patient.
Therefore, I am innocent."
Thus, we see that Popper's critique of the practical certainty, or at least high
probability, of inductive knowledge, if true, would not only destroy the cognitive
value of medical science but also the basis of human responsibility and medical eth-
ics. For ifno causality and no general laws of nature were known to exist, ethical re-
sponsibility for human actions (rather than pure inner intentions) would be destroyed
and the above kind of absurd ethical justification of medical malpractice would be-
come acceptable. 57
The type of chaotic world without general natures and laws, which the above and
absurdly sophistical self-defense of a physician against the charge of murder im-
plies, is simply and clearly not ours. Nature presents us with generic features and
with species of things that possess certain unities of characteristics and are governed
by certain general laws. Such an understanding of nature was well founded by Plato
and Aristotle who spoke of eide and forms which structure the world according to
meaningfully united general patterns. Of course, in an atheistically conceived uni-
verse, in which no intelligent author has shaped nature according to a specific plan
but pure chance prevails, the ontological and the epistemological foundations for
recognizing the value of inductive knowledge are denied: neither can our senses in-
form us of any objective reality nor can we trust that what appears to us as the objec-
tive nature of things would not suddenly change tomorrow. Thus, a radical skepti-
cism and belief in a chaotic world would undermine the foundation of empirical sci-
ence. This emerges clearly in Friedrich Nietzsche. 58

57 See Roman Ingarden, Von der Verantwortung. Ihre ontischen Fundamente (Stuttgart: Philipp Reclam
Jun., 1970).
58 In 1873 he writes in "Uber Wahrheit und Liige im aul3ermoralischen Sinn," that the fact that we al-
ways perceive the same ordered world, as well as the fact that our perception of the world is mutually
corroborated by a network of experience, is absolutely no proof in favor of the assumption (of induc-
tion) that things are objectively as they appear to us-"just as a dream, eternally repeated, would be
 NATURE AND GoALS OF MEDICINE 21

Experience and evidence, however, confirm daily that our world is no chaos but
a cosmos. We do not live in an absurdly disordered and chaotic world of the sort
pure empiricism or positivism, or a vehement atheism such as that of Friedrich
Nietzsche, want to make it out to be. The real world of forms, species, and genera,
however, which is given in thousand-fold manners to human knowledge and experi-
ence, fully justifies inductive knowledge and the certainty of its results even if it can
never reach the absolutely indubitable evidence which only necessary essences can
provide.
Empirical knowledge, of which observations (experiments) and inductive reason-
ing are the most essential parts, is the foundational knowledge of medical science.
The validity of inductive inferences alone can justify our entrusting countless times
our health and our lives to the hands of pilots, drivers, physicians, and nurses. If the
world were a chaos of accidental facts, this trust would be completely unfounded
and the same medicine or treatment could just as well once save lives and another
time destroy them-without any law, reason, or rime; and then the above-mentioned
defense of the malpractician would no longer be absurd.
Unlike a priori knowledge, empirical knowledge about universals is not absolu-
tely indubitable nor is its object absolutely necessary. For this reason, it requires re-
peated experiments, which would be non-sense in mathematics or ethics. On the oth-
er hand, repeated observation and experimental knowledge would also be non-sense
if the world consisted only of accidental unities of elements. The value of inductive
knowledge is based on morphic, meaningful species and neither on mere accidental
such-being unities such as a collection of fragments of organs after an accident that
lack any inner order and universal structure, nor on absolutely necessary and in-
telligible essences. 59 It is not enough to say, however, that the object of inductive
knowledge must be specific or generic meaningful forms and natures. For there are
also meaningful individual unities such as concrete personalities, historic events, or
works of art in which the meaningful unity does not constitute a specific or generic
pattern that would make experimental knowledge possible. These meaningful struc-

experienced and judged as reality. " Moreover, he raises the possibility that we would perceive like
wonns or other animals and hence understand that our sense impressions are purely subjective. See
Friedrich Nietzsche, Werke in drei Biinden, ed. Karl Schlechta (Miinchen, C. Hanser, 1954, vol. I and
vol. II; 1956, vol. III), and Nietzsche-Index zur Ausgabe von K. Schlechta (Miinchen: C. Hanser,
1965); "tiber Wahrheit und Liige im auBennoralischen Sinn," vol. III, p. 309-322:
Dagegen ist einmal zu sagen: batten wir noch, jeder fur sich, eine verschiedenartige
Sinnesempfindung, konnten wir selbst nur bald als Vogel, bald als Wurm, bald als
Pilanze perzipieren, oder sahe der eine von uns denselben Reiz als rot, der andere als
blau, Mrte ein dritter ibn sogar als Ton, so wiirde niemand von einer solchen Ge-
setzmlU3igkeit der Natur reden, sondern sie nur als ein Mchst subjektives Gebilde
begreifen. (p. 318)
... Nur durch das Vergessen jener primitiven Metapherwelt, ... nur durch den
unbesiegbaren Glauben, diese Sonne, dieses Fenster, dieser Korper sei eine Wahr-
heit an sich, kurz nur dadurch, daB der Mensch sich als Subjekt, und zwar als
kiinstlerisch schaffendes Subjekt vergil3t, lebt er mit einiger Rube, Sicherheit, Kon-
sequenz: wenn er einen AugenbJick nur aus den Gefangniswiinden dieses Glaubens
heraus konnte, so ware es sofort mit seinem 'SelbstbewuBtsein' vorbei. (pp. 316).
See also ibid., p. 314.
59 See on this crucial distinction Dietrich von Hildebrand, What Is Philosophy?, ch. 4.
22 CHAPTER 1

tures, for example the character and deeds of historical personalities, or works of art,
are fully individual and do not allow the kind of experimental inductive knowledge
on which medicine or biology are based.
Therefore, inductive knowledge rests on the existence of species and genera.
Only those meaningful gestalt-principles and forms that are the universal (though
contingent) species and genera that structure our world, make empirical natural sci-
ence possible.
We know indubitably that there are also absolutely necessary essences of things
in which absolutely universal states of affairs are rooted. The knowledge of strict
and necessary universality proves even more indubitably that empiricism is wrong
than the case of the human body and the many objects of empirical medical science,
which do not allow for the same indubitable knowledge of the universality of spe-
cies and genus.
But though we do not gain here indubitable knowledge, we have excellent rea-
sons to base our empirical science on the conviction, indeed on the discovery, that
there are, also in the contingently structured nature, meaningful species and genus
which justify the inductive methods of experimental medical and any other science.
This fact is certain enough to make us believe that a physician who would cut his
patient's head off and state afterwards that he had no good reason, from his and oth-
er doctors' observations, to conclude that this procedure would end his patient's life,
although it had ended the lives of millions, would be mad. But if Popper were right
and there would be no empirical certainty and even probability in our empirically
well-founded assumption that any cutting off the head of a patient will kill him, we
could not be justified in declaring such a physician to be a total fool or a cynical
criminal.
As Pfander puts it, inductive knowledge is justified where we have reason to be-
lieve that the being-P of a series of A's is rooted in their being S (in their genus or
species). Popper's-at least the earlier Popper's60-rejection of all 'what is ques-
tions' and of any 'essentialism' makes him uncritical with respect to the ontological
and epistemological issue of universals in nature (genus, species). He entirely over-
looks the foundational role of this ontological structure of the universe for the validi-
ty of induction and experimental sciences such as medicine, though he recognizes
that a purely statistical notion of order does not suffice to explain nature and thus
takes a somewhat ambiguous position on inductive knowledge, as critics have
pointed out.
Every child recognizes this non-empiricist principle of meaningful forms (such
as the forms of cats, dogs, horses, etc.). Chemistry, physics, biology, and medical
science enlarge this observation-and the validity of all their experimental inductive
methods depends on the truth of this observation.

60 Speaking later of a 'third world' and calling its structures 'intelligibilia', Popper might have moved
later away from his radical anti-Platonist and anti-essentialist earlier standpoint of his The Logic of
Scientific Discovery, 2nd ed. (New York: Harper & Row, 1968). See D. lakowljewitsch, "Die Frage
nach dem methodologischen Dualismus der Natur- und Sozialwissenschaften und der Standpunkt kri-
tischer Rationalisten", in K. Salamun (ed.), Karl R. Popper und die Philosophie des kritischen
Rationalismus. Zum 85. Geburtstag v. Karl R. Popper ( Amsterdam: Rodopi, 1989), pp. 116-117.
 NATURE AND GoALS OF MEDICINE 23

When Popper believes that the shift from verification to falsification and the de-
mand that no positive general scientific assumption be taken to be certain or even
probable can avoid radical skepticism,61 he is clearly mistaken. He himself sees that
under his assumptions not even probability of any degree could be attributed to em-
pirical science. 62 But how can this position fail to fall into radical skepticism regard-
ing the positive results of empirical science?
Such a skepticism is a logical consequence of Popper's denial that there are uni-
versal essences and states of affairs indubitably known to us. For any such denial of
human knowledge of true and non-tautological propositions known by us with cer-
tainty must lead also to a denial of the high probabilities of inductive knowledge.
Fritz Wenisch and others have shown63 that any assertion of probability presupposes
certainty of some knowledge. If therefore there does not exist certainty of knowl-
edge, there is also no cognitive probability regarding general (and even regarding in-
dividual) facts, and radical skepticism would be the inevitable consequence. More-
over, unrefuted mad assumptions could no longer be distinguished from unrefuted
reasonable assumptions in medicine, nor from evident insights.
That radical skepticism, and the dissolution of the value of scientific knowledge,
follows from such a position not only critics of skepticism and relativism but also
some skeptics, such as David Hume or Wolfgang Stegmiiller, admit. 64

61 See Popper, Objektive Erkenntnis, p. 5.

62 See Popper, ibid., pp. 86 ff.
63 See F. Wenisch, Die Philosophie und ihre Methode; the same author, "Insight and Objective Necessi-
ty. A Demonstration of Propositions Which are Simultaneously Informative and Necessarily True."
64 See the following famous texts of David Hume:
I am first affrighted and confounded with that forlorn solitude in which I am plac'd
in my philosophy, and fancy myself some strange uncouth monster, who, not being
able to mingle and unite in society, has been expell'd all human commerce, and left
utterly abandon'd and disconsolate. Fain wou'd I run into the crowd for shelter and
warmth, but cannot prevail with myself to mix with such deformity. I call upon oth-
ers to join me, in order to make a company apart; but no one will hearken to me. Ev-
ery one keeps at a distance, and dreads that storm, which beats upon me from every
side. I have expos'd myself to the enmity of all metaphysicians, logicians, mathema-
ticians, and even theologians; and can I wonder at the insults I must suffer? I have
declar'd my dis-approbation of their systems; and can I be surpriz'd, if they shou'd
express a hatred of mine and of my person? When I look abroad, I foresee on every
side, dispute, contradiction, anger, calumny, and detraction. When I tum my eye in-
ward, I find nothing but doubt and ignorance. All the world conspires to oppose and
contradict me; thou' such is my weakness, that I feel all my opinions loosen and fall
of themselves, when unsupported by the approbation of others. Every step I take is
with hesitation, and every new reflection makes me dread an error and absurdity in
my reasoning. (Hunie: Treatise on Human Nature, bk. 1, pt. 4, sec. 7, p. 264-265)
For with what confidence can I venture upon such bold enterprizes, when beside
those numberless infirmities peculiar to myself, I find so many which are common
to human nature? Can I be sure, that in leaving all establish'd opinions I am follow-
ing truth; and by what criterion shall I distinguish her, even iffortune shou'd at last
guide me on her foot-steps? After the most accurate and exact of my reasonings, I
can give no reason why I shou'd assent to it; and feel nothing but a strong propensi-
ty to consider objects strongly in that view, under which they appear to me. Experi-
ence is a principle, which instructs me in the several conjunctions of objects for the
past. Habit is another principle, which determines me to expect the same for the fu-
ture; and both of them conspiring to operate upon the imagination, make me form
24 CHAPTER 1

Besides pointing out the skeptical consequences of Popper's position, we add an-
other criticism of his position: Popper's own critique of induction itself would be-
come untenable without some knowledge characterized by cognitive certainty. Pop-
per's principle of falsification could not be claimed to be evident (as Popper as-
sumes all along) nor even probable if he seriously denied any certainty of knowl-
edge of universal states of affairs which are or which he regards as evident, such as
'induction is invalid' ,65 'falsification of general theories through observation of sin-
gle counter-examples is possible', etc. Also principles such as the absolute principle
of contradiction are said explicitly to be true by Popper and, at least implicitly, by all
other critics of cognitive certainty of universals. 66 Since then Popper's critique of in-
ductive knowledge necessarily contradicts itself, it is clearly untenable.
Only on the basis of a rehabilitation of inductive knowledge, thereby overcoming
the critique of induction by Popper, we can save medicine as a science. Otherwise a
mere 'abstract possibility that any result of medical science might be true' would re-
place scientific certainty or probability and medicine would sink down to the level
of a pure guesswork, a series of still unrefuted but at the same time unfounded gues-
ses bereft of any certainty and even probability.67
We need to consider another fact in our attempt to understand medical science.
The disciplines comprised in medical science are not necessarily interrelated or
united on purely scientific grounds. Instead, they are brought together as elements of
all those branches of human knowledge which to master is necessary to understand
and to further human life and human health. Unlike authors such as Galen, I think
that the unity of the science of medicine is more practical (in terms of the goals of
medicine and of every knowledge pertaining to their realization) than theoretical (as
'the science of the human body,).6 For the study of medicine is not restricted to the
study of the human body but includes other fields (such as parts of chemistry, phar-
macology, and pathology including virology, bacteriology, etc.) which are very rele-

certain ideas in a more intense and lively manner, than others, which are not at-
tended with the same advantages. Without this quality, by which the mind enlivens
some ideas beyond others (which seemingly is so trivial, and so little founded on
reason), we cou'd never assent to any argument, nor carry our view beyond those
few objects, which are present to our senses. Nay, even to these objects we cou'd
never attribute any existence, but what was dependent on the senses; and must com-
prehend them entirely in that succession of perceptions, which constitutes our self or
person. Nay farther, even with relation to that succession, we cou'd only admit of
those perceptions, which are inunediately present to our consciousness, nor cou'd
those lively images, with which the memory presents us, be ever receiv'd as true
pictures of past perceptions. The memory, senses, and understanding are, therefore,
all of them founded on the imagination, or the vivacity of our ideas. (Hume: Treatise
on Human Nature, bk. I, pt. 4, sec. 7, p. 265)
See also Wolfgang Stegmilller, Metaphysik, Skepsis, Wissenschaft (Milnchen: Piper, 1970).
65 This is true of a position that interprets induction as a formal-logical inference from repeated observa-
tion or"individual cases to a general law.
66 See, for example, Popper, Objective Knowledge, p. 13.
67 For a further critique of Popper's critique of induction see Josef Seifert, "Objektivismus in der Wis-
senschaft und Grundlagen philosophischer Rationalitlit"; and "Diskussion."
68 Cf. Claudius Galenus, A Translation olGalen 's Hygiene (De sanitate tuenda), edited by Robert Mon-
traville Green MD, with an Introduction by Henry E. Sigerlst MD (Springfield, Ill.: Charles C. Thom-
as Publisher, 1951).
 NATIJRE AND GoALS OF MEDICINE 25

vant for understanding health, sickness, and cure of the human body or psyche from
disease, while these fields of study would not at all belong to a systematic study of
the human body and psyche as such. Thus, medicine is not a pure science
determined by its subject matter and a logic proceeding solely from it; rather, it both
comprises a variety of sciences and does not consider these sciences under the
purely theoretical point of view of a biologist or chemist but under the pragmatic
aspect of how they serve to accomplish and to realize the goals of medical action.
Now what do all these observations about medical science have to do with our
effort to understand the nature of the physician? Are not the medical scientist and
the physician wholly different? The scientific side of the physician definitely does
not mean that the physician coincides with the medical researcher. We have to dis-
tinguish the two. The practice of medicine and its effects on human beings are, at
least in most respects, more important than medicine as a pure science. Nonetheless,
rational and effective medical practice presupposes medical research in which the
physician (unlike other medical practitioners) has to participate in some effective
way, in order to guarantee the solid basis of his medical interventions. And therefore
it is crucial that the individual physician gain access to the results of medical re-
search as quickly and as easily as possible. Also in this respect we find important
progress in medicine, as we shall see below.
As mentioned above, almost all of the sciences that are comprised in medical sci-
ence in the narrower sense are empirical sciences. Claude Bernard (1813-1878) has
insisted, in his Introduction to the Study of Experimental Medicine,69 on this empir-
ical side of medical knowledge and its manifold ramifications, sadly ignoring, in his
definition of medicine as the most empirical science, the deeper and philosophical
parts of comprehensive medical knowledge we are going to deal with in this work.

1.1.3. Immense Progress in Medicine as Experimental Science and as Scientifically

Supported Medical Practice
Now, in which way can we claim that the realm of empirical medical knowledge is
the sphere in which we find progress in medicine? Not with respect to all empirical
knowledge do we fmd progress; for many of the empirical observations of medical
science were accessible, at least in principle, to physicians of all times. Many others,
however, depend on the history of human ingenuity, the cumulative effect ofempiri-
cal science, and the development of sophisticated technologies. Many empirical
medical cognitions and cures became possible only through new instruments such as
electronic microscopes, through the invention of new medicines or medical technol-
ogy, and through the experiences gained by testing them.
Frequently, medical knowledge is obtained by systematic and repeated observa-
tions, systematic testing, and rigorous study and evaluation of test results. Not al-
ways a systematic empirical observation of facts precedes the discovery of new
medicines and cures but sometimes these are found by chance. Some medical
knowledge, for example concerning the effects of certain antibiotics, has been
gained by accidental, unplanned, and unexpected empirical observations, or also ob-
servations based on tragic accidents which one should never produce as 'tests', but

69 Claude Bernard, Introduction to the Study ofExperimental Medicine (1865).

26 CHAP1ER I

without which it would not have been gained. (To produce such 'tests' or to procure
the experience necessary to gain knowledge regarding facts which can only be
studied in gravely sick or mutilated persons would be highly immoral and involve
immoral methods of human experimentation reminiscent of those used in Nazi con-
centration camps). Still other medical findings rest on speculative theories and await
confirmation by the verification of these theories (or at least by their resistance to
unsuccessful attempts at their falsification).
While the physician does not have to be a scientist, let alone be in possession of
the immense reservoir of medical knowledge which no single human being can pos-
sibly master, we expect nevertheless from each physician some measure of scientific
training and continually updated acquaintance with the results of the latest medical
research of his time. For such knowledge in a physician is not a mere matter oftheo-
retical curiosity or interest but can restore health or save lives, and therefore negli-
gence and indifference of a physician towards the results of medical science are
clearly unethical and, in serious cases, tantamount to a malpractice which should be
publicly exposed when noticed. 70
Returning to the question of progress in medical science, we may say: in regard
to empirical knowledge, the scientific knowledge of the physician today differs posi-
tively from the relatively low level of scientific observations, explanations, knowl-
edge, experiments, etc., found in medicine men and natural medical practitioners,
however sophisticated their techniques may have been or still may be in certain
areas of medical knowledge. Even frequently repeated pre scientific experiences,
which give origin to prescientific medical theories, cannot replace systematic scien-
tific explorations in medicine; these have been advanced immensely in the last cen-
turies.
With respect to this first differentiating mark of medicine, that it is an art of heal-
ing and of other (for example of preventive) treatments based on science, we find no
doubt that both medical experience and the theoretical knowledge obtained there-
from grow cumulatively from generation to generation if the educational system is
good and if the results of experiences and theories are properly communicated
through oral traditions, apprenticeships, schools, learned journals, and other means.
Tremendous developments in medical science take place during each decade and
often during each year. In the use of psychopharmaca and in countless other areas of
medical knowledge, modern developments and discoveries rendered possible far
more complex scientific investigations, cognitions and techniques of treatment than
had been possible before.
In this respect (of the scientifically well-founded treatment and healing) medi-
cine is characterized by an immense progress. Just think of the developments that
took place from the discovery of vaccine against fowl cholera (1879), and of an ef-

70 See the interesting paper by Christopher Melley, "Medical Malpractice, the Hippocratic Oath, and the
Code of Silence," in European Philosophy of Medicine and Health Care (1996, 4:2): 6--17. The au-
thor argues that the Hippocratic Oath forbids any negligence and malpractice but that the silence it im-
poses cannot and must not be applied to an alleged verdict of not speaking out against clear cases of
malpractice and negligence observed in colleagues and hospitals. On the contrary, the gravity of con-
sequences of malpractice for patients demands to ignore a false sense of 'collegiality' and imposes a
duty for such honest speaking out.
 NATURE AND GOALS OF MEDICINE 27

fective cure against rabies (1885) by Louis Pasteur in the last century, and from Sir
Alexander Fleming's accidental discovery of penicillin in 192871 on to the present
moment! As to the having acquired sources of theoretical scientific knowledge, the
well-trained modem physician reaches heights of knowledge that were unheard-of
even 50 years ago. Medical science progresses continuously.
This does not exclude the fact that scientific learning as such and the scope of
scientific comprehension of a given subject matter are largely also consequent upon
a certain scientific, scholarly attitude and individual talents in which great men or
women in the history of medicine may have surpassed less learned and less gifted
members of later generations of physicians. On this higher level of scientific work,
understanding and intellectual depth, no continuous 'progress' is found except that
quantitatively more and more results of such work become available to the medical
community.
The progress of scientific medicine touches also an entirely different sphere of
progress: the sphere of communication. The practicing physician had until recently a
relatively limited access to the complex scientific knowledge in the field of medi-
cine, except perhaps in some areas of specialization where he was fully up to date.
The limitations of access of the single physician to the whole of available medical
knowledge constitute a major restraint of medical progress. Precisely this situation is
ameliorated daily quite essentially. Handbooks, medical journals, and other scientif-
ic publications are now available through Internet. Computerized data banks make
scientific medical knowledge more and more widely and quickly accessible to ev-
erybody, so that each physician in the 'global village' of the entire world can in prin-
ciple readily reach the whole universe of medical knowledge and thus participate in
the entire breadth of medical progress-incomparably more fully and more quickly
than through the methods available before. 72 This progress in communication and
new media gives rise to one of the most significant dimensions of progress in con-
temporary medicine. Think of the technologies used now to make accessible the
whole body of medical knowledge to the individual physician. Consider, for exam-
ple, the progress opening up today in medicine through the fact that computer pro-
grams can now gather, communicate, and apply concretely information regarding
vast medical fields to enormous numbers and varieties of patterns of symptoms, as
well as indicate available drugs or other cures almost instantly.
Modem computer technology has many other usages as well. Just think of those
usages of computer and virtual reality technology that allow surgeons to learn the
practice of modem methods of surgery on the screen.
Of course, the simpler and older methods of communicating medical knowledge,
for example by on-site training opportunities, by the publication and study of medi-
cal journals or by attending learned conferences, and by the live exchange of experi-
ences and ideas, are never dispensable, but they find an entirely new support in mod-
em technology. In part, these new means of communication may eliminate some

71 Only since 1938 penicillin was systematically produced.

72 One is reminded here of Marshall McLuhan' s idea of the global village which in recent years took on
much more advanced and sometimes frightening forms. See for instance Josef Seifert, Rocco Butti-
glione and Radim Palou§, Die Verantwortung des Menschen in eif!em globalen Weltzeitalter (Heidel-
berg: Universitiitsverlag C. Winter, 1996), pp. 28-73.
28 CHAPTER I

older ones entirely. Some authors, for example, believe that medical and other scien-
tific journals will completely cede to the much faster and quickly adaptable commu-
nications through Internet.
To assert such a tremendous growth of scientific medical knowledge, and of pro-
gress in and through medical and communication technology, is correct, although
we must overcome a blind feeling of awe in front of modem school-medicine (medi-
cine as taught in medical schools) and recognize serious deficiencies found in purely
chemical and materialistic approaches to the solution of health problems. These defi-
ciencies are widespread in the practice of modem medicine and are particularly due
to a blind application of the so-called 'biomedical model' in medicine. Such an ap-
proach has its clear philosophical roots and leads to a serious narrowing of the scope
of the empirical knowledge admitted in medicine.
At any rate, the picture of an almost automatic progress in medicine is very in-
complete. Already the mentioned fact that empirical knowledge demands interpreta-
tions, many of which are philosophical in nature, throws considerable doubt on a
simplistic vision of medicine as a progressively improving enterprise, even inas-
much as its purely empirical side is concerned. For wrong philosophical ideas and a
lack of deeper wisdom can lead to overlooking many empirical facts about human
health and human life. 73 Let us then be reminded again and again that empirical ob-
servations as such do not suffice to constitute medical science. They require inter-
pretations, which should do justice to the full range of bodily and mental phenom-
ena, which, for example, touch the various aspects of health and illness.
Given such a need for a comprehensive interpretation of the phenomena that
does full justice to their complex structure, any reductionist approach to problems of
health or of mental health is bad, however useful it might be in certain areas and re-
spects of empirical inquiry. Undoubtedly-in spite of the overwhelming progress of
empirical medical science-the development of scientific knowledge and of its in-
terpretation in modernity was for the most part one-sided and often formed by a ma-
terialistic-scientistic outlook which lost contact with many previously acquired cog-
nitions and experiences, not only of medicine men or of premedical healers who dis-
posed, and dispose, over experiences and techniques that were lost or ignored later,
but also of entire branches of medical knowledge that fell outside Western school-
medicine. Just consider homeopathic medicine as well as various ancient techniques
and experiences of Asian medicine, such as acupuncture, which were forgotten or
neglected later in Western-style medicine. Or bear in mind the newly rediscovered
Hildegard of Bingen medicine. We could apply here Theophrastus Paracelsus's
harsh words reported in an article about his thought:
His attitude upset the schoolmen. "The universities do not teach all things," he wrote,
"so a physician must seek out old wives, gypsies, sorcerers, wandering tribes, old
robbers, and such outlaws and take lessons from them. A physician must be a traveler,
... Knowledge is experience." Paracelsus held that the rough-and-ready language of the
innkeeper, barber, and teamster had more real dignity and common sense than the dry-

73 There are superb thoughts on this in Theophrastus Paracelsus's Labyrynthus medicorum errantium, in
Theophrastus Paracelsus, Werke, besorgt von W.-E. Peuckert. Bd. II, Medizinische Schriften, pp. 440-
495 (Darmstadt: Wissenschaftliche Buchgesellschaft, 1965).
 NATURE AND GoALS OF MEDICINE 29

as-dust scholasticism of Aristotle, Galen, and Avicenna, the recognized Greek and Arab
medical authorities of his day.74

Especially in the area of psychiatry and in the treatment of mental disorders as if

they and their solutions were mere chemical problems, a materialism as it often un-
derlies modem medicine frequently led to a false conception of the medical reality
and the method of medicine, and hence to a regress rather than to a progress in cop-
ing with problems of health, particularly of mental health. 75
Modem medicine is to a large extent dominated by modem philosophical
'models' which underlie our present chemical and technical sciences but are far less
adequate to the full reality of health and illness in their relationship to life than pre-
vious conceptions had been. These previous conceptions of man and of his health
problems formed empirical medical ideas and methods which were often far less ad-
vanced with respect to empirical details of knowledge, but in some respects better
able to provide solutions to the fundamental problems of human health. For they
were based on more adequate philosophies. 76
As we shall see, a vision of man as a complex machine does not do justice to the
organism and even less to the human person,77 and neither does a treatment of dis-
eases as if they were all caused by nothing but chemical and physical factors. Be-
cause this fact is increasingly recognized today, many physicians are happily mov-
ing away from a false idolization of Western-style scientific and materialistic medi-
cine to a more positive evaluation of less chemical and mechanical models of look-
ing at health and diseases, and at their cures.
Medicine men and other nature healers differ from the physician in the strict
sense in that they rely more heavily on local traditions and medical beliefs, coupled
with their own experience, rather than on the result of carefully conducted observa-
tions, experiments, and scientific research undertaken by a world-wide scholarly
community. Thus, in the medicine man genuine medical knowledge and well-
founded theory is often mixed with irrational beliefs. This deficiency of pre-medical
knowledge was partly overcome through modem empirical science.
Yet in the progress of medicine as natural science a sort of immediate and unper-
turbed contact with physical problems and natural cures was frequently lost. Healers
such as 'Pastor Kneipp' with his water cures had to develop their experiences in a
paramedical context, which was absorbed by medical professionals only at a much

74 See "Paracelsus" (with no author mentioned), in Encyclopaedia Britannica, Copyright (c) 1999.
75 Cf. my "Moral Goodness and Mental Health," in James M. DuBois (ed.), Moral Issues in Psychology.
Personalist Contributions to Selected Problems (Lanham/New YorklLondon: University of America
Press, 1997), pp. 43-64.
76 This important point is quite well brought out in Paracelsus's work. How important an adequate phi-
losophy is for medicine, Theophrastus Paracelsus especially points out in his Philosophia sagax, or in
the full title, Astronomia magna oder die ganze philosophia sagax der grossen und kleinen Welt
1537/38, in Werke, besorgt von W.-E. Peuckert. Bd. ill, Philosophische Schriften (Darmstadt:
Wissenschaftliche Buchgesellschaft, 1965), pp. 37-405.
77 See on this also Josef Seifert, Leib und Seele. Ein Beitrag zur philosophischen Anthropologie (Salz-
burg: A. Pustet, 1973); the same author, Das Leib-Seele Problem und die gegenwiirtige philosophi-
sche Diskussion. Eine kritisch-systematische Analyse, 2nd ed. (Darmstadt:-Wissenschaftliche Buchge-
sellschaft, 1989); and J. Seifert, What is Life?
30 CHAPTER I

later time. 78 Certain old cognitions of nature healers were thrown overboard, often
for rationalistic reasons, which demanded concordance with specific scientific meth-
ods and techniques. Under the influence of narrowing scientistic idols it frequently
occurred that genuine cognitions were rejected or forgotten because their effective-
ness could not be explained by the scientific standards of an empiricist conception of
natural science and because they lacked a sufficient theoretical basis. This was true,
for example, for natural methods of anesthesia and of healing,79 and remains true for
many extremely effective methods of anesthesia and cure, which are based on hith-
erto unexplained facts and sometimes on a speculative theory of the human body
foreign to modem science.
And yet the effectiveness of these old methods and cures proves that there is
much more to such forms of treatment than Western-style school-medicine is ready
to admit. Similar prejudices of school-medicine, as they are increasingly overcome
today, vis-a-vis such methods as acupuncture, still continue to prevail against proven
'house medicines' (such as vinegar socks which frequently lower high fever almost
instantly) or against similarly well established practices of Hildegardian or native
American Indian medicine, etc.
In recent medical research and praxis, a new open-mindedness vis-a-vis such
cognitions is to be observed, however. Alerted by ecological catastrophes and unde-
sirable side-effects of chemicals, we are moving-rightly-from a fetishism of Wes-
tern medical science and above all from purely materialistic patterns of medical ex-
planations to a more positive and sober evaluation of less chemical and materialistic
ways of looking at health and medical problems. Today generally the monopoly of
school-medicine is broken and a return to various alternative medical experiences
and practices is rampant. 80 All of these should be carefully tested, of course, and the
interest in the knowledge they contain should not go at the expense of sound scien-
tific methods. Today, we frequently find even a phenomenon, with its characteristic
dangers, opposite·to a one-sided dominion of school-medicine: a veritable boom of
alternative, unorthodox healing methods and of health theories a scientific explora-
tion of which is still missing and many of which are sham-medicine.
We must distinguish three things: There is a difference between the careful test-
ing and examining actual results and consequences (side-effects, etc.) of such alter-
native methods for patients and understanding why they work. In the first respect,
many of the outstanding results obtained by cures of 'complementary medicine'

78 These sophisticated cures and treatments of various circulatory problems with water of varying tempe-
rature, length of time, etc., are popular in Austria and Germany and have been developed further in
medical clinics. They show some remarkable results and have been tested by scientific methods and
found valuable.
79 Consider the totally unexplained effectiveness of healing practiced by the natural healers who are cal-
led 'Warzenmiinner' in Liechtenstein, or the largely unexplained effects of homeopathic medicine.
Even skeptics of these methods-like myself-will admit that some striking effects of these methods
in cases where treatments of school-medicine failed are undeniable.
80 The provincial exhibition of Lower Austria 1991 (Niederosterreichische Landesausstellung in
Gaming), for example, had as theme the art of healing in various chemical and natural forms. The ex-
istence of national exhibitions on such themes is a sign of the movement of contemporary medicine to
a more broadrninded vision of its history-away from a single-minded view of its linear progress
throughout history.
 NATURE AND GOALS OF MEDICINE 31

such as acupuncture, homeopathic medicine, diet-based allergy-treatments, etc., are

carefully investigated. In Austria, for example, there is an Academy of Complemen-
tary Medicine (Komplementarmedizin) which undertakes such careful studies and
fmds astonishingly clearly positive results of certain of these treatments and an ab-
sence of many of the side-effects of the medicines administered by school-medicine,
which is important for pregnant women or for patients suffering from heart-prob-
lems, etc.
Another question is the understanding why such methods of complementary
medicine (Komplementarmedizin) work. This is primarily of a purely scientific in-
terest and for the physician and patient of no real interest. If I get cured and if a
method works, at least when its side effects are carefully studied and are reduced to
a minimum, it is of no interest for me as patient or for the physician who takes care
of a health problem whether we understand why it works or have not the faintest
idea. Of course, such ail. understanding remains a significant goal from a purely the-
oretical point of view and also for future medical practice and a possible broader ap-
plication of methods of healing or treatment, which science presently cannot ex-
plain.
This understanding can thirdly also be significant from a purely philosophical or
religious point of view to the extent to which magic practices or obscure religious
ideas infiltrate such methods of 'natural medicine' and invite the patient to absorb
such ideas, which some claim frequently to be the case. But this certainly does not
apply to many of the ways of curing proper to such alternative medical methods that
are based on experience and knowledge lost in contemporary school-medicine.
In spite of all the limits within the sphere of modem empirical medical knowl-
edge and theory, however, today's vast body of scientific medical knowledge clearly
and overwhelmingly surpasses anything known to previous generations of physi-
cians. Therefore, the modem physician as scientifically trained healer represents,
generally speaking, an immense progress over the medicine man and over physi-
cians of past periods of medical science.
To sum up the general results of our reflection reached up to this point, we can
say the following things:
(1) Medicine is largely an experimental, inductive, and the 'most empirical sci-
ence'.
(2) Medicine is not being exclusively based on empirical methods, however,
which are unfitted for knowing the goals and ends of medicine.
(3) The physician is distinct from the pre-scientific medicine man by his training
in systematically, critically, and scientifically established knowledge about the func-
tions of the body and the causes of diseases and cures from them. 81
(4) In the scientific empirical exploration of the human body and of different
cures and technologies, and in the availability of the results of scientific investiga-
tions, we are faced with an immense progress and growth of knowledge. The pro-

81 Also Kant expresses this in Der Streit der Fakultiiten C, VII 26:
Der Arzt ist ein Kilnstler, der doch, wei! seine Kunst von der Natur unmittelbar
entlehnt und urn deswillen von einer Wissenschaft der Natur abgeleitet werden rnuB,
als Gelehrter irgend einer Facultat untergeordnet ist, bei der er seine Schule gernacht
haben und deren Beurthei!ung er unterworfen bleiben rnuB.
32 CHAPTER I

gress is overwhelming indeed with respect to the scientifically founded healing and
the technologies of medical practical art. With respect to these, the modem doctor
differs positively from the physician of previous times, let alone from the medicine
man or perimedical practitioner.
(5) This neither excludes that there are crucially important philosophical, ethical,
and a priori parts of comprehensive medical science (to which we shall return under
the heading 1.3. and in the whole second part of the present chapter), nor that alter-
native cognitions and forms of healing would not have been lost in school-medicine
and should be rediscovered.
(6) While it is crucially important that the individual physician gain access to the
results of medical research as quickly and as easily as possible, physician and medi-
cal researcher must not be identified. The importance of the quick and broad avail-
ability of the results of medical science becomes far more understandable when we
consider the fact that medicine is not a purely theoretical discipline, which pursues
knowledge for the sake of knowledge alone.

1.1.4. Medicine as Practical or 'Pragmatic' Science and the Respective Values of

Theoretical versus Practical Sciences
While each science and discipline, inasmuch as it pursues the knowledge of truth
and recognizes the value of knowledge as such, has a theoretical dimension, there
are purely theoretical disciplines such as metaphysics and philosophy as such in
which knowledge is primarily pursued for the sake of interest in the object of know1-
edge and of knowledge itself. 82 In the highest forms of cognition, knowledge is com-
pletely sought for its own sake in such a way that its own value is sufficient to
search for it and that no practical benefit needs to be derived from this knowledge in
order for it to possess its primary value. This is most true of metaphysics and largely
of philosophy as such.
This purely intrinsic justification and value of knowledge does not exclude, how-
ever, that superabundantly great benefits derive from such knowledge. Indeed, I
think that no other purely human knowledge can provide such far-reaching practical
consequences as philosophy, not only for the external administering of our lives and
states, but also for our happiness and personallives. 83 Nevertheless, the primary rea-
son to study philosophy lies in the meaning of the object and of our knowledge
thereof. No practical purpose is decisively or necessarily involved in our quest for
metaphysical knowledge. And precisely here, in the most non-pragmatic forms of
knowledge such as in philosophy, we find the noblest forms of cognition qua cogni-
tion, as Aristotle rightly states at the beginning of Metaphysics where he says that no
other discipline is more useless than metaphysics but none more sublime than it. For

82 See on the two-fold thematicity ofknowledge--object- and knowledge-thematicity, as well as on the

notional and contemplative theme of knowledge-Dietrich von Hildebrand, What Is Philosophy?, chs.
2 and 6.
83 Of course, religion and theology are in this respect even superior to philosophy, at least in certain re-
spects, while in others the benefits derived from philosophical knowledge remain supreme and irre-
placeable by any other knowledge including theology. This is already evident from the fact that theol-
ogy and religion necessarily have many philosophical presuppositions; and in regard to them at least,
they cannot replace philosophy or substitute for the benefits derived from philosophical knowledge.
 NATURE AND GOALS OF MEDICINE 33

its object and the knowledge gained in it alone fully justify its pursuit. Other forms
of knowledge are pragmatic, with a view to the practical goals to be achieved by
means of them, and therefore the knowledge itself attained in them, not being sought
so much for its own sake as for the sake of another good, thereby shows itself not to
be of the same high value as metaphysical knowledge.
While we agree with this judgment of Aristotle on the highest knowledge being
non-pragmatic, we must add that, depending on the height of those goods obtained
from knowledge which lie beyond the value of knowledge itself, it is not simply evi-
dent that 'practical' knowledge, inasmuch as it is sought for the sake of some other
good, is inferior to a purely theoretical one, at least not in all respects. For there
might be a higher value derived from a benefit that lies beyond knowledge itself.
And in this case the 'pragmatic' value of knowledge surpasses its purely theoretical
value qua knowledge. Certainly, nowadays we usually have in mind, under the
terms 'practical' and 'pragmatic', more physical results such as economic or career
advantages which of course also are of great importance for human persons. But the
same terms can refer to moral, cultural, or even religious goods that knowledge may
serve and that may well surpass the intrinsic value of a given knowledge. The goods
medicine seeks to realize, such as restoring and protecting human life and health, are
of a very elementary and at the same time high value.
And if we include under the name of 'practical knowledge', as Aristotle, the
Scholastics, and Kant did, ethical knowledge, it may well be questioned whether the
practical value of this knowledge does not even surpass its purely theoretical one.
For moral values are so deeply rooted in the essence of the person and surpass in
value all other personal values, as we shall see,84 that the acquisition of knowledge
in order to realize moral values can hardly be called 'pragmatic' at all, and certainly
must not be called 'practical' or 'pragmatic' in any disparaging sense. In this way,
inasmuch as some forms of ethical knowledge not only provide cognition of truth
but also guidance for the realization of moral values, this derivative value of ethical
knowledge is higher than the value it possesses in itself, if we agree that moral val-
ues rank higher than all merely intellectual ones. 85
This example already shows that under the umbrella titles of 'practical' and of
'pragmatic' we can include many things and many types of goods sought for by
means of knowledge, some ranking lower than scientific knowledge, others ranking
far higher. For this reason, the respective place of the value of medicine as theoreti-
cal and as practical science cannot be answered unequivocally but has to be an-
swered differently depending on which kind of practical goal of medicine one has in
mind.
If we take the term 'pragmatic' in its more 'physical' senses, not considering
here 'practical' values like moral ones, we must say that medicine is one of the most
clearly pragmatic fields of study. For we desire medical knowledge primarily for the
sake of some purpose outside this knowledge itself. Among these purposes the life

84 See below, chapter 3.

85 One must add that a purely theoretical and philosophical knowledge of ethics is not yet the practical
ethical knowledge which underlies directly our moral life.
34 CHAPTER I

and the health of human persons appear to hold a certain primacy and to be the
noblest ones.
Calling medical science 'pragmatic' could then be ambiguous and therefore mis-
leading, giving thus rise to different forms of misapprehension that we need to ex-
clude:
(a) A first potential misunderstanding of the 'pragmatic character' of medical
knowledge needs to be excluded: as if medical science, because of its practical
goals, were of inferior value. Let us state again that the height and the kind of the
'practical purpose' of a given knowledge or discipline accounts for immense differ-
ences in the rank of such a pragmatic knowledge. And given the immense impor-
tance of human life and health, the practical goods which medicine serves impart on
medical knowledge a greater dignity than many purely theoretical fields of study
(such as pure physics, pure mineralogy, etc.) possess.
Similarly to other pragmatic or practical sciences, the practical side and efficien-
cy of medical action is more important than its purely theoretical value: that a pa-
tient's life be saved is more significant than that the medical diagnosis and the theo-
ry of the physician, which underlies his treatments, embody a deep theoretical un-
derstanding of the human body, or that his judgments about the causes of diseases
and sources of healing be true.
(b) Now for such a pragmatic and practical discipline as medicine the recogni-
tion and knowledge of its goals, as well as its service to these, are decisive. This is
not true of purely theoretical disciplines which do not have such a practical goal,
though even they find their ultimate justificatIon in terms of their final cause and
goal which here lies first of all in the value of the knowledge itself which they aim
for but likewise in those (possibly even higher) values in the service of which they
and the knowledge gained in them stand. Thus, while some of what we are going to
say applies also to philosophy, most of it applies to medicine precisely because it is
a practical and pragmatic and not a purely theoretical discipline.
We could say with Aristotle that the final cause of medicine, which Aristotle
conceives as health, is the most important raison d'etre for the whole ofmedicine,86
though we will have to expand the Aristotelian description of the goals of medicine
so as to include other and equally or even more important goals of medicine besides
health. Medicine has to be understood primarily by its service to the goal of health
and to other goods.
(c) Not only the recognition of the nature and range of its practical use, the
knowledge of its ends, but also the actual service to these goals of those who prac-
tice medicine, are of utmost importance.
(d) It is in particular with respect to these goals that medicine is not a pure or
mere natural science and even less a mere system of neutral empirical cognitions
and techniques, but belongs to the humanistic arts and sciences, to the artes libera-
les among which, with the studies of law, it was included at some Italian Universi-
ties until recent times. In virtue of gaining knowledge of its true goals, and in its de-
dication to these, medicine goes beyond a purely empirical science. In these re-
spects, medicine is decidedly neither a natural science nor a merely empirical sci-

86 Aristotle, Nichomachean Ethics I, 1 (1094 a 5-10; 15).

 NATURE AND GOALS OF MEDICINE 35

ence but a hmnanistic and to some extent even a philosophical discipline. We shall
understand this humanistic dimension of medicine in particular when discussing
mental health. For this dimension of health makes it most clear that, in order to un-
derstand its proper end, medicine has to grasp much more than natural science af-
fords to know and has to teach more than practical techniques. It ha,s to proceed
from an understanding of the nature and value of hmnan health, of hmnan life, and
of hmnan personhood.
To say all this does not belittle the significance ofthe first two elements of medi-
cine: natural science and art. For they constitute an indispensable part of medicine
qua medicine. The best philosopher of medicine, and a person utterly committed to
the goals of medicine, may be the worst physician or no physician at all. This not-
withstanding, hmnan medicine has to be based on an understanding of the hmnan
person. Moreover, it is precisely in the light of the essential goals of medicine that
the significance of the empirical scientific and practical art of medicine reveals their
true meaning and importance. For only these goals reveal the value of medicine and
indeed constitute medicine qua medicine. For a person is and acts as a physician
solely as long as she serves these goods.
(e) Calling medicine a 'practical' or 'pragmatic' science calls for a further clari-
fication and prevention of another misunderstanding. Medicine is not exclUSively a
'practical' knowledge geared towards the restoration of health and the protection
and saving of other goods; it possesses its own dignity as pure theoretical medical
science and research. The value it possesses as a form of understanding the opera-
tions of the hmnan body, and even as investigation of the varieties ofhmnan infirmi-
ties and diseases, is different from its value derived from the practical advantages of
its service to hmnan health, and ensuing from this knowledge that tells the physician
how to act in order to promote health or save lives. There is definitely a high intrin-
sic value of medical science and understanding the wonder of the hmnan body and
of hmnan health. This high value is possessed by medicine as purely theoretical sci-
ence, i.e., completely abstracting from its practical applications.
It is in view of this its value of knowledge of the wonder of the hmnan body and
the hmnan being that it would be quite meaningful to study medicine even in a para-
disiacal world that would be free of diseases and other threats to hmnan health. Of
course, in such a world the study of the hmnan organism would not be called medi-
cine but perhaps' study of the hmnan body', or 'study of hmnan life and health' .
(t) Another misunderstanding of the designation of medicine as 'practical sci-
ence' is to be avoided. Medicine as practical science and as practical art does not
isolate medicine from a theoretical science. On the contrary: medicine as practical or
pragmatic science presupposes medicine as theoretical science, even though it might
limit the scope of its interests and investigations. (To realize these, one would have
to introduce pure medical science, comparable to pure physics, and distinguish it
from applied or practical medical science.)
Along the lines of Husserl's analyses of the relationships between theoretical and
normative disciplines,87 we can see that not only each normative discipline rests on a

87 See Edmund Husser!, Logische Untersuchungen. Text der ersten und zweiten Auflage, Bd. I: Prolego-
mena zu einer reinen Logik, hrsg. v. E. Holenstein, Husserliana, Bd. XVIII (Den Haag: M. Nijhoff,
36 CHAPTER!

theoretical one, but also each practical knowledge, in the last analysis, rests on a
theoretical knowledge or at least presupposes it, even if this is less clearly so in med-
icine and in more strictly experiential practical activities and pragmatic sciences
than in those normative sciences Husserl had in mind such as ethics, in which the
practical or ethical norms necessarily have a direct theoretical foundation from
which alone they flow.
(g) Whereas such a direct founding of a practical normative principle in a theo-
retical knowledge is found, for example, in the case cited by Husserl of the ethical
norm for a soldier: that he ought to be courageous-a norm that flows intelligibly
from the theoretical presupposition and truth that it is good to be courageous-such
a clear foundation of practical imperatives and actions in theory is not present in
medical praxis.
In medicine things are different because the practical effects can be learned by
experience and without understanding their reasons; in this sense, practical medical
knowledge does not rest entirely on theoretical foundations so as if these would have
to be known in order to know what sound medical praxis is. Physicians may well
have known for centuries what to with the blood of a patient after he had suffered an
accident, even if their opinions about the ground for the efficiency of such a treat-
ment and their theory about the movement of the blood were false and the discovery
of the circulation of the blood through William Harvey (1578-1657), and before in
Islamic medicine, was a much later medical discovery gained after the death of gen-
erations of physicians.
(h) In medicine the practical side is therefore relatively autonomous with respect
to theoretical knowledge in that it does not have to flow as intelligibly and as
directly from a theoretical conviction or from knowledge of the reasons why a cer-
tain treatment 'works'. While medical praxis also necessarily requires a theoretical
foundation in that it rests on the theoretical assumption or knowledge that the effects
of a certain practical action be good for the patient without which conviction medi-
cal praxis would lack its intelligible ground, medical action does not presuppose an
understanding of the causes of this practical efficiency. For this reason, medical
praxis does not necessarily presuppose the explicit or implicit theoretical knowledge
of the laws and facts that underlie it.

1.2. The Physician as 'Practical Artist' and Craftsman-and Progress in Medicine

The physician is not only a scientist and experienced knower of health and sickness.
He also is-in this respect not unlike the perimedical or premedical practitioner-a
practical man who exercises a practical art: the art of healing and of performing con-
crete actions which pertain to life, health or other basic ends the care for which is
entrusted to medicine. This side of the physician as a practitioner of the art of heal-
ing and medical care encompasses again a variety of activities each of which re-
quires more than purely theoretical knowledge and even more than just the applica-
tion of scientific knowledge to practical cases both in judgment and in action.

1975); Bd. IT, 1: Untersuchungen zur Phiinomenologie und Theorie der Erkenntnis, 1. Teil, Bd. IT, 2:
Untersuchungen zur Phiinomen%gie und Erkenntnis, 2. Teil, hrsg. v. U. Panzer, Husserliana,
Bd. xix, 1 und Bd. xix, 2 (Den Haag: Nijhoff, 1984).
 NATURE AND GOALS OF MEDICINE 37

If we look at the practical aspects of the medical art, we have to introduce a num-
ber of distinctions that lead us to acknowledge a great variety of such practical arts
in medicine:
(a) A very important and still more theoretical side of the practical expertise of
the physician consists in the experiential and prudential knowledge required for the
diagnosis of a concrete disease or of other concrete health problems. 88 This
diagnosis is often a mixture between an intuitive concrete cognition and the more
deductive method of proper subsumption of concretely observed symptoms under a
general pattern of diseases and under a theory. 'Intuitive' means here, unlike in
philosophy or mathematics, not a rigorous intellectual insight into essential necessi-
ties but something like an enlightened conjecture; diagnosis often begins with some
sort of enlightened guess that can be corroborated or refuted through a certain
number of tests deemed necessary by the physician in order to provide sufficient
foundation to his diagnostic judgment. Given the immense variety of symptoms of
diseases, and nevertheless their more or less clearly delineated general patterns, the
physician may nowadays, in difficult cases, even use computer-analysis as a help in
diagnosis, a help which of course can never replace the intuitive kind of knowledge
with the results of which the computer must be 'fed' by the practitioner. Not only
the gathering of the original input but above all any actual knowledge goes beyond
the capacities of the machine, which, as such, cannot think at all but only simulate
thought in various ways.89
(b) The practical side of medicine as art and as craft encompasses also a dimen-
sion of choice and of the will: the practical decision as to what to do in concrete
cases. This dimension of the art of medicine requires other faculties of the person: a
certain courage, a responsible taking risks, and elements of deliberation and of
evaluating the appropriateness of alternative healing methods, etc.
(c) Another and even more practical side of the physician as artist-most devel-
oped in the surgeon-consists in the ability and habit of actions required for carry-
ing out successfully and efficiently operations or other healing procedures, tests,
pain-relief, etc. This practical aspect of medicine ranges from the real art of highly
complicated and aesthetically challenging plastic surgery to a mere craft such as per-
forming routine surgery down to a mere administering of pain-killers or making in-
jections which any person without special training can be shown to do and which
neither require a special art nor craft.
(d) A further purely practical side of the medical art consists in the development
and use of techniques in surgery and in other forms of medical treatment, and in the
ability to use the products of modem technology in the service of these medical
techniques.

88 Also in this epistemological regard of the manifold methods and sources of medical knowledge we
find very interesting contributions in Paracelsus's immensely extensive and rich medical and philo-
sophical writings.
89 See on this Robert Spaemann, Personen. Versuche ilber den Unterschied zwischen 'etwas' und 'je-
mand' (Klett-Cotta, 1996); see also my "Sind Geist und Gehim verschieden? Kritische Anmerkungen
zu einigen Neuerscheinungen zum Leib-Seele-Problem," Allgemeine Zeitschrift fiir Philosophie 18.2
(1993),37--60.
38 CHAPTER 1

Here again we encounter immense progress in this sphere of medicine as practi-

cal art and in the use of technology. While certain aspects of diagnostic skills or
practical proficiencies in surgery may be crafts in which physicians of earlier times
may have rivaled our physicians or have excelled over modems, also in the second
respect, which is not scientific but practical, particularly in the technical aspects of
dentistry, surgery, etc., which are dependent on art and techniques as well as on
technologies, medicine has progressed enormously and keeps progressing continu-
ously. Consider for instance the development over the past few decades oflaser- and
computer-guided surgery, or of sophisticated methods of plastic surgery and dental
reconstruction. Think of the unheard-of techniques of prenatal medicine and surgery,
of stereotactic surgery by means of computerized MRI reconstruction, X-ray photo-
graphy, or of the efficient use of ultrasonics in neurosurgery, of the possibility of
blood transfusions and organ transplants, of cryosurgery (under temperatures of tis-
sues as low as -182° Celsius) used to destroy warts, cancerous skin lesions or cata-
racts, of surgical interventions by means of endoscopes, or of newest developments,
for example of techniques of performing brain surgery after having chilled the body
and having removed all blood from the brain, i.e. after having arrested circulatory
activity for a period of some time. 90
And yet, in spite of the many forms of immense progress in medicine, relativized
in certain areas of medicine in which ancient methods may excel over modem artifi-
cial chemical and unecological treatments, it would be premature to conclude that
medicine as such has progressed today. For the two mentioned dimensions, which
constitute that wonderfully strange being, the physician, namely scientific training
and practical art, do not exhaust his being and essence.

1.3. On the Constitutive Role ofa Philosophical Understanding of Man and

Morality for Medicine as Science, and ofMoral Commitments for the Physician as
Practitioner
The dimension which distinguishes the physician most from certain medicine men
and from magicians, and most of all from medically trained criminals, is either not at

90 See M. GrabenwBger, M. Ehrlich, D. Hutschala, A. Rajek, S. Thurnher, J. Lammer, E. Wolner, "Die

Chirurgie der Aorta descendens bei Dissektionen, Aneurysmen und Rupturen," in J Kardiol2001; 8:
30-33. The article reports on this technique of operating on the aorta descendens at the AKH Vienna
(in the Department directed by Univ. Prof. Dr. Ernst Wolner). Prior to the surgery the blood of the pa-
tient is taken out of the body of the patient, whose body is cooled to a temperature of 18° Celsius so
that a deep hypothermia and arrest of blood circulation can be induced without lethal consequences;
during the arrest of heart-beat the blood of the patient is collected in a heart-lung-machine so that the
surgical intervention (bypass operation) and potential replacement of parts of the aorta through artifi-
cial parts of the aorta can be performed in a 'dry operating field'. The use of oxyen sinks by 5% per
each Celsius degree of cooling the body temperature. The EEG in such patients during the arrest of
the circulatory activity and the external collection of blood equals that of a dead patient. Up to 50 min-
utes remaining of patients in this state is tolerated by brain cells and other parts of the nervous system.
Professor of Psychology Dr. Giselher Guttmann (University of Vienna) and his team examined the pa-
tients who underwent this surgery three times: before, shortly after, and three months after the opera-
tion. After three months they found considerably improved cognitive functions in the patients who had
undergone and survived this surgery.
 NATURE AND GOALS OF MEDICINE 39

all or insufficiently taught at most medical schools91 -and yet constitutes the
deepest mark which distinguishes the ars medica from a mere acquaintance with the
causes of health and sickness used to harm human beings, and the physician from
the scientifically trained opposite of the physician: i.e. from persons who use their
scientific medical knowledge to harm or destroy the goals of medicine instead of
serving them. The physician is therefore essentially and as physician determined by
his goal, by his vision of man, and by an ethics and personal moral commitment
based on this understanding of the human person. 92 And it is here that philosophy
and medicine meet most deeply and that the medicine man who kills or tortures
tribal enemies, or the criminal medical technician who becomes an instrument of
Nazism or of other evil regimes, differs most radically from the physician as the
practitioner of the art of healing and of life-saving. 93 Any untrained person who
seeks to heal or to save life is more similar to the physician than the medically
trained person who destroys health or life.
Therefore, we dedicate the entire second part of this chapter to the decisive topic
of the ends and goods of medicine.

2. THE PHYSICIAN-PHILOSOPHER: THEORETICAL AND PRACTICAL

PHILOSOPHICAL AND ETHICAL ASPECTS OF MEDICINE

2.1. The Goods Medicine Is Called to Serve and the Indispensable Moral Choice of
the Physician
It is from the commitment to its goals and the goods it is called upon to serve that
medicine receives its 'form' and essence. In order to understand better the practical
goods and goals of medicine, a personalistic concept of health and of life as well as
of the other goals of medicine-its service to alleviating sufferings, to preserve hu-
man consciousness, to restore the disfigurations of bodily form, and to the overall
good of the human person and the absolute good-is needed. 94 In this its philosoph-

91 The Medical School of the Pontifical Catholic University of Chile in Santiago is a laudable exception
to this rule. More and more universities world-wide recognize the indispensable need of bioethical
education as part of medical studies. Unfortunately, most of the time these ethical studies are more
than inadequate, and even harmful because of primitive, sophistical, and other false ideas which
dominate them.
92 See also Elio Sgreccia, Manuale di bioetica I. Fondamenti ed etica biomedicale, II. Aspetti medico-
sociali.
93 Plato shows a clear awareness of this in prescribing in the Laws S 933 even death penalty to a physi-
cian who harms the health or life of others:
So this statement shall stand as the law about poisoning:-Whosoever shall poison
any person so as to cause an injury not fatal either to the person herself or to her em-
ployees, or so as to cause an injury fatal or not fatal to her flocks or to her hives,-if
the agent be a physician, and if he be convicted of poisoning, he shall be punished
by death; but if he be a lay person, the court shall assess in his case what he shall
suffer or pay.
94 The development of a personalistic concept of human health was the theme of a two-year research
project at the International Academy of Philosophy in the Principality of Liechtenstein, supported by
the Swiss National Science Foundation (Schweizerischer Nationalfonds zur Forderung wissenschaft-
licher Forschung), which I directed. See some of the results in publications: Kateryna Fedoryka,
40 CHAPTER 1

ical dimension, medicine includes likewise various theoretical and ethical dimen-
sions, quite apart from requiring a personal moral commitment from the physician
and nurse.
It is the ethical as well as the theoretical philosophical dimensions of medical
science, a philosophical medicine and medical ethics, which will occupy us in the
following extensively and constitutes one main theme of a philosophy of medicine
and bioethics.
It is indicative of the change of times that Aristotle tries to exemplify the neces-
sity by which man, according to his view, strives for his happiness, and can choose
only between the means that lead to it, by reference to medicine, saying that the
freedom of choice of the physician does not refer to the goal, health, which is fixed
as his end by necessity. The choice could only refer to the means towards this end:
"A physician does not ask himself whether he should heal a sick person ... in such
matters one never deliberates about the end to be achieved ... ,,95
St. Thomas Aquinas agrees in his Commentary In decem libros ethicorum Aris-
totelis ad Nichomachum expositio completely, so it seems, when he says:
One has to consider, however, that in practical activity the end is the first principle; for
on the end the necessity of actions depends. And therefore one has to presuppose the
end ... for thus the physician does not deliberate whether he should heal the patient but
presupposes this as his end. And therefore no other subject of practical deeds deliberates
about the end. 96

Thus, Thomas says even more strongly that no acting person deliberates about
her end. Prescinding from the falsity of these statements also at the time they were
written, these Aristotelian and Thomistic statements give an impressive witness to a
noble age in which the goals of medicine and the principles of medical ethics were
taken for granted and in which the goods of life and health were regarded as the ob-
vious goals of all medical services.

"Health as a Normative Concept: Towards a New Conceptual Framework," Journal of Medicine and
Philosophy (22)2: 143-160, Ap 97; the same author, "Uber die Moglichkeit einer objektiven Grund-
lage in einer subjektbezogenen Medizin," in Imago Hominis, Bd. IV, Nr. 2 (1997), pp. 125-132;
Kateryna Fedoryka-Cuddeback, with Patricia Donohue-White, "The Good of Health: An Argument
for an Objectivist Understanding," in Paulina Taboada, Kateryna Fedoryka-Cuddeback, and Patricia
Donohue-White (eds.), Person, Society and Value: Towards a Personalistic Conception of Health
(DordrechtlBostonILondon: Kluwer 200 I). See also Paulina Taboada, Kateryna Fedoryka-Cuddeback,
and Patricia Donohue-White (eds.), Person, Society and Value: Towards a Personalistic Concept of
Health, symposium proceedings. See likewise Patricia Donohue-White, "Situating the Value of
Health in the Hierarchy of Values. Reflections from the value philosophy of Max Scheler," in James
M. DuBois (ed.), Phenomenology and Value Realism, in review with Kluwer. See also Josef Seifert,
"What is Human Health? Towards Understanding its Personalistic Dimensions," in Person, Society,
and Value: Towards a Personalistic Conception of Health; the same author, "Moral Goodness and
Mental Health."
95 Aristotle, Nichomachean Ethics III, 1112 b 12 ff.
96 See Thomas Aquinas, In Decem Libros Ethicorum Aristotelis ad Nichomachum Expositio, 1. III, I,
viii, 474:
Est autem considerandum quod in operabilibus finis est sicut principium; quia ex
fine dependet necessitas operabilium. Et ideo oportet finem supponere ... quia scili-
cet medicus non consiliatur an debeat sanare infirmum, sed hoc supponit quasi fi-
nem ... Et sic nullus aliorum operantium consiliatur de fine.
 NATURE AND GOALS OF MEDICINE 41

Even Aristotle knew the Hippocratic Oath, however, and could have concluded
from the fact that Hippocrates asked the physician to swear never to administer a po-
tion deadly to the child of a pregnant woman and never to commit euthanasia, even
when begged by the patient, nor to use any medical knowledge against health or life,
and to abstain from many other acts, that the proper ends of medicine must be freely
willed and that the opposite ends can be willed as well. In fact, the whole Hippo-
cratic Oath is permeated by the conviction that the physician is in constant and great
danger to betray the goals of his art, to substitute for them others and opposite ones,
or at least to violate them .. Let us recall the text of this Hippocratic Oath:
I SWEAR ... that, according to my ability and judgement, I will keep this Oath and this
stipulation .... 97 I will follow that system of regimen which, according to my ability
and judgement, I consider for the benefit of my patients, and abstain from whatever is
deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor
suggest any such counsel; and in like manner I will not give to a woman a pessary to
produce abortion. With purity and with holiness I will pass my life and practice my Art .
• • • 98 Into whatever houses I enter, I will go into them for the benefit of the sick, and
will abstain from every voluntary act of mischief and corruption; and, further, from the
seduction of females or males, of freemen and slaves. Whatever, in connection with my
professional service, or not in connection with it, I see or hear, in the life of men, which
ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be
kept secret. While I continue to keep this Oath unviolated, may it be granted to me to
enjoy life and the practice of the art, respected by all men, in all times. But should I tres-
pass and violate this Oath, may the reverse be my lot. 99

97 Here follows the beautiful moral commitment to the physician's teachers and their family and his
commitment to teach medicine only to those who keep this oath:
- to reckon him who taught me this Art equally dear to me as my parents, to share
my substance with him, and relieve his necessities if required; to look upon his off-
spring in the same footing as my own brothers, and to teach them this Art, if they
shall wish to learn it, without fee or stipulation; and that by precept, lecture, and
every other mode of instruction, I will impart a knowledge of the Art to my own
sons, and those of my teachers, and to disciples bound by a stipulation and oath ac-
cording to the law of medicine, but to none others.
98 Here a passage follows which is outdated in its concrete content but still important today in that it en-
tails a recognition both of the principle of subsidiarity, that demands that not everything be done on
the top level, and a recognition of the limits of the physician's art; in some subordinated forms of
medical actions other professionals have greater expertise and the physician ought to recognize this: "I
will not cut persons labouring under the stone, but will leave this to be done by men who are practi-
tioners of this work."
99 The text is taken from an article available on Internet: The Internet Wiretap Edition of Oath and Law
of Hippocrates. See also the following introductory note ibid.:
HIPPOCRATES, the celebrated Greek physician, was a contemporary of the histo-
rian Herodotus. He was born in the island of Cos between 470 and 460 B.C., and be-
longed to the family that claimed descent from the mythical Aesculapius, son of
Apollo. There was already a long medical tradition in Greece before his day, and
this he is supposed to have inherited chiefly through his predecessor Herodicus; and
he enlarged his education by extensive travel. He is said, though the evidence is un-
satisfactory, to have taken part in the efforts to check the great plague which devas-
tated Athens at the beginning of the Peloponnesian war. He died at Larissa between
380 and 360 B.C. The works attributed to Hippocrates are the earliest extant Greek
medical writings, but very many of them are certainly not his. Some five or six,
however, are generally granted to be genuine, and among these is the famous
"Oath." This interesting document shows that in his time physicians were already
42 CHAPTER 1

It is quite possible indeed for the physician to substitute for the true goods and
goals of medicine other and opposite ones. Therefore, the oath is called for. Political
powers such as the Nazi-regime, communist orders to send healthy people to mental
institutions or insane asylums, immoral commands of dictators, etc., can seduce the
physician to reverse the goals of medicine; and so can financial gain from abortions
and euthanasia or other seductions and social pressures. 100 (Euthanasia accounts
presently already for more than 2% of all deaths in the Netherlands,lol and abortion
in many countries already for more than 50% of all death incidents, in some
countries, for example in Russia or in China, even for much higher percentages. This
shows as it were statistically that there is no necessity to will the essential goals of
medicine. At the same time, the use and contents of professional medical oaths keep
declining. I 02)
Therefore, as much as we agree with Aristotle on the primary determination of
the art of medicine in terms of the end it is destined to serve, we cannot agree with
him at all when he overlooks both the need to will this end freely and the possibility
to substitute this end by its opposites.
Aristotle's use of the allegedly necessary directedness of the physician's inten-
tion at the good of health as illustration of the necessity with which man wills his
own happiness as his final end is strange for another reason. 103 For according to
Aristotle's general eudemonistic ethics we will necessarily, and can only will, our

organized into a corporation or guild, with regulations for the training of disciples,
and with an esprit de corps and a professional ideal which, with slight exceptions,
can hardly yet be regarded as out of date. One saying occurring in the words of Hip-
pocrates has achieved universal currency, though few who quote it today are aware
that it originally referred to the art of the physician. It is the first of his "Aphorisms":
"Life is short, and the Art long; the occasion fleeting; experience fallacious, and
judgment difficult. The physician must not only be prepared to do what is right him-
self, but also to make the patient, the attendants, and externals cooperate."
100 See on this the ethics for physicians, Deontologia medica segun el derecho natural, by G. Payen, S.l.
(Barcelona: Rambla, 1944).
101 According to a scientific report, cited in the Neue Zurcher Zeitung (279), 29.11.96, 3,200 patients
were killed by euthanasia in Holland in 1995, which amounted to 2.4% of all deaths in that period in
the Netherlands. Moreover, in the same period 9,600 patients asked for deadly drugs; 50% of all phy-
sicians practicing in Holland already performed active euthanasia, and only 12% of Dutch physicians
categorically refused euthanasia.
102 In this regard, recent findings are very interesting. See Robert D. Orr, Norman Pang, Edmund D.
Pellegrino (& others), "Use of the Hippocratic Oath: A Review of Twentieth Century Practice and a
Content Analysis of Oaths Administered in Medical Schools in the U.S. and Canada in 1993," J Clin
Ethics (Wint 1997), 8 (4): 377-388. This paper contains a survey of all medical schools in North
America to see what oaths were used in 1993. A comparison of similar data to surveys from 1928,
1958, 1978, and 1989, and a comparison of the content of current oaths with the classical Hippocratic
Oath led to interesting results. There has been a considerable quantitative increase (24% to 98%) in
the use of professional oaths in medical schools in the U.S. and Canada this century. At the same time
there has been a steady decrease in several content items (invoking deity -II %; abjuring sexual impro-
priety towards patients -3%, abortion -8%, and euthanasia -14%) from the classical Hippocratic Oath.
103 Luc Dauvin (a student) inspired these comments by an excellent remark he made in a course I taught
in the Spring of 1997.
 NATURE AND GOALS OF MEDICINE 43

own self-fUlfillment and happiness. 104 Now, a valid attempt to exemplify this neces-
sary goal of all human action (eudaimonia) seems to contradict the illustration of
this goal by the physician's aiming at the healtll of his patients. For this goal is in no
way self-centered but essentially other-directed. 105 The physician may even be ob-
liged to help a sick person (for example one who has the plague) riskirlg his own
health, life, and happiness. Thus, precisely the example of the physician's (allegedly
necessary) will to promote health should have shown Aristotle the indefensibility of
the immanentistically conceived good of eudaimonia (of our self-perfection and
happiness) as the supreme good which we (allegedly) will by necessity.
Be that as it may, at any rate objectively the physician not only does not will the
good of the health of others necessarily, but rather has to commit himself freely to it;
he also does not will just his own good but primarily serves that of others, and is, for
example at a time of plague, even ready to sacrifice all his own goods, including his
very health and life, to save the health and life of others. The whole ethics of Aris-
totle could at this point be improved by applying his analyses of the goal of medi-
cine back to general ethics.
Nevertheless, while Aristotle is definitely wrong in his claim that the physician's
acts are necessarily directed at health, he is definitely right on another and most es-
sential point: From this end of the good of the patient (to be willedfreely, as we have
seen!) medicine receives its most decisive essence. From faithfully and freely serv-
ing the goals oflife-saving and healing medicine receives its purpose and dignity, its

104 One could, however, note that in certain passages, for example in books VIll and IX of Nichomachean
Ethics, and in Magna Moralia, Aristotle states that true friendship requires love of one's friend for his
own sake. See, for example, Aristotle, Magna Moralia II, 1212a28-12l2b8:
13 . Since tiJere is, as we maintain, such a tiJing as friendship towards oneself, will
tiJe good man be a lover of self or not? Now tiJe lover of self is he who does every-
thing for his own sake in matters of advantage. The bad man is a lover of self (for he
does everything for his own sake), but not tiJe good man. For tiJe reason why he is a
good man is because he does so and so for tiJe sake of another; hence he is not a
lover of self. But it is true that all feel an impulse towards tiJings tiJat are good, and
tiJink tiJat they tiJemselves ought to have tiJese in tiJe highest degree. This is most ap-
parent in tiJe case of wealtiJ and rule. Now tiJe good man will resign tiJese to another,
not on tiJe ground that it does not become him in tiJe highest degree to have them,
but if he sees tiJat another will be able to make more use of these tiJan he.
See also Aristotle, Nichomachean Ethics vm, 1155bI7-1156a5: " ... but to a friend we say we
ought to wish what is good for his sake."
See also ibid., 1161alO-1161a29; ibid. IX, 1168a28-1168a34: "while the good man acts for
honour's sake, and tiJe more so tiJe better he is, and acts for his friend's sake, and sacrifices his own
interest."
Also, at the end of Eudemian Ethics and of Magna Moralia, Aristotle says tiJat the supreme hap-
piness and good of man is to give glory to God. In these and in some other passages, he introduces a
transcendent end of human life and action and overcomes the eudaemonism tiJat characterizes Book I
of Nichomachean Ethics and other passages of his work.
105 Mr. Dauvin tiJought tiJat for this reason, of having named tiJe healtiJ of patients tiJe necessarily willed
and first goal of medicine, Aristotle cannot have been a complete eudaemonist as he is often depicted.
But I believe that, while in many passages in Aristotle (for example, in his books on friendship in his
Nichomachean Ethics) and in this text, Aristotle does indeed transcend eudaemonism, he still holds a
strong version oftiJis position in tiJe general structure of his philosophy. This does not prevent tiJe fact
tiJat Aristotle has frequently his deepest insights when he does not just express the views that corre-
spond to his system.
44 CHAPTER 1

whole respectability. Entirely divorced from it, it becomes an exercise in crime. And
when the medical professional uses his knowledge and skills, rather than in order to
save life, in order to hann or to kill persons-perhaps in view of a financial gain or
for other motives-medical skills are degraded to a mere technical proficiency and
medicine ceases to be medicine. When alienated from its ends, it loses its essential
nature, which is inseparable from its commitment to its ethical and human ends. And
any dabbler in medical science and art, who takes, however, some healing measure
and who thus serves the goals of medicine, is more of a physician than a brilliant
medical technician and scientist who abuses his art for destructive ends such as the
Nazi physicians who starved babies of the inmates of concentration camps to death
in order to see how they would react to starvation,106 or who injected viruses and
bacteria in healthy women in order to study the percentage of deaths and of other
bad effects of diseases. 107 Such a turning of medicine against its proper ends we find
in an alarming and historically and quantitatively speaking unmatched measure in
the contemporary practice of medicine, as we shall see.
The positive ends and goals of medicine, however, we will have to investigate
more in depth and more in detail, dedicating in the second volume of this work sepa-
rate chapters to them and to the many moral obligations that proceed from them.

2.2. The Seven Goods or 'Seven Ends' the Physician Should Serve and Respect

It will be worthwhile to reflect on the ends or on the goods the medical professional
has to promote-by saving or maintaining them, or by bringing them about. It could
be shown that many of these goods (such as life, alleviation of pain, and health) are
also the aims of veterinarian medicine but possess there, on the level of animal life,
a profoundly different character which accounts for the fact that many actions which
are perfectly legitimate when committed towards animals would be morally pro-
foundly wrong when committed towards human patients. In the following, we will
investigate the goods and goals of medicine only from the point of view of human
medicine.
Few things are more significant for philosophy of medicine and medical ethics
than a reflection on these goals of medical science and practice, and on the obliga-
tory, licit, and illicit fonns of promoting them or acting against them. For such an in-
vestigation will allow us to understand four things: (a) which ends and goods the
physician should aim at and promote; (b) that there are fonns of promoting them
which are obligatory, or good and desirable, whereas others are wrong because they
violate morally relevant values; (c) that each of these goods the physician should
serve can be replaced by the respective evils which the medical professional often is
tempted to bring about and that therefore the succor of these basic goods is not nec-
essary but object of free choice; (d) and that the finality of medical action-which

106 I saw and heard myself the Jewish mother of such a baby on TV when she told the horror-story of the
notorious and opprobrious Dr. Mengele conducting this gruesome experiment on her baby, forbidding
her to breastfeed or in any other way to feed her baby, letting it starve to death before the eyes of his
mother, who was only allowed to try to quiet the baby as much as possible and who described how
she experienced this elegant and polite Nazi-physician as a veritable devil, ordering such an action.
107 See Wanda P6ltawska, Und ich forchte meine Triiume.
 NATURE AND GOALS OF MEDICINE 45

constitutes the very form and essence of the medical profession---can only be under-
stood by reference to philosophical truths which fall outside the scope of empirical
science.

2.2.1. Medical Service to Human Life in Its Uniqueness and Specifically Personal
Nature as well as in Its Right Place in the Whole Order o/Goods
The most fundamental good medicine serves is not health but life which the physi-
cian often has to save or to maintain; and undoubtedly, in the treatment of infertility,
he has also to help by aiding parents in the generation of new life and above all by
removing obstacles to its origins. Life, and in human medicine human life, is the
goal of three ethically legitimate kinds of medical actions:
(a) acts of serving the coming to be of new human life (in removing sources of
infertility and in assistance to fertility or rather in helping couples to conceive);
(b) actions of taking prophylactic measures (for example by immunization) of
protecting life against its destruction through sickness and other health problems;
(c) acts of saving life (for example by life-saving surgery) when it is in peril of
death or would be destroyed without medical intervention.
Life is an ultimate good and an Urphiinomen, an archphenomenon. It is comple-
tely irreducible to health already for the reason that it is primary with respect to
health as well as with respect to the latter's opposites or enemies: diseases, sick-
nesses, and infirmities of any kind. lOS Not only health but also disease and infirmity
presuppose necessarily life. Therefore, the good of life cannot be reduced to that of
health. (This is also evident from the tragic case in which great pain or a complete
absence of health leads to the wish of ending life in euthanasia or suicide in order to
escape the evils of incurable sickness or relentless pain.) The service to human life is
a first and most fundamental goal of medicine, as we shall see better when we will
discuss the value and dignity of human life in depth. Therefore, no more radical per-
version of medicine can be imagined than its turning to the very opposite of its first
and foremost task of serving human life.
Many branches of medicine are or should be occupied with the service to life.
Gynecology, obstetrics, and reproductive medicine ought to turn medical attention to
fertility problems, ought to protect the nascent life of the embryo and give it prenatal
care, assist at birth and thus serve in many ways the life and the coming to be of the
baby. Immunology serves to protect countless human lives from destruction. Inten-
sive care units or departments in hospitals, emergency medicine and other branches
of medical activity contribute to saving lives that are in immediate danger. Parts of
gerontology and medical care for the old also are involved in saving the lives of the
elderly.
With respect to medical services rendered in the service of the coming into being
of human life and of the protection or saving of life, we note once again, before our
more detailed analysis, that the branches of medicine which ought to be concerned
with this task, have today, more than ever in the history of medicine, by having turn-
ed to destroy the lives of the elderly and the unborn, changed into their own oppo-
sites: into forms of anti-medicine.

108 See Josef Seifert, What is Life?

46 CHAPTER I

More conspicuously than in euthanasia (with its often covert forms), countless
human lives of the unborn are destroyed today through abortion and abortifacients
such as RU 486 (Mifegyne), and through numerous other means of killing babies up
to the ninth month of pregnancy (as in the 'eugenic' abortions for the reason ofphy-
sical or mental handicaps, which type of abortion can be performed in many coun-
tries, such as Austria, up to birth without any legal sanctions to protect such lives
that obviously are regarded as '/ebensunwertes Leben ,), and even up to the middle
of the process of birth (in the 'partial birth abortions,).lo9 Abortions just moments
before birth are a particularly clear demonstration of the fact that to defend abortion
is clearly to defend infanticide and that what is being killed in abortion is not some
animal-like creature but a human baby who in most states, from the completion of
birth on, enjoys the full protection of the law but in many countries, also of the al-
leged 'axis of the good' (such as the USA and, in case of handicapped unborn, most
Western European countries), can be cruelly slaughtered seconds before. Something
similar applies to other medical actions destined to serve human life. Instead of serv-
ing fertility or teaching couples about their fertility or morally acceptable forms of
family planning and responsible parenting, 'reproductive medicine' concentrates to-
day far more on 'anti-reproductive measures' such as the temporary or permanent
anti-life acts which do not serve the coming to be or the saving of human lives but
the destruction of human fertility through sterilization, through the pill, through
IUD's, not to speak: again of the destruction of human lives themselves through
abortion. l1 ° Calling such actions 'medical', presupposes a concept of medicine di-
vorced from its primary end in the service of life, a value-free concept of human life
that becomes more and more widespread. III
If we can provide evidence that medicine ought to protect human life at all times
of its duration, a great perversion of physicians' relation to this flrst goal of medi-
cine becomes apparent today also at the other end of life, that of senior citizens, Alz-
heimer patients, and other suffering or demented patients a growing number of
whom are killed by euthanasia. This is increasingly true of the 'health-care' given to
the elderly in overt euthanasia in an increasing number of states, but also in covert
euthanasia that is performed in most countries today by medical staff 'discontinuing
tube feeding' (i.e., by starving patients to death), and by other procedures which are
given nice names but remain what they are: killing human persons.
This is not to deny that precisely the most advanced modern medicine also today
continues to serve many times the coming to be of human life, through fertility pills

\09 This horrible 'method' of abortion in which the baby's head is crushed and its brain sucked out during
the process of its being born was sanctioned by President Clinton in 1996 against the overwhelming
majority of the American Congress. Clinton overruled the Congressional Vote on this issue through
his presidential Veto. One assumes that ca. 5,000 babies, almost twice as many human beings than
those killed on the 11th of September in the terrorist attacks on the Twin Towers, are killed every year
in the USA using this gruesome method.
110 There are of course also today in the areas of gynecology or 'reproductive medicine' physicians who
dedicate themselves full-heartedly to the protection of human life, such as the Drs. John and Lynn
Billings and many others who practice this branch of medicine with utmost responsibility.
111 A beautiful and impressive exception is San Salvador which passed a Constitutional Amendment on
February 5, 1999, according to which the fIrst article of the Constitution now reads: "Likewise, it rec-
ognizes as a human person every human being from the instant of his conception."
 NATURE AND GOALS OF MEDICINE 47

and frequently through other spectacular new ways of infertility-therapy as well as

through saving or preserving the lives of the elderly.
The value of the service to the great goods of the existence and protection ofhu-
man life does not imply, however, that each and every means to procure this end is
justified. There are also, as we shall examine in detail, many ways of furthering life
and of assisting its coming to be, even when no fetuses and fertilized eggs are de-
stroyed,112 which are nevertheless morally wrong though they do not inflict any
harm on human lives. Actually there are two kinds of contradiction in medicine to
those actions of serving life to which medicine is called: acts of destroying human
life and acts of aiding its coming to be which are illegitimate because they divorce
the origins of life from other goods in whose context alone we find a truly human
and worthy origin of human life. Also the second opposition to the first goal ofmed-
icine is generally recognized today in many countries with regard to certain acts,
such as heterologous artificial insemination, but not with respect to many others. I 13
This shows that the first goal of medicine is not the isolated good of human life
but human life in its context of many other values and goods, with which it is con-
nected, especially those regarding the dignity and appropriateness of its origin. For
not only the value of human life as such, and the question whether one brings it
about or harms and destroys it, but also those fundamental human values which are
essentially linked with the only worthy origin of human life, must be respected by
medicine: its proceeding from the sexual act of the parents which is destined to ex-
press the mutual and definitive spousal love between them. In heterologous in vitro
fertilization, for instance, medicine serves the first goal of medicine, the good of hu-
man life, but violates the bond between marital love and the coming to be of a new
human person. But also many other values which have to do with morality, shame,
or discretion-as they are today often emphasized by the movements towards a
'frauengerechte Medizin'114 (a medical practice respectful of, and appropriate to,
women)--must be protected in serving this good of life. For these other values and
goods are intimately connected with human life.
Inasmuch as medicine should prevent deadly diseases and protect human persons
from them, we find a large scale of positive and progressive medical services in the
service of human life: more life-protecting actions and life-saving immunizations
can be and are administered by medicine to growing masses of people than ever be-

1\2 As in using or producing embryos to obtain stem-cells, or in IVF in which 'unused' fertilized human
eggs (and hence human lives) are destroyed.
113 We find in modem reproductive techniques such as in IVF, as we shall argue, not only a 'production'
of human life unworthy of the dignity of human life, but often these very same ways by means of
which the range and time-period of human fertility is enlarged and conception is made possible in
cases in which it was impossible before, for example through IVF, leads also to the destruction of oth-
er human lives. By destroying for example in the process of in vitro fertilization many human em-
bryos in order to achieve a single successful fertilization, and in destroying the 'surplus' or 'useless'
or 'unused' fertilized human eggs. Think of the British laws regulating the length of time fertilized hu-
man eggs may be kept cryo-conserved, and remember the destruction of thousands of fertilized eggs
in England (in 1996), at Prime Minister John Major's order, or of recent court orders forbidding the
adoption of unwanted embryos (cryo-conserved fertilized eggs).
114 The name of a new organization in Switzerland.
48 CHAPTER!

fore in history. Here we find a pure progress in modem medicine, only limited by
frequently shortsighted and wrong priorities set in medical research and funding. liS
With respect to the third goal of medicine regarding life, the saving of life when
it is directly at risk in consequence of acute health conditions, medicine likewise
made undoubtedly tremendous progress and is able to provide services to life never
achieved before. Precisely because medicine is better able to serve life in this form
than ever before, the perversion of medicine is particularly great when it turns to-
day-in incredible numbers of percentage points-against this its most specific ser-
vice, that to human life.
Ways to violate directly this third medical service to human life are-besides
abortion and euthanasia-assisted suicide, murder of any kind, torture which leads
to death, etc. All these acts are the strict contrary opposite of saving and protecting
life medicine is called to. Intentional and free acts, which aim at the destruction or
harm of human life, are always and under all circumstances wrong, as will be
shown. While this is true, and can be easily understood in its objective evidence by a
truth-loving mind that opens its intellectual eyes to seize truth, it is far from being
'obvious' in the sense that this evil would be recognized without difficulty or by ma-
jorities, let alone by all. The evil that lies in the perversion of a professional medi-
cine that serves largely the destruction of human life, instead of the saving and pro-
longing it, is overlooked by most.
As we have already seen in critique of Aristotle's philosophy of medicine: The
service to human life is not necessarily willed but a freely chosen goal of the physi-
cian. This good of human life is in many situations obligatory, for example in all cir-
cumstances in which its direct violation is at stake which always is forbidden or
when the assisting in birth is obligatory, such as when labor or childbirth have begun
and someone is in a position to help. In other circumstances, the service to human
life is not strictly obligatory, such as when we deal with increasing the chances of
fertility by fertility pills. I 16
In all cases, however, in which the physician is called upon to serve life, the ser-
vice to life has to be chosen freely by the physician.
When we look at the history of medicine, we recognize the fact that the moral di-
rectedness at the affirmation and protection of life which belongs to the essence of

115 In 1996, representatives of the famed Weizman Institute, a medical Research Institute in Israel, ex-
plained on the First Austrian Radio Station that every year the death of approximately more than 10
million people in the Third World from infections caused by parasites could be prevented if more
means were used for this branch of research. But since almost exclusively poor countries, in which
bad water quality leads to these parasite-caused infectious diseases are affected, the big money of
pharmaceutic industry does not flow into this part of research whose products the poor patients in
these countries could not pay for. Instead, medical industry develops frequently less needed medicines
or even means destructive of human life and health as long as the free market pays for them. These are
not only horribly misguided practices, which show that the ends of medicine touch not only medicine
itself but also industry, economic systems and politics, but they prevent also decisive medical progress
in understanding the development of immunization of bacteria and viruses which lead to the ineffec-
tiveness of those antibiotics which are used in the fight against most infectious diseases. Hence the
shortsighted policy of medical research also deprives the Western patient of significant blessings of
medical progress.
116 These can lead frequently to anti-life actions such as the selective abortion if 'too many' babies were
conceived.
 NATURE AND GOALS OF MEDICINE 49

the physician qua physician is not necessarily fulfilled by the medical practitioners,
by whom often life was destroyed and harmed, under the influence of different poli-
tical systems on medicine as well as by abortion and euthanasia. Even great and
noble thinkers did not reject the direct killing of innocent human life absolutely and
under all circumstances. 117
Peter Singer presented a well-known recent attack on such an absolute moral rel-
evance of the good of life. Singer uses the fact that many ancient thinkers proposed
eugenic abortions and other acts directed against life as an argument against bioethi-
cal positions such as the one defended here. He says that Plato and Aristotle recom-
mended the killing of deformed children. This interpretation might be correct, al-
though one could dispute it. 118 Great philosophers' opinions are never decisive argu-
ments for any position, only truth is. Singer himself should not hesitate to admit this:
For example, most philosophers now see it to be evidently the case that women pos-
sess the same dignity as men. The Greeks denied this. Aristotle also regarded wom-
en as essentially inferior to men, and Peter Singer would admit this Aristotelian
opinion to be false and even nonsense. Aristotle regarded non-Greeks (barbarians) as
essentially inferior to Greeks, and Singer would regard this as absurd. Aristotle
thought that some men are born slaves, and Singer would see this as a contradiction
to the intuition that all men are equal and born free. An evolutionary atheist and ma-
terialist will have to admit that the errors of Aristotle or Plato are not measures for
what we ought to consider being true. Singer overlooks this, however, as well as the
fact that the philosophy of man implied by both Plato and Aristotle (the existence of
a soul and its immortality) are exactly those foundations of which Singer holds that
they would make the euthanasia of handicapped human beings morally wrong. 119
Moreover, philosophical errors in ethics could be explained in quite different ways
than by Singer's relativism and denial of the truth that intentional and direct killing
of innocent human beings is always wrong. 120

117 This is even true of some texts in Plato and of some most probably spurious writings handed down to
us under Hippocrates' name. (I conclude that these 'Hippocratic Writings' are almost certainly not by
Hippocrates because their content on abortion and other issues directly and clearly contradicts the
Hippocratic Oath which an impressive number of scholars regard as genuine Hippocratic text.)
118 See Plato, Republic, 3.407 c ff., but the text does not speak of killing deformed or incurable persons.
Rather it relates that Asklepios did not apply medical cures where they only prolonged a miserable life
or did no longer help either the individual or the state. Some texts cited to prove that Plato recom-
mends the killing of deformed children, such as Plato's Theaefetus, 161 a, are, because of their ana-
logous context, rather inconclusive as to whether they express a view of Socrates that deformed chil-
dren may be killed or apply only to errors (deformed mental children) which is the context of the dia-
logue. Moreover, Socrates may just refer to existing laws permitting such killings and not to his own
view of the matter.
119 See Peter Singer, "UnsanctifYing Human Life," in Ethical Issues Relating to Life and Death, pp. 41-
61 (Melbourne, 1979).
120 For example, by pointing out that ethical knowledge has many moral presuppositions. See Dietrich
von Hildebrand, Sittlichkeit und ethische Werterkenntnis; see also Paola Premoli De Marchi, Etica
dell'assenso. Some religious authors gave also specifically religious explanations for the arising of
certain errors in ancient philosophy. Ancient philosophers' errors are seen, for example by St.
Bonaventure, as a sign of the blindness of a human intellect left to itself and as a proof for the im-
provement of purely philosophical intuitions through the availability to philosophers of the additional
light of Divine Revelation, through which their philosophical reason, too, was rendered able to see
50 CHAPTER I

Medicine, we are going to argue, loses its integrity entirely when it abandons the
unwavering absoluteness of its commitment to human life and when it ceases to ab-
stain absolutely, as the Hippocratic Oath demanded, from life-destroying acts. Mani-
fold are nowadays the temptations of the physician to turn against this first goal of
his profession and thus to betray medicine. There are not only practical temptations
of physicians and industries to turn against this first goal of their profession by pro-
ducing or procuring, for the sake of financial profit, deadly drugs for the elderly, as-
sistance to suicide, arbortifacients and other murderous means of 'reproductive
health'.
There are also purely theoretical ethical views that dispute the existence of in-
trinsically wrong acts and thus wish to make it only dependent on consequences and
on a consequentialist-utilitarian balancing of goods and evils whether human life
ought to be protected or destroyed. 121 Not only ethical nominalism but also situation
ethics and a whole avalanche of utilitarian-consequentialist ethicists, in philosophy
as well as in Catholic and Protestant moral theology, attack this kind of absoluteness
of moral acts. 122 Any medical ethics has to investigate these views carefully and crit-
ically; for the question of whether such a position, which has tremendous effects on
medical ethics, by permitting every kind of action under circumstances, is correct, is
of utmost importance for medical ethics, and for any kind of ethics.
Such a view which eliminates all moral absolutes and implies a rejection of the
very concept of 'intrinsically wrong acts', we are going to argue, profoundly contra-
dicts not only Jewish, Muslim, or Christian Ethics but also the human understanding
of morality that we find in Socrates, Hippocrates, or Cicero. The debate on this issue
has become one of the key elements in the philosophical discussion today including
moral theology,123 and in all ethics. 124
Two central concepts in those arguments in favor of a deontic ethics that does
not reduce the moral character of actions to the outcome of weighing the totality of
their consequences are also those of personal dignity and of fundamental human

more clearly what was in principle always accessible to reason but was not always in fact recognized
by philosophers.
121 We will deal with this crucial issue of the foundations of medical ethics in chapter 6, below.
122 Think of names such as Richard Mervyn Hare, Joseph Fletcher. (the later) Karl Rahner, Bernhard
Schiiller, Franz Bockle. Charles Curran, Josef Fuchs, Bernhard Haring, Franz Scholz, and countless
others.
123 Consequentialist ethics which entered also large numbers of books and papers of Christian moral
theologians, was criticized in many philosophical books and papers by the earlier Karl Rahner, by
Dietrich von Hildebrand, Karol Wojtyia, Tadeusz Styczei, Andrzej Szostek, John Finnis, Germain
Grisez, William May, Andreas Laun, Martin Rhonheimer, Robert Spaemann, John Crosby, Elizabeth
Anscombe, Julian Nida-Riimelin, Rocco Buttiglione, myself, and many others. This position was also
sharply criticized in the Encyclicals Veritatis Splendor and Evangelium Vitae. See, for example, An-
dreas Laun, "Das Gewissen-sein Gesetz und seine Freiheit. Anmerkungen zur heutigen Diskussion,"
in Aktuelle Probleme der Moraltheologie (Wien: Herder & Co., 1991), pp. 31-64.
124 See on this, e.g., Robert Spaemann, "Uber die Unmoglichkeit einer rein teleologischen Begriindung
der Ethik," Philosophisches Jahrbuch, 88. Jg. I. Halbband (1981), pp. 70-89; the same author, "Auto-
nome Ethik und Ethik mit einem christlichen 'Proprium' als methodologisches Problem," in D. Mieth
and F. Compagnoni (eds.), Ethik im Kontext des Glaubens. Probleme - Grundsiitze - Methoden (Frei-
burg/B. and FreiburgiSwitzeriand 1978), pp. 75-100; Julian Nida-Riimelin, Kritik des Konsequen-
tialismus (Miinchen, 1993); Stephen Schwarz, The Moral Question ofAbortion (Chicago: Loyola Uni-
versity Press, 1990).
 NATURE AND GoALS OF MEDICINE 51

rights. We hope to bring to evidence later, in chapter 6, that all actions that intend
directly the destruction or the damage of a human life that always is endowed with a
high inherent ontological dignity, are intrinsically wrong.12S We say this not in view
only of the totality of consequences of such actions but in view of the essential end
(the finis operis) itself of these actions.
While human dignity and human rights constitute an absolute reference point of
such intrinsically evil acts and moral absolutes in the protection of all human beings,
lately also the notions of 'human rights' and of 'person', however, became key no-
tions not only in the fight for the sanctity of human life but paradoxically also in that
against it. For the first time, both of these concepts have been used, not to defend
human life but to differentiate between those human beings (members of the species
homo sapiens sapiens) who are not persons or who do not possess human rights,
from other human beings who are persons and who do possess such rights. Robert
Spaemann showed that even the very notions of the inalienable dignity and human
rights of persons, which were originally introduced in order to justify the existence
of a universal human value, and of rights and of a human dignity proper to man as
such, are now frequently used for the opposite purpose. By introducing a distinction
between human beings which are not persons and those who are, one defends the
thesis of a lack of personal dignity in a huge class of humans: of unborn, old, re-
tarded, or in other ways deficient human beings. Spaemann pointed out sharply this
tension found in present human rights talk: On the one hand, we encounter the wide-
ly held conviction of universal human rights and dignity as a Magna Charta of de-
fending the essential superiority of the human person over all animals and as source
of inalienable rights. On the other hand, there is widespread use of human rights talk
for the sake of the negation of inalienable human dignity and rights to certain classes
of human beings. 126 The discussion of human life as the first good entrusted to med-
ical care will have to take into account and try to settle this debate.
Clearly, acts aimed at the destruction of human life are not exclusively per-
formed by physicians and therefore are to be considered not only by specifically
medical ethics but also by ethics as such. They can be performed by soldiers, and in
fact by any conscious human adult or even by children of a certain age. We shall re-
turn to these problems in a separate investigation into the value of human life as
foundation of medical ethics and, for now, only note that even Peter Singer does not
deny that there is a certain value of human life which to protect is a central goal of
medicine, even if he restricts the value of human life to that of normal and conscious
human life. He not only proposes that also the life and freedom from suffering of
animals requires respect,127 in which we completely agree with him, but he also pro-

125 In saying this, I prescind from cases in which this destruction is not intended but an unintended result
of self-defense or defense of one's country. I also prescind here from the question whether the justice
of punishment can require death penalty, as the Bible (Old and New Testament) implies and as, for
example, Thomas Aquinas thought and US law is based on. In none of these cases, the destruction of
life would be the directly intended end of one's action.
126 Spaemann criticized this distinction penetratingly. See Robert Spaemann, Personen. Versuche fiber
den Unterschied zwischen 'etwas' und 'jemand'.
127 The care for this good is entrusted to another branch of medicine, the veterinarian.
52 CHAPTER 1

poses to ''unsanctify human life," on which point we utterly disagree with him for
the reasons expounded in chapter 2.

2.3. 'Health' as a Fundamental Goal ofMedicine and as Disputed Question

The second great good or end to be protected and promoted by the physician with all
legitimate means is human health, both mental and physical. 128 Unlike the medical
service to human life, which, at least when it comes to the unborn and the aged, is a
disputed question today in medicine and regarding which it is now accepted by
countless physicians and politicians that medicine may destroy human life, health as
a goal of medicine does not seem to be a disputed question in contemporary medi-
cine. There is a universal consensus that medicine should serve the good of health.
And so it was in the past. Health was an undisputed good from antiquity to our
century. This may have been one of the reasons why Aristotle thought that the phy-
sician wills this good necessarily and never deliberates about this end of medicine,
whether he should promote it or not. Apparently, the good of health is so clearly de-
fined or at least so well understood and so universally accepted that one might be in-
clined to agree with Aristotle that this end is willed necessarily by the physician and
that the only question the physician can possibly ask himself is which means he
should employ to promote it. One therefore might also consider superfluous a philo-
sophical analysis of this goal of medicine.
But neither one of these opinions is correct. To begin with, there are three great
philosophical questions chiefly regarding human health: (1) What is health? (2) To
which extent should medicine protect and further health? (3) Which rank of value
does human health possess and how is it related to other goods? Depending on how
these last two questions are answered, many other questions will be answered differ-
ently, for example whether the value of health outweighs that of life or may be pro-
moted by all means including taking the risk of killing organ-donors, etc. The at-
tempt to answer these three questions will bring to the fore that the obvious and uni-
versally accepted goal of medicine, to serve health, is only apparently undisputed
but in reality very much a disputed question in medicine today.

2.3.1. The Question "What Is Human Health?" as a Philosophical and as Disputed

Question
The question what human health is, which necessarily entails the questions of the
nature of a human person and of what constitutes mental health, contains a tremen-
dous amount of aspects which only philosophy can investigate with its methods. 129
The disputed nature of the question of health becomes clear at once when we direct
our inquiry to the essence of health and ask whether health can be reduced to mere
physical conditions or to other data such as the capacity of carrying out goal-orient-

128 See on this Josef Seifert, "What is Human Health? Towards Understanding its Personalistic Dimen-
sions." See also Josef Seifert, "Moral Goodness and Mental Health."
129 See Paulina Taboada, Kateryna Pedoryka-Cuddeback, and Patricia Donohue-White (eds.): Person, So-
ciety and Value. Towards a Personalist Concept of Health. See also Josef Seifert, "Moral Goodness
and Mental Health. "
 NATURE AND GoALS OF MEDICINE 53

ed actions. Another even more fimdamental philosophical question regarding health

is whether it can be defmed in purely subjective terms (as every physical or mental
state which either a given subject of health or a given state declares or decrees to be
health), which would open the door to some form of nihilism and to complete arbi-
trariness in medicine and health politics, as we find it in some totalitarian systems in
which the state and its ideology become arbiter over who is mentally healthy and
who is sick. A similar road towards a complete subjectivism in the notion of health
is also found in psychiatric societies' health definitions throughout the globe with re-
spect to sexual normality/abnormality. In eliminating any descriptions of homosexu-
al,130 sadistic, masochistic, pederastic, transvestite, and other forms of sexual beha-
vior or sexual inclinations as 'abnormal', one introduces more and more a subjective
notion of health even in cases, such as sadism and pederastic sexual inclinations and
acts, in which there are clearly victims of such criminal behavior. A further crucial
philosophical question is whether the utopian aspects of the World Health Organiza-
tion's (WHO) definition of health (as including complete physical, mental, and so-
cial well-being) can be justified, or whether a narrower and more specific concept of
health must serve as foundation of medicine.
To understand all of these aspects regarding health as goal of medical actions,
we first have to acknowledge the indispensable role of philosophy in clarifying the
nature of health. This role will turn out to be quite crucial indeed, and we shall de-
velop it in our chapter on health in the second part of the present work.
Stressing already at this point the great role of philosophy in determining the na-
ture of health, we do not deny of course the equally great and in some respects much
greater role of empirical science in establishing the nature and concrete elements of
human health, and above all of the threats and opposites to health. All contingent
(non-necessary and not highly intelligible) aspects of human health must be investi-
gated not by philosophy of medicine but by the empirical branches of medical sci-
ence. Nevertheless, a critical examination into the WHO-defmition of health will
show us that the ultimate question of the nature, the objectivity, and the fimdamental
content of health, as well as its place in the hierarchy of goods, are purely philosoph-
ical questions, and simultaneously questions which are of utmost importance for
medical theory and practice.
This has been recognized more clearly in the past tradition of medicine than in
the present. The great ancient physician Claudius Galen is reported to have refused
to continue taking instruction from his medical teacher Athenaeus because the latter
insisted that the study of logic and philosophy was unnecessary for the physician. 131
Galen's realization of the importance of philosophy for medicine applies particularly
to the question "What is health?" itself, a question which Galen himself considers at
the very beginning of his Hygiene and which we wish to investigate later in depth in
a separate chapter. Calling medicine the one "science of the human body," Galen di-

130 Until recently, homosexuality and homosexual inclinations have been listed in the Handbook of the
American Psychiatric Association as sexual abnormality, but during the last years not only homo-
sexuality but other forms of abnormal sexual behavior are one after the other stricken from that list.
See Richard Cohen, Coming Out Straight. Understanding and Healing Homosexuality (Winchester,
Virginia: Oakhill Press, 2000).
131 See Claudius Galenus, A Translation olGalen's Hygiene, p. xvi.
54 CHAPTER 1

vides medicine into the primary science of preserving health and the secondary part
of curing diseases.

The Nature of Health and Reductionism. In this perspective, Galen gives consider-
able weight to the philosophical question what health is.132 Yet his answer to this
central problem, an answer which Galen later differentiates and improves in many of
his more concrete observations about the matter,133 is quite disappointing and re-
minds us of other reductionist health definitions such as those offered by the general
systems theory in our century. Galen writes:
Health consists in a definite proportion of so-called constituent elements, of wann, cold,
moist, and dry, and is fulfilled by the composition of the same organic elements, their
quantity, size, and conformation. So that whoever is able to preserve these, will be the
best guardian of health. 134

In a more precise study on health, we will see that such definitions of health fall
into the first danger of our understanding of health: reductionism. They fail to take
into account the proper nature of health in its relationship to life, which requires rec-
ognition of the many dimensions of mental and bodily human health, which are
omitted from such definitions.

Utopian Notions of Health. But we also have to examine critically the danger oppo-
site to reductionism: namely the danger of defining health in such broad bodily, psy-
chological, and mental terms that corresponding health-definitions become quite
utopian and more appropriately refer to perfect beatitude than to health. While the
health of mind and body indeed involves physical, psychological, social, and
rational-spiritual dimensions of well-being (which to have stated explicitly is a merit
of the World Health Organization's definition of health), it would certainly be prob-
lematic from a practical as well as from a theoretical point of view to define
health-with the WHO-in terms of such a universal well-being l35 that every hu-
man person who does not experience perfect wellness in physical, psychological,
and social respect would not be healthy. Health, while being 'holistic' inasmuch as it
regards the whole organic body and includes physical as well as psychic moments, is
not a whole or total well-being of human life in biological, psychic and social re-
spect; it is different from beatitude (which the WHO-'definition' would better fit)
and even from earthly happiness and other higher goods for the person than health.
Health is a certain immanent perfection and flourishing of life, and of the posses-
sion of all the central moments and capacities which belong to the life of a given
species or nature. Precisely for this latter reason a human person's health differs in
kind from animal health and includes, for example, mental health. For the same rea-

\32 Galen, ibid., p. 5.

133 See for example, Galen, ibid., pp. 15 (where health is related to "the functions of life" and to the
''unimpaired function").
134 See Claudius Galenus, A Translation o/Galen 's Hygiene, p. 5. See also ibid., pp. 7 f.
135 "Health is a state of complete physical, mental and social well-being and not merely the absence of
disease or infirmity" (preamble of the Constitution o/the World Health Organization, adopted by the
International Health Conference in New York, 1946).
 NATURE AND GoALS OF MEDICINE 55

son, of being an immanent perfection of a living being, those perfections that result
from qualitative values or from learning and the right use of intellect or will, moral
values, etc., are beyond the scope of health.
Health, moreover, is not only an immanent perfection of physical and mental
life, operations, and capacities but also merely a certain dimension of the immanent
perfection of the possession and flourishing of faculties characteristic of a given
form of life. Great physical strength, for example, or the good bodily shape that is
consequent upon hard sportive training, is different from health; it may even be un-
healthy but at any rate exceeds that measure of physical strength that is the imma-
nent perfection of the body, which forms part of health.
Human health also includes mental health, and hence a rudimentary perfection of
the intellectual capabilities of a human being. If one recognizes, however, that not
all but only rudimentary immanent perfections of the nature of a living being are
subsumable under the category of 'health', one might be inclined to identify human
'health' with a statistical IQ average, with a possession of immanent physical and
mental perfections to an average degree. But such a facile solution to solving the
problem of the nature of health would be completely wrong. For that immanent per-
fection of mental capacities, which is part of 'human health', is not 'statistic normal-
ity' but can lie well under average, without this low level of intellectual capabilities
constituting unhealth. On the other end of the spectrum, brilliance and other extraor-
dinary perfections of intellect are certainly not average but for this reason in no way
a sign of unhealth, nor of mental health. They are quite different from elements of
mental health and at the same time bring to evidence the difference between health
and an average degree of the possession of those abilities that belong to our nature in
two ways: (1) Their presence, though they are far removed from statistical average,
is in no way a sign of unhealth, which alone proves the difference between health
and statistical 'normality'; (2) Their possession does also in no way exceed mental
health in such a way as to prove the presence of mental health, even not of the intel-
lectual side of human nature, because geniuses whose intellectual capabilities are far
above average can be mentally very ill, as many biographies of great minds, recently
the biography of John Nash and the great movie A Beautifol Mind, impressively
show.
Thus, the mentioned inunanent intellectual perfections differ very much from
mental health and go in a direction of immanently perfecting human capacities in a
way entirely different from the mode in which health constitutes an immanent per-
fection of body and mind. Certainly, the presence of at least a certain limited (mini-
mal) degree of intellectual capabilities is part of human health. But mental intellec-
tual health does not only require a certain minimal degree of intellectual capacities
but also a certain specific kind of the immanent perfection of the ability to use one's
mind, distinct from many other immanent perfections and flourishing of intellectual
capabilities. Only that specific kind of ability to use one's intellect is part of mental
health for which reason geniuses with the highest degree of mental brilliance can be
sick also in the ways in which their intellect works. Thus, a minimal degree of intel-
lectual faculties per se constitutes only a necessary, though by no means a sufficient,
condition and part of mental intellectual health.
56 CHAPTER!

Even less can higher qualitative values and perfections of intelligence, such as
depth of mind or love of truth and objectivity of judgment, be subsumed under the
category of 'health'. In like manner, a certain volitional capacity, and at least a low
degree of strength of will, form part of mental health, not however the higher moral
qualities and values realized through freedom which surpass the perfection indicated
by the term 'health'. The same is true of many other dimensions of the physical,
psychic, and social well-being of persons that lie beyond the realm of health even if
they are in many ways connected with it. We will return to the question ofa realistic
and adequate definition of health in a later chapter.

Objectivity or Subjectivity of Concepts of Health? A third and possibly the greatest

of all dangers in health-definitions is an increasing subjectivism and relativism in
terms of which any subjective well-being or well-feeling becomes the standard of
health and unhealth. Here all essential characteristics of health, as well as its rela-
tionship to the life and nature of a given being are ignored, a view from which an ab-
surdly arbitrary notion of health follows.
The question of a correct definition and determination of the concept of health is
not only practically significant in that fmancial assistance of health-insurance com-
panies would have to be distributed in unimaginable proportions if the health defini-
tion were as inclusive as many think. 136 Rather, if the well-being of health is con-
ceived in utopian as well as in purely subjectivist terms, so that any limit on feeling
well is interpreted as a lack of health, it would also be necessary to consider certain
states which are clearly not diseases-for example pregnancies-as a kind of sick-
ness 137 to be treated by the public health system. This is already largely the case in
the notion and application of the term 'reproductive health', which, for example in
Hillary Clinton's opinion, would include "a right of every woman to abortion"
which implies the notion of pregnancy as some form of illness or infirmity opposed
to health.
In the light of all the preceding observations we can hardly fail to see that for a
proper understanding of health, especially for the understanding of mental health,
philosophy and a deeper vision of man-as it cannot be provided by medical sci-
ence-are indispensable,138 including an understanding of the moral order whose

136 For a critique of this view, see, for example, Rocco Buttiglione and Manuela Pasquini, "The Chal-
lenge of Government in the Constructing of Health Care Policy," in P. Taboada, K. Fedoryka-Cudde-
back, and P. Donohue-White (eds.), Person, Society, and Value: Towards a Personalistic Conception
ofHealth.
137 One can differentiate between the notions of 'disease' (as the objective root-problem of health here at
stake and as cause of sickness) and 'sickness' as the corresponding subjective state of illness. See on
this Manuel Lavados Montes, "Relations between Empirical and Philosophical Aspects of a Definition
of Health," in P. Taboada, K. Fedoryka-Cuddeback, and P. Donohue-White (eds.), Person, Society,
and Value: Towards a Personalistic Conception of Health. But here I use both terms in the same
sense.
138 See the results of the research on the philosophical concept of health carried out at the International
Academy of Philosophy in the Principality Liechtenstein 1994-1996 with the support of the Swiss
National Science Foundation (Schweizerischer Nationalfonds zur Forderung wissenschaftlicher For-
schung): Paulina Taboada, Kateryna Fedoryka-Cuddeback, and Patricia Donohue-White (eds.), Per-
son, Society and Value. Towards a Personalist Concept ofHealth.
 NATURE AND GOALS OF MEDICINE 57

violation for reasons of health would violate the higher good of man. To recognize
how the good of health must be seen in relationship to higher goods of the person in-
deed gives rise to a higher qualitative notion of health, a mental-spiritual dimension
of it that Plato calls "the health of the SOul.,,\39 But in employing such a higher, mor-
ally and spiritually speaking qualitative notion of health, we are using, albeit a valid,
a different concept of health that refers to a higher good of the person compared to
which the good that is intended by the 'normal' meaning of 'health' is merely ana-
logous.
Thinking of the nature of psychic health or of the health of the person qua per-
son, we come to a further conclusion: No other medical branch of health services re-
quires philosophy more directly than does psychiatry. And this central role of philo-
sophical clarification does not only touch specifically medical actions but many oth-
er spheres of human action and society at large.

2.3.2. The Question "To Which Extent Should Health Be Promoted in Medicine?"
as a Disputed Question
Medicine always ought to serve health and should invariably work towards serving
this great good-human health: it ought never to aim at realizing its opposites.
Unlike the first good medicine should serve, life, health does indeed seem to be
affirmed far more unambiguously by the medical profession. The imperative related
to health appears to be espoused almost universally. But upon closer examination of
the philosophical issues just discussed it will become clear that the claim of the un-
disputed character of medicine's call and duty to serve the good of health in contem-
porary medicine is not correct either. For not only is the destruction of human lives
by implication also the worst attack on health-by destroying its very condition and
foundation. There have been, also quite recently, times when, under various dictator-
ships, physicians such as the infamous Nazi doctor Mengele or communist physi-
cians and medical professionals destroyed the health of human patients unscrupu-
lously for the sake of medical research or for political reasons. In less dramatic but
still very seriously problematic ways we find a spreading opinion that gravely handi-
capped or persons suffering gravely from old age or other causes should not be
given any, at least no adequate health care.

2.3.3. The Question "What Is the Place ofHealth in the Hierarchy ofHuman
Goods? " as a Disputed Question
This leads us already to our third decisive question: that of the value of health and of
its rank within the whole realm of goods. Besides the question of what health is, we
must also explore the place its value has within the overall hierarchy of goods. Par-
ticularly the relationship of the value of health to that of human life is very much a
disputed question, as can be seen when it comes to the problem of whether health is
a condition of the value of human life as such. If one takes this position, it would

139 See Giovanni Reale, "If you want to cure the body, first cure the soul," in Paulina Taboada, Kateryna
Fedoryka Cuddeback, and Patricia Donohue-White (eds.): Person, Society and Value. Towards a Per-
sonalist Concept ofHealth.
58 CHAPTER 1

follow that the life of the handicapped and sick is "not worth living" (lebensunwer-
tes Leben).
In less radical forms, the relationship between the good of health and that of life
poses itself when the question is raised to which extent and how long patients should
be kept alive by artificial means in ICUS. 140 Here another side ofthe hierarchical re-
lation between the values of health and life is at stake; and while it will be defended
later in this book that it always is forbidden to kill a patient in view of suffering and
illness or 'quality of life', it is certainly not always obligatory to prolong life by arti-
ficial means at all costs.
Still another aspect of the importance of the axiological relationship between the
value of life and that of health is at stake when even persons who reject the identifi-
cation of brain death with the actual death of an individual human being,141 justify
organ explantation of vital organs with the argument that the destruction of human
lives of the so-called 'brain dead' and even of other 'low quality life patients' for the
sake of serving the life of normal persons is justified.
Considered only in terms of the first two fundamental goods medicine ought to
serve, we thus see a vast field of investigation before us. To delineate this task accu-
rately, the term 'medical ethics' appears, on the one hand, to be too narrow: what we
are dealing with here is a philosophy or even a metaphysics of the human person,
and an ethics of the beginnings and ends of human life viewed in the whole context
of human life and society.142 Let us add another general remark about our field of
study: while, on the one hand, the term 'bioethics' proves far too narrow to delineate
our whole field of studies, from another point of view and on the other hand, how-
ever, it appears to be too wide, namely inasmuch as the term bioethics can refer to
an ethics vis-a-vis all life. While we do not exclude the legitimate concerns of ani-
mal ethics and ecological ethics, not all living beings such as plants are the object of
bioethical oughts and values. At any rate, the part of ethics we are concerned with
here concentrates entirely on human persons and therefore requires a clear under-
standing of what distinguishes ontologically and axiologically personal health from
animal health.

2.4. The Fight against Pain (Suffering) and for Pleasure and Physical and Mental
Relief Preventing, Alleviating, or Freeingfrom Suffering (Palliative Medicine)-
Promoting Well-Being and Feeling Well

A third and distinct, as well as more specific, end of medicine which cannot be quite
subsumed under health, and comprises under it several different goods, is the freeing
from pain, or its mitigation, and the furthering of legitimate, health-related and sig-
nificant forms of pleasure in human life (for example with regard to curing sexual

140 This question was subject of a two-year research project directed by Professor T. H. Engelhardt, Jr.
See my contribution to this project, "Toward a Personalistic Ethics of Limiting Access to Medical
Treatment: Philosophical and Catholic Positions", in H. Tristram Engelhardt, Jr. and Mark J. Cherry
(eds.), Limiting Access to Medical Treatment in the Age o/Medical Progress: A Roman Catholic Per-
spective (DordrechtIBoston: Kluwer Academic Publishers, 2001), pp. 96--124.
141 This will be treated in volume II of the present work.
142 Julian Nida-Riimelin (ed.), Angewandte Ethik, pp. 833 ff.
 NATURE AND GOALS OF MEDICINE 59

anomalies or problems with the enjoyment of food).143 This can be a goal even
where health is impossible, such as in the case of palliative medicine administered to
the incurably sick, or in cases where health is indisputably present and the only
problem that exists is the lack of pleasure or the presence of pain.
Entire medical institutions, hospices, etc., are dedicated primarily to this goal of
palliative medicine. Hospices are institutions designed to relieve the physical and
emotional suffering of the dying, whose health cannot be restored but whose suffer-
ings can be diminished. They offer an alternative form of care for terminally ill or
cancerous patients and provide consolation and support for relatives and friends.
Their end is no longer health but the dispelling or reducing as far as possible the dis-
comfort and isolation of dying persons. While they are staffed with physicians and
other medical personnel, hospices are dedicated to creating a home-like environment
and to making the last days of the dying as little painful and as full of consolation as
possible. In this way, they are dedicated to many other goods still to be discussed
below and treat the patient as a whole. 144
Thus, while the good of the liberation from suffering is by no means the only
good promoted in hospices, this good is part of the object of hospice care. This im-
portant good consists in the prevention or alleviation of the evil of pain and suffer-
ing, and is a goal of palliative medicine. We could conceive of the respective good
intended by medicine not only in terms of the deliverance from pain and suffering
but also in positive terms: as increasing the positive well-being of patients, their en-
joyment oflife and pleasure, and their experience of meaning in their lives in suffer-
ing and dying, and in spite a/suffering and dying.
This good, which ought to be freely affirmed by the physician and by any mem-
ber in society as well, is most radically violated when physicians inflict suffering
without their action serving the good of the patient, such as when they partake in tor-
ture. Some modem declarations on medical ethics take this aspect into account, for
example the 1975 Tokyo declaration. 145

143 The added adjectives 'significant' and (at least in a wider sense of the term) 'health-related' are used
in order to clarify that there are countless pleasures such as the ones provided by cooks or by movies
and concerts which to further is not the task of medicine. The term 'legitimate' is added because it is
certainly not a task of medicine to provide sadists with the pleasures they desire or to provide, for
example (as it has led to a recent scandal in a German home for senior Citizens), 'professional help' in
the elderly achieving the pleasures of masturbation and of other forms of sexual arousal. This shows
again how important the sixth and seventh goods to be served by medicine tum out to be. For it is only
in the light of these goods of the human person that a distinction between legitimate and illegitimate
forms of furthering pleasure can be made.
144 The first priority here is the alleviation of pain through tranquilizers and other means. There are hos-
pices to care for patients with AIDS and Cancer stations. The modem hospice movement started in
England with St. Christopher's Hospice near London, in 1967. By the 1980s there were 1,400 hos-
pices in America. See Paul Torrens (ed.), Hospice Programs and Public Policy (American Hospital
Publishing, Inc., 1985). The thoughts expressed in the last paragraph and in this note have been ex-
cerpted and slightly altered from Compton's Interactive Encyclopedia, Copyright (c) 1994, 1995,
1996 (Compton's NewMedia, Inc.).
145 This was adopted on October 10, 1975 by the 29th World Medical Assembly, and deals in §§ 1-4 and
6 with torture [World Medical Association, "Declaration of Tokyo," Bull. Am. College of Physicians
17 (6); 15, 1976].
60 CHAPTER!

One could argue against the thesis that medicine should alleviate pain and never
inflict it, emphasizing that medicine has to inflict pain on patients and that this is the
reason why Plato says in the Gorgias that children will prefer the confectioner to the
physician because the first provides pleasure by baking pastry, the second pain by
cutting and burning. 146 Regarding this matter, however, the distinction between an
intentional and deliberate act of inflicting pain and the causing of pain as a mere side
effect of a salutary action will prove essential for medical ethics.
Many other questions have to be treated here: such as whether there is an essen-
tial difference between the pain of human persons and of animals, or whether we
should treat both on a par. A particular alarming dispute today is the kind of pre-
dominant concern with ecological and animal ethics, at the expense of human pain.
Nothing can throw more light on this than a comparison between present laws,
which forbid torture of animals, and abortion laws. Unborn babies up to the moment
of birth (for example in the partial birth abortion 'legalized' in the USA by Bill Clin-
ton's veto after the majority vote of the US Congress) remain completely unpro-
tected from infliction of pain upon them. To inflict pain on them in abortion is not
prohibited by any legal sanction, while inflicting much slighter pain on worms is
(for example in Liechtenstein the use of live worms for fishing is punishable under
the law). In the USA, the law better protects rat embryos than human babies. 147
Here, profound philosophical questions regarding a morally justified dealing with
human and animal pain will have to be posed.
The following ends, too, have to be considered carefully when it comes to allevi-
ating pain. The physician should not exclusively serve the cure or abatement of pain
but also further the right attitude of the patient towards suffering. This was implied
in the old definition of medicine as "the art of helping people to live and to die
well," implying that the accompanying and comforting of patients in pain and in the

146 Plato, Gorgias, 464 d-465 a:

Thus it is that cookery has impersonated medicine and pretends to know the
best foods for the boy, so that, if a cook and a doctor had to contend in the presence
of children or of men as senseless as children, which of the two, doctor or cook, was
an expert in wholesome and bad food, the doctor would starve to death. This then I
call a form of flattery, and I claim that this kind of thing is bad-I am now
addressing you, Polus-because it aims at what is pleasant, ignoring the good, and I
insist that it is not an art but a routine, because it can produce no principle in virtue
of which it offers what it does, nor explain the nature thereof, and consequently is
unable to point to the cause of each thing it offers. And I refuse the name of art to
anything irrational. But if you have any objections to lodge, I am willing to submit
to further examination.
Cookery then, as I say, is a form of flattery that corresponds to medicine, ...
147 In the USA one risks imprisonment, when violating laws which protect animal embryos from the mid-
term of gestation on. The 1986 "Animal Scientific Procedures Act" provides this protection to mouse
or rat embryos. One wishes to protect "any living vertebrate other than man" but fails to protect one's
own children and embryos, allowing most cruel abortions up to birth without even prescribing pain-
killers! There are now even some pro-abortionists and members of animal rights groups who demand
such restrictions on human experimentation and abortion as are already in law regarding animal pro-
tection. Cf. Victoria Macdonald, "Abortion doctors may give foetuses painkillers," UK. News, Aug. 9,
1998.
 NATURE AND GOALS OF MEDICINE 61

process of dying are legitimate tasks of the physician. 148 Such an attitude is desirable
both for the sake of its intrinsic value--even when no cure is possible--and as con-
dition of being healed in such cases of illness where a psychological dimension,
such as the will to live and the successful search for meaning, is required for getting
well. 149

2.5. The Conscious Life ofMan as Such and Personal Dignity

Another great and central good for the human person is her consciousness-the
basis of all knowledge, experience, enjoyment, and realization of things, and the
condition of all specifically personal goods a person can realize in and through her
conscious acts. The good of a person's conscious life does not consist only in pos-
sessing some dark consciousness of the sort animals possess but in a specifically
personal and rationally enlightened conscious life. The great value and good of
awakened personal consciousness is thrown into relief when we consider all the val-
ues and goods which only the full possession of the specifically rational, intellectual,
volitional, and affective conscious life of the person allows us to access and realize,
and when we contemplate the fact that only through this stream of our conscious life
we may take part in the whole world but especially through it alone we enter into
communion with other persons whom we love. Words fail us to describe the im-
mense wealth which a person may receive through awakening consciously and
through gaining access to the world of visible and audible beauty, to nature and art,
to literature and all kinds of beauty and knowledge, and above all to the world of
other persons. The possession of personal conscious life is the entrance door to the
lived contact with any reality including all lived human relationships. No being in
heaven and on earth can be reached by us except in and through our personal con-
sciousness. If we know for philosophical reasons that God exists or believe in God,
it is evident that any real lived contact to the divine being in prayer and in all kinds
of spiritual life and religious acts, including the joys and the eternal union with God
in paradise, is absolutely impossible without actual personal consciousness. All the
goods of union with God and of a reuniting with beloved persons, and all other su-
preme goods that are the most sublime object of human hope and for which we
yearn, can ultimately only be realized in and through personal consciousness.
In the light of all this we see the tremendous value of awakened conscious life of
human persons. The value of human conscious life, however, is not simply speaking
an automatic consequence of possessing rational personal consciousness in an awak-
ened state, although already in this lies a certain ontological value that possesses a
certain 'sanctity' and 'inviolability'. Nevertheless, the truly significant and ultimate
value of human personal consciousness depends on three further conditions or be-

148 See the beautiful short story of Turgenev, "The District Doctor," in Thomas Seltzer (ed.), Best Rus-
sian Short Stories, pp. 82-95 (New York: The Modem Library, Inc., 1925), which not only is a very
moving love story but also illustrates the great task of physicians to accompany and comfort the dy-
ing.
149 See on this Gregorio Maranon, La Medicina y los Medicos (Madrid: Espasa-Calpe, 1962), pp. 138,
182,188. Most ofViktor Frankl's work as a psychiatrist and as a theoretician is dedicated to this great
goal.
62 CHAPTER 1

longs to human consciousness only if three further conditions are fulfilled. If not, the
disvalues on the level of a person's conscious life may outweigh the values in such a
way that his or her death or his or her 'never having been born' would have been
better for a her.
Let us grasp this first from the positive aspect of the structure of values linked to
awakened human existence and rational conscious life. The immense value of hu-
man conscious life depends on three sources and is.fragile because each of these can
be missing:
(1) In the first place, it is nourished and enriched by the objects and their value
with which we unite through our intentional acts. And regarding this source of hap-
piness and quality of conscious life, the value of conscious acts, besides possessing a
general ontological value and a value of truth and adequacy (which makes it better
to know a sad truth than to live in an happy illusion), depends mainly on the world at
large, and on the nature of the objects with which we enter into conscious union.
Considered from the angle of this source of the value of conscious acts, their value is
very fragile as long as no lasting and eternal good is their object and the source of
this value of conscious experience. A man in possession of the highest 'quality of
life' and in possession of the greatest happiness, blessed with many, but perishable,
goods can within minutes be put into a state of misery in which he curses the day of
his conception or of his birth, like Job. And through this source of happiness or pain
external to the conscious life of a person itself, through this world of goods and evils
and of persons to whom we stand in contact through our intentional acts, we are sus-
ceptible to become filled with joy but also with horror and pain. Instead of being a
source of immense happiness and of allowing a person access to the most beautiful
and blissful things, her awakened conscious life can become a curse and a road to
her witnessing destruction, tragedy, horror, and to her suffering losses of all kinds.
This source of happiness and unhappiness, to the extent to which it is just rooted
in the real world, in real tragedies, horrors, evils, guilt of persons, is almost entirely
withdrawn from the field of medicine, even if physicians can treat certain aspects of
shock caused by guilt or by other experiences of monstrous cruelties, horrors, etc.
Not only medicine is called for here, and it belongs to the greatness of its task and of
its representatives to recognize the limits of medicine, as they are beautifully expres-
sed by the physician in Shakespeare's Macbeth. ISO

150 See ibid., V, 1:

DOCTOR: Hark! she speaks: I will set down what comes from
her, to satisfy my remembrance the more strongly.
LADY MACBETH: Out, damned spot! out, I say!-One: two: why,
then, 'tis time to do't.-Hell is murky!-Fie, my
lord, fie! a soldier, and afeard? What need we
fear who knows it, when none can call our power to
account?-Yet who would have thought the old man
to have had so much blood in him. 40
DOCTOR: Do you mark that?

DOCTOR: Go to, go to; you have known what you should not.

LADY MACBETH: Here's the smell of the blood still: all the
perfumes of Arabia will not sweeten this little 50
 NATURE AND GOALS OF MEDICINE 63

Nevertheless, this source of the value of human conscious life can be influenced
by many things including medicine because of two of the aspects of the world of
intentional objects of human acts which do not depend on the real world:
A. In the first place, medicine can often help when it is not the real world which
is the cause of pain and suffering but just a 'world' imagined by some sick imagina-
tion. If the intentional objects of conscious life that cause suffering and anguish have
no transcendent being in the world but are illusory, they can be produced by brain-
damage, by other physiological causes or drugs, by dreams and hallucinations, by
false opinions or wrong attitudes, etc. And a careful and cautious identifYing these
causes is at least partly the task of psychiatry and of other branches of medicine.
Nevertheless, medicine has to admit its limits here; for many reasons why people
hold wrong and illusory beliefs lie in their philosophies, in their religious beliefs,
etc. Therefore, depending on the individual cause and nature of such distorted or
false visions of reality as cause of suffering, medicine or other disciplines and pers-
ons can help overcome these.
B. A second large sphere of subjective experience which may be influenced by
causes treatable by medicine is some limited, irrational, or morally and humanly
wrong way to react to tragic realities in our lives, a hopelessness, an inability of co-
ping with them, a depression, etc., which may result from certain irrational physical
or mental causes but may also derive from a lack of sound counsel, from an oblivion
of meaningful aspects to be discovered in the events of our lives, from a lack of an
appropriate value response, etc. And regarding some of these aspects, psychology,
medicine, psychiatry, and spiritual help may lead to a deep influence on the way in

hand. Oh, oh, oh!

DOCTOR: What a sigh is there! The heart is sorely charged.
GENTLEWOMAN: I would not have such a heart in my bosom for the
dignity of the whole body.
DOCTOR: Well, well, well, -
GENTLEWOMAN: Pray God it be, sir.
DOCTOR: This disease is beyond my practise: yet I have known
those which have walked in their sleep who have died
holily in their beds.
LADY MACBETH: Wash your hands, put on your nightgown; look not so 60
pale.-I tell you yet again, Banquo's buried; he
cannot come out on's grave.
DOCTOR: Even so?
LADY MACBETH: To bed, to bed! there's knocking at the gate:
come, come, come, come, give me your hand. What's
done cannot be undone.- To bed, to bed, to bed!
[Exit.]
DOCTOR: Will she go now to bed?
GENTLEWOMAN: Directly.
DOCTOR: Foul whisperings are abroad: unnatural deeds
Do breed unnatural troubles: infected minds 70
To their deaf pillows will discharge their secrets:
More needs she the divine than the physician.
God, God forgive us all! Look after her;
Remove from her the means of all annoyance,
And still keep eyes upon her. So, good night:
My mind she has mated, and amazed my sight.
I think, but dare not speak.
64 CHAPTER 1

which a person responds to such events, finds or does not find meaning in them, etc.
Here the task of psychiatry and medicine at large but also the specific task of logo-
therapy as a search for meaning in Viktor E. Frankl's sense, lSI and other forms of
help from medicine and psychotherapy are relevant. Again, the physician has here to
recognize his limits. For the actual discovery of meaning does not fall into the sub-
ject matter of any branch of medicine but more into philosophy, metaphysics, and
religion. He also does not dispose over the deepest concrete means to help a person
recover access to peace and happiness, as the doctor in Shakespeare's Macbeth so
beautifully states. However, some forms of concrete and effective help to lead pa-
tients to discover such a meaning do belong to branches of psychology. And
branches of medicine may also remove some physiologically or psychically condi-
tioned blocks that prevent a person from reaching this meaning.
(2) Secondly, the existence and positive content of our conscious life also deci-
sively depends on the contents, which arise in human consciousness itself, on the
qualitative human and moral values that are realized in our conscious acts. These
values are of many different kinds and natures. They can be linked to intentional
acts or be entirely independent from them such as physical pain or pleasure. They
may also arise from the freedom of a person or have the character of feelings or ex-
periences, which the person undergoes or suffers. Many of these pleasant or unpleas-
ant, happy or unhappy, good or evil contents of human conscious life, for example
moral or religious qualities of the person, or feelings resulting from these, are entire-
ly beyond the scope of what medical art can change or secure. But this is not the
case with all evils afflicting our conscious life. For when unhealth is the reason for
imagining objects of anguish or fear, or when pain and pleasure have physiological
causes, medicine can very much contribute to restoring the positive quality of hu-
man conscious life. Thus here as well, we have to see the greatness and limits of
medical responsibility for this sphere of goods and evils afflicting human conscious
life.
(3) Medicine refers especially to a third sphere related to human conscious life,
namely to its fundamental non-intentional conditions and states of consciousness.
These are both a non-rational and non-intentional part of our conscious life and con-
dition or at least facilitate many of the highest dimensions of rational human con-
sciousness. The very presence of rational conscious life as well as its quality is not
independent of those non-intentional subjective states of mind and well-being, such
as having psychic strength, being free of excruciating pains, being awake, having
psychic energy, etc. Such states are conditions, and their opposites are impediments
to a certain dimension of a joyful positive quality of conscious human life. It is this
third level of non-intentional conscious states (such as experienced health and well-
ness, or physical strength, energy, pleasure, pain, etc.) which playa foundational
lSI
See Viktor E. Frankl, ... trotzdem Ja zum Leben sagen. Ein Psycho loge erlebt das Konzentrations-
lager, 19th ed. (Miinchen: Kllsel-Veriag and dtv, 2000); the same author, Man's Search/or Mean-
ing. An Introduction to Logotherapy (a revised edition of From Death-Camp to Existentialism)
(Boston: Beacon Press, 1963-2000). Cf. also Viktor E. Frankl, Logotherapie und Existenzanalyse.
Texte aus sechs Jahrzehnten, 2nd ed. (BeriinIMUnchen: Quintessenz Verlag, 1994); the same
author, Sinn als anthropologische Kategorie. Meaning as an Anthropological Category (Heidel-
berg: Universitlitsverlag C. Winter, 1996), pp. 19-29. See Elisabeth Lukas, Lehrbuch der Logo-
therapie. Menschenbild und Methoden (MiinchenlWien: Profil, 1997).
 NATURE AND GOALS OF MEDICINE 65

role as condition of the presence, and at least of the quality, of our intentional, ob-
ject-directed conscious life as well. And these states decisively depend on the sub-
jective and conscious aspects of human health, on how we feel health-wise. More-
over, while the intentional and spiritual acts of a person can in no way be caused or
produced by physiological causes or medical actions, the very conditions of our en-
tire conscious life lie very much in physiological factors in the brain and in the
whole body which account for health and wellness.
The great goods linked to the awakened conscious life of the person, this should
by now have become clear, are not sufficiently guaranteed by the possession and ex-
istence of awakened conscious life itself. For this life can become also the condition
of the worst kinds of evils, of all kinds of conscious physical and mental pains, of
anguish and horrors, of neurotic and psychotic symptoms that result from the objects
and contents of human conscious life, and of moral and religious evils.
Moreover, even when those values that are born by our conscious life give su-
preme value to rational consciousness and actualize the value-potentials of human
conscious life, the high good of such an awakened conscious life remains fragile for
another reason. The human person can be more or less radically deprived of specif-
ically human consciousness through serious brain damage and all sorts of mental
handicaps. Because this great good of human personal consciousness is so fragile
and because a certain part of it depends on physiological conditions and consequent-
lyon health, this third source and condition of the positive content of conscious hu-
man existence is specifically entrusted to medicine.
The physician has to serve the conscious life of man, not only by removing with-
in the limits of his art negative experiences (pain, the symptoms of neuroses, and
others) and by promoting the experience of happiness or physical pleasure and well-
being, but also by preserving or restoring consciousness, without which man cannot
live a fulfilled and awakened human life, without which he cannot face death in a
properly human way, suffer in a properly human form, and live in the right manner
those goods which can be realized only in consciousness, even when it implies suf-
fering.
In order to understand medical ethics in reference to consciousness, it is neces-
sary to grasp the real value of human conscious life, which entails an understanding
of those values linked to consciousness which exceed the mere evaluation of human
consciousness in terms of pleasure or displeasure for the patient, let alone for others.
The meaning of human conscious life involves many other dimensions of knowl-
edge, of will, and of human affections, of understanding oneself and the world, of
doing the good, coping with guilt, of asking for forgiveness and forgiving, of thank-
ing, of giving due value-responses to other persons, of transcending oneself in reli-
gious acts, etc.
The rapport of the physician and of the whole medical profession to conscious-
ness and its ethical implications have as yet been hardly touched in medical ethics,
although this is an important topic indeed.152 Regarding this matter, we find a

152 An unfinished dissertation of a student at the International Academy of Philosophy in the Principality
of Liechtenstein is planned to concentrate on this important and hitherto barely treated problem of
medical ethics: under which circumstances is the privation of a patient of his consciousness by drug-
66 CHAPTER 1

marked contradiction in modern medical practice and theory: between an exaggera-

tion of the role assigned to consciousness and its virtual negation. On the one hand,
one recommends the killing of human persons who are persistently deprived of con-
sciousness because one identifies their dignity and quality of life with conscious life
only. This exaggerates the role of consciousness and fails to recognize the objective
ontic status of the person as an individual and unique substantial being of rational
nature, as Boethius puts it, and the fact that human life is a deeper ontological reali-
ty in human persons than the awakening and actualization of life in consciousness.
Persons can never inhere in another thing, they stand in themselves in being; and
without this autonomy of being, freedom and personhood would be unthinkable. 153
Moreover, their life cannot be reduced to conscious life (as we all know from states
of sleep and unconsciousness which only an absurdly actualistic metaphysics can
consider a cessation of the person's identity).154 Rather, consciousness is the actuali-
zation of the person's life, or more precisely, it is one decisive condition of fully ac-
tualizing the personal being in the multiplicity of the acts, cognitions, volitions, af-
fective experiences, and real and intentional relations which belong to the essential
vocation and full actuality of the person's existence and life. Yet although con-
sciousness is the condition of the perfect realization and activation of personal life, it
is not this personal life itself, which lies deeper than consciousness and belongs to
the substantial being of the person, remaining in existence even duririg states of un-
consciousness. Thus, any reduction of the being of the person to her consciousness
constitutes an error in which the significance of consciousness is exaggerated by re-
ducing the whole being and life of the person to conscious life and awakened being.
On the other hand, one thinks too little of consciousness. Instead of seeing its ab-
solutely fundamental role as condition for living an actualized personal life, instead
of seeing its foundational character and value as the condition of the whole cognitive
and intellectual life, of the moral decisions and religious acts of persons, fewer and
fewer objections are raised against depriving patients of consciousness for superfi-
cial and unworthy reasons: either to reduce the burden for nurses and physicians or
to spare the patients the trauma of imminent death. This process of 'snowing' and
'quieting' old and especially dying persons or burdensome and suffering patients is a
sign of a widespread lack of recognition of the high value of personal consciousness
as condition even of the most sublime acts, and of the crucial significance and dra-
matic importance of consciousness for the person and especially for a properly hu-
man death.
Both the exaggerated importance assigned to consciousness and the overlooking
of its profound value are perversions which, as we shall see, violate the true dignity
of the being of the human person which persists even when she is unconscious, but
which, at the same time, requires that she be left conscious as far as possible-to
speak with Blaise Pascal's statement: "our whole dignity consists in thought." His
famous text reads:

ging him or by other means (so-called 'snowing' or terminal sedation) defensible from an ethical point
of view? And what is the value of human consciousness even when it is full of pain?
I S3 See for a defense of this Josef Seifert, Essere e persona, chs. 8-9.
IS4 Such a metaphysics is proposed by Derek Parfit in his Reasons and Persons (Oxford: Oxford Univer-
sity Press, 1985).
 NATURE AND GOALS OF MEDICINE 67
Man is but a reed, the most feeble thing in nature; but he is a thinking reed. The entire
universe need not arm itself to crush him. A vapour, a drop of water suffices to kill him.
But, if the universe were to crush him, man would still be more noble than that which
killed him, because he knows that he dies and the advantage which the universe has
over him; the universe knows nothing ofthis.
All our dignity consists, then, in thought ... '55

This thesis should not be interpreted so as to deny that primary ontological dig-
nity of human life, which exists regardless of consciousness and constitutes the dig-
nitas humanae substantiae. We will return to this absolutely essential question of
bioethics and philosophy of man when discussing the fourfold source of human dig-
nity in the next chapter. Rather, the statement of Pascal elucidates both the intrinsic
dignity of consciousness and conscious life itself and the fact that even the dignity of
permanently unconscious human life (for example in the 'permanent vegetative
state', misnamed if the latter must be considered just as a state in which a patient
loses ~ust all capacity to communicate his conscious life but not his conscious life it-
selt)1 6 can only be understood when one grasps the intrinsic and in-principle-faculty
and capacity of the person of rational and conscious life.
By dignity, Pascal, as the medieval philosophers preceding him, understood a
unique and higher excellence and value of personal being which we can only under-
stand when we contemplate the irreducible essence of the person as an individual
substance of rational nature and as characterized by the marks of consciousness,
knowledge, freedom, and many others. In a being endowed with intellect and free
will, and spiritual emotions-which account for a new world of potential knowl-
edge, morality, language, culture, and religion-we find an essentially higher and
nobler, as well as an inviolable and non-negotiable value, as Kant puts it. And this
value is meant by the dignity of the person.
As already mentioned, Pascal's statement must not be construed as a denial of
the fact that the person retains her dignity even when she is deprived of conscious-
ness but as placing an emphasis on that unique dignity which lies in the actualiza-
tion of the rational activity towards which each person possesses-by her very es-
sence-a potentiality. In other words, there is an inalienable dignity grounded in the
very substance and vocation of the human person to conscious life. 157 The inalien-
able dignitas humanae substantiae must be seen as the first and primary ground of
human worth and dignity, and it belongs to every being of human nature, as we shall
see in depth. Biological human life cannot be divorced from personhood nor from
the intrinsic dignity of a person's existence and substantial being.158
This does not preclude, however, that another dimension of personal dignity-
which involves the right to the freedom of conscience, the right to education and re-

155 See Blaise Pascal, Pensees, introduced by T. S. Eliot, translated by W. F. Trotter (New York: E. P.
Dutton & Co., Inc., 1958),347.
156 At the International Academy of Philosophy in the Principality of Liechtenstein we conducted a two-
year research program with Professor D. Alan Shewrnon in which this question, among others, was in-
vestigated carefully.
157 This dignity belongs to each living human being of whom we can know or assume that he is a person
even if he cannot function as a person. Cf. Stephen Schwarz, The Moral Question ofAbortion.
158 On the four sources of human dignity and the complexity and unity of human life see some later chap-
ters and also my What is Life?, ch. 3.
68 CHAPTER I

ligion, etc.-comes into play only when a person is awake as person. Of this digni-
ty-which is bound to consciousness and thinking-Pascal speaks.
Still another dimension of the dignity of persons is dependent on the right use of
their freedom and is opposed to the unworthiness and violation of personal dignity
through evil. But also this and another, fourth source and kind of human dignity, has
its root in human consciousness. To recognize their weight implies also an aware-
ness of the great good of rational human consciousness whose protection, preserva-
tion, rendering possible, etc., are often entrusted to medicine. We shall return to this
question of the various dimensions and sources of personal dignity in greater depth
and at greater length in chapter 2.

2.6. Integrity o/the Human Bodily Form and Aesthetic Values

Apart from health 159 also the integrity of the form of the human body is a goal of
medicine. This is true both inasmuch as the integrity of the body includes the ability
to perform the various bodily fimctions and inasmuch as it belongs to the basic in-
tactness and beauty of human form (and thus to health in the wider sense). But even
inasmuch as bodily sha~e goes beyond the fimdamental human aesthetic values and
involves higher beauty, 60 this strictly aesthetic good is not entirely outside the scope
of medicine. This goal of medicine, which is pursued in certain forms of dentistry,
dermatology, and of plastic surgery, especially when the latter is pursued for purely
cosmetic or other personal reasons (such as in order to render a person more attrac-
tive sexually) goes beyond that part of beauty (namely the fimdamental integrity of
the form of the human body) which is part of health in the wider sense of this term
and part of that wider specific good of the integrity and beauty of the human bodily
forms which are entrusted to medical care and action. 161
When the fundamental aesthetic integrity of the human body is at stake, which is
part of health and opposed to all kinds of serious deformations by diseases or in-
juries, medicine clearly has to preserve and to restore as far as possible the good of
the fimdamental bodily integrity of form. This is above all the case when accidents
or diseases such as leprosy destroy even the fimdamental shape of parts of the hu-
man body. It is not as clearly the case when beauty surpasses this fimdamentallevel.
But even here, aesthetic values such as the beauty and freshness of the skin or of the
physical appearance of a human face and of human teeth are to some extent legiti-
mate goals of medicine. While not being on the same level with health as a good en-
trusted to medicine, beauty and the whole range of aesthetic values even when they
go beyond the liberation from serious deformities and therefore definitely exceed the
realm of health, still remain important and distinct goods for human persons.
This is not at all the case, however, when plastic surgery does not restore the
fimdamental shape of the human face and body and not even embellish the pregiven

159 In our chapter on health in the second and more concrete part of the present work we will see that, like
consciousness, the basic dimensions of integrity and aesthetic value of the form of the human body
could be included in a wider notion of a person's health.
160 See on this distinction my "What Is Human Health? Towards Understanding Its Personalistic Dimen-
sions."
161 See Josef Seifert, "What Is Human Health? Towards Understanding Its Personalistic Dimensions."
 NATIJRE AND GoALS OF MEDICINE 69

and individual bodily fonns but constructs the body according to aesthetic whims
and wishes of persons, possibly even for criminal reasons. 162 This is no good at all,
and therefore no good entrusted to medicine. Rather, actions aimed at such modeling
of human bodies are clearly no goods and even in most cases morally wrong because
they constitute a serious infringement on the dignity of an individual and unique
bodily fonn and violate thereby the dignity of the human person which encompasses
also a certain dignity of his or her bodily fonn.
Whole fields of medicine, such as plastic surgery, serve the fundamental aesthet-
ic good of the integrity of bodily fonn, not solely the most basic parts of beauty that
are included in health, but also higher aesthetic values. There is no question as to the
legitimacy, in principle, of this branch of medicine which poses, however, a great
number of very specific ethical problems-already when it dedicates itself to purely
aesthetic values, but above all when it does not respect the original and individual
bodily fonn of a person but treats bodies as if they were clay for artistic creativity.
Other ethical problems for plastic surgery arise whenever there is a conflict between
aesthetic values and higher goods of man (such as risks to his life or health).

2.7. The General and Spiritual Good of Man and ofHis Vocation as Transcendent
Goal and Guideline for Medicine

2.7.1. General Remarks on the Ways in Which This Transcendent Good ofthe
Human Person Obliges the Physician
The good of man in a more encompassing sense is a sixth good and end of medical
care. Physicians and other medical professionals ought to respond to this good, parts
of which are even directly entrusted to medical care, especially to that provided by
the psychiatrist. Many dimensions of this sixth good are transcendent to what any
medical action can realize.
We should comprehend under this 'good of the person' not only all and especial-
ly the highest objective goods for persons but also the intrinsic value of the person
of the patient herself who is the primary object of the morally good affinnation of
the good the physician is called to realize. But also the goods of other persons, one's
teachers, their children, etc., inasmuch as we cannot directly realize them, fall under
this category, as well as many other human and social goods, bonds of gratitude, and
spiritual goodS. 163 Holistic Medicine (ganzheitliche Medizin) often emphasizes the
significance of this person-directedness of medicine.
Although the physician only rarely professionally and actively promotes the en-
compassing and especially the higher social and spiritual goods of the person, except
the psychiatrist to some extent, and the ordinary physician in some of his extra-pro-
fessional counseling l64-which often enters and should enter, however, into his hu-

162 Such criminal reasons for changing one's physiognomy are brilliantly depicted in the famous classical
Film-Comedy "Arsenic and Old Lace."
163 For a distinction of the intrinsic objective value and good and objective goods/or persons see Dietrich
von Hildebrand, Ethics, chs. 1-3; 17-18.
164 See Josef Seifert, "Meaning and Morality as Conditions of Mental Health: A Contribution towards a
Theory of Counseling as a Specifically Personalistic Method of Providing Medical and Psychological
70 CHAPTER 1

man relationship with patients-the physician has always to respect this transcend-
ent and ultimate good (which includes the moral integrity of the person) in the pro-
cess of serving health.
(1) The physician must know this encompassing good of the human person at
least to the extent of not violating it: This respect obliges the physician at least never
to violate this higher good of man in promoting his medical well-being, wherefore
Paracelsus is right when he demands from the physician a "complete understanding
of man." Also Hippocrates demanded such a complete understanding of man as
condition of a proper exercise of medicine. 165 This higher good includes also truth
and demands, as the Hippocratic Oath states so clearly, the truthfulness of the physi-
cian. It also includes the protection of the medical secret and of other secrets and in-
timate details, which the Hippocratic Oath forbids to divulge, though they are not di-
rectly entangled with medicine. This higher good related to the person includes
many other goods regarding the person of the patient and third parties which are not
the direct object of medical action but constitute standards of the extent and limit of
medical action.
(2) Two senses of 'transcendent aims' of medicine and the inability of medicine
of bringing them about: Thus, this good constitutes a 'transcendent end' of all medi-
cal action. The term 'transcendent' as it is used here involves the distinction of that
which is directly brought forth in action from the goods which only in the last analy-
sis are affirmed and served in action, such as the human person herself whom we do
not produce but for whom we only procure modest services as results of our actions.
The immanent goal of medical action would then be the state of affairs realized by

Help to Persons," Medicine, Mind, and Adolescence, 1996, vol. XI, n° 2, pp. 59-76. See also by the
same author, "Moral Goodness and Mental Health."
165 See Plato, Phaedrus, 270 f.:
SOCRATES. Now do you think one can acquire any appreciable knowledge of the
nature of the soul without knowing the nature of the whole man?
PHAEDRUS. If Hippocrates the Asclepiad is to be trusted, one cannot know the na-
ture of the body, either, except in that way.
SOCRATES. He is right, my friend; however, we ought not to be content with the
authority of Hippocrates, but to see also if our reason agrees with him on examina-
tion.
PHAEDRUS. I assent.
SOCRATES. Then see what Hippocrates and true reason say about nature. In con-
sidering the nature of anything, must we not consider first, whether that in respect to
which we wish to be learned ourselves and to make others learned is simple or mul-
tiform, and then, if it is simple, enquire what power of acting it possesses, or of be-
ing acted upon, and by what, and if it has many forms, number them, and then see in
the case of each form, as we did in the case of the simple nature, what its action is
and how it is acted upon and by what?
PHAEDRUS. Very likely, Socrates.
SOCRATES. At any rate, any other mode of procedure would be like the progress of
a blind man. Yet surely he who pursues any study scientifically ought not to be com-
parable to a blind or a deaf man, but evidently the man whose rhetorical teaching is
a real art will explain accurately the nature of that to which his words are to be ad-
dressed, and that is the soul, is it not?
PHAEDRUS. Of course.
SOCRATES IIS271 II Then this is the goal of all his effort; he tries to produce convic-
tion in the soul. Is not that so?
 NATURE AND GOALS OF MEDICINE 71

the act itself, while the transcendent goal would be the good affirmed through it but
not realized by it. The transcendent goal of an action is then not its immediate object
nor is it a good realized by it; it includes also the person of the patient herself. And
nevertheless, the affirmation of the person herself(not only of that part of her good
which I realize by giving her to eat or to drink) for her own sake can be regarded as
the soul of moral and medical actions. At the same time, 'transcendent' here can
refer not only to goods which lie beyond the immediate scope of what is realized by
our act but also to the ultimate and even to the eternal character ofthis good in con-
trast with the limited and passing goods such as health for the sake of which the
transcendent good of man must never be endangered.
By this good of man we do not understand only the objective good/or man but
also the good of his moral life, of his giving the proper response to goods other than
himself, the good of his value-responding love for other human beings and for God.

2.7.2. The Different Ways in Which This Transcendent Good o/the Human Person
Obliges the Physician
(1) The overall good of the person as regulative principle of medical actions that
forbids fulfillment of patient wishes which clearly violate this morally relevant good
of both the person of the patient and that of the physician or nurse: This good is
clearly a regulative principle of medical action and can be gravely violated not only
in the physician and nurse themselves, by all morally evil 'medical acts' and
breaches of moral obligations through the physician or nurse, and by medical advice
which involves immoral acts of patients-in abortions, sterilizations, assisted sui-
cide, immoral advice to overcome sexual tensions, etc., but also by the patient him-
self. And here it will turn out decisive for the entire medical ethics that physicians
and nurses always respond to this transcendent good of the patient (as well as their
own) which reaches profoundly into many medical actions, forbidding some and ob-
liging to perform others.
(2) The obligation of the physician to acknowledge the limits of his art with re-
spect to the highest good of the patient: The physician ought to be always aware of
the limits of his art that do not allow him to promote this overall good comprehen-
sively by the means of medicine. Therefore, he should always be open to human re-
lationships, to philosophy, to art, and to religion as giving answers or providing
complete means to further this higher good of the person as such. This stepping back
of the physician in so exemplary a manner described by Shakespeare is an extremely
important attitude of the medical staff. It contains two aspects: (a) an absence of the
attempt to provide themselves, by their own means, the instruments to bring this
good about by starting to replace what only relatives, human encounters, art, philos-
ophers or priests can provide; and (b) an awareness of the medical professional of
patient needs which go beyond the sphere of purely medical goods. Therefore, the
hospital staff should open the way for patients to seek help doctors cannot provide.
To this entire complex of questions we shall frequently return in the ensuing investi-
gations.
72 CHAPTER 1

2.B. The Special Relationship between the Physician and the Absolute Good (God)

It is relatively easy to understand, not only as religious believer but also as philoso-
pher of religion, that many specifically religious acts, for example prayers of adora-
tion, of thanksgiving, of spiritual request, of intercession, or of penance, have God
as their ultimate addressee or object-person. Likewise, the first commandment (of
loving God above everything else) according to Jewish, Christian, and Islamic faith,
and also according to a deeper philosophical understanding of God as infinite good,
demands that whatever else we do and affIrm or love, we should also affrrm or love
for the sake of God, in order to please and to glorify God.
This directedness of our moral life to God is not only a specifically Christian or
Jewish commandment but can be found very clearly in Plato, Epictetus, and particu-
larly in some striking passages in the Eudemian Ethics, in which Aristotle says that
the supreme end of all human acts is to contemplate and serve God. 166
Moreover, the metaphysical question of whether man is the supreme being or
whether God exists is not only in itself of the utmost importance and has not only
profound implications as to the last end and motive of human moral life, but the an-
swer to this question also has deep influence on whether man has the right, or lacks
the right, to perform certain actions.
A keen awareness of this source of moral obligations which cannot be reduced to
the inherent value of the goods to which our actions are directed, but is rooted in our
finitude and contingency, on the one hand, and in our relationship to a caring and
provident God, on the other hand, is found long before Christianity, and indepen-
dently of Jewish faith, in Socrates. Socrates explicitly rejects suicide-although he
claims that the philosopher is always preparing to die, because he has only hope to
gain the immediate vision of the complete truth, for which he always longs, after
death. 167 Socrates offers mainly two images to argue for his position against sui-
cide. 168 First, he says that we are like cattle of the god(s) and should as little remove
ourselves from our life as the cattle that belong to us. They would anger us if they
killed themselves and would have no right to die on their own accord because they
are ours. If we transfer this image to our relation to God, we must see what is the an-
alogous point and what must be disregarded in the image. The Socratic idea is no
doubt this: The human person belongs in a special way not to herself but to God, and
therefore has no right to kill herself. This obligation cannot be simply grounded, as
is often attempted, in our contingency and creaturehood as such, and in the fact that
we did not make ourselves. For it is evident that we have the right to sell our hair, to
eat and thereby to destroy a salad, or to kill mosquitoes that bite us, none of which
we have made. Thus, it is precisely only the person, i.e. a higher being, over which
we have no right to dispose when it comes to her life or death. Socrates' insight is

166 See Aristotle, Eudemian Ethics VIT, 1249a22 ff.:

What choice, then, or possession of the natural goods-whether bodily goods,
wealth, friends, or other things-will most produce the contemplation of god, that
choice or possession is best; this is the noblest standard, but any that through defi-
ciency or excess hinders one from the contemplation and service of god is bad.
167 Plato, Phaedo, 63 e ff.
168 See Plato, Apology, 28 e ff.; Phaedo, 62 c ff.
 NATURE AND GOALS OF MEDICINE 73

astonishing: precisely the person who is a higher being and never can be owned like
a thing by anyone else, belongs more deeply to God than an animal, though the per-
son belongs to God in another, personalistic way. In virtue not only of her contin-
gency but also of her great dignity, the person belongs to God and has no right to
dispose over her own or any other person's life. Though desirous for death, the lover
of wisdom ought to wait until God "sends a necessity," as Socrates puts it.
This Socratic argument is profoundly interpersonal and requires the insight that
the human person is both finite and possesses an incomparable high dignity, in vir-
tue of which she belongs in a special way to God.
The second image Socrates uses corroborates this interpretation: it is the image
of a mission on which each of us is sent in his or her life. And as a soldier must not
desert his mission without an external necessity or a command by the authority, so
man has no right to kill himself as long as he is sent on a mission by God. This idea
of a personal providence of God and a mission given to each human person invokes
even more deeply her dignity as a free agent as reason why the human person has no
metaphysical right to commit suicide.
We may generalize this Socratic argument far beyond suicide: the limitation of
our rights to dispose over certain deeply meaningful realities such as human life or
death, or such as the sources of human life or the genetic make-up of the human spe-
cies, is a deep reason why ethics is related to the absolute good, to God.
Now while this call to do all things also for the love of God, and likewise the ob-
ligation always to remain aware of the moral limits of our own metaphysical rights
and to acknowledge those rights that belong exclusively to God, address themselves
to everyone of us, they concern especially the physician. For he is not only called to
worship and revere God just like everyone else but, at least in many branches of
medicine, more than the rest of us. For the physician and nurse are faced in their ev-
eryday professional life with performing acts on which life or death of human per-
sons in various ways depend. The actions that are bound up with the limits of human
rights then are especially closely related to medicine. For this reason, the question
whether the physician recognizes the existence of God or is an atheist has profound
consequences for his medical ethical behavior.
There are of course, on the one hand, medical fields such as ophthalmology, den-
tistry, or orthopedics, in which physicians are hardly ever confronted with opera-
tions that have anything to do with human life or death. On the other hand, those
moral demands that issue from the relationship of the contingent creature to God are
in no way exclusively addressed to health professionals. Nonetheless, this source of
moral obligations is especially relevant for medicine.
One could object against our position in the following way, saying: "Anyone can
appreciate and ought to respect many aspects of the ethical significance of our con-
tingency and limitation, not just those who believe in God. Therefore, also any athe-
ist physician can understand that attempts to realize an earthly paradise, or to create,
through medical technology and genetic engineering, a perfect humanity, to engen-
der new hybrids between humans and animals in order for them to accomplish lower
kinds of work, etc., would constitute a hubris and forgetfulness of the limitations of
human nature."
74 CHAPTER 1

While this is fully correct, one might see in the undoubted insights of atheists,
who acknowledge their human limits of rights to act in certain ways, an implicit or
covert theism. At any rate, the full moral relevance of our human contingency, and
the totality of ethical obligations and prohibitions engendered by the fact of our fini-
tude, cannot be recognized, let alone be understood, fully without reference to God
as the absolute person without whom and without whose relationship to man we
cannot understand in depth those important moral imperatives that are most relevant
for medicine and are grounded in our metaphysical situation and in our lacking cer-
tain metaphysical rights such as that to freely dispose over life and death.
It might be good to contrast these moral imperatives that have such a close rela-
tionship to God with others which the atheist can as well recognize. There are many
morally relevant goods, such as human dignity, freedom, liberation from pain, sex-
ual integrity, etc., which can be understood in some measure without reference to
God, for example by the atheist who rejects torture or sexual child abuse. These
goods, and the moral obligations and prohibitions grounded in them, differ from the
other mentioned moral obligations that cannot be understood without seeing man in
the light of God.
Also an atheist can see, and even frequently uses his insights into the dignity of
the human person and into the absoluteness of the moral evil of torturing children or
patients, because these acts offend human dignity, as arguments against God's exist-
ence. 169 With Ivan Karamazov in Dostoyevsky's novel the Brothers Karamazov, the
atheist may reject God, an omnipotent and infinitely good personal being, precisely
for the reason that if God really existed, he could not permit the unjust sufferings of
innocent persons or of tormented children which many atheists deem not only intrin-
sic evils but evils of such metaphysical magnitude that they are incompatible with
God's goodness and 'omnipotence, and, since these are indispensable attributes of
the divine nature, with God's existence. Thus, we see that atheists can very well see
the moral and morally relevant goods and evils that forbid torture.
There are the other mentioned moral imperatives, however, which to recognize
without reference to God is hardly possible because they proceed directly from God
or from special relationships between God and finite goods. One may refer here to
decisions such as rejecting the proposition to assist the person who is determined to
commit suicide, or the refusal to administer deadly drugs to patients who implore the
physician to terminate their lives. The injustice and moral wrongness of acts of as-
sisting suicide or performing euthanasia of a violently suffering patient who pleads
his physician to kill him, can only be recognized clearly if we recognize God as the
Lord over life and death and acknowledge that we have no right whatsoever to de-
stroy directly a human life, except if death is a side-effect of an action aiming direct-
ly at a good such as self-defense.

169 By the syllogism that: (a) a good person does everything in her power to prevent evil; (b) an omnipo-
tent person has the power to do whatever she likes; is incompatible with (c) evils exist. See on this Jo-
sef Seifert, Gott als Gottesbeweis. Eine phanomenologische Neubegriindung des ontologischen Argu-
ments (Heidelberg: Universitatsverlag C. Winter, 1996; 2. erweiterte und verbesserte Auflage, mit
einem Nachwort fur die arabischen Leser, 2000); see also my "Zur Herkunft des Glaubens. Griinde
und Hintergriinde. Reflexionen ilber das Problem einer Theodizee angesichts der Leiden und Ubel in
der Welt," in Glaube im Unglauben der Zeit (Augsburg: Dialogsekretariat, 1983).
 NATIJRE AND GOALS OF MEDICINE 75

Even the acknowledgement of God's existence is not sufficient to see the wrong-
ness of euthanasia or suicide. As a matter of fact, some philosophers, for example
Seneca and other Stoics, defended suicide although they believed that man stands
under the special authority of God. They even used their belief in God as argument
in favor of suicide. For they thought that God had given the human person the digni-
ty of deciding on her own and of recognizing herself when the moment for a death
with dignity has come and when she should be permitted to leave life on her own ac-
cord.
Therefore, above and beyond the existence of God, also the absolute lack of the
metaphysical rights of man to dispose directly over his life and death has to be un-
derstood in order to see the intrinsic evil of suicide or assistance to suicide.
This insight that already Socrates gained requires both the recognition that we
are contingent and have not created life, and the insight that, while we may kill cat-
tle (which we also have not created), the unique inherent dignity of persons makes
that they belong in a profound metaphysical way to God and that we have no right to
dispose over their, including our own, life or death.
But this in turn presupposes the existence of God and can hardly be recognized
by the atheist, except inasmuch as he too may have some pre-rational awareness of
this fact. Also the evil of contraception, and possibly even the immorality of non-
therapeutic genetic experimentation with embryos can only be recognized as such, at
least fully, if we recognize that man has no right to manipulate the sources of human
life and is not lord over the origins of human life but their servant.
It is remarkable, however, that the atheist or at least agnostic Max Horckheimer
recognized the limits of human rights to dominate things and publicly defended Hu-
manae Vitae, in which the immorality of active contraception is taught, right at the
time of its publication in 1968, when many Catholic moral theologians attacked it,170
and with good arguments that were quite independent of our dependence on God.
Nevertheless, a full understanding of the limits of our metaphysical rights to
commit suicide or to perform contraceptive acts presupposes knowledge of the exist-
ence of God.
The existence of God, however, is not only an object of faith but can also be
known with our reason.171 We shall return to this point repeatedly in this work and

170 He did so on TV and also in his book, Die Sehnsucht nach dem ganz Anderen. Ein Interview mit Kom-
mentar von Hellmut Gumnior (Hamburg: Furche-Verlag, 1970), arguing that sexual intercourse, with-
out respect for the fertile period of the woman and readiness to abstain during this time, degenerates to
a pure disposing over women and transforms women and human sexuality into consumer goods, and
other arguments. For a philosophical discussion of contraception, see also Josef Seifert, "Der sittliche
Unterschied zwischen Empflingnisregelung und Kontrazeption."
171 There are many classical proofs for the existence of God. For example, Anselm of Canterbury in the
11th century and Thomas Aquinas in the 13th century elaborated such arguments for the existence of
God. These arguments can not only be defended "still today, " but they have been, in certain ways,
perfected and interpreted in a more personalistic way in the 20th century, after overcoming the radical
objections raised against them by Hume, Kant, and many others. (I myself tried to rethink and defend
such arguments in Josef Seifert, Essere e persona, chs. 10-15, and in my book, Gottals Gottesbeweis,
as well as in an article, "Die natiirliche Gotteserkenntnis als menschlicher Zugang zu Gott," in Franz
Breid (ed.), Der Eine und Dreifaltige Gott als Hoffoung des Menschen zur Jahrtausendwende (Steyr:
Ennsthaler Verlag, 2001), pp. 9-102. That God can be known by human reason, many ancient Greek
and also many Jewish and Islamic philosophers held to be true, and it was a general conviction among
76 CHAPTER 1

discuss extensively in volume II those parts of medical ethics which cannot be com-
pletely developed without taking into account man's relation to God, considering
these, however, as parts of purely rational philosophical ethics.
The intrinsic value of finite goods such as human life cannot sufficiently account
for the specific moral imperatives that forbid suicide, euthanasia, and similar acts.
For these prohibitions do not only proceed from the objective nature of the goods
that lie on the object-side of our acts but also from the essence of the human agent,
from our own contingent and limited nature. The fact that we are not God, that we
are not the Creator of life and that we are not lords over life and death, in other
words, our metaphysical situation and metaphysical limits, impose special moral
calls and obligations on us:172 we should never take the life of the innocent, never
forget that we should cooperate with God in procreation and are not entitled to inter-
fere with our human cooperation with divine creation by contraception, or to create
or 'make' children in vitro, etc. All of these actions many aspects of which specific-
ally pertain to medical practice, especially to gynecology, gerontology, and to emer-
gency medicine, require not only a humanistic grasp of the dignity of human persons
but also an understanding of the infinite perfection of God and of the exclusively di-
vine rights which the physician must arrogate to himself. 173

2.9. The Religious Transformation of the Image ofthe Physician and the Goods
Medicine Should Serve

Of course, the mission and vision of the physician is seen in a radically different
light when man is perceived in a transcendent and metaphysical, or in a religious
context. 174 Beautiful testimonies to this could be taken from some Stoic philosophers
and from Plato as far as the divine image in man and his calling to a homoiusis too
theoo (to a becoming similar to God as man's supreme moral task) are concerned.
According to Plato, a relationship exists between the microcosmic structure of man
and the macrocosm reflected in human nature: man unites matter, biological life and
spirit. Thus, he stands in an essential relationship of analogy to the entirety of the

Christian thinkers, not only Catholics but also Protestants. Luther, Melanchthon, Calvin, and other re-
formers, though they rejected the high value Catholics assigned to human reason, did not doubt natu-
ral theology and knowledge of God. The proposition that the existence and some essential attributes of
God can be known by human reason with certainty was declared as a dogma by the Catholic Church
in the first Vatican Council, following Saint Paul's letter to the Romans who asserted that the pagans
are inexcusable for their worship of false gods and animals because the invisible attributes and glory
of God could be known by man since the creation of the world.
172 This source of moral obligations is treated and analyzed in depth by Dietrich von Hildebrand in his
Moralia.
173 See on this my Gott als Gottesbeweis and my "Gott und die Sittlichkeit innerweltlichen Handelns.
Kritische philosophische Reflexionen tiber den Einfluss anthropomorpher und agnostischer Gottesvor-
stellungen auf Ethik und Moraltheologie," in Forum Katholische Theologie I, 1 (1985).
174 To concentrate on this new light of medicine in the light of Christian faith is the goal of the new Inter-
national Journal Christian Bioethics.
 NATURE AND GOALS OF MEDICINE 77

cosmos, but most of all to the spirit of the Demiurge whom Plato in the Timaeus
calls the father and maker of the universe. 175
Great witnesses to this are also Jewish and Islamic and other theistic physicians.
Examples of the opposite influence an anti-religious and anti-Christian attitude has
on medical ethics are the treatment of terminally ill patients by Nazi physicians and
in certain communist and atheistic regimes, but also abortion and euthanasia today,
which more often than not spring from an atheistic worldview. 176
One of the positive contributions contained in the writings of Peter Singer lies in
his emphasis of the change medical practice must undergo depending on whether a
materialist and evolutionary or a spiritualistic and theistic world view prevails. 177
And this insight opens our way to understand only the influence of metaphysical in-
sights into soul and God but also religions have on medical ethics.
In non-theistic religions we often fmd a deep general awe in front of life that in-
fluences also the judgment on any killing of human life. See for example the follow-
ing quote from Fleming: 178
In Japan, where traditional medical ethics is infonned by both Buddhism and Shinto, the
Seventeen Rules of Enjuin requires that the physician "should not kill living creatures",
nor should he "admire hunting or fishing." [Rule 81 " ... you should not give abortives
to the people. " [Rule 91 179

The attitude of the theistic physician is even far richer and deeper than any belief
in an impersonal divinity can possibly be, as the prayer (oath) attributed to the great
Jewish physician and philosopher Moses Maimonides testifies: 180

175 See the rehabilitation of the central metaphysical place of the Demiurge in Plato's philosophy, espe-
cially in the Timaeus, in Giovanni Reale, Verso una nuova interpretazione di Platone, 20th ed.
(Milano: Jaca Book, 1996); Giovanni Reale, Zu einer neuen Interpretation Platons. Eine Auslegung
der Metaphysik der grofien Dialoge im Lichte der "ungeschriebenen Lehren, " translated by L. Hol-
scher, introduced by H. Krllmer, edited with a Postface by J. Seifert (paderborn: SchOningh, 1993).
176 See on this Robert Stem, Die Diskussion um das "Biogenetische Grundgesetz" in Bezug aufden Wert
des menschlichen Lebens, aufgezeigt am Beispiel der Kindesabtreibung, Kindestotung und Eutha-
nasie: Haeckel versus Blechschmidt (Universitlit Bern: unveroffentl. Dissertation: Medizinhistorisches
Institut der Universitlit Bern, 1995), especially the parallel texts in Hitler's works and Haeckel on
pp. 42 ff. See also Wanda Poltawska, Und ichforchte meine Traume, a gripping description of her
experiences in the Nazi-Camp of RavensbrUck, in which human persons were treated like animals for
experimental purposes.
177 See on this Peter Singer, "Unsanctitying Human Life," in Ethical Issues Relating to Life and Death
(Melbourne, 1979), pp. 41-61.
178 John Fleming, "The consensus gentium and the culture oflife:-what the peoples of the world really
value," an address, delivered during the International Colloquium, Globalization and the Culture of
Life: Challenges and Directions, July 29-August 3, 2003, in Toronto, Canada (in press). With his
kind pennission, I use in this and the next chapter some of his results and give some quotes from this
interesting paper.
179 "The 17 Rules ofEnjuin", in Robert M. Veatch (ed.), Cross Cultural Perspectives in Medical Ethics:
Readings (Boston: Jones and Bartlett, 1989), pp. 140.
180 Moses Maimonides (1135-1204) was the greatest intellectual Jewish figure of the twelfth century,
who lived in Cordoba, Spain, and wrote important philosophical, legal, theological, and medical
works, one of them a popular miscellany of health rules. As a physician, he acquired rapidly such a
great fame that he was made the court physician of the famous Sultan Saladin and of his son al-Afdal.
He influenced scholastic philosophy and major thinkers up to Leibniz.
78 CHAPTER!

Almighty God, Thou has created the human body with infinite wisdom. Ten thousand
times ten thousand organs hast Thou combined in it that act unceasingly and har-
moniously to preserve the whole in all its beauty, the body which is the envelope of the
immortal soul. They are ever acting in perfect order, agreement and accord. Yet, when
the frailty of matter or the unbridling of passions deranges this order or interrupts this
accord, then forces clash and the body crumbles into the primal dust from which it
came. Thou sendest to man diseases as beneficent messengers to foretell approaching
danger and to urge him to avert it.
Thou has blest Thine earth, Thy rivers and Thy mountains with healing substances;
they enable Thy creatures to alleviate their sufferings and to heal their illnesses. Thou
hast endowed man with the wisdom to relieve the suffering of his brother, to recognize
his disorders, to extract the healing substances, to discover their powers and to prepare
and to apply them to suit every ill. In Thine Eternal Providence Thou hast chosen me to
watch over the life and health of Thy creatures. I am now about to apply myself to the
duties of my profession. Support me, Almighty God, in these great labors that they may
benefit mankind, for without Thy help not even the least thing will succeed.
Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit,
ambition for renown and admiration, to interfere with my profession, for these are the
enemies of truth and oflove for mankind and they can lead astray in the great task of at-
tending to the welfare of Thy creatures. Preserve the strength of my body and of my
soul that they ever be ready to cheerfully help and support rich and poor, good and bad,
enemy as well as friend. In the sufferer let me see only the human being. Illumine my
mind that it recognize what presents itself and that it may comprehend what is absent or
hidden. Let it not fail to see what is visible, but do not permit it to arrogate to itself the
power to see what cannot be seen, for delicate and indefinite are the bounds of the great
art of caring for the lives and health of Thy creatures. Let me never be absent-minded.
May no strange thoughts divert my attention at the bedside of the sick, or disturb my
mind in its silent labors, for great and sacred are the thoughtful deliberations required to
preserve the lives and health of Thy creatures.
Grant that my patients have confidence in me and my art and follow my directions
and my counsel. Remove from their midst all charlatans and the whole host of officious
relatives and know-all nurses, cruel people who arrogantly frustrate the wisest purposes
of our art and often lead Thy creatures to their death.
Should those who are wiser than I wish to improve and instruct me, let my soul
gratefully follow their guidance; for vast is the extent of our art. Should conceited fools,
however, censure me, then let love for my profession steel me against them, so that I re-
main steadfast without regard for age, for reputation, or for honor, because surrender
would bring to Thy creatures sickness and death.
Imbue my soul with gentleness and calmness when older colleagues, proud of their
age, wish to displace me or to scorn me or disdainfully to teach me. May even this be of
advantage to me, for they know many things of which I am ignorant, but let not their ar-
rogance give me pain. For they are old and old age is not master of the passions. I also
hope to attain old age upon this earth, before Thee, Almighty God!
Let me be contented in everything except in the great science of my profession.
Never allow the thought to arise in me that I have attained to sufficient knowledge, but
vouchsafe to me the strength, the leisure and the ambition ever to extend my knowl-
edge. For art is great, but the mind of man is ever expanding.
Almighty God! Thou hast chosen me in Thy mercy to watch over the life and death
of Thy creatures. I now apply myself to my profession. Support me in this great task so
that it may benefit mankind, for without Thy help not even the least thing will suc-
ceed. ISI

The Daily Prayer of a Physician attributed to him ("Prayer of Moses Maimonides"), but also
attributed to Marcus Herz, a German physician, first appeared in print in 1793.
lSI Translated by Harry Friedenwald. Encyclopedia of Bioethics, edited by Warren T. Reich (New York:
The Free Press, 1978).
 NATURE AND GOALS OF MEDICINE 79

This profoundly religious spirituality of the author of this prayer matches many
similar texts found in other religiously formed cultures. This profoundly religious
spirituality of medical commitment to all seven goods medicine is to serve was even
heightened by the Christian ideal of the physician as the healer moved by charity
and mercy. At this point one has to emphasize the entirely new image of the physi-
cian presented by the Christian faith-in contradistinction to other religions. Histor-
ically speaking, there is no doubt that the Christian vision of man led to a transfor-
mation of the image of the physician, as well as to the first founding of hospitals and
houses of medical care. Mother Theresa's work, which today extends into Russia
and Communist China, testifies in a living way to this. In this religious Christian vi-
sion of man the medical profession which aims at alleviating pain, curing diseases,
furthering and saving life, is seen as an expression of the central Christian virtue:
charity, especially as it motivates mercy and compassion. If the patient is seen as
loved and redeemed by Christ, the whole ethos permeating the human relationship
between physician and patient, the vision of the depth of the mystery of human life
and death, the meaning of suffering and death, etc., are changed and heightened. The
dialogue between Staretz Zoszima and the suffering women in The Brothers Kara-
mazov by Fyodor Dostoyevsky gives a marvelous artistic expression to this.
The Christus-medicus, the Redeemer and God-Man, who cures bodily and men-
tal or spiritual evils, and who alone, through his death and resurrection, can in an ul-
timate way cure patients and all humanity from death and destruction, becomes the
archetype of the physician in the Christian Middle Ages.
This in no way disputes the deep formative influence other religions exerted on a
transformation and religious motivation of the medical ethos, a fact for which many
Muslim, Jewish, as well as Buddhist and other religiously motivated hospitals and
forms of medical care throughout history give witness.
It is finally important to note that the religious motivation of medicine does not
change the nature of medical activity and professionalism. In the transformation of
medical activity by religiously motivated virtues, especially by mercy and caritas,
none of the natural virtues of the physician described by Hippocrates are lost or even
changed. On the contrary, they are just transfigured and redeemed.

2.10. The Remarkable World Wide Consensus on the Goods Medicine Should Serve

Many other beautiful texts in Jewish, Islamic, and Christian religious authors and
in other religions as well, but also in various secular Declarations of Human Rights,
emphasize all seven goods of medicine which we have discussed and reach a re-
markable consensus on them. Let us consider the evidence of this offered by John
Fleming, especially regarding the value of human life: 182
In Islamic Persia, in the Kholasah Al Hekmah (1770 AD) there is a list of ethical duties
of the physician. Rule 15 states that the physician "should never recommend any kind of
fatal, harmful or enfeebling drugS.,,183 And the Liber Regius (Kamel Al Sanaah al

182 John Fleming, "The consensus gentium and the culture oflife:-what the peoples of the world really
value." Fleming has outlined impressively this astonishingly universal consensus.
183 From the "Daily Prayer of a Physician," 1737-8, 1736.
80 CHAPTER 1

Tibbia) advises the physician "to worship God and obey his commands." The physician
is "never [to] prescribe or use a harmful drug or abortifacient.,,'84
... The oldest Hebrew medical text (3rd-7th century), the Oath of Asaph, requires
the student to ''take heed that ye kill not any man with the sap of a root; and ye shall not
dispense a potion to a woman with child by adultery to cause her to miscarry; ... and ye
shall take no bribes to cause injury and to kill ... Neither shall ye mix poisons for a
man or a woman to slay his friend therewith; nor shall ye reveal which roots be poison-
ous or give them into the hand of any man, or be persuaded to do evil. ,,185
The Indian physician Caraka (I st century AD) instructs teachers to tell students
"There shall be nothing that thou should not do at my behest except hating the king,
causing another's death, or committing an act of great unrighteousness or acts leading
to calamity. ,,186 [My emphasis]
If we add to that the proscriptions against killing in the Oath ofHippocrates we can
say that the tradition of medical ethics is religious and overwhelmingly pro-life. Fur-
thermore, we have the formative role played by Judaism, Islam and Christianity in cul-
tures of so many parts of the world.
It is noteworthy that the major author of the Universal Declaration of Human
Rights located the ideological roots of the Declaration in the Ten Commandments '87 of
which the Fifth Commandment, "You shall not kill," (Exodus 20:13) is pivotal for bio-
ethics.

2.11. The Physician-Philosopher and the Nature of the 'Practical' Philosophy in

Medicine with Respect to the Seven Goods
In stressing the philosophical side of the physician, it is necessary once again to em-
phasize that the physician is neither a medical researcher and scientist nor a philoso-
pher. He is both of these and neither, as well as more than them. This means that he
does not have to conduct scientific research and have a properly scientific mind but
it is enough that he be informed by scientific knowledge, which is explored system-
atically by science and scientific researchers. Similarly, the physician does not have
to be a philosopher in the academic sense, but he has to be informed by philosophy
or at least be formed by a good pre-philosophical common sense, which is not possi-
ble if he does not love truth and pursue the authentic knowledge of man's true nature
with all means available to him and compatible with his practical tasks. It is thus im-
portant to see the physician as a sort of practical philosopher and to grasp his ethical
dedication to his goals as a constitutive part of the physician's profession. This di-
mension also distinguishes essentially the specifically anthropological aspect of the
medical profession and practices from the treatment of animals or plants, however
analogous the purely scientific and technical sides of the veterinarian art and of hu-
man medicine are. In virtue of the difference between man and animal, the veterinar-
ian and even more the botanical arts of healing can occasionally legitimately be used
to destroy undesirable animals and plants-because the organisms below persons do
not possess any dignity comparable to that of the human person. Therefore, the true
physician must also be a true humanist. This can be well demonstrated by the history

184 Encyclopedia ofBioethics, 1735.

185 Ibid., 1733.
186 Oath of Initiation [Caraka Samhita], ibid., 1732.
187 Rene Cassin in John Warwick Montgomery, Human Rights and Human Dignity (Dallas: Probe Books,
1986), p. 30.
 NATURE AND GOALS OF MEDICINE 81

of medicine, even though-and on this I agree with Peter Singer-we must not as-
sume that all kinds of cruel and frequently unnecessary experiments with animals
and all cruelties and intrusions on non-human nature are morally permitted. 188

2.12. Conclusion of Our Reflections on the Goods Medicine Should Serve, and
Theophrastus Paracelsus on the Transcendent Ends of Medicine

It is clearer now than before that the third fundamental dimension of medicine, the
ethical and philosophical one, involves both a theoretical and a practical side. The
physician should strive in every way to understand the nature of man and of the five
goods he serves directly-in the context of the sixth and seventh goods, which he
serves chiefly indirectly. Therefore, certainly philosophical anthropology and medi-
cal ethics, but perhaps even metaphysics and philosophy at large l89 should be re-
quired subjects for medical students, and the physician should be something like a
universal man. The famous Theophrastus Paracelsus, one of the most distinguished
16th century physicians and professors of medicine (in Basel)-who was born in
Einsiedeln, Switzerland, and died in Salzburg, Austria-has expressed this most
clearly when he used the beautiful-though partly exaggerated-formulation:
The physician alone can ... celebrate God in all categories and hierarchies in which
praise is due to him; therefore he has to be better instructed than anyone. And nobody
can understand man with greater depth and exactitude, in all his parts, and in the whole
greatness God has conferred on him, than the physician . .. And I say that no one who
ignores these things should vainglory himselfwith the name of medicine. Therefore the
physician should examine with the greatest possible attention what he has in hands. And
he should contemplate that the highest and noblest of all things is given into his
power. 190

Elucidating the values medicine should serve shows clearly that a person is a real
physician rather than being a criminal only to the extent to which she actually serves
the goods medicine is ordered to. This is obvious when she is faced with the deci-
sion to cure or to inflict torture, to murder or to save life. But the decisive philosoph-
ical and value-oriented dimension of medicine also enters all other goods and objec-
tive goals of medicine. All of these the physician ought to serve, and to do so in the
right order. Otherwise he is a 'medical sophist' who only appears to promote the
well-being of his patients while really injuring them.

188 Peter Singer is not the first person to introduce an animal ethics. See on this Julian Nida-Rfunelin,
"Tierethik I: Zu den philosophischen und ethischen Grundlagen des Tierschutzes," in Angewandte
Ethik. Die Bereichsethiken und ihre theoretische Fundierung. Ein Handbuch herausgegeben von
Julian Nida-Riimelin.(Stuttgart: Alfred Kroner Verlag, 1996), pp. 458--483; see also Julian Nida-Rii-
melin und Dietmar v. d. Pfordten, "Tierethik II: Zu den philosophischen und ethischen Grundlagen
des Tierschutzes," in Angewandte Ethik, pp. 484--50. See likewise another Christian perspective on
animal ethics in Andreas Laun, "Tierethik-Anmerkung zur aktuellen Diskussion," in Kirche heute
10/0ktober (1996), pp. 13-31.
189 At a Jewish or Christian University also biblical and theological anthropology. Also Muslimic and
other Universities related to religion should seek to educate medical students in the search for under-
standing deeper the religious dimension of reality and human life.
190 Paracelsus (Theophrastus Bombastus von Hohenheim), "Opus Paramirum." (The translation is mine:
see Paracelsus, Obras Completas, Libro IV, "Opus Paramirum," ed. Kier, trans. Estansilao Lluesma-
Uranga [Buenos Aires, 1945].)
82 CHAPTER 1

3. THE PHYSICIAN AS MORAL AGENT AND FURTHER HINTS AT THE

PlllLOSOPHICAL DISEASES OF MEDICINE AND THEIR CURE

3.1. Importance ofthe Subject ofMedicine and His Inalienable Rights as Person:
Physicians, Nurses, and Other Health Professionals Are Not Mere Technicians or
Instruments in the Service ofHealth and of the Other Goods ofMedicine or of
Patient Wishes but Acting Persons

There is another important side to the indispensability of the humanistic and moral
dimension of medicine: namely not in relation to the object-person, the patient and
the goods to be promoted in his or her life, but in relation to the subject of medicine,
the physician. One could say, the difference we have in mind is that between the
physician as person and the physician as a mere deliverer and cause of medical ser-
vices. Both patient and physician have also to take into account the fact that the phy-
sician is a person and neither a machine nor a slave of patients or hospital admini-
strators, nor a health-service station, nor a dead medical computer.
This fact, which will more clearly emerge in chapter 3, is particularly relevant
when it comes to the ultimate subjective criterion of moral action as distinct from
the objective standard of morality, which is the same for physician and patient. From
the fact that the immediate subjective authority over the moral quality of our acts is
our moral conscience-a personal voice in each man which depends on the level of
his pre-philosophical ethical knowledge and judgments, or on his prejudices-an
important consequence follows: What the patient does or desires-not only when he
acts from an evil will, but also when he chooses a course of action in accordance
with his (the patient's) genuine moral conscience-as such is not binding for his
physician and not even a source of moral legitimization for the physician's rendering
his patient the requested 'medical services', if these violate what the physician him-
self holds to be ethically obligatory.
For in rendering those medical services, the medical practitioner also acts as a
person in her own right, and her action of rendering medical services to her patient
or of cooperating with fulfilling the latter's wishes is definitely not dependent on the
conscience of the patient nor does her action receive legitimization through her pa-
tient's conscience. No, a physician's action can only be legitimized objectively
through the truth about the good and subjectively through the physician's own con-
science.
Whatever therefore the conscience of his patients permits them to do, the physi-
cian's own actions, as well as his cooperation with the actions requested by his pa-
tients, must always remain under the rule of his own convictions and under the dic-
tate of his own conscience, and these in turn should surrender to the rule of truth and
to the demands of those goods which constitute the seven ends of medical action.
The same also applies to all nurses and any other health-professionals or secre-
taries-and to exactly the same degree. 191

191 Therefore, the exclusion of applicants, who refuse to cooperate in abortions, from entering the nursing
school for midwives in Zurich, Switzerland, is a scandalous violation of the fundamental human right
to the freedom of conscience. This, and similar violations of the consciences of the medical and nurs-
 NATURE AND GOALS OF MEDICINE 83

These reflections do not have a purely theoretical or abstract nature but are ex-
tremely concretely relevant for medical practitioners. A few years back, I was in-
vited to discussions on the philosophical aspects of gynecology. It became apparent
that a good number of the gynecologists who participated in this meeting were con-
vinced that such actions as abortions or sterilizations were morally wrong, but that
they, as physicians, would have to serve their patients and do for them whatever the
patients' conscience allows them to do. This is a profound ethical confusion of mo-
mentous consequence, and one which forgets that no man must and can sell his con-
science and soul to another man, a physician not to his patient and a patient not to
his physician. The physician ought to serve his patient as a person, not as an instru-
ment. If we recognize all of this clearly, another great threat to the dignity of the
medical profession and to the dedication of medical professionals to the ends of
medicine becomes manifest: the physician being regarded today as mere source of
medical services rather than as an acting person. Of course, the physician will be un-
able to convince many of his patients that it is wrong to kill babies or to use contra-
ceptive sterilization, etc.---even if he himself is convinced of that. But he is just as
much entitled and obliged to follow his conscience, as are his patients. For his own
actions he is responsible and no one else.
Both doctor and patient are endowed with the dignity of a person, a dignity
which calls for each one following his own conscience and for the profound respect
for each other person's very own inviolable and inalienable conscience-which of
course ought to be formed in accordance with objective ethical truth about the goods
entrusted to the medical profession, as much as each man is capable of seeing that
truth. And both physician and patient have to act in accordance with the direct and
transcendent goods medicine ought to serve. These goods in turn are connected with
obligations and rights that must not be violated.
Thus, another great danger of the corruption of medicine and of betraying its
ends becomes apparent: a depersonalized picture of the medical profession in rela-
tion to patient wishes and to the goals of medicine. For this reason, chapters 3 and 4
are very much part of the foundations of medical ethics. For they will elucidate the
unique depth of moral values and their roots in freedom, thereby showing that the
physician, nurse, and other medical professionals never must sacrifice the purity of
their moral life to considerations of health or patient's wishes.
The ethical knowledge required and opening up here must not be reduced to a
few principles that are then applied to specific cases. Neither the wealth of intuition
into moral and morally relevant goods nor the understanding of morality can be thus
reduced, although of course, on the other hand, universal principles cannot be re-
duced to casuistry in ethics. 192
These seven goals bind each physician directly and immediately in his or her
conscience. In fact, here we can well claim that the sixth goal of medicine, the good
of the person, which includes in primary place the moral goodness of the person, en-

ing staff in hospitals led to the formation of the already mentioned association "Betroffenes Spital"
("Concern: Hospital") which intends to protect the freedom of conscience and of religion.
192 Cf. Bernard Gert, Charles M. Culver, K. Danner Clouser, "Common Morality versus Specified Princi-
plism: Reply to Richardson," Journal of Medicine and Philosophy, (2000 June), 25(3): 308-322. Cf.
Dietrich von Hildebrand, Moralia.
84 CHAPTER 1

ters into medical ethics not only as a transcendent goal which lies beyond what the
physician and nurse can realize but also as an immanent goal to be realized in the
specific medical actions by and in the physician himself. The violation of this good,
by reducing the physician to an almost mechanical provider of all kinds of 'medical'
services, is definitel1 another source of medicine losing the character of medicine
and its rootedness in the goods it is called to serve. Hippocrates has seen this just as
clearly as he has perceived the necessity to keep in mind the value of life and health
and the dignity of the person of the patient.

3.2. Finding Anew Its Roots? A Word on the History and the Essential Ethical
Dimension ofMedicin~the Hippocratic Oath as More than an Ornament ofthe
Medical Profession
The idea of the medicus, the discovery of over 100 drugs still essential in today's
medicine, and many of the ethical aspects of medicine existed certainly in Egypt and
other cultures millennia before Greek antiquity, but the theoretical elaboration of
medicine in its specifically humanist-ethical dimensions is most explicitly the contri-
bution of Greece. It would be very fruitful for a philosophy of medicine to examine
the Platonic dialogues under the point of view of the vision of the physician they
contain. 193 Hippocrates is the classical exponent and to some extent, with Plato, the
father of this new and perennial idea of the physician and of medical ethics. He was
in many ways related to the Platonic school, and in his life and thought he brought
the discovery of the third-the philosophical-dimension of the physician to a first
climax and gave it its perennial expression in the Hippocratic Oath. 194 Hippocrates
and his school composed this oath and obliged all those whom they accepted into the
community of physicians to swear it. It remained the professional medical oath until
a short time ago--at least in many countries: 195 it expressed the decisive act in
which the physician committed himself to the ethical side and moral goals of his
profession.
Without the goals of healing and life-saving, the archaic medicine man or the
most sophisticated modem medical technician uses his science for or against man,
for man's good or for his evil, as an act of healing or as an act of destruction. But
then his whole being becomes ambiguous, and he fluctuates between a physician
and a murderer or enemy of other humans who are no longer his patients but his vic-
tims. This became evident in the Nazi-physicians as well as it becomes evident in
the homicides perpetrated today by physicians.
This third constituent element of the physician could be taken for granted in the
past but should be made a key element in medical education today because of the

193 The physician is the most frequent example Plato uses as image of the philosopher, for example in the
Gorgias.
194 See the above rendition of the text.
195 In the United States of America it still exists, but parts of it-especially those which refer to abor-
tion-were omitted or replaced by other texts. In other countries the oath is still sworn in its original
version, while all physicians during their education are asked to participate in abortions, such that they
are, paradoxically, educated to violate an oath they are required to take. In still other countries, for ex-
ample in Switzerland, the oath has been entirely abandoned.
 NATURE AND GoALS OF MEDICINE 85

unheard-of decline of public medical ethical standards and ethical value-knowledge

in our society. Each medical school should therefore require from future physicians
a proper training in medical ethics, based upon the serious quest for truth about the
ethical foundations of medical praxis-in keeping with the fact that it is most essen-
tial indeed for the physician to add this philosophical and ethical dimension to his or
her professional proficiency.
Above all, the medical practitioner's uncompromising commitment to the ulti-
mate goals of medicine and to the virtues, which constitute the physician properly
speaking, is at least just as decisive for the true essence of the medical professional
as the two other aspects of his art.
It is indeed in his benevolent service to mankind, in his directedness towards
healing, in his commitment to saving and not to destroying life, wherein his deeper
essence as physician is to be sought. The commitment to these goals makes of the
physician one of the great archetypes of mankind. His dedication to the well-being
of human persons and to their cure from their real diseases and disorders, as opposed
to the merely subjectively unpleasant but wholesome discomforts, led Plato to com-
pare the philosopher to the physician and the sophist to the pastry COOk. 196 Whereas
the latter seeks the mere subjective satisfaction of his customers even at the expense
of their true well-being, the physician on the contrary is committed to their true
physical well-being and health even when the methods to obtain it are subjectively
dissatisfying or painful. For Plato the physician is constituted by, and differs from
the baker of sweets through, his directedness to the objective good of his patients.

3.3. Progress or Decline of Medicine with Respect to Its Value-Base and Third
Philosophical-Ethical Dimension: Modern Medicine-Immense Progress or Regress
behind the Age ofthe Medicine Man?

The third and most radically different aspect by which the physician differs from the
medicine man, then, is a decisive element in the meaningful use and the synthesis of
the scientific and technical sides of the medical profession with the goals of serving
human life and health and with a broader vision of man which manifests itself also
in many other duties of the physician towards his patients which appear in the Hip-
pocratic Oath: for example in his duty towards truth, etc. Thus, the physician-scien-
tist and the physician-artist must merge with the physician-philosopher who has hu-
mane goals, who follows principles of medical ethics and shares at least an implicit
philosophical anthropology which recognizes the essential difference of man from
plants and animals. 197 The physician must also recognize the absolute good, God,
whose rights over life and death and whose intrinsic glory constitute the supreme
object of all human acts, and especially of those medical actions which are dictated
by the seventh described good medicine ought to serve and require the humble ack-
nowledgement of the limitations ofthe metaphysical rights of man.

196 This classical philosophical image of the physician contained in the Hippocratic Oath is also present
in different related professional and medical oaths.
197 Again, Peter Singer and others question this as a kind of 'speciecism' (which favors illegitimately hu-
man beings and gives unwarranted preference to members of the biological human species over mem-
bers of other species).
86 CHAPTER 1

With respect to the third aspect of the physician. which is related to the entirety
of the goals of medicine, medicine has in no way progressed over the last decades or
centuries. On the contrary, in this respect we witness an unprecedented decline of
medicine, indeed a threat to its very continued existence in that-while Hippocrates
in the 5th century BC had every physician swear never to act against human life and
health-uncounted numbers of human persons have been tortured, killed, and
abused in the 20th century in concentration camps and Gulags with the help of phy-
sicians, and over 60 millions of innocent human beings are nowadays killed every
year in abortion by medical professionals. And not only that: excellent theoretical
declarations-such as the Paris declaration of June 5th, 1973-and similar ones l98
stand against other declarations which go against some of the most basic ends of
medicine, thus transforming medicine into something else which it is not: a scientifi-
cally founded exercise in evil and criminal actions.
As we have already explained before, we see in the increasing collapse of this
third element in modem medical history the greatest threat, if not the very end, of
the medical profession as a humanistic profession. At least we must say: to the ex-
tent to which this third dimension of the medical professional is lost sight of, to that
extent the medical profession is vitiated or even turned into what truly is its own op-
posite. This opposite of medicine does not lie primarily in unprofessional medical
dilettantism but in the anti-medical purpose of the abuser of medical knowledge and
arts.
Therefore, we ought to deplore the watering down and gradual elimination of the
professional medical oath in its Hippocratic form and substance, which was still bas-
ically preserved in the medical "Oath of Geneva" (1948) which read:
At the time of being admitted as a member of the medical profession:
I solemnly pledge myself to consecrate my life to the service of humanity;
I will give to my teachers the respect and gratitude which is their due;
I will practice my profession with conscience and dignity;
The health of my patient will be my first consideration;
I will respect the secrets which are confided in me, even after the patient has died;
I will maintain by all the means in my power, the honor and the noble traditions of the
medical profession;
My colleagues will be my brothers;
I will not permit considerations of religion, nationality, race, party politics or social
standing to intervene between my duty and my patient;
I will maintain the utmost respect for human life from the time of conception; even
under threat, I will not use my medical knowledge contrary to the laws of humanity.
I make these promises solemnly, freely and upon my honor. 199

198 Association de mooecins pour Ie respect de la vie, Diclaration des Midecins de France. B.P.-75661.
Paris. CEDEX 13, 1973. This excellent declaration stands in sharp contrast with, for example, the
Declaration of Oslo 1970 (Dictionary of Medical Ethics, London: Darton, Longman & Todd, 1977),
which is based on a fundamental relativism and legal positivism which approves of abortion in accord
with the personal convictions of each (no. 3) and positive law (no. 4).
199 The "Oath of Geneva," adopted by the General Assembly of the World Medical Association at Geneva
in 1948 and amended by the 22nd World Medical Assembly at Sydney in 1968, was still basically
akin to the original spirit. The Declaration of Geneva was one of the first and most important actions
of the Association. It is a declaration that was especially important in view of the medical crimes
which had just been committed in Nazi Germany. The Declaration of Geneva was intended to update
the Oath of Hippocrates, which was no longer suited to modem conditions.
 NATURE AND GoALS OF MEDICINE 87

While medical oaths in general increase in quantity, more and more medical
oaths of such quality disappear. 2oo This is especially deplorable at a time when other
professionals adopt professional ethical commitments similar to the Hippocratic
Oath. 201
In this respect, we witness a relapse of modem medicine into the stage of the
medicine man or even far below this stage. We may say that the use of a morality-
free and philosophy-free 'medical art' is against the true medical art with its decided
ethical dimension; it is a practice of medicine against medicine and against man202
and stands in violation of what truly is medicine: namely the performing of such ac-
tions as stand in the service of life, health, and other goods and which never aim at
destroying these goods.
In phenomena such as abortion and euthanasia, medicine has turned against it-
self, against its deepest raison d'etre: to stand in the service of the high goods of
health and life. 203 Medicine has become anti-medicine just as philosophy becomes
sophistry and anti-philosophy if it serves no longer wisdom and knowledge of truth
but error or political ideological goals divorced from truth and justice. In this regard,
we see a great analogy between philosophy, art, and medicine. This analogy can to
some extent degree be extended to other disciplines such as psychology or sociol-
ogy, while many others (such as biology, geography, etc.) remain what they are even
when they are abused. Part of the reason why this is not the case with medicine is
that here we are dealing not just with theory and knowledge but also with a value-
oriented praxis.
Not only cowardice and concessions to political powers, however, have led to
the loss of the human and ethical dimension of medicine: also a widespread skepti-
cism and relativism that regards the ethical standards of the medical profession as
mere matters of subjective feelings, of social and historical prejudice, of an illegiti-
mate transition from an 'is' to an 'ought', etc., have led to an increasing abandon-
ment of the third dimension in the physician. In order to establish again the image
and vocation of medicine, it will therefore be necessary to investigate in the follow-
ing first the question of the objectivity of truth about values and of human dignity as
foundation of objective and intelligible principles of medical ethics-and therefore
the objective and intelligible values and foundations of the physician as friend of
mankind, as opposed to the medically trained criminal and enemy of human persons.

200 I refer again to the article Robert D. Orr, Norman Pang, Edmund D. Pellegrino (& others), Use o/the
Hippocratic Oath, and its above mentioned findings.
201 An example thereof is the new trend in banks of motivating customers to commit themselves to "ethi-
cal-ecological investments." Another example is the professional 'Hippocratic Oath' of philosophers
introduced in the International Academy of Philosophy in the Principality of Liechtenstein---certainly
following many other examples of such professional ethical commitments and pledges. See the IAP-
Report (Schaan, 1990).
202 I remind here of the book of Gabriel Marcel, Les hommes contre /'humain (1951); in German, trans.
by Herbert P. Schad, Die Erniedrigung des Menschen, 2nd ed. (Frankfurt: Knecht, 1964).
203 See on this Margaret Mead's comments inHuman Life Review, II: 63,1988.
 CHAPTER 2

THE DIGNITY OF THE HUMAN PERSON AS A

'UNIVERSAL OF MEDICAL ETHICS'

1. PROLEGOMENA

The destiny of medicine, nay that of humanity itself, largely depends on our way
of thinking about the human person and about human dignity. None of the seven
goods medicine is called to serve can be separated from human dignity, which gives
human life, human suffering, human integrity of form, etc., their peculiar moral rele-
vance and distinguishes them profoundly from animal life and animal health, and
from the integrity of animal form. Since all the ends of medicine are so closely
bound up with human dignity, a philosophy and ethics of medicine has to give pri-
mary weight to the questions of the human person and of her value, and to bring to
evidence and then to analyze carefully this fundamental value called 'human digni-
ty,' its objectivity, its sources, and its dimensions. For if this value is only subjective
and dependent on our opinions, it does not possess any true morally binding force
nor can it be the source of human rights that are independent from political whims of
tyrants and from popular vote and ought to be respected by medical professionals.
Moreover, if just one of its many sources and dimensions were taken to be the only
source and dimension of human dignity, and its other dimensions and sources neg-
lected, then the physician might unjustly exclude hosts of human beings from the
realm of those beings that possess human dignity, and act accordingly.
Therefore, hardly any other theme is as central to medical ethics and, in fact, to
any ethics, as that of the dignity of the human person. Human dignity, as we shall
seek to bring to evidence, is an objective and sublime value in which important mor-
al obligations and fundamental human rights are rooted. It therefore plays an absolu-
tely foundational role for any medical ethics, since medical actions, unlike many
other fields of human and professional activity, have human beings, human life, hu-
man health, and human well-being at large, as their primary object.
Knowledge of, and respect for, human dignity is likewise of decisive importance
for the right physician-patient relationship and for the human and ethical dimensions
of the bond between medical staff and patients. Any veritable knowledge of authen-
tic values possesses a unifying power that is far more profound than the neutral
knowledge of the world. For the knowledge of values brings us into contact with the
unifying force of values themselves. The central value of the human person qua per-
son called dignity, however, is of special importance in this regard. For it is human

89
90 CHAPTER 2

dignity that grounds, in virtue of the centrality and sublimity of this value, moral
calls, human rights, and the community between physicians and patients.
Knowledge of values, however, is not enough to actualize their unifying force.
The fundamental values accessible to any human experience, and in particular to the
physician in his or her close relationship to patients, unfold their profoundly unify-
ing power among men much more fully when they are not only known as such, but
also accepted, responded to, or concretely realized in action. This factor is so impor-
tant that when a value is known but rejected or disrespected by the will, it does not
unfold its unifying force at all. Its rejection divides the person who possesses dignity
and the one who fails to respect it.
When patients and medical staff know and at the same time fully affirm human
dignity and other values linked to persons, a human and moral bond of greatest sig-
nificance arises between them, and their actions receive their proper reason and mo-
tive. If the intrinsic value of the human person is understood more deeply still, it
motivates not only respect for dignity but love, which brings about a far more pro-
found unity among persons and responds to them in view of the beauty and lovabili-
ty they possess because of their intrinsic preciousness. I
Conversely, objective evils, especially moral evils such as hatred, pride, envy,
jealousy, cruelty, etc., as soon as they enter persons or creep up between them, be-
come a source of discord and dissension among them---even when they appear to
unite persons, such as when a physician carries out immoral wishes of his patient.
If we shall succeed in discovering that this value which we call human dignity is
quite objective and sublime, it will become clear that a thought that opens up to the
true nature of things is not truly realist unless it recognizes, besides objective being
and truth, values as well, since the good and values constitute in a certain manner
the heart and the most important dimension ofbeing.2

1.1. The Theoretical and Practical Significance of Understanding Human Dignity

Values, and the question whether we can know them, are of utmost significance for
medical ethics on a theoretical as well as on a practical level. On the theoretical
level, the issue of human value and dignity touches the first good medicine is called
to serve: human life, but is inseparable as well from the other six goods we found to
be the ends medical action ought to serve. We can only properly understand these
goods if we can know values and if an appropriate awareness of the distinct value
called human dignity is reached by us.
We can take one step further and say: No theoretical knowledge of human life it-
self can be complete as long as human dignity is not understood, since any true
knowledge of a being requires knowledge of its value. Knowledge of the high intrin-
sic value of human life call~d dignity is therefore decisive for understanding human
life itself. It is the central part of that Orientierungswissen (knowledge that gives ori-

I Cf. Dietrich von Hildebrand, Das Wesen der Liebe, chs. 1 and 6.
2 See Josef Seifert, "Die verschiedenen Bedeutungen von 'Sein' - Dietrich von Hildebrand als Meta-
physiker und Martin Heideggers Vorwurf der Seinsvergessenheit," in Balduin Schwarz (ed.), Wahr-
heit, Wert und Sein. Festgabe fUr Dietrich von Hildebrand zum 80. Geburtstag (Regensburg: Habbel,
1970), pp. 301-332.
 HUMAN DIGNITY 91

entation to hwnan life and action) without which the Verfiigungswissen (the practi-
cally useful knowledge) of medicine remains useless and sterile.
That it is never possible to understand a thing properly speaking without under-
standing its value or disvalue, its good or evil character, applies quite specifically to
the subject matter of medicine. We can acquire the minutest knowledge of every em-
pirical medical and psychiatric detail of the hwnan body and psyche-without pos-
sessing any veritable knowledge of the hwnan person, as long as we do not attain
knowledge of the value of the hwnan person and as long as we treat a hwnan being
as if it had no more value than an animal or than the price of a few pounds of fat, or
of organs and other ingredients calculated in terms of their market value.
This is the way in which Lenin once measured the worth of a hwnan being;' and
this way, which entirely ignores hwnan dignity, became formative of countless er-
rors and ideologies such as the anti-personalistic ideology of communist totalitarian-
ism that led to regimes which committed shocking atrocities.
Some intuition into hwnan dignity, however, lies even at the root of communism.
The original communists presupposed and formulated impressively an understand-
ing of the dignity of the hwnan person. In fact, Marxism derived its vast influence
on many noble thinkers from an intuition into the dignity of the oppressed and ex-
ploited worker, forcefully expressed by Marx and Engels in the Communist Mani-
festo, in which the notion of personal dignity (personliche Wiirde) plays a key role
as the point of reference for an ethics that rejects abuse and exploitation of hwnan
beings:
We said that knowledge of the value and dignity of hwnan life is decisive both
from a theoretical and a practical perspective. The theoretical knowledge of the hu-
man being and of hwnan life and health aimed at by the physician is in no way com-

3 When his high-school teacher read approvingly this text of Lenin, this experience awakened in Viktor
E. Frankl his radical opposition to a view of the human being without recognizing the meaning and
value of human life. See Viktor E. Frankl, Logotherapie und Existenzanalyse. Frankl's whole logo-
therapy and psychiatric treatment of patients is built on a vision of human life being filled with mean-
ing and value.
4 See for example, the following text:
The bourgeoisie, wherever it has got the upper hand, has put an end to all feudal, pa-
triarchal, idyllic relations. It has pitilessly tom asunder the motley feudal ties that
bound man to his 'natural superiors', and has left no other nexus between people
than naked self-interest, than callous 'cash payment'. It has drowned out the most
heavenly ecstasies of religious fervor, of chivalrous enthusiasm, of philistine senti-
mentalism, in the icy water of egotistical calculation. It has resolved personal worth
into exchange value, and in place of the numberless indefeasible chartered freedoms,
has set up that single, unconscionable freedom-Free Trade. In one word, for ex-
ploitation, veiled by religious and political illusions, it has substituted naked, shame-
less, direct, brutal exploitation.
The bourgeoisie has stripped of its halo every occupation hitherto honored and
looked up to with reverent awe. It has converted the physician, the lawyer, the priest,
the poet, the man of science, into its paid wage laborers.
The bourgeoisie has tom away from the family its sentimental veil, and has re-
duced the family relation into a mere money relation.
Karl Marx/Friedrich Engels, Communist Manifesto; see Hal Draper, The Adventures of the
Communist Manifesto (Centre for Socialist History, Berkeley 1994); Manifest der Kommunistischen
Partei, in Marx-Engels, Werke, Band 4 (Berlin: Dietz Verlag, 1974), pp. 459-493.
92 CHAPTER 2

plete, in fact it is in a deep sense non-existent and at least of no avail, if it is not

crowned by the knowledge and understanding of human dignity; only through this
knowledge of human dignity we really recognize the true nature of the human per-
son. Not merely practically useful scientific knowledge, but only a knowledge that
provides orientation and order for human acting, which can only be achieved
through knowledge of values and human dignity, can also preserve the value of sci-
entific knowledge and protect science against its threatening abuse, as recently
Steinberg, the Rector of the University of Frankfurt, noted in a remarkable speech. 5
Any true knowledge of the human person requires knowledge of her particular
value that we call 'human dignity' and will recognize to be a sublime intrinsic pre-
ciousness of persons.
Moreover, only that exalted value which we call 'dignity' provides the key for
understanding acts that are intrinsically wrong and therefore must never be admitted
in medical praxis, as we shall see in chapter 6. Thus, not only the theoretical
knowledge of the human person but also medical practice, its goals and what is right
and wrong in it, depend on the dignity of the human person and on our understand-
ing of it.
The question of human dignity is of extreme practical significance for medicine
not only because of its importance for the intrinsic moral character of medical ac-
tions, however, but also in view of the practical consequences of human acts ofphy-
sicians: the respective answers to the question of human dignity and its dimensions
and sources entail a verdict on the life or death of countless human beings entrusted
to medicine. Millions of human lives of the unborn and of the elderly, and of many
other groups of human society-such as those of a certain race or those afflicted
with physical or mental handicaps-depended in the past and depend in the present
on convictions about the nature of the human person and of the sources of human
dignity, since millions and millions of human beings were and are being killed, often
by physicians, because they or society at large deny them human dignity and human
personhood in an ethically and legally relevant sense.
Consequently, there is hardly any higher duty and responsibility for anyone of
us, and quite particularly for physicians and health workers, than the search for the
truth about human dignity. The absence of understanding of, or the lack of free re-
spect for, human dignity-or both-lead to a profound disrespect of human beings
in numerous forms, many of which are found in medical praxis.
We have stressed in the preceding chapter that also scientific medical progress is
devoid of value without knowledge of human dignity and of the seven goods medi-
cine ought to serve (all of which can be properly assessed in their ethical relevance
only in the light of recognizing the nature and dignity of the human person). Medical
progress in scientific and technical fields is impressive--however, as soon as we
come face-to-face with the misuse of technical progress and the instrumentalization
of medicine for torture or murderous purposes, medicine turns into its own opposite,

5 I refer to the closing address Rudolf Steinberg, Rector of the Johann Wolfgang von Goethe-Universi-
ty, gave at the end of a two-day symposium organized by ISESCO (the equivalent to UNESCO in the
Arabic-Islamic states-seated at Rabat, the capital of Morocco) between Sept. 29-30,2003 in the In-
tercontinental Hotel in Frankfurt a. M. under the title: "Dialogue among Civilizations: diversity within
complementarity. "
 HUMAN DIGNITY 93

as we have observed before. Even though normally we only benefit from modem
medicine and medical progress saves thousands of human lives, as soon as such pro-
gress remains disrespectful of human dignity, millions of humans die or are 'uti-
lized' for explantations of organs or for research purposes, and medicine regresses-
much more than that: is infected by a deadly philosophical disease that transforms it,
in a horrible metamorphosis, into its very opposite.

1.2. Can Human Dignity Be Known to Be an Objective, Universal and

Simultaneously Uniquely Individual Value?

But can the nature and the existence of the dignity of human persons be known?
And can we possess any objective knowledge of human dignity as a 'universal of
medical ethics' valid at all ages and in all civilizations? This question is so important
that we will dedicate to the issue of the relativity or absoluteness of values (and
hence also of human dignity), and to the question whether we can know values ra-
tionally, an entire chapter critical of any form of relativism, subjectivism, or agnosti-
cism regarding truth about values.
Yet, since the negative answer to the question about the objective existence of
human dignity provokes such a serious philosophical disease of medicine, and since
knowledge of human dignity is the condition of all we wish to say in this chapter
and said in the last one, already here a few words on the question of whether and
how we know the universality and objectivity of the dignity of the human person are
in order.
In the first place, we must sharply distinguish between (a) the universality of the
value of human dignity that is a consequence of its objectivity and of its objective
belonging to all human persons, (b) the universality of this value that results from its
universal cognitive accessibility in principle, and (c) its universality in the sense of
its actual general recognition. The first two senses of the universality of the value of
human dignity are in principle quite independent from the third. We will try to show
that human dignity is a universal value in these two senses (a and b), but in the third
sense not at all so-neither on the level of theory, except perhaps implicitly on the
level of pre-theoretical knowledge, nor on that of ethical praxis.
It is important to understand from the outset, however, that calling human digni-
ty a 'universal value' or 'a universal of medical ethics' must not give rise to the pro-
found misunderstanding as if human dignity were some abstract value common to
all human beings. No, it is, just as each person who possesses it, absolutely unique
in each person. In other words, as it grows out of the unique and irreplaceable per-
son, it is each time the unique value of this or that unique person. What is universal
is, on the one hand, that each individual person possesses dignity, at least in its first
and foundational dimension, and on the other hand, that this value of human dignity
addresses itself objectively to all health professionals and to all human persons re-
gardless of their religious creeds or civilizations, and that it can be known in princi-
ple by all.
94 CHAPTER 2

1.3. Can Consensus Be Reached about Human Dignity and Can It Function as a
Common Ground for Medical Ethics-as a 'Medical Ethical Universal '?
When looking at the practice of medicine from a worldwide perspective and from an
ethical point of view, we are struck by apparently opposite impressions regarding
the question whether the intrinsic value of human dignity is actually universally rec-
ognized (in the third sense, c, explained above):
A. On the one hand, we find a great variety of culturally and religiously, but
most of all-across each and every civilization and country-of individually shaped,
ethically different, and partly opposite forms of practicing medicine. As we have al-
luded to, there exist fundamental conflicts and oppositions between ethical positions
on almost every basic content of medical ethics.
B. On the other hand, regarding this fact, two things are remarkable:
(a) There is, on the highest political and international level, namely that of the
United Nations, an almost 100% consensus on the intrinsic dignity of human per-
sons and on the objectivity of fundamental human rights, given the fact that well
over 99% of the countries of the world have signed the Universal Declaration ofHu-
man Rights and other declarations in which the intrinsic value of human dignity and
the fundamental human rights are expressly declared and detailed ethical and legal
consequences are drawn from this declaration. In a recent paper, John Fleming has
expressed and elaborated this consensus impressively. He writes:
The Universal Declaration is, then, something that is morally and legally binding in the
sense that member states assent to it by virtue of their membership of the United Na-
tions and in the sense that it embodies human values expressed as human rights on
which civilized people are agreed. And by the end of 2000 there were 192 member
states representing a total estimated population of 6,029,694,000. 6 The world population
in 2000 was estimated to be 6,070,581,000. 7
This means that about 99.3% of the peoples of the world belong to nations that are
member states of the United Nations and are thereby committed, at least morally, to the
Universal Declaration ofHuman Rights. 8

(b) Opposite opinions regarding human dignity and human rights exist not so
much between cultures, and not even so much between religions, but within the
same cultural and (vaguely) religiously formed world. More radical and sharp ethi-
cal differences in practicing medicine exist within each and every country and civili-
zation (and often even within the same religious community of Christians, Jews,
etc.) than between them. (Of course, this observation does not intend to deny the
great differences between physicians who belong to different religions and who
practice their religious beliefs rigidly, even though between the ethical teachings of
most religions including Hindu and Buddhist religions we find a remarkably large
common ground, particularly in medical ethics. 9)

6 http://esa.un.org/unpp/p2kOdata.asp
7 Ibid.
8 See John Fleming, "The consensus gentium and the culture of life:-what the peoples of the world
really value."
9 See for example John Fleming's references, in his cited paper, to some Buddhist and Hindu texts:
 HUMAN DIGNITY 95

In order to see that the most divisive differences between diverse views on ethi-
cal matters are not primarily cultural, just consider the opposites between medicine
and anti-medicine we have discussed before. These opposites exist in the United
States, in Europe, in Canada, in the same towns or villages, in the same century and
decade, or even between physicians in the same Jewish, Christian, or secular hospi-
tal. At the same time, one will not find any hospital in the world in which not many
physicians and nurses, regardless of their religious orientation, will agree on human
dignity and human rights as well as on countless concrete consequences and applica-
tions of these.
In other words: It seems as if the chief moral opposition between different forms
of acting in medicine exists between individuals everywhere in a similar fashion and
does not so greatly depend on the historical, cultural, or religious shape of societies
as on the individual physician or health professional. Hand in hand with this, we find
a remarkable similarity between the best forms of ethical behavior within different
cultures and religions: whether we would have been patients of Hippocrates in an-
cient Greece, of Moses Maimonides in the Middle Ages, or today in many of the
hospitals in India, New York, Santiago of Chile, or Japan-we could have encoun-
tered physicians of different religions and worldviews who share a remarkable con-
sensus on most of the goals and values important for medical ethics. This gives wit-
ness to the fact that there is a universal experience of moral data, which are the same
everywhere in the world.
Hence, to just unfold these data and objects of universal and worldwide human
experience should be sufficient in principle to gain not only an objectively universal,
and therefore common, ground in bioethics but also to reach, in the respect for hu-
man dignity, a universally recognized common basis for bioethics, a true 'medical
ethical universal': namely a ground that is recognized worldwide by the best judg-
ments within all nations and by the best individual persons working in health profes-
sions.
Such a common basis for bioethics is also in no way purely formal but rich in
content; for an ethical judgment on many concrete actions follows immediately from
the recognition of human dignity and fundamental human rights, as we shall see in
this chapter and, more extensively, in Part II of this work.

From Christ to Buddha, Mohammed, Confucius, Judaism and Hinduism the codes of
medical ethics show a common commitment to the preservation of human life and
the moral prohibition of killing the innocent.... In Japan, where traditional medical
ethics is informed by both Buddhism and Shinto, the Seventeen Rules ofEnjuin re-
quires that the physician "should not kill living creatures," nor should he "admire
hunting or fishing." [Rule 8] "In our school, teaching about poisons is prohibited,
nor should you receive instructions about poisons from other physicians. Moreover
you should not give abortives to the people." [Rule 9] ... "The 17 Rules of Enjuin,"
in Robert M. Veatch (ed.), Cross Cultural Perspectives in Medical Ethics: Readings,
p.140.
Fleming continues to write: "The Indian physician Caraka (1st century AD) instructs teachers to
tell students, 'There shall be nothing that thou should not do at my behest except hating the king,
causing another's death, or committing an act of great unrighteousness or acts leading to calamity'
(emphasis John Fleming). Oath of Initiation [Caraka Samhita], ibid., 1732."
96 CHAPTER 2

1.4. The Role ofRealist Phenomenological Philosophy in Showing Human Dignity

to Be Truly a 'Medical Ethical Universal'

We may entertain the justified hope that an elucidation of the nature and dimensions
of human dignity will let this consensus grow. The phenomenological method of
philosophy, especially the realist phenomenological method,1O precisely has this pur-
pose: to let the intelligible objects of universal human experience show themselves
in their true identity; and not to overlook them, not to misconstrue them, nor to re-
duce them to other things to which they cannot and must not be reduced.
Therefore, a philosophical medical ethics that proceeds phenomenologically in
the sense of realist phenomenology can indeed reach that common ground of moral
data which are accessible in principle to all mankind and which constitute a truly
universal basis for medical ethics of many civilizations and religions: of Jews,
Christians, Muslims, and members of other authentic religions. II
In fact: Since we will try to show that human dignity is not only a matter of faith
but clearly accessible to rational human understanding, our investigation of the dig-
nity of the human person and of its moral implications addresses itself to all men
and should provide indeed a 'medical ethical universal': human dignity as a founda-
tional morally relevant value addressing itself to the whole world and to all cultures
and individuals in harmony with authentic human reason.
A thought that targets nothing but the truth of things has many points of contact
with the experience of the most different people, whether they are drawn, in their
quest for the truth, from the Western or the more colorful Eastern world, from Chris-
tian experience, or from the religious world of Judaism or the Islam, or from Hindu
and Buddhist societies. Such a philosophy is also closely connected with, and eluci-
dates in a certain way, the experience of the 'simple man' and the best part of so-cal-
led 'common sense'.
There exist in fact everywhere the same original data (urphenomena) that unfold
in different degrees and dimensions in any human experience: everywhere we find
colors, forms and sounds, pleasure and pain, knowledge and error, reality and imagi-
nation, humans and animals, love and hatred, birth and death, affectionate mothers,
loving couples, generous sharing and envy, things that are good and bad, fair and
unfair. Nothing of all that is exclusively 'Western' or 'Eastern', 'medieval' or'mod-
em', 'Muslim', 'Hindu', or 'Christian'. Heraclitus may have had something similar
in mind when he said that the logos (meaning, truth, etc.) is common to all men and
that he who does not heed this universal logos and who deviates from it and behaves
as ifhe had his own private logos, is an idiot. 12

10 See Adolf Reinach, "Uber Ph!lnomenologie"; Dietrich von Hildebrand, What Is Philosophy?; Josef
Seifert, Back to Things in Themselves; the same author, "Ph!lnomenologie und Philosophie als strenge
Wissenschaft. Zur Grundlegung einer realistischen ph!lnomenologischen Methode - in kritischern
Dialog mit Edmund Husserls Ideen fiber die Philosophie als strenge Wissenschaft."
II The opposite of authentic religions of such a description would be, for example, satanic sects and similarly
'irreligious religions'.
12 Heraclitus, Fragment 2, Sextus Adv. Math. VII, 133: "It is necessary to foUow the cornmon (universal);
but although the logos is cornmon, the many live as though they had a private understanding."
 HUMAN DIGNITY 97

For this reason, in common life and in philosophy, as well as in medical care, we
can start from a universal experience, strongly emphasized by ancient philosophers
(after Heraclitus especially by the Stoics), but also by many later philosophers and
by Christian, Jewish, Muslim, Indian, and Chinese thinkers. This universally acces-
sible experience precedes philosophy.
When the greatest philosophers clarity the nature and intelligible essences of
these data, and even more when persons of the active life, such as Mahatma Gandhi
or Mother Theresa, embody them, we can clearly grasp them, and, at least as long as
a person does not set into motion all kinds of sophistry or internal resistance to evi-
dent truth, almost nobody can resist their intelligibility and the evidence of their
knowledge.
This is especially true of those values and fundamental human rights that form
the object of the analyses of this chapter: the dignity of the human person and the
fundamental obligations and rights rooted in it. Their evidence led the world com-
munity in 1946 and later to formulate repeatedly catalogues of fundamental human
rights. The universal experience of what is human and of what is good links all hu-
mans together: every man is acquainted with it; and the data of this experience are
accessible to any person's reason prior to, and irrespective of, her religious convic-
tions.
This is true even when it is a matter of those values and ideals that physicians
and nursing staff, or other human beings, often fail to realize. Also these values can
be perfectly evident in themselves, even though their invisible law is not automati-
cally recognized in the real world and although they do not 'function in the praxis'
but frequently remain unobserved by a majority of humans, including-around the
globe-many followers of religions, and are contradicted by laws, political actions,
and medical praxis. In spite of being disregarded by many, however, and as a condi-
tion of being immorally neglected, they can be seen.
Yet, even if ethical norms and values are not only not obeyed in practice but
when also a majority of mankind does no longer see them and they therefore are no
longer object even of a silent universal consensus, the human values and the funda-
mental morally relevant and moral values that we experience remain nevertheless
evident in their essence, if only we cast an intellectual glance at them and at the be-
ings out of whose nature and existence they grow. What is further required to see
human dignity, and values in general, clearly, besides a serious intellectual effort of
opening one's mental eyes, is an openness towards, and a love of, truth, as well as an
inner readiness to accept values intellectually even when they impose certain moral
obligations on us which to accept sometimes may be disagreeable or costly for us.
To cast a mental look at values and human dignity is the task of every human
being but quite especially of the medical profession to whom life and death, health
and sickness, are entrusted in a very special way. Each person's task is not to let
herself just be steered or determined by 'what one thinks' or by 'positive laws' but
only by the truth of things themselves.
Therefore, the results of an adequate philosophical research into these data also
are accessible in principle to everyone. As soon as a person brings these fundamen-
tal data to bespeak their own essence, in poetry or in philosophy, everyone who has
an open mind can see them. That explains why the works of ancient Greek philoso-
98 CHAPTER 2

phers and tragedians who grew up in a religion quite foreign to ours contain a uni-
versally recognized wisdom that had a deep impact on the entire word, and why
Arab philosophers of the Islamic religion have been able to acquire great and deci-
sive importance in Western philosophy formed by Jewish and Christian faith when
they lent their voice to the same experience, to the same truth, to the same funda-
mental data.
As we shall see, existing disagreements on values often depend on disagreement
on the nature of things, rather than being really value-disagreements. This applies
especially to bioethics where the questions of matter of fact (for example whether a
tiny embryo is a human person) are frequently more difficult to settle than the value-
questions themselves, once we agree on the nature of a thing, for example on the na-
ture of persons, embryos, comatose patients, or on whether a given being is a person
or not. For this reason, part of this chapter on the dignity of human persons will be
dedicated to the question "What is a person?" because some of the value questions
concerning human dignity can solely be answered on the basis of understanding the
nature of a person.
I shall subsequently defend the intuition of a universal human dignity and of uni-
versal human rights, which proceed from four quite distinct levels and dimensions of
human dignity. All of these can be shared by all men of good will, but especially by
Muslims, Jews, Christians, and other believers of monotheistic religions by whom
some dimensions of human dignity are acknowledged which members of other reli-
gions or atheists cannot see.
Yet the reality and many of the dimensions of human dignity can also be recog-
nized by atheist physicians and by persons who are not members of any religion. As
a matter of fact, some of the most potent arguments in favor of atheism, for example
those presented by Ivan Karamazov in Dostoyevsky's Brothers Karamazov, rest on
the intuition into the depth and objectivity of the exalted value of human dignity.
Ivan believes that it is impossible and morally unacceptable to believe in a God who
allows the horrible attacks against the value and dignity of the innocent children
whose unspeakable mistreatments and sufferings he describes. Thus, Ivan's atheism
is atheism in the name of the absoluteness of human dignity that ought to be respect-
ed even by a God. His argument is: "God does not exist because, if He existed, He
would never allow such cruel attacks against the dignity of innocent children!"
To unfold the nature and dignity of the human person in its objective evidence
will not only elucidate an abstract and content-less value on which almost everyone
agrees and from which no concrete moral contents would follow. On the contrary,
human dignity is in itself a most content-full and unique value from which many
concrete ethical consequences derive. We will recognize in each one of the different
dimensions and levels of human dignity a high value from which many concrete
contents of medical ethics can be derived. Some of these will be discussed in the
present volume, but a discussion of most of the concrete cases and applications of
the knowledge of human dignity will be reserved for volume II of the present work.
The following reflections then intend to elucidate the nature and existence of hu-
man dignity and of fundamental human rights, inasmuch as they are accessible to
human reason and to universally accessible philosophical evidence.
 HUMAN DIGNITY 99

1.5. The Main Theses to Be Defended in This Chapter

Speaking here of medical action, I wish in particular to defend, as an important ob-

ject of a desirable consensus of the world's medical community across world cul-
tures, the following theses which I will seek to bring to evidence:
1. In order to understand human dignity, we need to gain a proper understand-
ing of what it is to be a person, to reach an adequate ontology of the person
and a proper philosophical anthropological concept of human personhood.
2. Human dignity is a high and irreducible objective value peculiar to persons.
3. Each person has dignity.
4. Man has dignity because he is a person (impersonal creatures, animals, and
even human corpses that are not persons, while likewise possessing some dig-
nity, possess dignity only in an essentially weaker or merely analogical
sense).
5. Every human being is a person.
6. What we call 'human dignity' has four general sOurces and dimensions, and
some of these comprise again very different further dimensions and contents.
7. These dimensions of personal dignity are the basis of:
a. ethics and medical ethics;
b. a natural law independent of positive law and therefore to be respected by
all positive laws and medical codes;
c. four distinct levels of human rights many of which are of paramount sig-
nificance for the physician and other health workers.

1.6. Two Ways to Know What It Is to Be a Person: Immediate Phenomenological

Experience ofPersons, and Intuition into the Ontological Ground that Intelligibly
Underlies Experience

Two key epistemological questions of medical ethics concern the question of the
knowledge of dignity. They are:
(1) How can one know at all in an objective way, on the basis of rational under-
standing and without presupposing religion, human dignity that is an important part
of the foundation of medical ethics?
(2) How can one know, in a manner that rests on universal human experience
and reason, the being and nature of persons as a source of a human dignity that be-
longs to all human beings and not only to some?
A purely rational and philosophical understanding of human dignity can be
reached primarily in two ways:
(a) One can choose as a starting point the aspects and structures of personal
being which can be directly experienced and analyzed in their essential traits, espe-
cially the following ones: (1) intentional, rational consciousness; (2) the capacity to
know, conceptualization, logical reasoning and language; (3) freedom, autonomy;
(4) spiritual forms of feeling; (5) relatedness to the world instead of a simple rela-
100 CHAPTER 2

tionship with the environment; (6) hwnan community (I-Thou-we); (7) relatedness
to God.
(b) Besides such a philosophical anthropology that consists in the analysis of ex-
perienced acts and other characteristics of persons, not ignoring their value, we can
strive for a metaphysical understanding of the person that proceeds from experience
to understand the ultimate ground of this experience. To be precise, one can, by tak-
ing one's starting point from the internal experience of our own personal being and
acts, as well as from the experience of other persons, seek to understand, by means
of rational intuition and argwnents, along the lines of a 'universal return to things
themselves', the ultimate metaphysical essence and being of the person that grounds
all those characteristics of persons that one experiences immediately. Likewise, such
metaphysics of the person should be close to the data, realist and phenomenological,
and hence based on experience, on the immediately and mediately given: also these
ontic roots and metaphysical structures of the person are, though partly only indi-
rectly and less straightforwardly, given in experience.
Such a metaphysical surpassing of the immediately given traits of personhood in
order to reach fundamental data that lie, as it were, partly in, but partly also behind
the immediately given aspects of persons is especially necessary for bioethics and
medical ethics. For only through some going beyond the immediately experienced
traits of personhood of children or adult patients can we understand the objective
personhood of a great nwnber of hwnan beings (unborn children, comatose or other-
wise unconscious patients, etc.) whose personal being does not manifest itselfimme-
diately in our experience but which to recognize is decisive for the ethical nature of
many actions of physicians.
Now, while it would be quite natural to begin our reflection with a phenomenol-
ogy of the experienced traits of personhood, we will, in order not to repeat ourselves
when we need to provide such an analysis later (in order to understand the second
dimension ofhwnan dignity), proceed in the reverse order: We will first discuss the
metaphysical conceptions of personhood and only then, when getting to the deeper
axiological definition of the person in terms of her dignity, unfold the more imme-
diately given traits of personhood. .

2. WHAT IS A PERSON? ONTOLOGICAL AND AXIOLOGICAL

UNDERSTANDING OF THE PERSON

An appropriate metaphysics of the person specifically leads to very different pos-

sible 'definitions' of the person among which we intend to explore in the following
three: (a) an ultimate ontological subject (substance) ofa rational nature; (b) a sub-
ject that is distinct in virtue of his dignity; (c) an individual rational subject as essen-
tially ordained to other persons (a 'thou', a 'we'), as 'a being with others.'

2.1. The Person as Ultimate Individual Subject ofRational Nature

The first 'classical' metaphysical definition of a person is the one given by Boethius
as follows: "A person is an individual substance of rational nature" (individua sub-
 HUMAN DIGNITY 101

stantia rationalis naturae).13 There is, we will argue in the following, an undeniable
truth in this definition. Let us therefore examine and substantiate its elements.

2.1.1. Person as a Substance

In fact, a person cannot be a mere set or effect of brain functions or any mere prop-
erty or function of any other thing, be it even of God, but must absolutely stand in
itself in being, be 'something' or better somebocry who, even if wholly dependent on
absolute being and not possessing being from itself (a se), is a being in itself (in se),
a being that stands in being on its own feet, so to speak. This self-existing being-as
opposed to mere attributes of something else-was called a substance (ousia) by
Aristotle. We can recognize this as the first mark of a person. A person must stand in
itself in being and not be a mere quality or predicate of anything else, if he or she
truly is a person. A person herself is in an autonomous manner someone and does
not exist only in another thing.
He or she stands even necessarily and in an archetypal form in itself in being and
can never be the attribute of something else. Even Kant, whose philosophy does not
admit of such an intuition and who subjectivized all categories such as that of sub-
stance, understood this fundamental truth about persons when he said in his late Lec-
tures of Metaphysics (held in the 1880s), forgetting as it were his entire Critique of
Pure Reason:
But I know ofthe soul:
That it is a substance; or: I am a substance. The 'I' means the subject, inasmuch as
it islIPM20211 no predicate of another thing. What is no predicate of another thing is a
substance.
The 'I' is the ... subject of all predicates, thoughts, actions ... it is absolutely im-
possible that the 'I' be the predicate of something else. The 'I' cannot be the predicate
of another being. In fact, predicates belong to me. The 'I' itself, however, cannot be
predicated of another thing, I cannot say: Another being is the 'I'. Consequently, the 'I'
or the soul which is being expressed through the 'I' is a substance. '4

It is absolutely evident that nothing can be a person if it only inheres in another

thing, is part or accident thereof, like a color, shape, form, quality, epiphenomenon
or supervenient property of something else, for example of the brain.

13 "Persona est rationabilis naturae individua substantia" (the person is an individual substance of ration-
al nature). Boethius, Contra Eutychen et Nestorium, cap. 3; in Patrologia Latina 64, 1343, the
formulation differs slightly: "persona est naturae rationalis individua substantia."
14 My translation of Immanuel Kant, Vorlesungen iiber die Metaphysik (Politz), PM 201-202:
Ich erkenne aber von der Seele:
1) daB sie eine Substanz sey; oder: Ich bin eine Substanz. Das Ich bedeutet das
Subject, sofern es IIPM20211 kein Pradicat von einem andern Dinge ist. Was kein
Pradicat von einem andern Dinge ist, ist eine Substanz.
Das Ich ist das ... Subject aller Pradicate, alles Denkens, aller Handlungen ....
Es geht also gar nicht an, daB das Ich ein Pradicat von etwas anderm ware. Ich kann
kein Pradicat von einem andern Wesen seyn; mir kornmen zwar Pradicate zu; allein
das leh kann ich nicht von einem andern pradiciren, ich kann nicht sagen: ein ande-
res Wesen ist das leh. Folglich ist das Ich, oder die Seele, die durch das Ich ausge-
driickt wird, eine Substanz.
In addition to this text, dating from the years after 1781, Le., after the Critique ofPure Reason, see
also Immanuel Kant, Critique ofPractical Reason VI, 33.
102 CHAPTER 2

2.1.2. The Person as 'Thing in Itself

A person has to be in itself still in another sense: No being that is nothing but a pure
intentional object of our consciousness is (really) a person. Dreamed persons,
fictitious persons and phenomena in Kant's sense are not persons. The characters of
Shakespeare's dramas are neither men or women, nor any other persons, because
they only have a way of being that is constituted through the acts of other subjects:
they are merely imagined persons, not real ones, because they depend entirely on
other persons' conscious acts; they are only objects of these acts, and this contradicts
personhood which requires a being in itself of persons who are themselves subjects
distinguished from being a mere object of consciousness. The person of a suffering
patient is only a person and is only a patient if she does not just appear in the dreams
of a nurse or the hallucinations of a schizophrenic physician but exists in herself.
Without a realism that recognizes the knowledge of the thing in itself, there is no
possible knowledge of persons. 15 This philosophically required realism includes both
a realist theory of knowledge and realist metaphysics-the two being necessary for
any appropriate understanding of the person.
Kant as well, despite his criticism, which forbids this knowledge, asserts-con-
trary to his system-not only the being of the substance, but also a being in itself of
the person. Even though Kant had denied knowledge of the noumena (things in
themselves), he made, in his resolution of the antinomies as well as in his practical
philosophy,16 a certain exception for the free subject (person): he says that freedom,
without which neither the reality nor the life of the person is possible, can only be-
long to the noumena (being in itself that is not dependent on being the object of our
consciousness), not to the phenomena (appearances dependent on consciousness).
Thus, though he had denied any knowledge of things in themselves which do not just
exist as objects of human consciousness and thought, he still continued to see the
datum that persons and their free acts and causation of acts cannot be just appear-
ances but must be real in themselves, autonomously.17 Yet Kant has absolutely no

15 See Josef Seifert, Erkenntnis objektiver Wahrheit; from the same author, Back to Things in
Themselves; still from the same author, Ritornare a Platone. Lafenomenologia realista come riforma
critica della dottrina platonica delle idee. 1m Anhang eine unveroffentlichte Schrift Adolf Reinachs,
edited, prefaced and translated by Giuseppe Girgenti (Milano: Vita e Pensiero, 2000).
16 See Josef Seifert, Oberwindung des Skandals der reinen Vernur!ft.
17 See, for example, Immanuel Kant, Critique of Practical Reason (Kritik der praktischen Vernunft
[1788]), Akad. V, 86-87:
Es kann nichts Minderes sein, als was den Menschen iiber sich selbst (als einen
Theil der Sinnenwelt) erhebt, was ibn an eine Ordnung der Dinge kniipft, die nur der
Verstand denken kann, und die zugleich die ganze Sinnenwelt, mit ihr das empirisch
bestimmbare Dasein des Menschen IN8711 in der Zeit und das Ganze aller Zwecke
(welches allein solchen unbedingten praktischen Gesetzen als das moralische ange-
messen ist) unter sich hat. Es ist nichts anders als die Personlichkeit, d. i. die Frei-
heit und Unabh!ingigkeit von dem Mechanism der ganzen Natur, doch zugleich als
ein Vermogen eines Wesens betrachtet, welches eigenthiimlichen, nlimlich von sei-
ner eigenen Vemunft gegebenen, reinen praktischen Gesetzen, die Person also, als
zur Sinnenwelt gehOrig, ihrer eigenen Personlichkeit unterworfen ist, so fern sie
zugleich zur intelligibelen Welt gehort; da es denn nicht zu verwundem ist, wenn
der Mensch, a1s zu beiden Welten gehOrig, sein eigenes Wesen in Beziehung aufsei-
ne zweite und hOchste Bestinunung nicht anders als mit Verehrung und die Gesetze
derselben mit der hOchsten Achtung betrachten muB.
 HUMAN DIGNITY 103

epistemological basis left for this intuition that he gains malgre lui, i.e. in contradic-
tion to his basic systematic theory of knowledge. Only an authentically realist phi-
losophy can reach that basis, not by the force of a mere belief but on the strength of
indubitable evidence of knowledge of things in themselves and absolutely necessary
laws rooted in their essences. Based on a critique of all Kantian and other subjecti-
vism in epistemology, realist phenomenologists have attempted to show in many
works that, and in which sense, the human intellect can actually know the noumena
(the intelligible being and essence of things) and hence also truly know that intrinsic
being (the being in itself) of persons to which the Kantian insights refer without
being based on such a rationally justified base. 18

2.1.3. The Person as a Living Substance

As a real spiritual substance (of rational nature), the person is essentially a living
subject as well. Only a living human being or spirit (or a living 'separate soul') is a
person, never a corpse. Therefore, to understand what it is to be a person also re-
quires an understanding of what it is to live. 19 That is why a human corpse, while it
has some dignity in an analogical sense, cannot have the same dignity and rights of a
person, and has even much less dignity than the lived body of a human person which
partakes in many ways in the dignity of the person whose body it is; a life-less being
never possesses personal rights in the strict sense, wherefore one may decree to do-
nate one's corpse to hospitals for study and dissection purposes-something which
would be a crime when applied to a (living) person who would give her body free
for vivisection.
Some authors who seek to defend the thesis that personal dignity comes in many
degrees misleadingly refer in this context to the dignity of corpses, which do not

An extraordinary passage on the intrinsic (absolute) reality of the freedom of the person is again
found in Kant's Vorlesungen iiber die Metaphysik (politz), PM 206-207:
Ware ich nicht frei; so konnte ich nicht sagen: Ich thue es; sondem mill3te ich sagen:
Ich filhle in mir eine Lust zu thun, diejemand IIPM20711 in mir erregt hat. Wenn ich
aber sage: Ich thue es; so bedeutet das eine Spontaneitiit in sensu transscendentali.
Nun bin ich mir aber bewuBt, daJ3 ich sagen kann: Ich thue; folglich bin ich mir kei-
ner Determination bewuBt, und also handele ich absolut frei. Ware ich nicht frei,
sondem nur ein Mittel, wodurch der Andere immediate in mir etwas thut, was ich
thue; so konnte ich nicht sagen: Ich thue. Ich thue, als actio, kann nicht anders als
absolute frei gebraucht werden. Aile praktischen objectiven Siitze hiitten keinen
Sinn, wenn der Mensch nicht frei ware. Aile praktischen Vorschriften waren unniitz;
man konnte alsdann nicht sagen: du sollst dies oder das thun. Nun giebt es aber sol-
che Imperativos, nach denen ich etwas thun soli; mithin miissen aile praktische Siit-
ze sowohl problematisch, als pragmatisch und moralisch, in mir eine Freiheit vor-
aussetzen; folgiich muB ich die erste Ursache seyn von allen Handlungen. Da wir
aber in der empirischen Psychologie die praktische Freiheit erwiesen haben, nach-
dem wir frei sind von der Necessitatione a stimulis, so konnen schon dadurch die
praktischen S!1tze statt finden; mithin ist in Ansehung dessen die Moral sicher, wel-
ches auch unser vomehmster Zweck ist.
For a further discussion of this point and other passages see my discussion of the third antinomy in
Josef Seifert, Oberwindung des Skandals der reinen Vernunft.
18 See especially the epistemological works by Adolf Reinach, Max Scheler, Dietrich von Hildebrand,
and myself cited before.
19 Cf. Josef Seifert, What is Life?
104 CHAPTER 2

possess 'a lesser degree of personal dignity' but no dignity of persons at all because
only living beings can be persons. Therefore, hwnan corpses possess dignity only in
an essentially different and analogous-though important-sense but this must not
be adduced as an argwnent in favor of a gradation of the ontological dignity of
persons, who are only persons as living beings and as long as they are alive. 20

2.1.4. Personal Individuality (Uniqueness)

The unrepeatable unity of each person, as well as her absolute individuality, distin-
guishes the spiritual person from all material and purely biological substances,
whose genetic code-the same in identical twins and present and duplicated in all
body cells as it is--can never account for this unique, indivisible and unrepeatable
character of each person.
The unrepeatable uniqueness of each person is apparent not only in an abstract
metaphysical intuition but also in the love for a person as well as in his or her moral
responsibility and freedom, and in our own self-experience: each person is absolu-
tely unparalleled and unrepeatable, as well as unique in a more qualitative sense of
the 'unrepeatability' of each personality. Persons must therefore never be considered
from a mere quantitative perspective. Totalitarian ideologies and regimes, as well as
pantheistic philosophies, ignore in principle this uniqueness of each individual per-
son by reducing persons to simple moments within other concrete or abstract entities
such as States or an impersonally conceived divinity. Superficial ideas and programs
of genetic engineering, of family planning, of cloning, etc., forget as well, for entire-
ly different reasons, this absolutely matchless quality and absolute uniqueness of
each person; at least they fail to draw the ethical consequences from this knowledge.
They treat persons as if they were mere nwnbers or elements of certain quantities,
thus forgetting the unique and unrepeatable individual thisness of the person, which
John F. Crosby considers, besides the essence of the person, as the second source of
hwnan dignity.21

2.1.5. The Person as a Spiritual Substance and the Human Soul

If we describe the person as 'substance', we do not mean that the person is 'a thing',
let alone a purely material thing, but only that the person is an ultimate subject that
stands in itself in being. The person is living and at the same time spiritual, indivisi-
ble and invisible, and in possession of reason (of course, a human person is a ration-
al subject that is an incarnate personal being and therefore has a visible body). The
term 'spiritual' is here taken in the sense of the German word geistig, and not in that
of geistlich, which refers to specifically moral and religious dimensions of the lives
of persons. The spiritual nature of the person in our sense is characterized by the im-
materiality as well as by the positively spiritual and rational aspects of the person
which we will discuss in the context of the second source of hwnan dignity; these
include objectively also the spiritual dimension in the narrower (specifically reli-
gious) sense of this term (geistlich) but are in no way reducible to it and can be rec-

20 If they are immortal, they will eternally remain living persons.

21 See John F. Crosby, The Seljhood o/the Human Person.
 HUMAN DIGNITY 105

ognized also by those who do not believe in the existence of a distinctly religious
spiritual life. 22
A person is not only a living and individual real substance, but essentially an in-
tellectual or spiritual substance as well. Also within the soul-body unity characteris-
tic of human persons, what really founds the human being as person is her spiritual
soul. Therefore, a philosophy of the person requires at least a short development of
the major proofs of the existence of a spiritual soul (of the spiritual nature of the per-
son).

Arguments for the Existence of the Soul: We can identity four groups of phenome-
nological and purely philosophical arguments for the existence of the soul.

(i) Arguments from consciousness and the indivisible unity of its subject as such:
Let us start with a simple experience of which the Nobel Laureate and great brain
scientist Sir John Eccles said that it is far more evident than all evidences of brain
science: 23 In all conscious experiences of the human person we find the arch-datum
of the absolutely indivisible 'I', of the subject of conscious experience: I am, as one
and the same subject that is not composed of non-identical parts, present in myriads
of experiences; I, the identical Self, have to remain present, even for the smallest ex-
perience (hearing a melody, for example) to be possible, in innumerable temporally
separated mental operations which would not be experienced and related to each
other without the indivisible and experienced identity of myself as subject of con-
sciousness. We also find the same subject present in an enormous variety of kinds of
conscious experiences, such as perceiving, thinking, judging, questioning, willing,
loving, etc.
This subject possesses dimensions of unity that are inexplicable in principle
through matter. No material entity including our brain could explain such a unity
and identity of the conscious subject, because (a) the matter of our brain has astro-
nomically many non-identical and divisible neurons, plus their dendrites and other
innumerable smaller parts, and thus differs essentially from the simple subject of
consciousness;24 (b) there is not even an analogy to the simple human subject in the
brain: any single biological focal point or center to which all information would
flow is missing there. Even less could an epiphenomenon or supervenient product of
brain activity account for the personal 'I', because in virtue of its nature of an acci-
dent, any such dependent quality or product of something else (brain events) would
even lack the most elementary character of a person, the ontological self-standing in
being, i.e., the character of a subject or substance, as we have seen in our short dis-
cussion of the person as substance above.

22 For a more detailed comment on the terminology used here see the Appendix of the second edition of
Josef Seifert, Das Leib-Seele Problem und die gegenwiirtige philosophische Diskussion.
23 This did not prevent David Hume and other non-ownership theoreticians of the mind to deny it with
sophistical and contradictory arguments. See Sir John Eccles and D. N. Robinson, The Wonder of
Being Human; see also John C. Eccles and Karl R. Popper, The Self and Its Brain.
24 Cf. G. W. Leibniz, Monadologie, in Leibniz, Die Hauptwerke, zusarnmengefaBt und libertragen von
Gerhard KrUger (Stuttgart: Alfred Kroner Verlag, 1958), 17. See also John C. Eccles and Karl R. Pop-
per, The Self and Its Brain.
106 CHAPTER 2

(ii) Arguments from specific conscious experiences and acts:

(1) Each act of knowledge depends on, and is detennined in its content by, the
nature of the known object. This grasp of the nature of anything would be absolutely
impossible, and the rationality of cognition would be destroyed, if chemical or phys-
ical forces would not only be conditions but causes by which knowledge and its con-
tents would be determined. In that case the content of knowledge would not depend
on the nature of things but on blind chains of physical and chemical forces. It would
be different not in accordance with the differences in things but in dependence on
different physical events in the brain. But knowledge and its rationality require far
more than a strict dependence in its content on the nature of the object known in an
intentional act of cognition: cognition entails not only an objective being detennined
by the object but involves a unique transcendence of the subject without which
knowledge, i.e., an actual reaching of the object in the intentional cognitive act,
would not be possible. Knowledge, and most of all the clearly and indubitably given
phenomenon of cognitive evidence, and therewith of knowing that we know some-
thing, would be entirely impossible if our knowledge were detennined 'from the
back' through blind physical causes and if it were to change in its content not in ac-
cordance with changes in things but with mere changes in our physical make-up and
material forces operating on us.
(2) Especially rational knowledge of universals, the fonnation of concepts and
judgments, the perception of beauty, and most of all the knowledge of eternal, invi-
sible, intelligible, necessary, and immaterial truths and essences as well as objects
such as ideal numerical relations could never be accounted for as effects of brain
events;25 for neither are the essences and intelligible objects material things nor
could these account for their knowledge: matter can only enter into a purely partici-
patory and objective relation to universals, eternal truths and immaterial essences,
never into an experienced conscious contact with an immaterial world.
(3) Freedom as such and self-detennination of the subject through his own will is
another indubitable phenomenon: even if we could be deceived about our very being
[which is absolutely impossible], says Augustine, it would still be indubitably clear
that we would not want to be thus deceived; and in this evidently known free resis-
tance to error our freedom is clearly manifested, as also Plato had stated before
Augustine. 26
Now, such self-detennination of a subject in freedom would be absolutely im-
possible if the subject and his act were a material object, let alone a causal effect (or
epiphenomenon) of material processes; thus the existence and evidence of freedom
refutes any materialism.
In general, we must distinguish identity, condition, cause, and effect. The brain
and brain processes can very well be conditions and effects of truly rational acts and
experiences of the described sort, but never be identical with them, or with their
cause, or with their subject.

25 See Josef Seifert, "Essence and Existence"; Sein und Wesen, chs. 1-2.
26 Plato, Phaedo, 94 b-95 a; Phaedrus, 245 d-246 a; Nomoi, 895-896; Politeia, IV, 439; C/eitophon,
408; with reference to Anaxagoras Craty/us, 400.
 HUMAN DIGNITY 107

The general structure of these arguments for the mind (soul) from specific ration-
al acts is, expressed in a traditional logical form, the following:
1. S (knowledge, free acts, etc.) implies Y (the existence of a simple spiritual
substance as subject), and not-P (the immateriality of the subject of conscious-
ness), not-R (its non-identity with the brain), and not-Z (its not being an epiphe-
nomenon or supervenient characteristic of brain events) (If S, not-P, not-R and
not-Z are true);
2. S (knowledge and free acts exist and are known to exist through evident
knowledge).
Therefore Y and: not-P, not-R, and not-Z.
Similar arguments as those from the specific essences of knowledge and freedom
could be developed from reflection, memory, and many other acts.
(iii) Arguments from an ontology of the substantial nature and subject of human
consciousness:
The personal I, the subject of consciousness, is not only concluded to but itself
clearly given. And it is absolutely evident that this I and free Self can never be an
accident, a property of something else. As center of consciousness and subject of
free acts, I stand in myself in being as substance, as subject (hypostasis). This is
what Thomas Aquinas or Boethius, who defined the person as "individual subject
(substance) of rational nature," saw.27 As our experience of sleep or loss of con-
sciousness but also a deeper ontological reflection show, while the conscious sub-
ject, and not something 'behind it', is the person, the person still cannot be reduced
to her conscious state and awakening as conscious subject: what awakens here pre-
cedes temporally and ontologically the conscious state.
But how can we prove the spirituality and immateriality of the personal subject
(soul)?
1. The ultimate subject of consciousness possesses the single marks of substantiality
more perfectly than it is even thinkable in a material thing:
(a) The person, as indivisible, unique Self and as living, conscious and freely
acting subject, stands more clearly in herself than any material thing could ever do;
she does not inhere in another substance, possessing inseitas (subject-character) in
an exemplary fashion inaccessible to matter.
The person hence is not only also a substantial being but substance in a more
proper sense than matter ever can be. Also from this absolute impossibility that a
material thing could be so perfectly substantially self-standing in being, the soul's
spiritual, immaterial nature becomes obvious. Therefore, she cannot only not be the
brain, as we have seen. She can even less be an effect of the brain which could never
be a substantial entity/subject standing on its own feet in being.
(b) Moreover, the person possesses an absolutely irreplaceable individuality as
the simple and unrepeatable subject of conscious and free acts in a way in which no
material thing can ever be an individual tode ti (this there), as Aristotle calls sub-

27 Boethius, Contra Eutychen et Nestorium, cap. 3; Patrologia Latina, 64, 1343. For the full text see
heading 2.1.
108 CHAPTER 2

stance. Each subject of consciousness, by possessing the unrepeatable individuality

and uniqueness described above, cannot ever be explained by the brain, among
whose billions of neurons and parts only the elementary particles possess a compa-
rable unrepeatable individuality of an indivisible element.
No lesser philosopher than Roderick M. Chisholm wanted to identify one un-
identified elementary particle with the Self, whose evident absolute indivisibility he
recognized. 28 These elementary particles of matter, however, do not live, whereas the
conscious subject lives, nor are they as such connected with consciousness. There-
fore, they can never explain the conscious subject. Also in that they occupy space
and have a certain size, in their spatial 'exteriority', they can never possess the whol-
ly different simplicity of the conscious Self that necessarily lacks size and parts out-
side each other in space. Moreover, elementary particles possess only an anonymous
individuality of a 'building block', a character opposite to the profound individuality
of the person. The unique unrepeatable individuality of the simple personal Self can
also not be explained genetically through matter (for example through a unique gen-
etic code) because each genetic code is duplicated in each cell and can be redupli-
cated in identical twins, clones, and, however slim the chances of a repetition of a
genetic code in independent organisms are, it could in principle be thus repeated in
the course of history, whereas the personal subject is absolutely unique and unre-
peatable in any possible world. Moreover, this unrepeatable thisness is not a mere
objective individuality, as also each stone and tree possesses it, but an absolutely un-
repeatable thisness and individualness of the rational and free subject experienced
from within. Only a spiritual and immaterial subject can possess these characterist-
ics, a personal soul which neither is a composite whole, as all complex matter, nor a
simple part thereof (elementary particle or atomon), that, while no longer being real-
ly divisible, is still extended in space and mathematically divisible. A being charact-
erized by size and the 'exteriority' of material parts or energy fields never can expe-
rience from within its own individuality.
(c) The person possesses also more perfectly a further characteristic of sub-
stance mentioned by Aristotle, a sameness that endures throughout change and time:
while body cells and all other body parts can and do change,z9 or can be implanted,
the personal Self remains the same from beginning to the end of life. Moreover, the
person lives consciously and remembers her enduring being.

28 See Roderick M. Chisholm, "Is There a Mind-Body Problem?" in Philosophic Exchange 2

(1978): 25-32; The First Person (Minneapolis, 1981); for a critique of Chisholm's position, see Josef
Seifert, What is Life?, ch. 4.
29 Neurons certainly grow and multiply during embryonic development; in addition, recent studies have
shown the incorrectness of the long-standing belief of neurologists that brain cells later do not multi-
ply, cannot be grown in cell-cultures, and are not substituted after early infancy. See, for example, the
report on the research done by Dr. Elizabeth Gould of Princeton University, et aI., published in the
Proceedings o/the National Academy o/Sciences, and also in Science, Oct. 15, 1999,286:548-552.
Prof. Peter Fromharz, Dr. Michael Maher and others have made similarly interesting experiments at
the University of California in San Diego of growing animal brain cells on neurochips. So did Dr. Ira
Blash of Robert Wood Jolmson Medical School and University of Medicine and Dentistry of New
Jersey, and Dr. Helen Blau of Stanford University. See Science, Dec. 2000.
 HUMAN DIGNITY 109

These more perfect modes of endurance throughout time make the person more
perfectly a substantial being than matter can possibly be and again show that the per-
son must be an immaterial and spiritual substance and cannot be a material thing.
2. The ultimate subject of consciousness possesses the single marks of substantiality
in a far more perfect unity than it is possible in a material thing: Besides possessing
each mark of substance more perfectly, the person above all possesses them in a mu-
tual union more perfect than conceivable in matter: for example, the individual this-
ness of the personal Self is not founded on another level than that of the substantial
subject, whereas in a material object its essence and form that gives, for example, a
marble statue of Michelangelo individual thisness and separates it from surrounding
parts of marble blocks does not reside on the level of the ultimate 'substantial'
micro-parts. In the person, the simple subject himself is individual, enduring, and
delineated from all other beings.
But this unity of the marks of substance in the personal subj ect of rational acts-
which is unattainable in principle in a material substance in which these marks are
necessarily more separate-proves again the spirituality and immateriality of the in-
dividual substantia rationalis naturae.
(iv) Arguments from the 'lived body' and union of body and soul. One might object
that a human being is a person who has a body, an incarnate spirit, a soul-in-a-body,
and that the body-soul unity is opposed to any Cartesian conception of the human
person as a pure spirit (soul) to whom the body is merely extemal. 30 Obviously, the
human mind is not that of an angel. It is closely and intimately related to the human
body in many ways. But precisely the phenomenon of the Leib (the 'lived body') re-
veals the distinctness between body and soul and cannot be accounted for without
admitting it. This we see more clearly upon considering the different types of body-
mind relationships.
1. Static relationships: The body, and in particular the brain, is, as is medically
speaking obvious, a condition of earthly conscious experience, but it is a contingent
(non-necessary) condition; this we cannot only understand because we lack any
comprehension of an inner necessity here but because we see positively that there is
no absolute necessity why conscious life should depend on the brain. 31 But the brain
as contingenf2 condition without which consciousness or concrete experiences can-
not take place is evidently distinct not only from identity but also from an efficient
cause through the power of which conscious experiences are caused. With regard to
some conscious experiences their physiological causation in the psyche is possible;
for example, a state of feeling nervous may be caused. But the role of the brain as
cause and as condition of conscious states and acts is entirely different, just as the
motor and the processes of combustion in it that cause the movement of a car are

30 See also Josef Seifert, "EI hombre como persona en el cuerpo," in Espiritu 54 (1995): 129-156.
31 See Josef Seifert, Das Leib-Seele Problem und die gegenwiirtige philosophische Diskussion.
32 In contradistinction to absolute conditions of conscious life (such as that there be the subject of con-
sciousness), these contingent conditions, the contingency (non-necessity o/which) we can recognize
philosophically, do not apply absolutely and can therefore cease to be conditions of conscious life in
an immortal existence. See Josef Seifert, What Is Life?; "Gibt es ein Leben nach dem Tod?" in Forum
Katholische Theologie, 5, Heft 4,1989.
110 CHAPTER 2

distinct from the many conditions (inside the motor and in the surroundings) of its
motion.
Another static relation of the body to the soul completely distinct from a condi-
tion is found in the body as a visible and audible expression of the person. Ifwe look
at the quality of the human voice, at the shape of the human face, the upright pos-
ture, the forehead, the eyes, the whole aesthetic quality of the human body, we find
an amazing fact: that which belongs to the order of the physical expresses and mani-
fests in an immediately accessible way the dignity and nature of the human soul, of
the human person. It is no accident that a human person does not look like a worm
or dog. In this sense, Ludwig Wittgenstein rightly said that the best image of a per-
son is the human body. Therefore, the appearance of a pig, quite natural for a certain
animal, would give rise to a horrible disharmony between the bodily form of a pig
and the essence of a person, if a human person would look like a pig, or also like an
orangutan. The human form of the body, however, is an extraordinarily appropriate
medium manifesting the nature of personhood in the sensible world. If we look at
the nature of the close union of body and soul in the phenomenon of expression,
however, we find that never one body (one material thing) can express itself in an-
other one in the way in which the human body expresses a person. In other words,
one term of the relation of expression has to be spiritual and immaterial in order for
the body to be able to express it. Similarly, not two physical words of language can
express each other but only conceptual meanings (distinct from physical words) can
be expressed in language. 33
2. Dynamic body-mind relationships: This broad category includes again many
types:
(a) From body to mind:
<l. Causal relationships: Non-rational experiences such as physical pain and non-
intentional emotional states, which are not meaningfully and intentionally related to
objects, or also disturbances of the rational conscious contact with objects, allow for
being caused by brain events. Moreover, we have many empirical medical evidences
of causal relations through which somatic factors lead to changes of psychic states.
Alcohol, drugs, wounds, concussions, poisons, etc., obviously exercise effects on the
mind and cause drunkenness, headaches, other pains, etc. Brain lesions or certain
diseases can causally destroy even the concrete having at one's disposal mental fac-
ulties.
~. Very different is the role of the body as a medium of certain receptive acts.
Here the body is just the medium of all those receptive cognitive acts that involve in
some way directly or indirectly the bodily senses, rather than being their cause.
These intentional receptive cognitive acts have their origin in physical events in the
external world that exert some causal influence on the body but where the cognitive
and meaningful relations to the world are merely mediated, not caused by the body.
In sense perceptions the body plays such a medial role because the causal chain of
physical and physiological events stands in the service of an entirely different re-
ality-the intentional consciousness of an object which becomes the main source of

33 See on this Edmund Husserl, Logical Investigations, trans!. J. N. Findlay (London: Routledge & Ke-
gan Paul, 1970), II, 1, "Expression and Meaning."
 HUMAN DIGNITY 111

the content of these conscious acts: for example, we listen to Beethoven's Seventh
Symphony; here it is Beethoven's music that we get to know and on which, and on
whose good or bad performance, the object (and content) of our knowledge depends.
The events in our sense organs and brains playa mediating role enabling us to be in-
formed by those objects which the senses and brain events as it were merely carry to
us: we see the musicians and the conductor, we listen to the good or bad perfor-
mance of the symphony, and not to brain waves or events in our body. These un-
doubtedly required events thus playa merely mediating role.
The body and the brain can exert this mediating influence on intentional acts un-
consciously (for example, by nervous and brain events). The body can also be, how-
ever, a consciously lived medium of intentional relationships to objects in sense per-
ceptions and relations to other persons such as in the sense of touch and other sense
perceptions.
The medial function of the body is much more complicated and indirect when it
operates in relationship to the recognition of objects as belonging to a certain species
or genus and other intellectual cognitive acts. But in all of its forms it plays this role,
and is so closely connected with the conscious life of persons, only because this con-
scious life and its subject is not physical. Again, the close unity of body and mind in
the mediating role of the body throws light on the immateriality of the human soul
because two material things cannot be thus related.
(b) From mind to body and through the body to the world: There are also mind-
body relations of an inverse direction, relations in which the origin and initiative lies
with the soul (mind) and in conscious acts which then have effects or other conse-
quences in the body or, through the body, in the world. In these body-mind relations
the irreducibility of the mind to the brain or to an epiphenomenon or supervenient
property thereof becomes most clearly evident.
a. Inner free acts of concentration on an object can certainly have effects on the
body and also conditions in the body, but they can never be caused by the body nor
can the body be their source (except via motivation). The evidence of this necessary
state of affairs, and of the actual existence of inner free acts that cannot be created
by any cause outside the soul and the conscious subject, proves that their origin can
only lie in the free mind, their subject, and never in brain events; but they can cer-
tainly have effects in the brain.
B. When emotions and volitional attitudes [md a bodily expression, what happens
in the body is not only an effect but also renders visible (expresses) concrete mental
acts. But again, the close connection between body and mind in free acts and in the
expression of emotions in the body is only possible if one of the terms of this rela-
tion (the free act or the emotions which are expressed in the body) is immaterial and
not itself a physical reality. The essence of will and of emotions even forbids that
these be causally produced by the body (by brain events, etc.).
The problem how exactly the spiritual soul can influence the body and be influ-
enced by it remains highly mysterious and in many respects incomprehensible. No
one should expect a total solution of the mystery of this body-soul relationship about
which both highly intelligible, evident relationships and impenetrable mysteries
112 CHAPTER 2

exist which make a person-in-carne a puzzle which no scientist and no philosopher

will ever be able to solve entirely.
The soul has been called the forma corporis. This cannot mean the external
shape of a material thing. This is, of course, not the human soul, nor is the soul the
'form' of a material thing that makes it from within into a determinate kind of matter
Gust as the 'form' of silver, lead, etc.). Identifying the human soul with the inner
formedness of the body in its fragmentation and lack of simplicity would contradict
the simplicity of the soul as well as the experience of the partial identity between the
form of the body of the living man and the corpse. Even a third sense of form, the
life-principle of plants and animals, a form which, in Aristotle's words, is not a body
but something in and for a body,34 cannot be identified with the nature of the human
soul, because it is suitable only for the lower functions of the human soul.
In a fourth sense one can speak of 'form' when one characterizes the human
spiritual soul as the substantial form of the body. The spiritual human soul not only
does not 'exhaust itself in its animating and informing influence on the body; it is
not merely 'more' than form of the body (matter), but in regard to its spiritual and
most meaningful acts it is not at all primarily to be understood or to be defined as
'form of the body'. Intellectual, scientific, or philosophical knowledge, moral good-
ness, love, or religious acts represent a spiritual world in themselves which does not
allow that the essence of the human soul be conceived of primarily in terms of its
being 'form' of the body.
The spiritual soul of man, while being infinitely more than forma corporis, still
is, however, forma of the body. The deepest reason for the human body becoming a
Leib (lived body in the specifically human sense) lies in its being essentially des-
tined to be united with, and an expression of, the mental and spiritual life of the soul.
In that the human body stands in the service of the 'logos' (spirit, mind, meaning),
as Gregory of Nyssa especially emphasizes, and in that it serves a spiritual life,
which transcends it, the human body receives from this spiritual life its 'form' in the
deepest sense. The body is not only assumed into the life of the spirit but is also, ac-
cording to its innermost structure, ordained to union with the spiritual soul. The
body visibly expresses the mental and spiritual life which unfolds the wealth of its
meaning in the human soul; and the human body cannot at all be understood in its
significance without reference to the spirit-soul. The logos-bearing functions of the
human eye, mouth, hands, voice, etc., provide as it were the sole key for understand-
ing the essence and nature of the human body, even for comprehending its biological
properties and exterior shape and form, all of which receive their ultimate and spe-
cifically human character through their reference to the spiritual soul of man. In this
sense the human spirit is indeed the form (the principle of unity and intelligibility
and meaning) of the human body. And it is this most profound union of body and
soul, which is evident from our experience. The human soul is precisely form of the
body by not primarily being form of the body. It informs the body, both raising it up

34 See Aristotle, De Anima (On the Soul), end of Part I, translated by J. A. Smith, from Internet-edition.
Cf. also Aristotle, De Anima, On the Soul, trans!' J. A. Smith, in R. McKeon (ed.), The Basic Works of
Aristotle (New York: Random House, 1971), pp. 533-603. Josef Seifert, Leib und Seele, pp. 71-89;
344 f. Hedwig Conrad-Martius, Die Seele der Pjlanze, in Conrad-Martius, Schriften zur Philosophie,
Hrsg. Eberhard Ave-LaUement, Bd. 1 (Miinchen: Kosel, 1963), pp. 276-362.
 HUMAN DIGNITY 113

and 'incarnating', concretizing and 'expressing the life of the spirit in the body',
most deeply in those dimensions of its life that are not 'for the sake of the body'.
The unity of man as consisting of body and soul is not threatened or rendered im-
possible by the mind, but the difference of the mind from the body constitutes the
only conceivable basis for doing justice to the unity of man, in whom body and soul
are joined to form a much more unified being than two sorts of matter could ever
constitute, as Bergson said:
By pushing dualism to an extreme, we appear to have divided body and soul by an un-
bridgeable abyss. In truth, however, we were indicating the only possible means of
bringing them together. (H. Bergson, Matiere et Memoire. Essai sur la relation du corps
aI'esprit, pp. 221-222.)

2.1.6. The Person as an Individual Spiritual Substance-in-Relation to Other Persons

A person is also essentially characterized by the fact that she stands in relation to the
world, to others, and ultimately to an absolute being. This distinctive relational es-
sential feature of the person, which is decisive for at least three of the four sources
of personal dignity to be discussed below, should not be confused with an unbear-
able reduction of personal being to relational being: each person is a unique subject
and any real relation already presupposes the substantiality of its terms. Persons are
not relations, but find themselves essentially in such relations. This standing in rela-
tion characteristic of persons also is not an entirely abstract ontological moment of
'relation', but rather a standing in concrete and specifically personal relations to the
world and to other persons, as well as a being ordained of persons to enter into per-
sonal relations, to give appropriate value responses to other beings and persons, to
stand in loving relations to other persons-in a word, to enter into specifically per-
sonal relations of the kind we can never find in the impersonal world. These
personal relations culminate in the love of other persons whom we ought to affirm
for their own sakes, giving ourselves in a mutual loving self-donation and thus form-
ing human communities of marriage and family, as well as loving, adoring and wor-
shipping God, the highest and absolute good, simply because love and adoration are
owed to Him.35
We will see later that the seven essential marks of the conscious and experienced
life of persons to be discussed below will also throw additional light on the spiritual
nature of the subject of personal consciousness. Not to repeat ourselves, however,
we delay the discussion of the further characteristics of persons, and hence also of
the rational nature of the human person to which Boethius refers, to the part of the
present chapter in which the second source and dimension of human dignity is our
theme.
From all the preceding and many other arguments the spiritual and non-material
being of the person-a being that is absolutely irreducible to the brain or to superve-

35 For an in-depth analysis of the due-relationship and value response see the works of Dietrich von Hil-
debrand, Das Wesen der Liebe, in Dietrich von Hildebrand, Gesammelte Werke ill (Regensburg,
1971), 2nd bilingual edition: Essenza dell 'amore, translated, edited and introduced by Paola Premoli
De Marchi (Milan: Pompiani, 2003); Ethics, chs. 1-3, 17-18; Liturgie und Personlichkeit (Salzburg:
Anton Pustet. 1933; 5th ed. St. Ottilien: Eos Verlag, 1989). See also Karol Wojtyia, Love and
Responsibility.
114 CHAPTER 2

nient characteristics and epiphenomena of brain events---emerges clearly before our

mind. And to recognize this spiritual nature of the hwnan person (of the soul) will
turn out to be a crucially important anthropological and ontological foundation of
medical ethics and of the proper understanding ofhwnan dignity.

2.2. A Definition ofthe Person by Her 'Inviolable'Dignity

The person is not only defined as an individual subject of a rational nature, but also
as a being distinguished in virtue of her dignity: "person is a hypostasis [substance]
whose distinguishing feature is something pertaining to dignity (proprietate distinc-
ta ad dignitatem pertinente}."36
This definition of the person in terms of her dignity is of primary importance for
a work dedicated to philosophy and ethics of medicine. We have called the dignity
of the hwnan person and the existence of fundamental hwnan rights medical ethical
universals in the sense that they are absolutely foundational morally relevant values
for all ethics, and particular for medical ethics which deals expressly and profession-
ally with the lives and health, and with other goods ofhwnan persons.
But what is this dignity of the person? Dignity is first of all an intrinsic and ob-
jective value. It never exists only as something that gives me subjective satisfaction:
her dignity makes the person possessing dignity positively important,l7 intrinsically
precious. This intrinsic preciousness is more than, and the foundation of, what Kant
calls the person being, and always having to be treated as, 'an end in itselt'. If a phy-
sician, who cruelly torments a prisoner at the behest of a totalitarian state, says that
such an act is a source of pleasure for him in the same way that recognizing the dig-
nity of the prisoner and protesting the cruelty of the evil physician gives us
subjective pleasure, the absurdity of such a statement becomes clear. Man's dignity
is an absolute and objective value, and does not depend, as the pleasurable does, on
subjective preferences. It does not cease to exist if a physician fmds pleasure in in-
flicting torture.
Dignity is not only an objective value, but also a high and sublime one, which for
this reason has no price (as Kant asserts) and is inalienable and inviolable in the
sense that no action directed against it can destroy it; but also in the sense that mor-
ally speaking no person ought to treat other persons in ways that violate their digni-
ty: for example by killing, torturing, buying and selling a person, or by regarding her
only as means for other ends, etc. We must not, and cannot validly, sell hwnan per-
sons who possess this dignity as slaves; we must not, for money, sell personal beings
to teams of organ transplantation surgeons or leave them at the mercy of prostitu-
tion.
Why not? Because they possess an inalienable and inviolable dignity. As beings
eminent by their dignity, persons are also subject to absolute moral obligations and
bearers of absolute hwnan rights.

36 See, for example, Thomas Aquinas, Summa Theologica I a, q. 29, a. 3, ad 2.

37 Cf. Dietrich von Hildebrand, Ethics, chs. 1-3.
 HUMAN DIGNITY 115

The question that must be asked is whether all human persons have the same dig-
nity, and how one can deny that there exists a gradation of human dignity and that
an embryo or a person in a coma does not have the same dignity as an adult or a
conscious child. The answer to this question is again of crucial relevance for medical
ethical issues such as abortion, euthanasia, killing of the mentally or physically han-
dicapped, etc. The answer to this question can be easily found when we make the
following distinctions.

3. THE FOUR SOURCES AND DIMENSIONS OF HUMAN DIGNITY AND

THEIR CHARACTERISTICS

3.1. Ontological Dignity of the Human Person as Such andfrom the Very Beginning
ofHer Existence
The first source of human dignity is simply the nature and the real existence of the
human person: this is the dignity of the human substance (the 'dignitas humanae
substantiae '). The being of a person as such is the condition of the possibility of any
awakening of the conscious person and of the dignity residing in thinking-yet it
precedes that! The root of this first dimension of human dignity lies in what an indi-
vidual and rational subject is and in the potentialities of the person (the individual
subject of rational nature) as such: the actual existence and potencies of any person
are the root of this dignity.
(a) Answer to arguments against the dignity of all human beings from the inabili-
ty of many human beings to act as persons: Many contest today the dignity of un-
born children; they demand the freedom of abortion, denying the personhood of em-
bryos because they cannot act as persons or show any evidence of the behavior char-
acteristic of persons. Such objections, however, forget that it is not true that whoever
is a person must also be able to act as a person. There is not only the actualized be-
ing (energeia on), but also the potential being (dynamei onys of persons or, to be
more precise, of what can and ought to awaken in persons; these potentialities neces-
sarily precede their actualization, they are presupposed by any 'actual awakening' of
consciousness. The ontological dignity of the person then is not solely based on the
actual substantial being each person is and the substantiality of the human person
(human soul) as an individual substance of rational nature but also on the (-in-prin-
ciple) potency to act as person.
(b) Biological arguments and arguments from the wisdom contained in language
in favor of personal identity and personhood from the beginning: Man should from
the outset be recognized as person. The individually structured form of a man's ge-
netic code right from the beginning of human life, the profound unity of soul and
body, the sense of human fatherhood and motherhood, the fact of experiencing one's
own identity from earliest childhood on, and the manner in which our language re-
flects our own continuous reality and identity when we speak of our conception: all
of these confirm the continuity of the 'I' of each person from conception to death.

38 These Greek terms and the great philosophical discovery they express stem from Aristotle.
116 CHAPTER 2

(c) An,swer to objections from the Aristotelian teaching of 'delayed animation'

and to modem arguments against the personhood of the embryo from twinning:
Peter Singer and others refer to the fact that Aristotle, and Thomas Aquinas as well,
taught that the animation of the embryo is delayed and that therefore not every hu-
man being is a person. The philosophical and biological arguments of a delayed ani-
mation (in the writings of Aristotle and Thomas Aquinas) are based on an outdated
biology and are today devoid of any serious empirical or philosophical basis. Aris-
totle thought this way because the entering of the rational soul into a body requires
some 'formed embryo', that is an embryo that is not just an unformed blood clot or
piece of matter. In critique of this objection through a repetition of Aristotle's and
Thomas Aquinas's teachings we can say: (1) The biological basis on which Aristotle
and Thomas Aquinas held this view is hopelessly outdated: they did not even distin-
guish between the menstruation blood and early embryos.39 Therefore, after the dis-
covery of the genetic codes, of chromosomes, etc., any appeal to these opinions,
which neither Aristotle nor Thomas Aquinas would defend today, as if they still had
some weight of authority, is completely unfounded. 40 (2) There are many positive

39 "sicut etiam menstruum materia embrionis dicitur, ...." Thomas Aquinas, In II Sent., ds 18, qu 1, aI,
ra 2.
40 That Thomas Aquinas would not defend his theory of delayed ensoulment today is also clear from a
consideration of Thomas Aquinas as theologian. Aquinas used his purely philosophical theory on de-
layed ensoulment as his main (Philosophical) objection to the teaching on the Immaculate Conception
of Mary (that is her freedom from original sin from conception on), which had not been declared a
Catholic dogma yet. Had it been declared as dogma at his time, he would have no doubt accepted it
and, by the same cogent logic of his argument against this teaching of Immaculate Conception have
rejected his theory of delayed ensoulment also on theological grounds. His objection was entirely log-
ical and rested on the premises: 1) Mary was a normal human being who did receive her soul just
when any other human being is ensouled, namely long after conception; 2) Nobody can either have
original sin or be freed from it who does not have a rational soul. Therefore, Mary could, at the time
of her conception, neither have had original sin nor have been exempted or freed from it. The four
most important passages are the following: Thomas Aquinas, Summa Theologica, Tertia Pars, q. 27, ar
2, co; Compendium Theologiae Ib 1, cap. 224; In III Sententiarum, ds 3, qu 1, ar Ib co; In III Sen-
tentiarum, ds3, qu 1, ar la, co.
See, for example, the following text from In III Sententiarum, ds3, qu 1 ar la, co:
... ; unde sanctificatio tantum ad eos pertinet qui gratiae capaces sunt: et quia
proprium subjectum gratiae est rationalis natura; ideo ante infusionem animae
rationalis beata virgo sanctificari non potuit etc .
. . . et ideo beata virgo in peccato originali fuit concepta, ...
In III Sententiarum, ds 3, qu 1, ar la, co:
respondeo dicendum, quod, sicut dicit dionysius, sanctitas est ab omni immunditia
libera et perfecta et immaculata munditia; unde cum sanctificari sit sanctum fieri,
oportet quod sanctificatio emundationem ab immunditia spirituali ponat, prout nunc
de sanctificatione loquimur. emundatio autem a spirituali macula, scilicet culpa, sine
gratia esse non potest, sicut et tenebra non nisi per lucem fugatur.
In III Sententiarum, ds 3, qu 1, ar Ib, co:
ad secundam quaestionem dicendum, quod sanctificatio beatae virginis non potuit
esse decenter ante infusionem animae, quia gratiae capax nondum erat, sed nec
etiam in ipso instanti infusionis, ut scilicet per gratiam tunc sibi infusam conservare-
tur, ne culpam originalem incurreret.
Compendium Theologiae Ib I, cp 224:
non autem talis sanctificatio praecessit infusionem animae. sic enim nunquam fuis-
set peccato originali subiecta, et redemptione non indiguisset. non enim subiectum
 HUMAN DIGNITY 117

reasons from the biological unity of the human organism, from our conception and
beginning, etc., briefly repeated elsewhere in this chapter, to argue that it is against
reason to assume that a human being is a sort of sub-human animal during the first
phases of its development rather than a human person 'from the beginning'.
A new argument against the personhood of man from the very beginning takes
its point of departure from the possibility of twinning during the first two weeks
from conception. This argument runs like this: (a) first premise: it is absolutely im-
possible to split a person and get two from one; but (b) second premise: one can split
embryos during the first two weeks of their life; therefore (c) conclusion: embryos
during the first two weeks of embryonic life cannot be persons. This argument fails
similarly to prove the absence of an indivisible personal soul from the onset of hu-
man life and can be criticized in the following ways: (I) In some cases twinning
may be the consequence of two souls and personal selves being present from con-
ception on so as to form two bodies in correspondence to the two persons (souls)
present from the beginning; (2) in other cases of naturally occurring twinning, and
always in artificially produced twinning, the biological process of twinning may just
play the same role as conception and give rise to a new human being that receives a
new soul. Therefore, the process of twinning can in no way prove that prior to it (or
its possibility) there is no person or soul. (3) We can understand the invalidity of this
argument much better today, at a time when cloning has become possible and is
biologically speaking very similar to twinning. In cloning, also a new human being
is 'generated' from a living one: by introducing the nucleus of a cell in an enucle-
ated ovum. The human being generated by cloning is very similar to an identical
twin-of a slightly or greatly different age than the cell (nucleus) donor. The possi-
bility of cloning an adult (and eventually the emergence of a cloned 'genetic twin'
from cloning this adult) obviously does not prove that the original human being,
from whose body the nucleus of a cell was taken in the process of cloning, was no
person. The possibility of producing a clone from you or me does not prove that
either one of us has not been a person prior to the generation of our 'clone'. (4) If
things were as the criticized argument has it, absolutely nobody would be a person
because cloning by the use of nuclei of our body cells remains possible until our
death and perhaps some time beyond our death. (5) Even less does the possibility of
'cloning' an adult human person mean that in this process the original human person
who was cloned has been divided into two persons; for it is absolutely and essential-
ly impossible to split one person so as to get two (an intuition that is presupposed by
the whole argument against the personhood from the beginning by referring to twin-
ning). (6) The result of this reflection is clear: Biological processes and the source of
a spiritual person are linked but they are situated on totally different levels, which
forbids quick and unfounded transitions from one level to the other.

peccati esse potest nisi creatura rationalis. similiter etiam gratia sanctificationis per
prius in anima radicatur, nee ad corpus potest pervenire nisi per animam: unde post
infusionem animae credendumest eam sanctificatam fuisse. eius autem sanctificatio
amplior fuit quam aliorum in utero sanctificatorum. alii namque sanctificati in utero
sunt quidem a peccato originali mundati, non tamen est eis praestitum ut postea non
possent peccare, saltern venialiter. sed beata virgo maria tanta abundantia gratiae
sanctificata fuit, ut deinceps ab omni peccato.
118 CHAPTER 2

(d) An argument from doubt of personhood from the beginning for the respect of
the ontological human dignity from the beginning: Suppose, however, that Aristotle
is right with his theory of gradual and delayed animation. In this case, the early hu-
man embryo would not be a person for the first forty or sixty days because it would
only have a sort of plant-soul (vegetative or nutritive soul) or an animal soul (sensi-
tive soul) but not yet a rational soul. Even if an embryo during the first weeks were
not yet really a person, however, we argue, we ought to treat him as a person as long
as there are some good reasons for thinking that he is a person and as long as we are
not certain that he is not a person. We must not kill him since it is impossible for us
to know that he is not a person. We must not shoot at a living being behind a bush if
we are not morally certain that it is not a human being. The 'in dubio pro reo' prin-
ciple has here a new application: in dubio pro vita. 41
(e) What is ontological dignity (value) and what its characteristics? The ontologi-
cal dignity of the person is not an ideal object and even less just an object of our
feelings and consciousness. On the contrary, it exists in the innermost core of the be-
ing of the person. It intelligibly springs from the essence and the existence of each
and any person. The ontological dignity of the person is also inalienable and belongs
to each human person, in a manner that absolutely cannot be eliminated; thus one
cannot lose this dignity either. It is independent of age, consciousness and illness:
the sheer fact of being a human person suffices to possess it, as Paul Ricoeur says.42
There are no degrees ofperfection of this human dignity, which is thus indivisi-
ble, and not weak in certain human beings and 'strong' in others. It possesses an on-
tological inviolability that makes it impossible for a human person to be deprived of
her ontological dignity, and a moral inviolability and an untouchable nature that
makes it always unethical to act against the dignity of persons. Against many opin-
ions we may add: no experience of the attack against one's rights is presupposed for
this first founding form of dignity and the fundamental human rights grounded in it
to exist. These fundamental human rights, as well as those rooted in other sources,
are not constituted by any social, historical, or cultural opinions or by negative ex-
periences, however helpful these may be for the discovery of human dignity, nor is
human dignity constituted by any consensus regarding it, as Jfugen Habermas
holds"3

41 Moreover, even an embryo that would be regarded as not being a person but would be destined to re-
ceive a rational soul would also have a dignity that makes advocates of the delayed animation theory
such as Thomas Aquinas refuse abortion.
42 Paul Ricoeur, "Pour 1'6tre humain du seul fait qu'il est humain," in Le fondement des droits de
I 'homme (Florenz : La Nuova Italia, 1966), especially p. 122.
43 Cf. Jiirgen Habermas, Wahrheit und Rechtfertigung. Philosophische AujSiitze (Frankfurt a. M.: Suhr-
kamp, 1999), pp. 332-333. Jiirgen Habermas claims on the one hand, in keeping with his general dis-
course theory of truth and of ethics, that the "status of juridical persons as bearers of subjective rights
can only constitute itself in the context of a community based on mutual recognition," and on the
other hand holds, likewise in keeping with his discourse-consensus theory of ethics, that the agree-
ment on binding norms and fundamental human rights "(reciprocal human rights and duties) does not
depend on the mutual appreciation of cultural achievements and styles of life but on the supposition
(Unterstellung) that each person as person has the same value."
By de-ontologizing human dignity and calling it a supposition or even fiction (Unterstellung),
Habermas makes the basis of human dignity a sort of agreement and consensus mediated by discourse
instead of a value rooted in the objective existence and essence of persons and known with evidence.
 HUMAN DIGNITY 119

Its undisposability (Unverfogbarkeit) is the reason for which the sale of hwnan
beings for organ-extraction or other purposes, and the trafficking and slavery are es-
sentially immoral and without legal validity (legally impossible) as well. In virtue of
their ontological dignity, persons must never be owned, bought or sold (and validly
never can).
With its unconditioned nature and inalienability, we express its law-establishing
role and the fact that each positive legal order presupposes and above all ought to re-
spect hwnan dignity as source of a natural law that precedes any man-made law: no
law and no act can prevent or deny it in a morally or legally effective way, precisely
because it is unconditioned, innate, and inalienable and cannot be removed from a
person by any state or individual.
This dignity also is the foundation of absolute obligations on the moral and legal
levels (and thus of an intrinsece malum, of an intrinsically evil character of all acts
directed against it, a fact to the explanation of which we will dedicate chapter 6).
Since this ontological dignity is of such an 'absoluteness', it cannot be the object of
a calculation or weighing, balancing the good and bad effects, as if a preponderance
of good effects could justify its violation or as if it could be reckoned in terms of
costs and profits. Any attempt at treating persons as factors in such a calculus of
good or bad consequences, when we are dealing with acts that constitute by their
very nature an attack on hwnan dignity, is unjustified. The violation of the ontologi-
cal dignity of persons is always an injustice. This dignity is characterized by an ab-
soluteness that can neither be weighted nor counted, as also expressed through the
medical ethical principle of 'neminem nocere' (do not wrong anyone, or: damage
nobody!).
Some absolutely fundamental human rights and legitimate rights, which never
ought to be violated by others, are based on this first source of (ontological) dignity:
the right to life (which forbids any homicide, abortion, and euthanasia), the right not
to be used as a pure means (which forbids, for instance, the life-taking, 'conswn-
ing', or destructive use of embryonic stem cells as mere means of research or of
healing others), the right not to be sexually abused in a state of unconsciousness for
pornographic films or sexual acts, even when in a permanently unconscious state, as
well as the right to a treatment that is worthy ofa human person.
We call this ontological dignity also 'sacred', in order to emphasize an awe-in-
spiring and morally 'untouchable' quality of it, and say that it grounds certain abso-
lute moral imperatives.
We may already here point out, however, that this foundational principle of just
constitutions and positive laws, the recognition of the 'inviolability' ofhwnan digni-
ty, stands under many attacks today. It may be helpful both to understand the differ-
ent ways of weakening the concept of such an ontological dignity of persons and to
respond to them.
The example of new interpretations of the Grundgesetz of Germany, one of the
few countries in which the Basic Constitutional Law includes explicit reference to
120 CHAPTER 2

human dignity, will be instructive. Ernst-Wolfgang Bockenforde showed44 that, un-

der the mask of a mere revision of the famous 45 years old Commentary on the Ger-
man basic constitutional law (Grundgesetz},45 the new edition of the commentary-
in particular on § 1.1 (by Matthias Herdegen) and on Art. 2.1 (by Udo von Fabio)-
deeply calls into question the inviolability written into the German Basic Constitu-
tional Law (Grundgesetz). Bockenforde argues very well that the new edition of the
classical commentary undermines the clear meaning not only of the German Basic
Constitutional Law but also of the original edition of Diirig's commentary.46 Diirig
regarded Basic Law 1.1. as "the supreme constitutive principle of all objective law"47
and as "pregiven even to the legislator." The new edition of this classical Commen-
tary changes some of its most basic contents. 48 If we read and philosophically inter-
pret Bockenforde's study, we see that there are at least four attacks on the concept of
inviolable human dignity in the new Commentary on the German Basic Constitu-
tional Law:
In the first place, instead of being seen as an entirely objective and intrinsic val-
ue, human dignity is now relativized and seen as object of human subjectivity, con-
sensus, and legislative arbitration.
The pre-positive character of human dignity as a value that binds all states and
constitutions, and has to be recognized but in no way decreed by them, is replaced
by an exclusive emphasis of the anchorage of this value in the positive constitutional
text. In other words, § 1 of the Grundgesetz is reinterpreted: instead of being recog-
nized as a declaration of natural law and of a basis of positive law that is found and
discovered by the legislator as a pregiven truth founded upon the value-laden nature
of the human person (dignity) and withdrawn from all legislative power of states to
change it, it is now declared an expression of positive legislation, as if it were just a
positive law.

44 See the excellent critical article entitled "Human Dignity was inviolable: Ernst-Wolfgang Bocken-
fOrde, 'Die WUrde des Menschen war unantastbar' ," Frankforter Allgemeine, Mittwoch, 3. IX. 2003,
p.33.
45 Maunz-Diirig, Das Grundgesetz. Kommentar.
46 Art. I:
(I) Die Warde des Menschen ist unantastbar. Sie zu achten und zu schUtzen ist Ver-
pflichtung aller staatlichen Gewalt.
The dignity of man is inviolable. To respect and to protect it is an obligation of any
state power.
(2) Das Deutsche Volk bekennt sich darum zu unverletzlichen und unveriiujJerlichen
Menschenrechten als Grundlage menschlicher Gemeinschaft. des Friedens und der
Gerechtigkeit in der Welt.
The German people therefore professes (commits itself to) inviolable and inalienable
human rights as foundation of human community, of peace, and of justice in the
world.
(3) The following basic human rights (Grundrechte) bind legislative, executive, and
judiciary power and administration of justice (jurisdiction) as immediately binding
law.
47 Btickenftirde, ibid.
48 Therefore, its new edition, still called Maunz-DUrig, should, as Bockenforde rightly demands, remove
the names of the original authors.
 HUMAN DIGNITY 121

Therefore, instead of being declared to be an 'immovable part' of the Gennan

constitution withdrawn from any legislative, judiciary or executive power, and from
any popular vote, the fundamental human rights are now being presented as if they
were decreed by, and not withdrawn from, legislative consensus of majorities; and
hence it is implied that they would be open to being changed by future legislators.
This dignity is also no longer regarded as one and the same for all stages of hu-
man development but interpreted as a gradated, process-determined value that
comes in 'different degrees'. To argue in this way for the first and primary meaning
of human dignity, which we have just discussed, creates a revolutionary change and
even an abandonment of the idea of the inviolability of human dignity. Such a
change in the concept of 'inviolability' can in no way be supported by the chief in-
sights of ontology of the human person and into the ontological dignity (first dimen-
sion and source of human dignity) expounded above.
In consequence of these four decisive changes of interpretation, the very idea of
an inviolable dignity of every human person is abandoned and replaced by a fluc-
tuant notion of human dignity. Human dignity, according to this view, is open to be-
ing changed by future democratic popular votes and open to commentaries, which
reinterpret the basic constitutional law in such a way as to dissolve its original mean-
ing and the very notion of an inviolable dignity. As will become clear in the light of
the ensuing distinctions, what can be said correctly of other dimensions and forms of
dignity (within which we do find gradations and in which different rights of chil-
dren, of adults, of conscious persons, etc., are grounded) is here mistakenly attrib-
uted to the first source and dimension of human dignity in which, for example, the
right to life has its root. 49 And this ontological dignity of the substantial human being
is not subject to any gradation but belongs to each person from the first moment of
her existence.

3.2. Dignity o/the Conscious and Rational Person and Its Levels

"All our dignity resides in thought," says Blaise Pascal in a magnificent and all the
same dangerous passage of his Pensees, dangerous if necessary explanations of this
phrase (many of which Pascal himself gives) are omitted. so He draws attention in this
sentence to a real source of personal dignity that is totally different from the first di-
mension of dignity (ontological dignity): the dignity of the consciously awakened,
thinking subj ect.

49 See ibid., p. 33.

so Blaise Pascal, Pensees, 347: "All our dignity consists, then, in thought." See ibid., 365: "All the digni-
ty of man consists in thought.)
Ibid., 146:
Man is obviously made to think. It is his whole dignity and his whole merit; and
his whole duty is to think as he ought. Now, the order of thought is to begin with
self, and with its Author and its end.
Now, of what does the world think? Never of this, but of dancing, playing the
lute, singing, making verses, running at the ring, etc., fighting, making oneself king,
without thinking what it is to be a king and what to be a man.
122 CHAP1ER2

Singer reduces human dignity precisely to this level' I and therefore makes the
"proposal that we reject the sanctity of human life," with immense consequences for
all medical ethics. 52 He thinks that the value of human beings can only lie in their ac-
tual capacity to think, to will, etc. He goes as far as to defend the view that retarded
and otherwise handicapped children are less endowed with dignity than pigs or
chimpanzees,53 a position from which one might immediately conclude that the kil-
ling of such children to use or sell their organs for medical cure, to liberate society
from their burden, or even for the sake of their industrial exploit or of their use for
manufacturing food-products would be justified.
While we totally reject any such negation of the first and most foundational level
of human dignity, and all the medical ethical consequences of such a position as Sin-
ger's, we do not deny that actual consciousness and lived conscious life, the ration-
ally awakened state of the person conscious to herself and to the world, originates a
second and new dimension of the dignity of persons, and that this dignity of which
Pascal is speaking is inseparable from what a person essentially is called to be.
This second source of the dignity of the human person lies in the conscious actu-
alization of the person, in the awakened life of a personal being who is aware of her-
self and of the world, stands in meaningful conscious relations to other human per-
sons and to the absolute ground of her being.
This dimension and source of personal dignity is indeed so important that we
may well say that the features of the person in which this dignity is grounded are es-
sential for the being of the person as such: that lucid being awakened of the personal
subject to itself, the intentional conscious relation of the person to the world, her
knowledge, her freedom, etc., are constitutive for the essence of the personhood of
persons. And all these features of personhood, in terms of which we define persons,
are situated on this second level and source of dignity: actual personal conscious-
ness. Moreover, without experiencing such conscious acts in some individuals, we
could not know at all what a person is nor could we know those potentialities of the
dormant (unborn, aged, impaired) human person toward conscious life, potentialities
which are precisely constitutive for her ontological dignity (the first dimension and
source of dignity). In other words, we can also know the ontological dignity of the
person and the potentialities of a rational nature only because we know that dignity
of her thought and conscious life of which Pascal speaks and which allows us to un-
derstand the high dignity of a being that is, by its very nature and substantial being,
capable, at least in principle, of rational conscious life. Thus, the awakened rational
life of the person, as it were the actuality of being as person, has an immense value
and even a certain purely axiological priority of founding the dignity of persons, a
priority which corresponds to the Aristotelian proposition that act has priority over
potency.

51 Peter Singer, "Unsanctifying Human Life," pp. 4l-6l.

52 Singer, ibid., pp. 41 ff., p. 59; ibid., p. 43; p. 50.
53 In rejecting this dignity founded on the very substance of the person, Singer makes an excellent point
regarding abortion. See Singer, ibid., p. 50:
I will only point out that if we believe it is the potential of the infant that makes it
wrong to kill it, we seem to be committed to the view that abortion, however soon
after conception it may take place, is as seriously wrong as infanticide.
 HUMAN DIGNITY 123

And yet: none of this rational awakening of the person has to be actualized yet
for there to be a person, i.e., a subject of rational nature endowed with the potentiali-
ty for actual rational conscious life. Therefore, the ontological dignity of the person
retains its full priority and weight. In other words, being human is enough, being a
subject of rational nature capable in principle of rational conscious acts is enough to
possess the inviolable and inalienable ontological dignity of a person.
Nonetheless, the dignity of the actualized conscious subject of rational nature is
also an entirely newly actualized dignity. Therefore, the second dimension of per-
sonal dignity is related to the first like act to potency. This dignity of actual rational
conscious life, inasmuch as it is not grounded just in the ontological potentiality to
rational conscious life possessed by every person, is rooted in the actually awakened
rational life of persons. Therefore, it does not have the inalienable and indestructible
character of the ontological dignity of the person but can be absent in seriously re-
tarded persons or in human beings in the 'persistent vegetative state' (PVS) but also
in small embryos.
Of course, we might never be absolutely sure that patients in PVS do not actually
possess rational consciousness and thought and that their condition only prevents
them from expressing it; there are even some good arguments and scientific research
that speak in favor of such a position. 54
When does rational and thinking life begin in the course of the normal human
development? Engelhardt assumes that normal children reach the state of actualized
personhood only after the second year of life; one could also put it at a later or earli-
er date. For the consciously awakened being of the person undergoes an infinity of
shades and degrees, from the first prenatal experiences in the embryonic state to the
early childhood until adulthood.
What are then the foundations of the dignity of the conscious and spiritually
awakened person? These include knowledge and its transcendence (its relationship
with truth); freedom (free and conscious action, and internal freedom); feelings and
love, as well. as the gift of language, social relations, and-above all-the relation-
ship with the absolute being and religious acts directed at God such as thanksgiving
or adoration. The person as a rational and conscious 'living center of action' is the
source of this dignity.
There is undoubtedly such a fully new dignity of the conscious person, which
also finds a new level of expression in the adult and mature person.
The characteristics of this second dimension/source of dignity are totally differ-
ent from those of the first. Not just to be a person but also to be a conscious person
is its condition. This condition can be lost. It has many degrees (can be weak and
strong and take many different forms).
A paradox of modern society comes from the fact that on the one hand this digni-
ty is today scorned, for example in the praxis of 'terminal sedation' and other acts
which treat humans as if they were rabbits that could in a morally permissible way
simply be put to sleep until death, and, on the other hand, immoderately exaggerated
by Peter Singer and others as the unique source of human dignity and human rights.

54 See D. Alan Shewmon, Gregory 1. Hoimes, Paul A. Byrne, "Consciousness in congenitally decorti-
cate children: 'developmental vegetative state' as self-fulfilling prophecy," Developmental Medicine
and Child Neurology 41(6): 364-74, 1999.
124 CHAPTER 2

On the one hand, then, one treats human beings as if only their biological vegetative
life counted and as if their conscious life would not possess an immensely high sig-
nificance, constituting one of the goods medicine ought to serve; on the other hand,
one absolutizes the value of conscious life so as if a person deprived of it did not
possess an ontological dignity.
In the consciously awakened being of the human person we find indeed the root
of a new dimension of dignity which expresses itself in the acquisition of human
rights which are not grounded-as the right to life and not to be sexually abused-in
the very being of a person, in the substantial character of personhood, but in the dif-
ferent degrees of consciousness and maturity. For example, the human right to 'free
and informed consent' before medical treatment, the right to refuse any, and in par-
ticular, risky medical interventions, the freedom of speech and of movement, or to
education, cannot be attributed to a small child, as little as the human right to marry,
to educate children, etc. These rights which are grounded only in awakened and con-
sciously lived personhood of a certain level of maturity are unlike the rights not to
be subjected to murder, to mutilation, or to undignified treatment, etc., which is root-
ed in the first source of human dignity, of the living human person as such.
This dignity is the source of many other human rights that do not apply at all to
unconscious embryos or to persons in a coma. Some of the human rights originating
from this second source are as follows:
(1) Human rights that are rooted in thought and consciousness as such include
first of all the right not to be deprived of consciousness for less than serious reasons
(such as otherwise inevitable and unbearable pains). Reasons for which the privation
of consciousness is not justified and would violate a basic human right include doing
so for a prolonged and continued period of time intended to last until death (thus de-
priving a patient of the right to face his or her own death consciously), doing so to
avoid minor pain of patients, or the use of terminal sedation for egocentric motives
of relatives who wish, for example, to gain an inheritance by putting their parents or
other relatives into a state of complete oblivion and incompetence. Illegitimate is
likewise terminal sedation administered by medical workers in an understaffed hos-
pital in order to reduce their working load with dying or suffering patients.
(2) Human rights that are rooted in the transcendence in knowledge of the sub-
ject55 include: the right to truth including the right to be told the truth about one's
medical diagnosis and likely future prospects (a right which babies or comatose
patients do not actually possess); also the right to the search for truth and the right
not to become imprisoned in a world of illusions due to a given state's or physi-
cian's lies, etc. 56
(3) Human rights that are based on freedom: the right to the enjoyment of free-
dom, particularly the right to the freedom of conscience which we found an extreme-
ly important and inalienable right of patients, physicians, and other health profes-
sionals; the human right to the free choice of a husband or wife; the right to found a
family; to educate one's own children; and to political activities.

55 I have tried to throw into relief 'receptive transcendence' as an indispensable element of all knowl-
edge in Josef Seifert, Erkenntnis objektiver Wahrheit.
56 Cf. Vaclav Havel, In der Wahrheit zu [eben (Hamburg: Rowohlt, 1990).
 HUMAN DIGNITY 125

(4) Human rights which are rooted in the faculty offeeling and the affective life
of persons prohibit various actions: such as the refusal to alleviate other person's
pain in any way, when this is practically possible, or the use of torture in politically
controlled medicine; or the inflicting of not freely accepted pain in medical experi-
mentation; or the use of psychological terror in psychiatric experiments or treat-
ments. The fundamental human rights rooted in the affective experience also include
the right not to be subjected to cruel psychological experiments with human feel-
ings, etc. They are rooted in the emotional experiences of human persons (they
would have no sense for a person who is exclusively endowed with intellect and
will).
(5) Human rights based on the relationship of the person with the world: the
right to a worldview (Weltanschauung); a general cosmological view of the world
(case of Galileo); a comprehensive vision of reality and of its spiritual dimensions;
which is violated by militant political Marxism and many other ideologies and polit-
ical systems but which might also be infringed upon in hospitals that refuse to allow,
or fail to facilitate, those acts of persons which are related to their philosophical or
religious worldview.
(6) Human rights and community: the right to marriage, family, and family cohe-
sion; and the right to set up associations as well as secular and religious communi-
ties. Totalitarian, dictatorial, racist, but also private actions often violate these rights.
These rights can also be violated by certain kinds of exaggerated restrictions of visit-
ing hours and visitors in hospitals.
(7) Human rights that spring from the human person's relationship to God: the
fact that the human person is ordained to know, love, and worship God57 is the foun-
dation of other human rights: the human right to freedom of religion (for without
freedom religion loses its true meaning and dignity) and to private and public wor-
ship, the right to celebrate liturgical feasts: rights which are also grounded in human
freedom as such.
Militant atheism-but also regimes that want to force human persons to embrace
specific religions-infringe seriously upon these human rights (that are grounded in
the relation to God and the integral role of freedom for the true value of any relig-
ious act). These rights can also be violated by medical staff or hospital policies that
do not facilitate, or even actively prevent, those acts of patients rooted in this dimen-
sion of conscious personal life.
An important question regarding the second source and dimension of human dig-
nity concerns the problem of how essential it is for human dignity as such to achieve
the dignity of a 'thinking' and meaningfully willing and feeling human existence.
Having introduced the notion of, and grounds for asserting, the ontological dignity
of the human person possessed by each human being even when deprived of all ra-
tional conscious life, we have given part of this answer, but we may add another part
of an answer now: the dignity of awakened rational conscious life is so essential for
the human person, though not indispensable at each phase of human life, that the or-

57 This is not only accepted by most religions but also recognizable by human reason. See Epictetus,
Diatriben, "Von der wahren Freiheit," ibid., p. 158; "Von der Vorsehung," in Epiktet, Teles und Mu-
sonius. Wege zu gliickseligem Leben, ed., trans!., and introd. by W. Capelle (Ziirich: Artemis Verlag,
1984), p. 100. Cf. also Josef Seifert, Gott als Gottesbeweis.
126 CHAPTER 2

dination of the person to awaken to rational life, the faculties that enable her in prin-
ciple to perform rational acts, do belong to the essence of the person. Moreover, if
we follow the proofs for the immortality of the human soul or provide better ones,
we may assert with Socrates and Plato that every human person, at least after death,
will once and even forever possess the second source of personal dignity in which a
unique actualization of the person's being takes place. 58

3.3. Third Source and Sort ofDignity: 'Acquired Dignity' and Moral Dignity

A totally different dimension of human dignity draws its origin from the right use of
reason and will. It stems from the activity of persons and supposes it anyway. It is of
radically different types. Acquired dignity as such should be distinguished from im-
manent and more technical improvements of human abilities through teaching and
learning that have little to do with dignity. Only a more profound value can be de-
scribed as dignity: such as the dignity the person acquires through the search for,
and the recognition of, truth, and moral dignity. Pascal also recognized this dimen-
sion and kind of human dignity in the continuation of the text just quoted before. 59
This more profound dignity of the person is lastly unthinkable in a purely subjec-
tive, self-encapsulated consciousness retreated into itself, but is on the contrary pos-
sible only through a fondamental human relationship to a truth, to values, to other
persons, and to God who transcend human subjectivity and are independent of our
opinions but to which the subject can enter into relation.

58 See on this Plato, Phaedo; see also Josef Seifert, "Das Unsterblichkeitsproblem aus der Sicht der phi-
losophischen Ethik und Anthropologie," Franziskanische Studien, H 3 (1978); see also the chapter on
philosophical arguments on immortality in Josef Seifert, Das Leib-Seele Problem und die gegenwiirti-
ge philosophische Diskussion.
59 See Blaise Pascal, Pensees, trans. by W. F. Trotter:
365. Thought.-A11 the dignity of man consists in thought. Thought is, therefore, by
its nature a wonderful and incomparable thing. It must have strange defects to be
contemptible. But it has such, so that nothing is more ridiculous. How great it is in
its nature! How vile it is in its defects!
But what is this thought? How foolish it is!
See also ibid., 146:
146. Man is obviously made to think. It is his whole dignity and his whole merit;
and his whole duty is to think as he ought. Now, the order of thought is to begin with
self, and with its Author and its end.
See likewise:
347. Man is but a reed, the most feeble thing in nature; but he is a thinking reed. The
entire universe need not arm itself to crush him. A vapour, a drop of water suffices
to kill him. But, if the universe were to crush him, man would still be more noble
than that which killed him, because he knows that he dies and the advantage which
the universe has over him; the universe knows nothing of this.
All our dignity consists, then, in thought. By it we must elevate ourselves, and
not by space and time which we cannot fill. Let us endeavour, then, to think well;
this is the principle of morality.
The Quran also considers acquired and moral dignity to be the most profound dignity when it says
that the greatest dignity among men belongs to the just. Cf. Quran 49: 13 "Verily the most honoured
of you in the sight of Allah is (he who is) the most righteous of you."
 HUMAN DIGNITY 127

If man were entirely cut off in his knowledge from reality and truth, he could not
acquire such a dignity. Let him fail to respond appropriately to truth and value, and
he will not acquire it.
Even though already in authentic knowledge of reality an important part of the
acquired human dignity is rooted, the climax of this dignity and a completely new
sense of 'acquired dignity' are to be found in moral dignity. Within the dignity built
on the transcending relationship of the person with truth and the good, moral dignity
is the highest of a1l60 and is of a completely new nature, as we shall see in detail in
the next chapter.
As opposed to a strong will which does not give a person any dignity but only
power, and even in contrast to pure intellectual achievements of a more profound
type, only moral virtue and perfection, which obviously also occur in relation to a
person's intellectual life (for instance, in the search for truth and the assent to truth)61
offer the truest dignity to a person. This kind of dignity culminates in holiness (as
also Kant has seen).
It is absolutely not 'innate': it is much rather the fruit of human acts. It also is
dignity of another type. It is not the ontological value of the person that one cannot
lose (first dimension) but it can be lost. Moral dignity also has, in contrast to the
first, numerous degrees, levels, forms and dimensions. .
Good example and education (and thus also an influence from other persons)
contribute to it. Since it possesses an infinite number of degrees, it is likewise not in-
divisible, at least not in the same sense as ontological dignity. (While one does not
have to possess it 'wholly,' it still requires the presence of all moral values, and in
this sense is as well 'morally indivisible').
Within this higher and acquired dignity, moral dignity is the most profound: it
flows from free acts that are above all of a moral and religious nature. A qualitative
value is at stake here: it is a dignity far more sublime than the first two that a demon
possesses as well.
Moral dignity is rooted in the moral goodness of the person. The ontological val-
ue of the person (first dimension) does not make a person morally good; but since it
constitutes the foundation of moral calls and obligations, it is morally relevant. 62
Morally acquired dignity is not only morally relevant like the first, by imposing on
us a moral obligation to respect it, but it is also a moral dignity in itself.
Moreover, moral dignity possesses, as opposed to the first kind of dignity,
various opposites: not only the partial or complete loss of this dignity, an opposite to
dignity that the first dimension of dignity, the ontological dignity of a person, does
not have as long as the human being exists; but also the antithesis of this dignity in
the indignity and vileness of the evil deed or the evil person, an opposite that even
the second dimension of dignity does not have.

60 It is surpassed only by some realms of religious dignity (the most important dimension of which,
sainthood, however, entails highest moral perfection).
61 Cf. on this point John Henry Cardinal Newman, An Essay in Aid of a Grammar ofAssent (Westmins-
ter, Md.: Christian Classics Inc., 1973); Paola Premoli De Marchi, Etica deU'assenso; also Marian
Eleganti, Man muj1 gut wollen, um wahr denken zu konnen. Ein Beitrag zum Wahrheitsverstiindnis
von Romano Guardini (InnsbrucldWien: Tyrolia Verlag, 2003).
62 On this crucial ethical distinction, see Dietrich von Hildebrand, Ethics, ch. 19.
128 CHAPTER 2

As opposed to the impossibility of loss of the ftrst ontological dimension of dig-

nity, there exists a high risk of losing dignity with respect to the third. Human beings
are subject to a great danger and a great risk precisely because this most profound
dignity is ftrst of all something to be fulftlled through ftnite freedom, and therefore
is always in peril.
Moreover, it can be contrasted by its very antithesis.
Such dignity is thus not a possession, as the ontological dignity of the human
substance, but a conquest, as Gabriel Marcel observes63 • Acquired dignity is on no
account smaller than the ftrst two: on the contrary, it is in some true sense incompa-
rably higher; it is the universal vocation of man and belongs to the ultimate raison
d'etre of the human person.
This moral dignity also establishes new human rights: the right to be respected
that corresponds to the moral status of a just life, the right to a good reputation and
not to be ruined by bad reports, which in the case of the just man are not truths but
lies or calumnies, etc. Some phrases of the Hippocratic Oath for physicians refer
also to this dimension of dignity: for example, not to divulge knowledge about inti-
mate things obtained in the relationship with patients.
Also many rights associated with the second level of dignity are not unaltered if
acquired dignity is lost or replaced by indignity. A criminal loses for example the
right to freedom. The actual possession of such rights depends on the lowest (mini-
mal) degree of the third dimension of dignity: non-criminal behavior. The loss of the
right to the freedom of movement through imprisonment, for instance, is the just
consequence of a criminal act. Besides, the criminal loses other particular rights: the
right to be honored in society, the right not to suffer from remarks that attribute to
him a bad conduct or reputation, or the right that no one calls him a criminal.
This third source of human dignity is of great importance in order to understand
the moral call of physicians and health workers because it refers to a dignity they are
called to acquire through, and to manifest especially in, their medical actions to-
wards patients formed by respect and benevolence. It is also a most important di-
mension of the two transcendent goods of patients, which we have identifted in the
previous chapter as the sixth and seventh end of medicine.

3.4. Fourth Source/Dimension ofDignity-Dignity as Gift/Bestowed Dignity

A fourth dimension of human dignity possesses a source outside the person herself,
and yet in its most sublime dimensions surpasses the dignity which flows from the
nature of the person as well as that (third) dimension of human dignity which
springs from human acts of intellect and will. It is bestowed on man in the radically
different sense of a gift from the outside or from above.
Like the third, the fourth source, and at the same time dimension, of dignity has
also an inftnite number of degrees and exists in fundamentally different forms. It can
be conceded by men (or a human community), such as the dignity of judges or of
chief physicians or hospital directors; it can flow from interpersonal relations (such

63 Gabriel Marcel, Die Menschenwiirde und ihr existentieller Grund (Frankfurt a. M.: Josef Knecht,
1965).
 HUMAN DIGNITY 129

as the fact of being parents, husbands, or wives), or from nature (in the form of spe-
cific talents); or it can, as the religious believer accepts and the pure philosopher of
religion intuits merely as a possible variety of the fourth kind of dignity, directly be
bestowed upon man by God (such as blessings and graces the reality of which can
only be accepted in faith but the possibility and general nature of which is also giv-
en to purely philosophical insight).
(1) First of all, let us briefly identify the various fundamental sorts of dignity that
are conceded by nature. 64
A. High natural talents that confer, for instance, on a genius a special dignity and
certain rights to promotion by society.
B. Natural relations with other persons (such as the fact of being a parent) that
establish, for instance, that dignity which is the subject of the fourth commandment
(recognized by Jews, Christians, and Muslims but also in less explicit ways ack-
nowledged by many other religions and civilizations, for example very strongly em-
phasized in Roman Law) that demands to honor father and mother; this dignity dif-
fers from the preceding ones also by addressing itself specifically to the children of
parents, and is consequently in a certain sense a relational dignity or rather a dignity
the respect for which is entrusted and confided to some persons (the children and
grand children) more than to others. This does not exclude that in some 'external
ways' this parental dignity has to be respected as well by other persons, for example
by physicians, when they ought to respect the special relation and dignity parents
have in relation to their children.
(2) Secondly, there are also various forms of dignity that are conceded by the hu-
man community or the State, such as:
A. The dignity stemming from special offices or ranks, such as that of a king or a
judge, or also the dignity and authority of a Senior Consultant, or the Chief Head of
a Department in a Medical School. Sometimes, this dignity, such as that of a judge
or king, is not entirely humanly bestowed but also has sources that do not come from
the human community-such as an authority that is not solely humanly given. 65 The
dignity bestowed upon persons by human society is frequently intimately connected
with forms of dignity of the third source such as the nature and value of justice that a
judge or a sovereign should exercise and that give his office and person real dignity,
which he loses when he acts cruelly and unjustly to the point where it may be a duty
to depose or overthrow him; or the hard study and deep knowledge which gives
Chief Heads of Departments of Medicine a greater dignity and authority in their
fields than a mere administrative decision of a hospital to offer them this post can
bestow on persons. We may raise the interesting question here to which extent this
type of humanly bestowed dignity of patients may justify a preferential treatment of
patients endowed with such a dignity. Ought physicians to treat Presidents or kings
entrusted to their care with greater attention than 'normal patients'? It would seem
that some forms of responding to these kinds of socially or politically bestowed

64 Of course, also these have their ultimate root in a divine gift.

65 See on this Dietrich von Hildebrand, "Zum Wesen der echten Autoritat," in Dietrich von Hildebrand,
Gesammelte Schriflen (Verlag Josef Habbel: RegensburglVeriag W. Kohlhammer: Stuttgart, 1971-
1984), Bd. VIII.
130 CHAPTER 2

dignities in patients is quite legitimate, as long as they do not lead to the detriment
and neglect of other patients, other forms of preferential treatments for dignitaries
not.
B. From the fact of being loved and chosen by other persons emerges a new val-
ue of the beloved being that Saint-Exupery described in Le Petit Prince as 'being
tamed', which raises the rose or the fox, through being loved by the Little Prince,
high above all other roses and foxes. Being loved differentiates a being from all oth-
ers of the same nature. Being loved by other persons also bestows a new value and
dignity on persons: the dignity that an accepted or adopted child or a fiance has.
It is extremely important for medical staff, however, to realize that the onto-
logical dignity of the person is absolutely irreducible to this level, though such a
reduction is often attempted, as when one supposes that the embryo would receive a
status that is worthy of protection only if it is first loved and chosen by the parents,
or in ancient Roman times and Roman law when paternal acceptance decided on the
life or death of a child. Far more drastically, in modem abortion law and 'reproduc-
tive medicine' the value of an unborn child is often measured solely in terms of pa-
rental acceptance.
(3) Thirdly, there are also many sorts of dignity not granted by humans. The
most profound sources of these kinds of dignity, which transcend human nature and
humanly bestowed gifts, are of a religious character. Therefore, a purely philosophi-
cal ethics of medicine cannot affirm the real existence of these sources of dignity
(except where they proceed from philosophically evident metaphysical truths such
as the dignity of a creature or image of God)66, however a pure philosophy of reli-
gion can investigate the nature and the types of such a dignity the real existence of
which only the religious believer can assert. In this sense of a pure philosophy of re-
ligion the following remarks can be read by the secular reader. These not humanly
bestowed religious data of dignity can have very different characteristics:
A. This kind of dignity may be a universal value of each human person (such as,
according to all monotheistic religions, the fact of being created, of being made in
the image of God and of being loved by God,67 or the fact that all men have been re-
deemed by God, as Christians believe).
B. The fourth kind of dignity, however, can also consist in the value of a purely
objective and non-universal degree of actual participation in this dignity conceded
by God, such as that which flows from circumcision according to Jewish faith, or
from special divine blessings according to Jewish and Muslim faith, or from
baptism, the desire for baptism, or the different sacraments, according to Christian
faith.
C. Bestowed dignity in its religious dimensions can also result from a sort of in-
ner union and collaboration between bestowed dignity (4th source) and dignity ac-

66 I remind the reader that I have dedicated several works to a demonstration that a purely rational and
philosophical knowledge of a personal God is possible. See my following three works: Essere e per-
sona, chs. 10-15; Gatt als Gottesbeweis; "Die natiirliche Gotteserkenntnis als menschlicher Zugang
zu Gott."
67 This dignity, recognized more profoundly in religion, is also understandable philosophically, as many
texts in Plato, Aristotle, Epictetus, and other ancient philosophers prove and as could be made under-
stood by in-depth studies of metaphysics which we cannot here present.
 HUMAN DIGNITY 131

quired through freedom, such as that dignity which flows according to Islam from
true faith and divine blessings, and according to Christianity from real faith, divine
grace, and the sacraments, and according to Catholic and Orthodox Christian faith
also from active love, good works, and a free cooperation with divine grace. Various
levels and forms of participation in this dignity, which culminate in holiness, can be
distinguished.
D. Another sort of dignity that differs in essence from the two preceding ones
comes from particular religious institutions and missions (such as the dignity of
prophets, priests, etc.). These dignities are not universal but individual, but they do
not have to go hand in hand with high moral perfection; many prophets, such as
Jonas, and priests, may be morally evil and show unworthy or even horrible beha-
vior. Therefore, their dignity as prophet or priest is in principle wholly distinct from
the dignity of the state of grace or holiness.
It is incumbent on the phenomenological philosophy of religion to look into
these phenomena in their essence-by performing an epoche regarding their real ex-
istence (bracketing their real existence); they can only be recognized by a religious
faith, and really exist only if that faith is true, while the essence of these phenomena
is open to purely rational knowledge.
In its human and social levels, the actual existence of a humanly bestowed digni-
ty (of judges, kings, loved ones, etc.) is manifest.
It is interesting to recall here that the very name of 'person' historically speaking
comes from the recognition of this fourth source of human dignity. This connection
between the humanly bestowed fourth source of dignity and the first (ontological)
dignity is marvelously expounded and rendered understandable by Thomas Aquinas
and by a commentary Edith Stein gives of his text:
To the question of whether the word person is always applicable to God, Thomas re-
sponds: " 'Person' refers to what is most perfect in all nature; namely to what subsists in
a rational nature (subsistens in rationali natura). Yet, all that is perfect should be attri-
buted to God because His essence contains all perfection. This name [person] should
thus be attributed to God. Not, it is true, in the same manner in which it is attributed to
creatures but in a more excellent fashion." 68 That it [its use for God and for man] is an
analogical use of the word has already been shown. 69 This use--according to Thomas-
should extend also to cover the original meaning of the word persona, which refers to
the various roles in a play. In this sense, the word person is not appropriate for God
according to its etymology but in relation to what it should express: "Since well-known
men are represented in comedies and tragedies, the word person has served to designate
dignitaries. That is why some people have defined the word person as follows: person is
a hypostasis [substance] whose distinguishing feature is something pertaining to dignity
(proprietate distincta ad dignitatem pertinente). And as it is great dignity to possess a
nature endowed with reason, any individual being endowed with reason is called per-
son ... But the dignity of divine nature surpasses any other dignity; that is why the
word person in the highest degree is God's due." 70

68 Thomas Aquinas, Summa Theologica I a, q. 29, a. 3, c.

69 Edith Stein, Endliches und Ewiges Sein. Versuch eines Aufttiegs zum Sinne des Seins, in Edith Steins
Werke, Bd. II, Hrsg. 1. Gerber, 2nd ed. (Wien, 1962; 3rd unaltered ed. Freiburg: Herder, 1986), VI,
§4,4.
70 Summa Theologica I a, q. 29, a. 3, ad 2. Quoted with the comments of Edith Stein, Endliches und Ewi-
ges Sein, quotation p. 330 and ss.
132 CHAPTER 2

The characteristics of this fourth 'bestowed' or 'borrowed' dignity are as fol-

lows: It does not originate in the personal acts of the subject of this dignity, but in
acts of other persons, and in gifts. There are within it countless degrees, inequalities
and sorts of gifts, talents, roles, etc. It can be lost.
It would be harebrained to deny the existence of a socially conferred dignity be-
stowed on 'dignitaries' (of the sort of the holders of such offices of kings, etc., that
were depicted in Greek tragedy through the masks called personae), but the real pri-
mary dignity of the person is absolutely irreducible to this type of dignity.
Its highest dimensions, namely those linked to the dignity of man based on di-
vine gifts, and not on inter-human relations, lie with respect to their real existence
beyond the reach of philosophical knowledge, although their essence and difference
from the other dimensions of dignity are evident to a philosophy of dignity and of
religion. This dignity can be universal (as it is the case with the dignity of being cre-
ated in the image of God according to the three 'abrahamitic' religions), but this is
not always the case. There are within it several dissimilarities depending on different
gifts or graces.
Therefore, for the fourth as well as for the third and second dimensions of digni-
ty, unlike for the first, it is a fact that fraternity (fraternite) does not mean recogni-
tion or a cry for equality (egalite) of dignity which here often does not exist, but the
loving and envy-less recognition of the different degrees in which others possess it,
as Gabriel Marcel emphasizes. 71 In contrast, the ontological dignity and the 'equality
before the law' that is rooted in the second source of human dignity require the full
acceptance of the principle of egaliM.
There are numerous fundamental human rights that arise from this fourth source
of dignity in its interhuman dimensions like, for instance, parental rights, children's
rights, the right of adoption, the human right relating to the independence of judges
and others. Many rights of Senior Consultants, Department Heads, physicians,
nurses, etc ... have their root here. Of course, physicians and hospitals have to respect
also rights of this fourth kind in patients and in their parents, children, or other rela-
tives.
Religious rights, particularly the rights owed to religious communities and reci-
pients of holy orders, of spiritual authority and leadership, are also rooted in the reli-
gious (and often simultaneously in the humanly bestowed) dimension of conceded
dignity.

3.5. Relations between the Different Sources and Dimensions ofPersonal Dignity

It is important, after appropriate distinctions have been made, to look also, at

least briefly, at the close relationship that exists among the four dimensions of digni-
ty.
(a) Relationship of condition and foundation: The first dimension of dignity is
the foundation of all others while the second is the absolute condition for the emer-
gence of the third. The second also is sometimes the condition of the continued ex-
istence of the third dimension of (acquired) dignity; solely conscious rational sub-

71 See Gabriel Marcel, Die Menschenwiirde und ihr existentieller Grund.

 HUMAN DIGNITY 133

jects, for instance, can acquire moral values. But this is not always and necessarily
so; consider that many dimensions of acquired dignity, for example moral values,
while they necessarily presuppose at their origin consciously awakened existence,
continue to exist in patients who are in a coma and deprived of consciousness.
(b) Cooperation: Within the humanly bestowed dignities of a judge or a king, the
true dignity of those offices and professions require clearly a free cooperation of the
persons who hold them and possess their authentic dignity-bestowing function only
if at least a minimal free cooperation and some dimensions of acquired moral digni-
ty are present. 72 This goes as far as to justifY an immediate deposition of judges,
kings, heads or chancellors of state, and other 'dignitaries' when they act grossly un-
justly and against the dignity of their office. The most profound bearings of the third
and fourth dimensions of human dignity, according to the religions of Judaism,
Christianity, and Islam, are only possible through the cooperation (and co-action) of
the third with the metaphysico-religious fourth dimension of dignity.
(c) Being ordained towards/Destination: The four different dimensions of digni-
ty are also ordained to each other. For example, the first ontological dimension of
dignity is destined to lead also to the second, the second to the third and all three
ought to be perfected by many aspects of the fourth dimension of dignity.
The first two dimensions of dignity are presupposed by the third and several as-
pects of the fourth kind of dignity, and at the same time ordained to be united with
them.
The third dimension becomes in a new way a calling in virtue of the fourth,
while the second and third dimensions of dignity are ordained in still another sense
to be perfected by the fourth.
(d) Priorities among the four kinds of dignity: We may speak also of different re-
lations of priority between the four dimensions and sources of human dignity. We
may distinguish (a) ontological priorities, (b) temporal priorities, and (c) axiological
priorities. 73
Speaking of ontological and temporal priority (a and b), we must say that the
first dimension and source of dignity has absolute priority because it is the condition
of all others; the second source and dimension of dignity possesses ontological and
(at least in human life) temporal priority with respect to the third because it is its
condition; the fourth source of dignity presupposes ontologically only in some of its
forms the second, in other forms only the first onto logically speaking.
Regarding axiological dignity, things are very different, if we do not speak of a
purely ontological-axiological priority by which one value is condition of other val-
ues (in which sense the second to the fourth forms of dignity presuppose the first
which thus has priority), but of a purely hierarchical axiological priority by which
one dignity is of higher value than the others. While such a comparison as well is
difficult to draw simply speaking (because the ontological value of the person is ofa
very different nature than qualitative values, and therefore a more essentially lasting

72 I wish to acknowledge the excellent questions and observations of the doctoral candidate Marin 00-
linta that made me more clearly aware of this point.
73 lowe this question to Dr. Esther Gomez who asked the interesting questions and made some remarks
that inspired the following distinctions.
134 CHAPTER 2

value than the other dimensions and kinds of dignity, lastingness/endurance being
one of the criteria for a hierarchy of values)/4 we can nevertheless say: in no way is
the ontological value of the person (which also the utterly evil person possesses)
higher than acquired moral values. On the contrary, the sublimity of moral goodness
is an incomparably higher value (even though it as well partakes in the highest po-
tentialities of the ontological value of the person and perfects them as it were),
which is the reason why we do not call a person good primarily because that person
exists and lives. We will return to this question in the next chapter. Humanly be-
stowed values, on the other hand, even the being loved, can never be as sublime and
high values as the ontological value which has also axiological priority with respect
to them. If divinely bestowed dignity is accepted to exist, however, this dignity,
while purely ontologically-axiologically speaking also secondary to the ontological
value, could surpass it by far in a purely axiological sense.

4. DIGNITY AS OBJECT OF RATIONAL KNOWLEDGE AND ANSWER TO

SOME OBJECTIONS AGAINST THE RATIONAL KNOWABILITY
OF HUMAN DIGNITY

How can we, however, recognize this objective and central value of inviolable digni-
ty? We answer that it is purely philosophically understandable. Already Cicero and
Sophocles had found in ancient times magnificent words about this dignity, which
grows intelligibly from the essence and reality of persons. Of course, values and dig-
nity are not like other 'natural' characteristics of objects.75 We cannot see them,
smell them, touch them, and test them in a laboratory, nor are they 'constitutive'
properties such as (immaterial) feelings or cognitions. 76 That is why certain philoso-
phers used to regard something such as value and dignity as 'quaint' or 'queer' and
for this reason, for its 'oddness', used to reject it. 77 However, this is a very primitive
view. We also cannot see, smell, touch, or experimentally verify in a laboratory the
truth of a proposition, or the logical validity of a form of reasoning and logical argu-
ment. Yet, everyone, including those philosophers who put forward this unreason-
able argument against values, view the truth of their assertions and the logical validi-
ty of the forms of argument by which they derive their conclusions from their prem-
ises as an understandable and objective thing-although they cannot be verified by
sense perceptions and laboratory testing. 78

74 See Max Scheler, Der Formalismus in der Ethik und die materiale Wertethik.
75 The not entirely clear or fortunate notion of 'natural' properties (which chiefly means sensibly verifi-
able but also all other constitutive properties of beings) and 'non-natural' properties was introduced
by G. E. Moore in his Principia Ethica, 14. ed. (London: Oxford University Press, 1971). Sir W.
David Ross, Foundations o/Ethics, added the distinction of founding or original and 'consequential'
properties, counting values among the latter. See also John F. Crosby, "The Idea of Value and the
Reform of the Traditional Metaphysics of Bonum," in Aletheia I (1977), pp. 231-339.
76 See John F. Crosby, "The Idea of Value and the Reform of the Traditional Metaphysics of Bonum."
77 For example, Mackie uses this observation against the objectivity of moral values. See J. L. Mackie,
Ethics: Inventing Right and Wrong (New York: Penguin Books, 1977).
78 For a lucid criticism of this rejecting values and dignity because of their alleged oddness, cf. John Fin-
nis, Natural Law and Natural Rights (Oxford: Clarendon Press, 1980).
 HUMAN DIGNITY 135

As we have stated before, the practical implications of this theoretical knowledge

about the four dimensions and sources of dignity are considerable for our society
and for medicine: more human beings live or die on the basis of philosophical or
ideological ideas about dignity rather than on the basis of progress or regress of
medicine and medical science. (Only through abortion and euthanasia over 70 mil-
lion human beings die every year; and many others through ideologically motivated
wars based on a lack of the sublime value of human dignity.)
Only an adequate understanding of the person as a rational substantial subject of
a spiritual nature can allow us a well-founded knowledge of the full ontological dig-
nity of every human person, of the unborn as well as of persons who lapsed into per-
manent unconsciousness. Therefore, a brief defense of the human soul was inserted
into this chapter.
Any skepticism, general relativism, or value relativism, but also any insufficient
and limited understanding of the foundation of human dignity (for example, its deri-
vation from social acts and the human dimensions of the fourth source, or from the
mere fear and anxiety of being reckoned among those who do not possess human
dignity, etc.) can lead to grave violations of the dignity of many persons and of the
human rights founded in the dignity of the person. Only the objectivity and universal
intelligibility of the dignity of the person can ground natural and human rights that
command absolute respece9
For this reason, it is not relativism, as many believe, that can provide a founda-
tion for medical ethics and for the respect of human rights in a pluralistic democ-
racy. Quite on the contrary, only the recognition of an objective knowledge of hu-
man dignity and human rights can secure the respect of human dignity.
Adherents of the school of 'critical rationalism' will cry out that this is untrue
and that the idea of an objective truth lies at the root of totalitarianism and fascism
and countless other horrors in history. Only when humans become more modest and
conceive of their philosophical and religious beliefs as merely subjective personal
convictions that should not be forced upon anyone else, will there be peace, mutual
respect, and democracy.80
Convincing as this objection sounds at first sight, it is incorrect. The recognition
of objective truth can be linked to totalitarianism and the violation of human rights
only if false assumptions are held to be true, or if concrete persons violate those
things that they recognize to be true. Relativism, however, by its very essence can
give rise to totalitarianism of any kind and can at any rate offer no valid, let alone
strong, reason to resist it. Moreover, de facto, the worst forms of totalitarianism and
repression of human rights, Nazism, communism and fascism, were all imbued by
relativism, which also exerts alarming effects and leads to a profound crisis and phil-
osophical disease ofmedicine. 81

79 See on this Martin Cajthaml, Kritik des Relativismus.

80 See Sir Karl Popper. See also Hans Albert, Traktat iiber Rationale Praxis (Tiibingen: Mohr/Siebeck,
1978); the same author, Traktat iiber kritische Vernurift, 5th ed. (Tiibingen: J.C.B. MohrlPaul Siebeck,
1980).
81 See on this Rocco Buttigiione, Augusto del Noce. Biograjia di un pensiero (Casale Monserrato:
Piemme, 1991); see likewise Josef Seifert (ed.), Dietrich von Hildebrands Kampfgegen den National-
136 CHAPTER 2

Besides, respect for natural and human rights cannot be established in real life
unless clarity prevails as to the difference between human persons and animals. As
soon as the presented distinctions are overlooked and, for example, the degrees of
the second and third dimensions of human dignity are applied to the first, which ob-
jectively is of the same rank in all human beings and cannot be lost, the reduction of
embryos, euthanasia, etc., to mere useful objects may easily ensue. One cannot en-
joy a universal right for life in society unless the various dimensions of human dig-
nity are distinguished and, above all, the first is recognized in its own particularity
and foundational, inalienable nature.
Human dignity as a sublime value that is inalienable and calling for an appropri-
ate and unshakeable respect is in fact widely recognized today and receives large
consensus. But it is only when one understands and recognizes its sources, chiefly
the first one, that one can prevent it from being simply declared to be something that
applies solely to those who are born, or to a special race or group, whereas millions
of other human persons (the unborn, the comatose and unconscious, Blacks, Jews, or
Arabs, etc.) are regarded as having no claim to the same human dignity.
It is only through a comprehensive understanding of the sources and sorts of dig-
nity that one can avoid terrible confusion and reach the recognition of human rights
on all levels. If one does not carefully distinguish between the levels of human dig-
nity, one will apply degrees of dignity, which truly exist from the second to the
fourth dimension of dignity, also to the first indivisible dignity-with countless er-
rors and potential crimes resulting, quite especially within the domain of medical ac-
tions.
It emerges from all that has been said that there is hardly anything more impor-
tant to society and to medicine than a clear and comprehensive understanding of the
high value, significance, sources and dimensions of human dignity as a foundation
of a medical practice based not only on state law but on inalienable human rights
and absolute moral imperatives. And on this level of general human experience all
human persons of good will can and should fight together against an avalanche of at-
tacks on human dignity.

5. HUMAN DIGNITY AS A UNIFYING BOND AMONG MEN AND MEDICAL

PROFESSIONALS WORLDWIDE

All the mentioned values and dimensions and properties of human dignity can be
known in principle by all human beings and address themselves to all human per-
sons-and all the mentioned disvalues contradict the most profound essence of any
man and of any true religion. Love and friendship, kindness and charity are the same
in their eternal beauty and sublimity in Israel and Palestine, in Morocco and in Ger-
many, in Chile and in Siberia, in Afghanistan and in New York, in Syria and in Ger-
many, in the Iraq and in Liechtenstein, in the Christian and in the Islamic orbit, in
the West and in the East, even if most humans do not actually recognize or respect
them.

sozialismus (Heidelberg: Universitlitsverlag Carl Winter, 1998). The Encyclical Centesimus Annus
(Vatican: Libreria Editrice Vaticana, 1991), ch. V, pp. 94-97, explains this point very deeply.
 HUMAN DIGNITY 137

All those who recognize these fundamental values and goods at all the extremes
of the earth, and all those who practice the said sublime virtues are far more pro-
foundly united with each other than with those fellows of their religious community
who do not possess these virtues nor aspire to them. Just and kind Christian physi-
cians have more in common with fair Muslim doctors than with corrupt and non-
caring Christian physicians who harm their patients. Charitable Muslim nurses have
less in common with uncaring Muslim nurses than with good Christian and Jewish,
or atheist medical staff of the sort of the good physician in Camus's The Plague, at
least as far as the moral bond between humans is concerned.
Profound unity also forms within a thought that remains faithful to ethical and
human experience, as well as in the struggle for human life and health, and other
benefits. In this moment of world history and of global connections of worldwide
nets of health systems it is more important than ever to seek to be just and differen-
tiated in one's judgments on members of one's own and on members of other reli-
gions, and to look for universal and common foundations of a peaceful and good hu-
man society.
The closely shared life of Muslims, Jews, and Christians, as well as of agnostics
and atheists, in Africa, Asia, Europe, and the whole world should not only lead to a
deeper community based on the shared theoretical recognition of human dignity on
the level of pure reflection, but also to a unity on practical, social, and political
grounds: in the course of their pursuit of common goals, the representatives of va-
rious religions and all honest and morally striving human beings are being called to
share important truths and values-for example, on account of common commit-
ments in favor of the inviolable value of human life, or in a joint attempt to under-
stand certain rational and universal foundations of all their religious doctrines. All
these and many other forms of community among persons of different religions and
worldviews are highly valuable and surpass in certain respects, owing to their hu-
man and their specifically religious dimensions (that the pure rational intellect often
is unable to reach and to know), the contribution of philosophy to inter-religious dia-
logue.
Having stressed unambiguously that human dignity can be known by human rea-
son-based on human rational value-knowledge-and that therefore the knowledge
of human dignity does not depend on the beliefs of religious communities, as of
'moral strangers in a public world', we do not deny that some central dimensions of
human dignity are only open to religious faith and can only be revealed by God. We
have already stated this from a purely philosophical point of view (in discussing
those dimensions of the fourth source of human dignity that philosophy cannot know
in their existence but only in their general essence). In Judaism and Christianity the
human dignity of each person is far more profoundly believed-based on faith in di-
vine revelation-than pure reason alone can comprehend it. Divine Revelation
teaches to the believer a far more sublime reason of this dignity-in the character of
the human person as an image and likeness of God, in divine blessings, redemption,
and grace that raise the human person far above human nature as such. Judaism and
the Islam as well as other religions recognize different dimensions of divinely be-
stowed human dignity.
138 CHAPTER 2

Nonetheless, while these dimensions of human dignity can only be believed, not
known, the objectivity and the different sources of personal dignity discussed in the
preceding parts of this chapter can be known by pure reason.
But is it desirable to look for human dignity also in those of its dimensions that
are accessible to human reason and independent of religious beliefs? Certainly, the
authentic believers in their own faith might become worried and alarmed that a
broader philosophical basis of the recognition of human dignity and a shared life in a
pluralistic society might endanger the cognition of the truth we all search for, and
they might become wary of efforts to find a 'medical ethical universal' in human
dignity. But to such timid believers I might give a philosophical advice: The preser-
vation of religious truth does neither occur by excluding the broader universal
knowledge of dignity as a universal bond of mankind nor by limiting or prohibiting
the free practice of religion and religious teaching, and definitely not through calum-
ny, xenophobia or violence, but through the convincing power of truth itself, from
which alone we can reach a basis open to all mankind and from which alone as well
religion can draw its value and true strength. Hence we should put to good use the
great chance of a social and political life shared by all of us, in a pluralistic society.
We should respect the freedom of each other and not forget that any well-founded
peaceful coexistence among peoples is based only on a firm foundation when it is
based on the recognition of absolute truths, moral imperatives, and fUndamental hu-
man rights known by all of us independently of our religion-and not when it is
grounded on indifferentism and relativism. From truth alone the woes of society can
be cured.
We have already touched upon another point: the vital import of a dialogue on
human dignity and of sharing many insights into human dignity and its dimensions
for the medical world-community. Few things have greater importance for the pres-
ent medical world-community than a rational knowledge of human dignity shared by
all health professionals of good will, as well as a practical and unambiguous ack-
nowledgement of human dignity as a fundamental value in medicine.
A close cooperation of the entire medical community for the protection of human
dignity in contexts of medical action must not solely be restricted to those aspects of
dignity known by reason. It can of course also draw attention to these important
common foundations that bind more closely believers of different religions, espe-
cially believing Muslims, Jews, and Christians. Many forms of fruitful inter-reli-
gious contacts and the Universal Declaration of Human Rights and other Declara-
tions are proof thereof. And many international groups of persons united in the rec-
ognition of human dignity have repeatedly and magnificently expressed themselves
in affirming their absolute and uncompromising commitment to human dignity that
is so crucially important for medical ethics today.
The cure of the profound philosophical disease of medicine that lies in the
eclipse of a clear conception of the sublime dignity of human persons lies in a fruit-
ful cross-cultural cooperation in the pursuit of truth and of the good shared by all
members of the medical profession who ought to be reunited in their joint search for
a life based on the truth and on the unwavering affirmation of human dignity as a
true universal of medical ethics.
 CHAPTER 3

FROM THE MORALLY RELEVANT GOALS

OF MEDICINE TO MEDICAL ETHICS
On the Superiority of Moral Values over All
Extramoral Goals of Medicine

1. INTRODUCTORY NOTES ON ETHICS IN ITS RELATION TO MEDICINE

The concept of a philosophy of medicine and in medicine frequently is reduced to

medical ethics. Given the centrality of ethical questions for medicine, this is under-
standable, although such a reduction is obviously inadmissible because there are
many other problems of philosophy of medicine besides those pertaining to medical
ethics, for example the epistemological question discussed before: "What is the
knowledge gained in medicine?" or the questions pertaining to a philosophy of life
and of philosophical anthropology, "What is human health?" or, "What is human
life?".
Also questions of 'medical ontology' are many and important. This field of in-
vestigation deals with very abstract general ontological categories such as those of
sets, Urelements, classes, lists, spatio-temporal modes of being, substances, things
and states of affairs, general and negative states of affairs, species and genus, etc.,
and their applicability to medicine. 1 Medical ontology deals also with questions that
are far more concretely and directly related to medicine, such as whether or not hu-
man persons and the species man are related inherently and essentially, or solely ac-
cidentally and externally, to the biological species homo sapiens sapiens. Medical
ontology investigates whether the name 'person' refers only to individual subjects,

1 See for example Edmund Husserl, Logical Investigations; Alexander Pfander, "Die Lehre vom Ur-
teil," in Alexander Pfander, Logik; AdolfReinach, "Zur Theorie des negativen Urteils," in Siimtliche
Werke, pp. 95-140.
Regarding the application of formal ontology to medicine and computerization of ontological cate-
gories, think for example of the work of Heinrich Herre and others at the Institute for Medical Onto-
logy at the University of Leipzig (http://www.onto-med.de) which studies general ontological lan-
guage (GOL), many questions of ontology such as the differences between sets, classes, Urelements,
lists, etc. See for example B. Heller, H. Herre, "Formal Ontology and Principles of GOL," Onto-Med
Report No. 1/2003 (Research Group Ontologies in Medicine, University of Leipzig); B. Heller,
H. Herre, M. Loeffler, "Research Proposal," Onto-Med Report No. 2/2003; B. Heller, K. Lippoldt,
K. Kuehn, "Guideline for Creating Medical Terms," Onto-Med Report No. 4/2003; B. Heller, K. Lip-
poldt, K. Kuehn, The Onto-Builder Handbook Version 1.1 Part I: The Construction of Medical Terms.
Technical Report, Onto-Med Report No. 512003.
139
140 CHAPTER 3

to someone, or also to a general nature. 2 Medical ontology deals with still much
more content-full and concrete issues such as the ontological status of patients in
different states and at different ages (embryos, babies, children, adults, old, con-
scious, unconscious, competent, and incompetent patients, etc.); with the ontological
categories applicable to health, to diseases, illnesses, or to privations such as blind-
ness; with the ontology of values such as those of health and of life, and of various
other phenomena; as well as with the ontological status of medicine itself and of the
different classes of medical actions.
These questions belong to an area of philosophy of medicine distinct from ethics
even though also some results of an ontology of medicine have great influence on
medical ethics and on medical practice. 3 Consider for example the question of the
ontological status of the human person herself as well as of human health:
(a) besides the classical position defended in chapter 2, that human persons are
substantial beings of rational nature,
(b) a second possible answer to this question: that the ontological status of per-
sons, or that of personal health (to be examined carefully in volume II of this work),
is none other than that of a social fiction, or nothing but an object of intersubjective
consensus, may exert a huge influence on the ethics and practice of medicine.
The content of health and the ontological status of human persons will then be
regarded as inherently subjective and as solely judged by subjective individual or so-
cial criteria. This position could lead to, and certainly would justify, arbitrary redefi-
nitions of life and death, and equally arbitrary subjectivist criteria of health as well
as of life, death, and of the personhood of human beings at different stages of their
development. If persons, life, and health have their own objective essences, how-
ever, that are quite distinct from social fictions, as we sought to show in the preced-
ing chapter and elsewhere: purely subjective and changing historical and social cat-
egories are wholly inadequate for the serious task of intellectually capturing and
adequately defining the kinds of entities to which these categories are applied.
Consider for example the position according to which small children are not ob-
jectively persons but are to be protected (and infanticide ought to be excluded) only
or mainly because small children are regarded as persons by their parents. To re-
duce the ontic status of the personhood of children to a function or consequence of
parental treatment of small children as persons or to an intersubjectively accessible
experience and socially shared perception of certain beings as persons, goes in a
similar direction of a psycho-social subjectivization of the concept of personhood
and or fictionalist account of what persons are.
(c) In order to see the significance of ontology for medical ethics, consider also a
third ontological opinion, namely that human life as such is ontologically speaking
not essentially but only gradually different from animal life for the reason that it is

2 See Robert Spaemann, Personen. Versuche fiber den Unterschied zwischen 'etwas' und 'jemand '.
J See Paulina Taboada, Kateryna Fedoryka-Cuddeback, and Patricia Donohue-White (eds.): Person, So-
ciety and Value. Towards a Personalist Concept ofHealth; see also Josef Seifert, Sein und Wesen.
4 See on this question Josef Seifert, "What Is Human Health? Towards Understanding Its Personalist
Dimensions." See also Josef Seifert, Sein und Wesen; the same author, Ritornare a Platone.
 SUPERIORITY OF MORAL VALUES 141

either identical with brain processes5 or only an accident, epiphenomenon, or super-

venient property of certain brain events. In consequence of such a theory the impor-
tant difference between organisms would no longer lie in their generic and specific
natures (humans, animals), but solely in the degree of actualization of their respec-
tive consciousness, in the level of their conscious life produced by their brain pro-
cesses. This position inevitably leads to the opinion that some healthy animals are
more properly speaking 'persons' than seriously handicapped or persistently uncon-
scious human beings. This theory can be linked to evolutionism, as in Peter Singer's
writings, but it can also be independent from an evolutionist theory of the origin of
the human species, according to which gradual changes of animals could give rise to
the coming to be of human persons without any extrinsic intervention that would
explain the origin of the human soul and personhood. 6 The category by means of
which this third, materialist theory of the ontological status of persons seeks to grasp
personhood plays a significant role in the current bioethical debate: the opinion that
personhood is identical with brain events or nothing but an epiphenomenon or super-
venient property of brain processes and for this reason can be attributed to some, not
to other individuals of the human nature. It follows from this opinion that person-
hood, possibly while not lacking an essential difference to animal life, is only exter-
nally and contingently related to the biological species of homo sapiens because it is
in itself identical with, or a mere accident of, brain processes. In other words, per-
sonhood is no ontic character of individual human beings as such. Some human be-
ings would be persons, others not, precisely because personhood is, according to this
view, only loosely and accidentally connected with the biological human species in
virtue of its merely coinciding with, or proceeding from, certain processes of a hu-
man brain which do not occur in all human brains. Consequently, also the posses-
sion of a specifically human brain or the life of an organism of a specific human na-
ture, would not per se guarantee the presence of a human person or entail an essen-
tial difference between human beings and animals, because any distinction between
persons and animals would only depend on brain function and the human brain does
not function in all individual members of the human species. For the reason of an
ontic status of persons as mere brain events or as mere supervenient accidents of
them, there would be no essential but merely a contingent and tenuous bond between
the human species and personhood.
(d) The same result of a negation of an essential unbridgeable difference between
animals and human persons follows also from a fourth possible ontology of human
persons: namely from the theory of the origin of species according to which persons
are just an evolutionary product of inunanent developments of animal organisms and
for this reason not essentially but only gradually distinct from animals. Such an evo-
lutionism would not only claim a mere gradual distinction between human beings

5 For a critique of different varieties of such a mindlbrainlidentity theory cf. Josef Seifert, Das Leib-
Seele Problem und die gegenwartige philosophische Diskussion.
6 See on the many varieties of the confused and pseudo-scientific theory of evolution Josef Seifert,
"Philosophy and Science in the Context of Contemporary Culture," in The Human Searchfor Truth:
Philosophy, Science, Theology. The Outlook for the Third Millennium. International Conference on
Science and Faith. The Vatican 23-25 May 2000 (Philadelphia: Saint Joseph's University Press),
pp.23-71.
142 CHAPTER 3

and animals but likewise relativize the gradual superiority of members of the human
species within the evolutionary chain of beings, because this gradual superiority of
human beings over animals would not be true for all members of the human species,
which to believe would be a sheer prejudice called by Singer 'speciecism.' A (mere-
ly gradual) superiority of human beings in relation to animals would only be found
in mentally healthy exemplars of the human species. Under this assumption, mental-
ly retarded human beings could be of a much lower ontological level and value than
healthy animals. Peter Singer suggests such an evolutionist ontology and draws such
far-reaching bioethical consequences from his (in my mind very deficient) fluid and
essence-less ontology of human persons which lacks both a clear concept of the es-
sentially necessary difference between persons and non-persons, and an understand-
ing of the inner unity of genus and of species in general. 7
(e) Often this opinion goes hand in hand with a fifth-'actualistic'-variety of
the ontology of the human person, according to which persons could be reduced to
their actions. This actualist opinion as well as the other three mentioned ontologies
of the human person indirectly have been refuted by the arguments for the spiritual
substantiality of the human person briefly presented in the last chapter. 8
Both classical and current bioethical views are thus largely based on an interpre-
tation of the ontological category of persons. Besides the classical ontological under-
standing of persons as (a) substantial, self-standing beings of rational nature, we
identified contrary ontological views of persons (b) as mere objects of individual or
social and historical subjective consciousness, (c) as identical with brain processes
or as mere accidents (epiphenomena or supervenient properties) of brain processes;
as being different from animals only by degree (d) on account of an evolutionist, and
biologically speaking entirely 'fluid' ontology of human beings and of species in
general, or (e) on account of actualistic ontological theories of persons. Many of
these latter ontological theories (b-e) lead to virtually identical results and conse-
quences for bioethics even if some of their starting points are incompatible with
each other. (For example, a subjectivistic theory of personhood contradicts a
pseudo-scientific, evolutionary account of the nature of persons and of the human
species meant to be entirely objective.)
On the basis of such-sometimes mutually compatible, sometimes mutually ex-
clusive--ontologies of the human person, different authors, including Peter Singer,
give a negative answer to the question whether there is an essential distinction be-
tween the different species or realms of being in general and specifically between
human persons and animals, claiming that this difference is merely a gradual and an
accidental, not an essential and abysmal one. To assess and critically to examine all
of these and similar claims requires medical ontological investigations.
Medical ontology must not neglect either an examination of more general onto-
logical issues such as an ontology of genera and species of being as such.

7 See Peter Singer, Ethical Issues Relating to Life and Death (Melbourne, 1979), especially "Unsancti-
fying Human Life," ibid., pp. 41-61.
8 See on all this also John F. Crosby, "Evolutionism and the Ontology of the Human Person." See also
Josef Seifert, What is Life?; the same author, Das Leib-Seele Problem und die gegenwiirtige philoso-
phische Diskussion, and "Philosophy and Science in the Context of Contemporary Culture."
 SUPERIORITY OF MORAL VALUES 143

An ontology of personal health is another important sub-area of medical ontolo-

gy which asks whether personal health contains essentially different dimensions
from those encountered already in animal health or is sufficiently accounted for in
terms of more abstract notions of health such as are applicable also to animals. 9
Within the manifold relations between philosophy and medicine, two are of para-
mount significance, however: the relationship between medicine and philosophical
anthropology, and that between medicine and ethics. Notwithstanding the crucial
foundational importance of epistemological, ontological, and anthropological ques-
tions for medicine, ethics plays an even more directly foundational role for medical
actions, even though ethics itself rests entirely on prior epistemological, ontological,
and anthropological cognitions.
Let us therefore now turn to ethics. Thus far we have not really begun to discuss,
in this book, bioethics, or medical ethics strictly speakinglO because ethics deals pri-
marily with what is morally speaking good and neither life nor any of the other four
immanent ends of medicine we discussed in chapter 1, nor ontological human dig-
nity, discussed in chapter 2, are morally speaking good, even though in analyzing
them one inevitably touches on ethics proper because these morally relevant goods
of life, health, alleviation of pain, etc., issue moral imperatives and are objects of
morally good or evil acts.
We touched upon moral goodness more directly in several other contexts, how-
ever, especially when we spoke of the last two-transcendent-goods medicine
should serve and when we said that the physician, who is called, as Paracelsus
noted, II to understand the whole human nature, must not violate the higher good of
the person. And this higher and highest good of the person, which the physician
must not violate, includes also, and quite especially, the patient's, physician's and
nurse's moral goodness. But what is moral goodness? What are moral values?
In order to place the investigation into this question correctly within the whole
edifice of ethics, we should try to see this issue in its relationship to other topics of
ethical research.
Ethics investigates chiefly four kinds of things:
(1) In the first place, ethics, as a discipline distinct from the more broadly foun-
dational fields of epistemology, ontology, and philosophical anthropology, studies
its own general foundational concepts and data, namely the good and value as such,
as well as the fundamentally different meanings and categories of value and of the
'good' (or the important). Into this general theory of value and of the good falls also
the question of the opposites of value: disvalue and evil. (A study of its still broader

9 See, for example, Josef Seifert (besides "What Is Human Health?"), "Moral Goodness and Mental
Health."
10 One might distinguish bioethics and medical ethics in at least three ways, although a number of auth-
ors use the two terms virtually in the same way: (I) Bioethics is the wider field because it also deals
with ethical issues related to animals, plants, and to geology, and not just to human beings. (2) Bio-
ethics is also a wider discipline than medical ethics because it does not specifically refer to medical
actions towards human beings but includes also all other, extra-medical actions related to human life.
(3) One might also characterize bioethics as a part of ethics distinct from medical ethics by being a
more modem and less classical field of ethical studies, dealing more with those ethical problems
posed by the most recent advances in the life-sciences.
II See the quote above, chapter 1, 2.11.
144 CHAPTER 3

and more general epistemological, anthropological, and ontological foundations may

be included in ethical works as Prolegomena to ethics but falls outside the strict con-
fines of ethics itself.)
(2) In the second place, and more specifically, ethics studies that which is moral-
ly relevant, i.e., those goods and values, or rights and other phenomena from which
moral calls and obligations issue, while they are not themselves morally good, such
as the first five goods medicine ought to serve; neither human life nor human health
nor freedom of suffering, etc., are morally good. Yet these goods are morally highly
relevant. From them moral calls proceed. 12 We have discussed thus far precisely
those morally relevant goods which medicine should pursue, such as health or life.
Within this realm of the morally relevant factors and the motives of moral acts we
find also other data such as different kinds of 'oughts', or imperatives, obligations,
happiness, etc. 13
(3) Thirdly, ethics studies the morally right and wrong acts and investigates the
objectivity and nature of these categories of the morally right and wrong. Inasmuch
as actions are only objectively right or wrong, however, performing them does not
yet necessarily give rise to morally good or evil acts in the acting person because, for
example, he who acts ethically wrongly may be morally speaking innocent. He may
not be in possession of the ethical knowledge and understanding necessary to be-
come morally evil by doing what is morally wrong. 14 Or his motivation, though he
performs objectively right acts, may lack the conditions and necessary motivation
for performing morally good acts.
(4) Fourthly, ethics speaks of the morally good and evil themselves, of the vir-
tues and vices, the good and evil acts of persons. This realm of properly moral good
and evil then forms the core of the subj ect matter of ethics. Ethics has the lofty task
to explain the excellence of moral virtues and perfections that alone deserve to be
called the real excellence (namely virtue, arete) of the human person. IS And it is
chiefly this task to which we are going to contribute in the present chapter.
Modem medical ethics often exclusively speaks of the first two issues and kinds
of goods, perhaps also of the third one, therein frequently ignoring the fact that the
consequences of human acts as such never suffice to constitute their moral character,
and that it is not the positive balance of the consequences alone that makes them
right or wrong.

12 Later, we shall see that there are three senses of 'morally relevant', and that in one of these what is
morally good itself is eo ipso also morally relevant.
13 See my thesis that seven distinct factors are morally relevant and thus ought to motivate the morally
good (obligatory) action in Josef Seifert, Was ist und was motiviert eine sittliche Handlung? (Salz-
burg: Universitlitsverlag A. Pustet, 1976).
14 See on this also Roderick M. Chisholm, Ethics and Intrinsic Values, edited and introduced by John R.
White (Heidelberg: Universitlitsverlag C. Winter, 2001).
15 The philosophical as well as linguistic revolution of the Socratic-Platonic transformation of the notion
of (human) excellence (arete)-which only from Socrates on is recognized to be (moral) virtue as the
only true human excellence, (wherefore only after Socrates the word arete may be translated as 'vir-
tue'}-has been noted by various authors. To elucidate the nature of moral excellence and to show the
truth of this revolutionary thesis of Socrates is the core task of ethics. See especially Balduin Schwarz,
"Bemerkungen zu Platons Menon," in Salzburger Jahrbuch for Philosophie 10/11 (1966/67), S. 361-
380, reprint in Balduin Schwarz, Wahrheit. Irrtum und Verirrungen, pp. 101-129.
 SUPERIORITY OF MORAL VALUES 145

Those who teach medical ethics or write on it frequently keep ignoring as well
the fact that the moral values themselves are higher than the values of the conse-
quences of human acts and even those of mere moral correctness (right ethical beha-
vior, bereft of the proper moral motivation or of ethical knowledge, may be lacking
in moral goodness).
We conclude: the extramoral (though morally relevant) goods and values, such
as human life and health, which medical action ought to serve but which are not
morally good (even though they have a decisive bearing on morality), should not be
all medical ethics takes into account. No, the medical ethicist should fix his mental
eye also on what is specifically moral in medical action. We turn now to this core of
medical ethics, to the question of the specifically moral values and disvalues.
The question, "What is the nature and essence of moral values?" is a crucial one
in itself and for a philosophy and ethics of medicine. Yet it also is a hotly disputed
one, and the most diverse and opposite views about morality are being offered, so
much so that we are always tempted to become moral relativists; and many, or even
most, authors today espouse, in one form or another, a moral relativism, a position
which challenges radically the character of ethics as an objective knowledge and sci-
ence.
Faced with a shocking plurality of opposite views about the nature, role, and
contents of moral values, on the one hand, and with the central importance of ethics
for medicine, on the other, the following question takes on great significance: Is
there any objective criterion for correct medical ethics or do we here just move into
the domain of personal and thoroughly subjective opinions? In the latter case, there
would be no real medical ethics at all, nor could ethics, interpreted as a wholly un-
scientific and subjective domain, belong essentially to medicine. Through their total
subjectivity, ethical positions would wholly fall outside scientifically based medi-
cine and be irrelevant for it.
But this is not at all the position defended in this book, which understands ethical
relativism to be one of the chief philosophical diseases of medicine and seeks, if
only by way of examples and without offering here a systematic presentation of the
method and whole body of ethical knowledge, to demonstrate that, on the contrary,
ethics is an objective and rigorous science. 16
Moreover, a commitment to the basic tenets and results of ethical inquiry, even if
accepted only in a pre-philosophical and pre-scientific mode, are an indispensable
part of the medical profession.
Yet even after successfully defending the claim that there are objective standards
and values at the origin of ethics-in view of the many mutually exclusive claims to
ethical truth-the question remains: Which ethics, and which view of the nature of
moral values should the contemporary physician or nurse adopt?17
Before arguing extensively for the objective character of ethical knowledge in
chapter 5 and prior to answering a number of criticisms leveled against ethical ob-
jectivism, let us already here attempt to give a brief answer to the question about the

16 The issues ethical relativism raises are so fundamental for medical ethics that we will have to investi-
gate them carefully in chapter 5 of the present work.
17 This question will mainly occupy us in volume II of the present work.
146 CHAPTER 3

objective or purely subjective character of ethics and of moral values by an investi-

gation into the essential traits of that unique domain of values which we call moral
values. Accomplishing this goal, we will also take important steps towards solving
the question which ethics physicians and nurses should espouse. The question about
the properly moral values themselves, and about their foundations, will lead us into
the heart of ethics.
But why should a philosophy of medicine, as well as medical professionals, be
so centrally concerned with the specifically moral sphere as such and with the inner-
most dimension of ethics as the exploration of what is not only morally relevant but
morally good or evil? And what is the connection between moral values and the sev-
en goods of medicine discussed so far?
Let us attempt to answer both questions at once: Moral values, in their unique
superiority over all others, arise precisely from a response to the morally relevant
values and goods some of which we treated when discussing the seven goals of med-
icine. The need for an ethics of the specific moral values first to understand those
goods which are morally relevant and give rise to moral imperatives applies espe-
cially to the human person herself, and to the goods for the sake of which medicine
exists, which should first be known and explained, at least to some extent, before the
moral issues related to them can be properly understood. Therefore, we have begun,
in chapter 1, with a brief exposition of the seven fundamental goods medicine has to
serve, and discussed the ontology and dignity of the human person in chapter 2.
In our following exposition of medical ethics we shall concentrate primarily on
moral values themselves. At the same time, in so doing, we shall take-regarding
philosophy of man-the inverse route, proceeding from ethics and moving from it
back to philosophical anthropology. This method, also used in Karol Wojtyla's work
The Acting Person,18 is justified inasmuch as ethics considers what is most personal
in the person: her freedom and that unique good and evil of her actions which de-
serve to be called good and evil in a primary way, which proceed from the person's
center of self-determination and self-governance and spontaneous responses, which
involve the sphere and the 'kingdom of justice', and which are lifted out of all other
goods and evils by many further decisive marks and characteristics (for example,
they alone are linked to the sublime dimensions of moral conscience, of guilt and
merit, reward and punishment).
Moral values appear 'on the back' of actions in which those who perform medi-
cal services honestly commit themselves to the life, health, and well-being of pa-
tients. 19 But at the same time, in this free response of the person to morally relevant
goods an entirely new sphere ofvalues is born: moral values. Moral values ofphysi-
cians and nurses are not just means to bring about the morally relevant goods of life

18 Karol Wojtyla, The Acting Person; cf. also the corrected text, authorized by the author (unpublished;
(official copy), Library of the International Academy of Philosophy in the Principality of Liechten-
stein.
19 This does not exclude, within the sevenfold motivation of moral acts, a motivation by the moral val-
ues of our own acts and persons themselves. See my attempt to prove this, against Scheler who held
that moral value can only appear on the back of our acts and never be intended freely, in Josef Seifert,
Was ist und was motiviert eine sittliche Handlung? See also Max Scheler, Der Formalismus in der
Ethik und die materiale Wertethik; see likewise Dietrich von Hildebrand, Ethics, ch. 19.
 SUPERIORITY OF MORAL V ALVES 147

or health of patients but they are high values in their own right. Therefore, and be-
cause of their high rank, we will have to investigate them carefully in the bulk of
this chapter.
Such an investigation is especially called for in a book on medical ethics because
the professional acts of medical care are not morally neutral but to a large extent
moral acts. For while other professions deal with subjects which have little relation-
ship with morality, such as producing or selling stamps, cars, or soccer balls, most or
all medical actions are inseparably connected with the moral life of the person since
they deal chiefly with suffering human persons in need of help. As a consequence,
ethics is more intimately bound up with medicine than with many other professions
and disciplines. Hence, it is understandable that physicians more than members of
other professions have to take a professional oath and that in each article of the Hip-
pocratic Oath mostly moral issues are present. Therefore, the following investigation
will also throw light on the specific nature of medicine.
I do not deny here that there is an ultimate level of moral and spiritual life in
which every properly personal act, every actus humanus, and therefore also any pro-
fessional activity, has some connection with morality. But certainly many things and
activities in life do not have a direct connection to the moral sphere in and of them-
selves, as, for example, the production and use of most of the purely useful things
desirable for mere reasons of comfort, such as producing or using china, bicycles, or
sofas, or taking a car instead of walking, etc. 20
If even free acts such as producing fine cars can be morally speaking relatively
neutral, the assertion of the extramoral character of many human acts applies most
of all to those activities which are merely acts of man (intended by the classical no-
tion of actus hominis) and not free personal acts, and which therefore lack any moral
character, as opposed to the properly personal human acts (which are meant by the
medieval concept of the actus humanus), which, at least in their most significant
sub-species, are free. The properly personal human acts have been distinguished
clearly, especially by Thomas Aquinas and by Karol Wojtyla, from the automatic
and not properly intentional human acts, such as sneezing, which lie outside the
moral sphere. See this classical distinction in Thomas Aquinas:
I answer that, Of actions done by man those alone are properly called 'human', which
are proper to man as man. Now man differs from irrational animals in this, that he is
master of his actions. Wherefore those actions alone are properly called human, of
which man is master. Now man is master of his actions through his reason and will;
whence, too, the free will is defmed as 'the faculty and will of reason'. Therefore those
actions are properly called human which proceed from a deliberate will. And if any
other actions are found in man, they can be called actions 'of a man', but not properly
'human' actions, since they are not proper to man as man. Now it is clear that whatever
actions proceed from a power, are caused by that power in accordance with the nature

20 See Czeslaw POTlebski, Lohnt es sich, moralisch zu sein? (Freiburg in der Schweiz, Universite de Fri-
bourg Universitatsverlag, 2000). The author has shown that also many of these acts, such as the pro-
duction of cars (in which, for example, the weight given to the safety of the drivers and passengers
playa great role) have important ethical implications.
148 CHAPTER 3

of its object. But the object of the will is the end and the good. Therefore all human ac-
tions must be for an end. 21

While we may be surprised that Aquinas sounds in this text (no doubt uninten-
tionally) as if only free actions and only acts done for the sake of an end were prop-
erly speaking human acts, so as if cognitions and affections and even free but purely
interior responses and fundamental attitudes (without an 'exterior end' to accom-
plish) were to lie outside personal acts,22 we agree fully with his and Karol Wojtyia's
great insight that personal free acts differ sharply from all unfree happenings in
man,23 and that moral acts are personal acts in Thomas's sense of the term 'actus hu-
manus'. They are free personal acts and can only therefore be moral acts.24
Consequently, an analysis of the moral dimension of human actions, which ap-
pears to force us to leave our efforts to understand the human person as such, will
actually lead us most deeply into what is the most personal in the person and into
doing philosophical anthropology. For these reasons, an investigation into the ques-
tions of ethics will provide also a new and fine continuation of our inquiry into the
nature and dignity of the human person who reveals herself with particular clarity
when she is seen in relationship to moral calls, obligations, and values.
The general nature of medicine in its relationship to philosophy as described in
chapter 1 shows us that medicine essentially has an ethical dimension and that the
physician has to be something like a practical philosopher, and in particular that he
always-or well-nigh always25_in his professional work is also a morally acting
person and makes ethical judgments, and not only judgments about how to realize
those goals of medicine which in themselves are extramoral goods such as health.

21 Thomas Aquinas, Summa Theologica, Prima Secundae, q. I, a. I, co, I-IS:

respondeo dicendum quod actionum quae ab homine aguntur. iIIae solae proprie
dicuntur humanae, quae sunt propriae hominis inquantum est homo. differt autem
homo ab aliis irrationalibus creaturis in hoc, quod est suorum actuum dominus. un-
de illae solae actiones vocantur proprie humanae, quarum homo est dominus. est au-
tem homo dominus suorum actuum per rationem et voluntatem, unde et liberum ar-
bitrium esse dicitur facultas voluntatis et rationis. illae ergo actiones proprie huma-
nae dicuntur, quae ex voluntate deliberata procedunt. si quae autem aliae actiones
homini conveniant, possunt dici quidem hominis actiones; sed non proprie humanae,
cum non sint hominis inquantum est homo. manifestum est autem quod ornnes actio-
nes quae procedunt ab aliqua potentia, causantur ab ea secundum rationem sui ob-
iecti. obiectum autem voluntatis est finis et bonum. unde oportet quod omnes actio-
nes humanae propter finem sint.
See also Karol Wojtyla, The Acting Person.
22 At least for cognitions Thomas Aquinas would certainly admit their fully personal character and also
calls them often acts (actus). He would not perhaps recognize the fully spiritual character of certain
human affections. See on this Dietrich von Hildebrand, Ethics, ch. 17; see also by the same author,
The Sacred Heart: An Analysis of Human and Divine Affectivity (BaltimorelDublin Helicon Press,
1965; 2nd ed.: The Heart, Chicago: Franciscan Herald Press. 1977), ch. 2, "Spiritual and Non-Spirit-
ual Forms of Human Affectivity."
23 See on this also Josef Seifert, "Karol Cardinal Wojtyia (Pope John Paul ll) as Philosopher and the
CracowlLublin School of Philosophy."
24 Because of the central significance of the free character of moral acts we will dedicate the whole
fourth chapter of this volume of the Foundations of medical ethics to the topic of freedom.
25 I prescind here from certain medical activities like cosmetic operations or laboratory tests which have
mere statistical purposes and thus may lack any, or almost any, moral significance.
 SUPERIORITY OF MORAL VALUES 149

And it is their moral nature, which is of primary concern for ethics, to which we
now turn.

2. THE AMBIGUITY OF THE NOTION OF THE GOOD

On the Totally New Quality of Moral Goodness and Evil in Comparison with all
Other Goods and Evils

That we neither have been quite wrong in dealing with the seven goods and goals of
medicine nor have reached yet the core of medical ethics, or even medical ethics
properly speaking, becomes apparent when we contemplate a certain ambiguity of
the undoubtedly true statement of the classical ethical tradition, regarded by Thomas
Aquinas as the primary ethical imperative: Do the good, avoid the evil!, or: The
good ought to be done, evil avoided. This is undoubtedly a true fonnulation of the
most basic and the most universal objective moral imperative which we can recog-
nize and which infonns human conscience (synderesis}.26
And because we ought to do the good, we ought no doubt to realize goods such
as the life or health of persons. As a matter of fact, these are not only good things
endowed with some objective value as that of a brilliant scientific work or a chess
game; they are also morally relevant goods. Whether or not we are morally good de-
pends on whether or not we respond properly to those morally relevant goods, as we
have repeatedly said.
Though the physician should, however, precisely from a moral point of view,
realize and serve life and health, nevertheless, these goods are clearly not themselves
moral goods. Nobody is morally good because he lives or is healthy-and yet, moral
values of our acts appear 'on the back of the genuine commitment to these morally
relevant goods.
Notwithstanding this close relation between moral and morally relevant values,
from a moral point of view, we should not exclusively be directed towards realizing
morally relevant goods, such as life. This is already apparent from the fact that we
could also serve the realization of these same goods for egotistic reasons which in no
way make our act morally good; for example, a physician could save a baby's life
solely for fmancial gain (and perhaps kill on the same day another one for the same
reason).
But the physician should not only strive to serve the good of health and life of
his patients for the right reasons, that is, because they are high goods and oblige him
or her to serve them. Physicians and nurses should also not solely be concerned with
realizing morally relevant goods such as, for example, life, for their own sakes.

26 See Thomas Aquinas, Summa Theologica I, q. 79, co:

Now the first speculative principles bestowed on us by nature do not belong to a
special power, but to a special habit, which is called "the understanding of princi-
pies," as the Philosopher explains (Ethic. vi, 6). Wherefore the first practical princi-
ples, bestowed on us by nature, do not belong to a special power, but to a special
natural habit, which we call 'synderesis'. Whence 'synderesis' is said to incite to
good, and to murmur at evil, inasmuch as through first principles we proceed to dis-
cover, and judge of what we have discovered. It is therefore clear that 'synderesis' is
not a power, but a natural habit.
150 CHAPTER 3

They should likewise and above all realize and also intend to realize moral val-
ues such as justice, kindness, love, and do so, as Anselm says, propter rectitudinem
voluntatis ipsam, for the sake of the inner rightness of our will itself.27
We should realize moral values primarily for their own sakes and for the reason
of their intrinsic ultimate 'rectitude' which does not lie in something external to the
morally good act itself, in some consequences of human actions, but in the personal
act and its subject. 28
That a consideration of this circumstance is very relevant for medical ethics be-
comes particularly apparent when we consider that none of the immanent chief
goods which ought to be realized by the physician, neither life nor health, nor free-
dom from pain, nor beauty or integrity of form, are moral goods. No person is mor-
ally speaking good because she is or remains alive, because she is healthy, free of
pain, or because she no longer is deformed after having undergone plastic surgery.
Moreover, even the deliberate realization of these morally relevant goods is not nec-
essarily morally good; the physician can realize these morally relevant goods for
such motives that his acts fail to possess any moral value (for example for pure fi-
nancial gain).
If we concentrate on the absolute newness of the moral goodness in comparison
with all extramoral-though morally relevant-goods, we recognize the ambiguity
of the maximfac bonum, vita malum (do the good, avoid the evil) which can refer

27 See Anselm of Canterbury, De Veritate, cap. 12, "De iustitiae defmitione" (8. Anselmi Opera Omnia,
vol. 1, p. 194):
D. lustus namque cum vult quod debet, servat voluntatis rectitudinem non propter
aliud, inquantum iustus dicendus est, quam propter ipsam rectitudinem. Qui autem
non nisi coactus aut extranea mercede conductus vult quod debet: si servare dicen-
dus est rectitudinem, non earn servat propter ipsarn sed propter aliud.
M. Voluntas ergo ilia iusta est, qua: sui rectitudinem servat propter ipsam recti-
tudinem.
See also the following text from Anselm of Canterbury, De Libertate Arbitrii, cap. 3 (S. Anselmi
Opera Omnia, vol. 1, p. 212):
M. Bene ad interrogata respondisti; sed adhuc opus est ut consideremus, propter
quid ilIam rectitudinem servare debebat rationalis natura: an propter ipsam rectitudi-
nem, an propter aliud.
D. Si non ilia libertas data esset ilIi natura: ut voluntatis rectitudinem propter ip-
sam servaret rectitudinem, non valeret ad iustitiam; quoniam constat iustitiam esse
rectitudinem voluntatis propter se servatam. Sed ad iustitiam prodesse arbitrii liber-
tatem credimus. Quare indubitanter asserendum est rationalem naturam non earn ac-
cepisse nisi ad servandam rectitudinem voluntatis propter ipsam rectitudinem.
M. Ergo quoniam onmis libertas est potestas, ilia libertas arbitrii est potestas
servandi rectitudinem voluntatis propter ipsam rectitudinem.
D. Non potest aliud esse.
M. lam ergo clarum est liberum arbitrium non esse aliud quam arbitrium potens
servare rectitudinem voluntatis propter ipsam rectitudinem.
28 This does not exclude that the religious person, or the person who holds for philosophical reasons that
God exists (think of the Stoic philosopher Epictetus's Diatribes and the hymns to God contained in
this work, or of the purely philosophical arguments for the existence of God, even of a personal God),
is convinced that there is a transcendent goal of the moral act beyond the moral value of the act itself,
an 'end' that lies in the glorification of the absolute good, of God, as our primary vocation. But this
type of 'transcendent' goal is in no way some external effect of moral values but closely linked to
their own innermost level of value and meaning.
 SUPERIORITY OF MORAL V ALVES 151

both to what is morally good and to what is morally relevant without being morally
good. Hence the above formulation of the fundamental and foundational ethical im-
perative is ambiguous.
Thus we see an important distinction within the meaning of the good, a truly
classical distinction: the distinction between morally relevant goods and moral
goods or moral goodness. 29 Life, health, and the other goods to be realized by the
physician certainly do have much to do with morality. They impose moral calls and
moral imperatives on us. They are therefore morally relevant. But they are not mor-
ally good. And moral goodness is a far higher and more significant value than those
morally relevant goods which are not themselves morally good and which we have
discussed thus far.
A second fundamental distinction is that between responding to the morally rele-
vant goods such as human life because they are morally relevant goods (thereby be-
coming morally good) and realizing them for other (for example for purely legalistic
or mercenary) reasons.
We get to ethics properly speaking only, however, when we ask a third question,
namely which moral goods physicians and other health professionals should realize
and what their moral value lies in and is grounded in. What then, we ask first of all,
is this higher and incomparable good, which we call moral good? Let us analyze its
intelligible marks.

3. THE NATURE OF MORAL GOODNESS

3.1. Moral Values Are Objectively Good

Kant says that only the morally good will is "good without qualification."30 Moral
goodness is first of all good without qualification inasmuch as this goodness does
not depend on the subjective judgment about it. The goodness of moral values is not
relative to, nor dependent on, anybody's judgment. Moral goodness is not just good
according to some person's opinion. It is not just the purely intentional correlate of
human imagination, nor are the states of affairs about moral values purely inten-
tional correlates of the judgment. We will see this more clearly when we will
criticize ethical subjectivism and relativism.
It is of course possible that a Pharisee who is in reality very evil is judged to be
morally good by someone, or that some good deeds evoke in a person subjectively
bad feelings so that he or she judges the deed to be bad; but this never constitutes
moral goodness or evilness themselves. Moral goodness, when it is really found in a
person, is thus not just good in relationship to the judgment of a person but 'in it-
self. Neither David Hume nor C. L. Stevenson and A. J. Ayer have seen this point. 3l
John L. Mackie in his Ethics: Inventing Right and Wrong recognizes the inherent

29 Cf. Dietrich von Hildebrand, Ethics, ch. 19. See also, for the three meanings of moral relevance, his
Moralia.
30 Immanuel Kant, Groundwork of the Metaphysics of Morals (393), translated and analysed by H. J.
Paton (New York, Hagerstown, San Francisco, London: Harper & Row, Publishers, 1964), p. 61.
3l See J. Barger, "The Meaningful Character of Value-Language: A Critique of the Linguistic Foun-
dations ofEmotivism."
152 CHAPTER 3

claim of moral judgments to assert some objective qualities not relative to our judg-
ments and ethical propositions but holds that these claims are illusory. But we see
clearly: if moral qualities were not properties of a will independent of anyone's
judgment, they would not be morally good nor could they be 'good without qualifi-
cation'. Moreover, we see that, whenever we perceive moral values such as that of
the authentic respect of human life or of truth, these values objectively belong to hu-
man acts and human persons and do in no way depend on our opinion and judgment,
and that, if they so depended on our subjectivity, they would be no moral values at
all.

3.2. Intrinsic Goodness (Value) Rather Than Being Merely Agreeable or Even Only
Objectively Good for Me

'Good' in the context of moral goodness is understood as 'good without qualifica-

tion' also in a third sense, that of intrinsic goodness, i.e., as that which is not merely
subjectively satisfying or relative to our inclinations in its importance.32 (We shall
return to this crucial distinction in the next chapter.) This unconditional goodness in
the sense of the intrinsic preciousness of a thing signifies also that which is not just
good/or a person or from the points of view of certain interests. This objectivity of
value is 'not relative to our inclinations'. It is an objective value that neither is ex-
clusively subjectively satisfying for our inclinations nor even exclusively an objec-
tive good/or US. 33
Before turning to these further insights, however, let us dwell on the important
discovery of the character of moral values in its utmost significance for medical eth-
ics. It could appear superfluous and too theoretical for medical ethics to dwell on the
intrinsic goodness of moral values themselves, but the first meaning of 'unrestricted
goodness', the objectivity of moral values that is inseparable from their character of
intrinsic value-importance and goodness, is really absolutely decisive for under-
standing medical ethics. So many physicians regard moral values as subjective and
therefore will carry out patients' wishes thinking that the patients' morals are just as
good as their own and that they therefore have to carry out willfully and obediently
what the patient wishes. But this treats moral values or disvalues not as objective

32 Dietrich von Hildebrand and Rudolf Otto have clarified this sense of value far beyond Kant, and in
criticizing his epistemology. See Dietrich von Hildebrand, Die Idee der sittlichen Handlung; the same
author, Ethics, chs. 1-3, 17-18. See also Rudolf Otto, "Wert, WUrde und Recht," Zeitschrift fUr
Theologie und Kirche, 12 (1931): 1-67; reprinted in R. Otto, Aufsiitze zur Ethik, edited by J. S. Boozer
(MUnchen: Beck, 1981), pp. 53-106.
33 This is clearly stated by Kant as an essential feature of moral and of morally relevant values, namely
of the person's dignity which is of 'absolute value' and from which moral imperatives proceed:
But suppose there were something the existence of which had itself absolute worth,
something which, as an end in itself, could be a ground of definite laws. In it and
only in it could lie the ground of a possible categorical imperative, i.e., of a practical
law.
Now, I say, man and, in general, every rational being exists as an end in himself
and not merely as a means to be arbitrarily used by this or that will. ... All objects
of inclinations and the needs founded on them did not exist, their object would be
without worth ...
Kant, Groundwork of the Metaphysics ofMorals, BA 64,65. See also Kant, CpR 61, 61.
 SUPERIORITY OF MORAL VALUES 153

and intrinsic positive or negative importance of human acts but along the lines of the
merely subjectively satisfying or some other form of relative importance. One can
easily see how radically this single ethical insight into the objectivity of moral value
changes the whole outlook of the physician on the moral sphere and on his or her
concrete actions.

3.3. Moral Values Are Necessarily Linked to Freedom

Moral values are also necessarily dependent on freedom, on free will. Without free-
dom-in a world in which personal acts would be determined by outside forces or
by nature-moral values are absolutely impossible. Also this is an eternal and evi-
dent truth, as is the truth that to be a person requires freedom. Kant mentions this
fact. No act that is simply produced by nature or causes external to a subject can
give rise to moral goodness. Freedom involves the faculty to be the cause, in a sense
the ultimate and 'first' cause, of our own acts. Freedom means to have the power of
self-determination, of self-governance, of self-possession through freedom. Free acts
are because I will them; they would not have been if I had not willed them, as
Augustine puts it in The City of God. Aristotle says that in freedom we are the lords
over the being or the non-being of our acts. Cicero holds the same. This does not
preclude that we have been endowed with the power of freedom and have not origi-
nated this power itself by our own act. 34
But freedom also involves the capacity of saying a free 'yes' or 'no' to an object,
to take a free stance. Not only is freedom presupposed for moral values, as also
knowledge is presupposed for morality, but moral values are rooted in freedom, in
free acts. In this way they are not rooted in knowledge. Moral goods or evils do not
only presuppose freedom (also any artistic creativity or exercise of a craft or any
human playing of a game presupposes freedom) but they are in a certain sense the
values of the free agent qua free subject.
This is much more than freedom being a condition of moral acts. Freedom is
such an important condition of moral values and so intimately linked to the moral
life of the person and to moral personhood that we will dedicate the next chapter en-
tirely to freedom; for morality can be understood only if the reality and drama of
freedom are understood.
Freedom dwells in the heart of moral goodness and moral goodness lies in the
heart of freedom. Moral goodness constitutes the most central value of personal
freedom.

3.4. Moral Values Presuppose a Certain Morally Relevant Object or Matter (Which
Can Be Grave or Light)

Another essential mark of moral values is that they can arise only, as we have seen,
in response to certain goods or evils, which are morally relevant, or on a very pro-
found level of understanding all goods in their (often hidden) moral relevance. Even

34 In this manner, Fichte's idea that the'!', in order to be free, has to posit itself in being, is wrong, as we
will see in the next chapter.
154 CHAPTER 3

a value that is not directly morally relevant such as the beauty of nature or of music
can reveal itself to the deeper mind in its moral relevance, which demands our love
of beauty, our rejection of ugliness, etc. Still, in response to the many goods that are
clearly not morally relevant, such as in the delight over the smooth surface of a new
street, fine and tasteful Persian rugs, good chess-games, or even a brilliant intellect,
etc., moral values do not arise.
What are the morally relevant goods and evils?
Man, other persons, and many concrete realities in persons (such as pain, plea-
sure, knowledge, education, moral and religious acts in them), and to, some extent
also lower creatures, especially animals (to torture animals is morally wrong), truth,
and other goods are morally relevant.
In order to understand the significance of morally relevant goods for moral good
or evil, we also have to understand their exact role. They issue moral calls and obli-
gations to us, whereas all other values address only a far more general and far less
absolute call for an adequate response to us. Certainly, also the beauty in nature and
art calls for an adequate response of joy or admiration; but if we fail to give the ap-
propriate value response to these values, there is no moral disharmony in the dis-
crepancy between the call to give an appropriate (due) value response also here, but
this call does not have the unique weight and seriousness of the moral call and above
all of the moral obligation. Also the objective goods for persons, rights, freely en-
tered bonds through promises and contracts, etc., the metaphysical condition and
limitation of man, which excludes certain rights, etc., possess moral relevance.
Moral values and disvalues arise 'on the back' of a due response to morally rele-
vant goods; moral disvalues proceed from an inappropriate response to morally rel-
evant goods.
Also for this reason, that not all values are morally relevant, the assertion Bonum
est faCiendum is not clear enough as formulation of the fundamental moral norm or
imperative. Many goods do not have the necessary link to morality that is their mor-
al relevance. Therefore, the general oughtness by which we ought to realize any
value must be sharply distinguished from the moral ought that issues only from mor-
ally relevant goods. 35 For this reason, we can also call the ethical principle of Moore
and of 'utilitarianists': "to aspire to the greatest good for the greatest number" or to
the greatest sum-total of value, too indeterminate and therefore too bare of content,
to delineate the specific essence of morality from extramoral and morally irrelevant
spheres of values and goods.
Morally relevant goods (such as a large versus a small sum of money, human
suffering versus animal suffering), and certain types of actions directed against them
(such as taking human life, only risking it, not being grateful for it, etc.) can consti-
tute a serious (grave) matter (such as taking human life) or a less serious (light) mat-
ter (such as a small risk to human lives in inattentively driving a car). Correspon-
dingly, moral values or disvalues are grave or light transgressions in relationship to,
and in dependence on, the degree of moral relevance of their object which is one im-
portant factor, although not the only one, which accounts for the gravity of a moral
evil or the greatness of a moral virtue. Therefore, an action such as small theft of 5 $

35 See Dietrich von Hildebrand, Moralia, where this distinction and its fonns and roots are analyzed.
 SUPERIORITY OF MORAL VALUES 155

or of inflicting small pains on an animal, is incomparably less immoral than taking

an innocent human life or inflicting terribly cruel pains on a human being.

3.5. Moral Values Imply a New Type a/Ought Which Elucidates the 'Absolute
Sense' in Which They Are Good

Also an entirely new kind of oughtness is linked to moral values only. All goods and
bearers of value of which we can say that it is good that they are, ought to exist in a
wider and purely objective sense of the term; in another sense of the word 'ought'
persons ought to realize all kinds of values in the arts or in sports, etc. But in an en-
tirely new, more solemn and serious way we ought to do what is morally speaking
good. Only here we encounter that unconditioned sense of oughtness that Kant be-
lieved to capture by the logical category of the 'categorical imperative'.
This new moral ought, however, cannot be reduced to a 'categorical imperative'
for at least two reasons: (1) In the first place because there are supererogatory and
meritorious morally good acts that are not demanded 'categorically' (but rather in
the form: "if you want to be perfect, sell your possessions and commit yourself en-
tirely to a higher cause"). Some of these moral invitations (which address logically
speaking 'hypothetical imperatives' to us) can allow for the most sublime moral acts
such as Maximilian Kolbe's freely giving his life and taking upon himself a most
cruel death in the stead of a family father condemned by the Nazis to die in a hunger
bunker. If the Nazi officer had obeyed the absolute moral obligation addressed to
him by the same good of the life of the man not to kill him unjustly, his act would
have been morally good but not especially meritorious or sublime. (2) Secondly, the
difference between a categorical and a hypothetical imperative is a purely logical
difference, not an ethical one. In fact, even a blatantly unjust command can take the
logical form of a categorical imperative. The Mafia Boss can command his under-
lings: "Go and kill Mr. A.! No conditions and no 'ifs'!" This is logically speaking a
categorical imperative but an immoral one.
Therefore, the unique weight and nature of the ethical demand and the uncondi-
tional call to pay heed to morally obligatory moral values is a specifically moral da-
tum that is irreducible to the logical form of the categorical imperative.
This moral ought is not identical with the mere call found in each value (for ex-
ample in a beautiful landscape) for an adequate response. It is a much more serious
and different kind of moral ought addressed to our freedom.
At the source of this ought addressed to acting persons we find, with morally rel-
evant values, also another metaphysical sense of ought: as that which absolutely
speaking should be. This purely axiological 'oughtness', however, is radically dis-
tinct from the moral ought that addresses itself to a subject and calls on a free per-
son; therefore, the moral ought, because it addresses itself to acting persons, is also
described as 'imperative'. The purely metaphysical oUghtness is no imperative but in
a sense is the foundation of all imperatives. We are called to realize what (in itself)
ought to be.
A moral call or imperative in its qualitatively new and higher weight can address
itself to a person in two fundamentally different ways, only the first of which can be
called in a specifically moral sense' categorical' , namely morally speaking absolute:
156 CHAPTER 3

(1) The moral call can take the form of a moral obligation. To disobey the moral
obligation is evil and must absolutely not be done in the wholly new moral sense of
oughtness.
This new kind of moral oughtness and its absoluteness throw light on the sub-
lime sense of moral values and on a new dimension of the unrestricted sense in
which they and the good will as their source are good: such a categorical obligation
can only be linked to a sphere of values which is good in a profoundly 'unrestricted
sense' .
(2) Besides such a metaphysical sense of 'oughtness' and the new unconditional
obligatory oughts (strict moral obligations), however, we find in the moral sphere
also the new moment of a 'moral invitation' distinct from moral 'obligations'.
Kant's position that turns all moral calls into categorical imperatives is reductionist
and omits the sphere of meritorious but 'optional' or 'heroic' moral acts. Take Fath-
er Maximilian Kolbe's action which is of extremely high moral value but not a re-
sponse to an obligation; or think of the bestowing of a good that is not owed to us,
the generosity of a gift, the self-sacrifice of love. All these are not obligatory but su-
pererogatory acts, but of a sublime moral value. 36
Nevertheless, in all moral values lives a unique and irreducible type of oUghtness
which elucidates the truth that can be regarded as a chief content of Plato's and
Kant's insights, through which Plato and Kant contribute to the paideia of medical
professionals by elucidating the fact that "moral goodness alone is 'good without
qualifications'. "

3.6. Moral Values Are Dependent on the Knowledge ofMorally Relevant and of
Moral Goods and Evils
Moral values and disvalues necessarily presuppose the person because they also pre-
suppose necessarily some knowledge of good and of evil, of moral good and evil,
but also of morally relevant goods and evils. While knowledge of the Good does not
necessitate the good will and while neither virtue can be reduced to knowledge nor
vice to ignorance (Socrates), nevertheless Socrates saw that moral good and evil is
absolutely impossible without knowledge and can already for this reason not exist in
a plant or animal deprived of the knowledge of the good. No unconscious and non-
understanding creature can be(come) morally good and bad. Moral values and dis-
values presuppose, in their origin, even actual rational consciousness and knowl-
edge (though the person remains good or evil superactuallyand also in a state of un-
consciousness). Sleep and unconsciousness do not cancel the morally good or evil in
and of a person, but in a state of pre-rational consciousness and during states of un-
consciousness persons cannot perform acts that make them morally good or evil.
Moral values cannot come to exist in a radically unconscious person, even if they re-
main in such a person after she fell unconscious (if she once had been conscious).
The person who is unconscious from birth on, however, can never actually bear
moral values but only potentially-in virtue of her essence as person-remain capa-

36 See Roderick M. Chisholm, Ethics and Intrinsic Values; see also Dietrich von Hildebrand, Ethics,
"Ethical Rigorism."
 SUPERIORITY OF MORAL VALUES 157

ble ofpossessing them, and possess them potentially. Their actual possession, how-
ever, demands the actual possession of rational consciousness at some time during
the given person's life.
For being the subject of the moral call or obligation, the truth bonum est facien-
dum, as well as the morally relevant object of moral oughts, but also the ought and
the moral value themselves which pertain to one's own acts, must be understood.
The same is true of moral evil. Only persons have this degree and rationality of con-
sciousness and knowledge, which is a condition for the arising of moral goodness or
evil.
To consider the high value of morally good acts and how consciousness and ra-
tional knowledge are presupposed for their realization is particular important for
medical ethics as a reason why any prolonged or terminal privation of a person of
her conscious life (the fourth good entrusted to medicine, as we have seen in chapter
1) for insufficient reasons is immoral.

3.7. Moral Values Involve Responsibility

From their link to freedom and from the moral relevance of the goods that are the
objects of moral acts follows the mark of 'responsibility'. Responsibility presup-
poses three marks of morality:
(1) The weight of morally relevant objects and of morality; the mere link to free-
dom, for example of building a house from building blocks and then destroying it, is
not enough to account for responsibility if the object of free acts lacks moral rele-
vance.
(2) Also knowledge is required for responsibility (for acting unknowingly is a
form of the 'involuntary' action analyzed by Aristotle in the 3rd book of Nichoma-
chean Ethics). Such an act-as giving a person poison, in the belief that it is a good
medicine---cannot be morally evil, and the person cannot be held responsible for it
except if she could have known better or neglected the search for ethical knowledge;
there are also other kinds and objects of knowledge presupposed for moral values,
for example the knowledge of moral goodness itself, as we have seen.
(3) Freedom is likewise necessarily presupposed for responsibility. Without free-
dom responsibility is impossible.
But responsibility is not just the combination of these elements. It is a being ac-
countable for one's acts and even for one's being because of the weight of morally
relevant and moral values and disvalues, and because of our freely originating them,
a having to answer for them (which implies also reference to another person and
judge). We will return to this in the next chapter on freedom.
The understanding of the personal responsibility of a physician and nurse is ex-
tremely important for medical ethics: no physician can transfer his own responsibi-
lity for his actions to the hospital administration or to the patient; no nurse can trans-
fer her own moral responsibility to the physician. It is they themselves who are re-
sponsible for their actions. This personal responsibility for moral acts also has strong
legal implications and therefore is equally important for medicine law, for suits be-
cause of malpractice, etc.
158 CHAPTER 3

3.8. Moral Conscience

The Ijnk to the datwn of moral conscience is an essential mark of the moral sphere.
Moral conscience is another unique phenomenon related to morality; conscience is
not just ethical knowledge which can refer to other persons and general norms as
well, whereas these are not related to our conscience in the strict sense: only our
own acts are. Conscience is also not just the organ of ethical cognition, or at least
this is quite another meaning of the term 'conscience'. Even here the organ of uni-
versal ethical knowledge of good and evil and of ethical principles (a faculty attribu-
ted by Aristotle and Thomas Aquinas to synderesis) would hardly be comprised un-
der the term conscience, but if the latter term is meant as organ of moral knowledge,
it would refer to more concrete ethical cognitions both of moral qualities and of
moral oughts and morally relevant goods in concrete situations (an organ of know1-
edge or 'dianoetic virtue' referred to by Aristotle and Thomas Aquinas as pru-
dence). Even if interpreted in this way, 'conscience' would not much refer to the
knowledge about other person's moral qualities but to knowledge pertinent to our
own moral life. In the strict sense of the term, however, conscience is not simply ab-
stract or concrete ethical knowledge (which is basically the same whether I am deal-
ing with my own, other persons', or fictional characters' acts). Rather, it is a very
different urphenomenon connected with our own acts. In the first place, closely as-
sociated with, and in some ways based on, our moral intuitions and convictions re-
lated to the general essences of moral and morally relevant values, it is not identical
with, but intimately interwoven with, a unique type of 'reflective consciousness' of
our acts, a consciousness o/them prior to reflection properly speaking.37 This 'reflec-
tive consciousness', which is distinct from the inner 'attributive' consciousness of
our acts, can precede, accompany, or succeed our moral acts themselves. Being
more than just a reflective consciousness of our own acts, it is also not simply the re-
flective cognitive consciousness of our own acts with regard to their morally good
and evil character, a kind of inner awareness of their good and evil character. Con-
science is more closely connected to that mysterious part of the reflective conscious-
ness of our own acts that illumines and judges them. Moreover, it is an existential
representation of the moral ought as it is addressed to us as the subj ects of a moral or
immoral act, and of our own moral acts and our responsibility for them. It brings
home to us the inherent importance of the moral sphere of our own acts in its link to
our responsibility and to the consequences of obeying or violating moral obligations
or calls-it is as it were a 'subjective' appropriation and application of an objective
ought to our own acts. And it fulfills this function not in a neutral abstract and pure-
ly intellectual way but like a voice in us and yet as a voice from above or outside our
own self, and a voice deeply linked to our heart and emotions, which awakens in us
feelings of shame or of peace, feelings of being afraid to do something bad which
we are about to do, or of being accused of having done or thought something moral-
lywrong.
Different dimensions of conscience correspond to different good or evil acts and
to the different points in time when our conscience speaks. We find the peace of

37 This distinction between reflective consciousness and reflection proper has been made carefully by
Karol Wojtyia in his The Acting Person.
 SUPERIORITY OF MORAL VALUES 159

conscience when we do the good. Conscience can also, and most characteristically,
speak to us in the form of an admonition, or by urging us on, when we are not de-
cided to do a good we ought to do; it can give us a warning when we are about to do
evil or while we are doing it; it can torment and reproach us when we have already
committed a moral evil. This phenomenon of moral conscience, however, is exclu-
sively and necessarily related to the moral sphere alone, it is thoroughly imbued with
the essence and atmosphere of the moral life. The voice of conscience partakes also
in the seriousness of the moral ought itself and precisely related to this has a charac-
ter of a voice in us but from somewhere 'above US'.
Needless to say, all the results of our brief discussion of moral conscience apply
to medical ethics and playa great role for it. First, they show that patient, physician,
or nurse never must refer lightly to what their conscience allows them or demands
from them, confusing it with personal wishes or arbitrary opinions. Before invoking
such a great thing as conscience, we should make a deeply respectful pause and lis-
ten to its voice during a moment of silence and in the spirit of a deep self-examina-
tion. Secondly, these brief reflections show that conscience is a voice based on prior
cognitions. It itself therefore is not an absolute, self-standing authority, to which we
could refer as if it were the ultimate objective criterion of moral acts, but its content
depends on our ethical convictions and cognitions, and ultimately on the moral and
morally relevant values and oughts themselves. Therefore, our conscience needs to
be formed; it must rest more and more on our prior· adequate ethical knowledge,
wherefore the first duty authentic conscience brings home to us is the call to search
for ethical truth, to understand all morally relevant and moral values as properly and
deeply as possible. Thirdly, a philosophy of conscience shows us that the depth and
solemnity of this voice, when properly listened to, reconfirms the truth that the
moral values are higher than health or even life; and therefore that physicians and
nurses must never disobey their conscience, even not in order to save their own or
their patients' lives.
Socrates even sees in the essential connection between immoral acts and this ur-
phenomenon of moral conscience-a solemn voice that warns us solely against mor-
al evil, never against pain or death-a special proof for the insight that injustice is a
greater evil than death.
To appropriate to themselves this ethical insight of Socrates would lead physi-
cians and nurses to the cure from one of greatest philosophical diseases of medicine,
namely that common philosophical disease that now has reached the medical profes-
sion full force (a profession which, at least in its general principles, had resisted this
disease longer than the rest of mankind): namely the philosophical disease to put
progress, scientific research, or even the financial gain from certain acts, above the
moral question and above what conscience commands us. By deafening themselves
to the voice of conscience and to its sober message about the hierarchy of values,
medical professionals are doing in innumerable so-called medical acts, permitted or
forbidden by our laws, what the conscience of each physician and nurse, when prop-
erly listened to, forbids them to do. 38

38 Plato, Apology, 40 b--c.

160 CHAPTER 3

3.9. Moral Values Deserve Praise or Blame in a New Sense

With Cicero we can say that all praise and blame presuppose freedom and moral val-
ues or disvalues. While also political or other merits in sports, etc., may deserve
praise or blame in some sense, which presupposes human freedom, only properly
moral values and disvalues fully and in an entirely new and original sense deserve
praise and blame.
Blame and praise in a unique sense relate only to moral values. The same is true
for acts such as admonition, exhortation (these acts are not meaningfully related to
all free acts), and reproach. The acts performed in a chess play are free but not
meaningful objects of blame and praise. 39
Also this feature of moral values obviously finds an application in medical ethics
and accounts for the fact that malpractice as well as directly wrong or even criminal
actions performed by medical professionals deserve blame and reproach-which
fact is likewise the condition for filing rightfully suits against medical malpractition-
ers.

3.10. Moral Goodness Alone Can Constitute a Certain 'Worthiness ofHappiness',

Moral Evil a 'Deserving ofPain'

This fact about morality, which is close to that of deserving reward and punishment,
was especially emphasized by Anselm and Kant,40 but would merit careful analysis. 41

39 Of course, the act itself of playing, when one plays too often or for wrong motives, can be morally
blameworthy as a loss of time, etc. See my Schachphilosophie, ch. 4, "Zu einer Ethik des Schach-
spiels," especially pp. 90 ff.
40 For the non-eudemonistic interpretation of the idea of 'deserving reward' for morally good acts, see,
for example, Immanuel Kant, Critique ofPractical Reason, V, 129-130:
The moral law commands me to make the highest possible good in a world the final
object of all my conduct. But I cannot hope to produce this except by the harmony
of my will with that of a holy and beneficent author of the world; and although in
the concept of the highest good, as that of a whole in which the greatest happiness is
represented as connected in the most exact proportion with the greatest degree of
moral perfection (possible in creatures), my own happiness is included, this is never-
theless not the determining ground of the will that is directed to promote the highest
good; it is instead the moral law (which, on the contrary, limits by strict conditions
my unbounded craving for happiness).
For this reason, again, morals is not properly the doctrine of how we are to
make ourselves happy but of how we are to become worthy of happiness. Only ifre-
ligion is added to it does there also enter the hope of some day participating in hap-
piness to the degree that we have been intent upon not being unworthy of it.
Someone is worthy of possessing a thing or a state when it harmonizes with the
highest good that he is in possession of it. It can now be readily seen that all worthi-
ness depends upon moral conduct, since in the concept of the highest good this con-
stitutes the condition of the rest (which belongs to one's state), namely, of one's
share of happiness. Now, from this it follows that morals in itself must never be
treated as a doctrine of happiness, that is, as instruction in how to become happy; for
morals has to do solely with the rational condition (conditio sine qua non) of happi-
ness and not with the means of acquiring it. But when morals (which merely im-
poses duties and does not provide rules for selfish wishes) has been set forth com-
pletely, then-after the moral wish, based an a law, to promote the highest good (to
bring the kingdom of God to us) has been awakened, which could not previously
 SUPERIORITY OF MORAL VALUES 161

Because moral good is freely brought about and has the other described marks, it is
related to happiness both by rendering it possible, in the sense of Augustine: "Thou
has ordained it so, and so it is: that any disordered (evil) spirit is a punishment unto
himself,"42 and by giving a person a certain justification and 'worthiness' of being
happy. Correspondingly, moral evil makes the person 'deserving' of punishment and
pain. This 'worthiness of happiness' in a sense to be carefully analyzed in order to
avoid pharisaical pride,43 and the unworthiness of happiness following moral evil,
are closely linked to the following marks of morality, which are deeply rooted in its
essence.

3.11. Also Guilt and Merit, Reward and Punishment Are Essentially Related to
Moral Good and Evil, and to It Alone

There is both an 'inner' consequence of happiness and unhappiness resulting from

good and evil by their nature, and also a certain dueness of happiness (reward) to the
good, of punishment (unhappiness, pain) to the morally evil person and act. To see
the difference of these two elements it is sufficient to consider the extreme limitation
of that actual happiness and unhappiness which follows inevitably from good and
evil and which even the just man who is cruelly tortured and the evil man who raves
in his evil deeds experience. But certainly this happiness of the heroic martyr for the
good cause is not the same as the happiness 'he deserves', nor is the unhappiness
deep down in the soul of the cruel man who jubilates in his evil deeds the full un-
happiness he deserves.
Rather, this happiness and unhappiness and the relationship of 'deserving' of re-
ward or punishment is far deeper and refers not only to another personal being, who
alone can be judge and reward and punish, but also to a higher superhuman kind of
being or judge, who alone can share out the truly deserved measure of deserved hap-
piness and unhappiness and bestow just moral reward or punishment on us. Plato has
seen this when he referred in the Gorgias (524 a--e) to Minos and Rhadamanthys as
the judges of the dead who will see the souls of kings and of beggars naked and
spoilt of all the deceiving garments and ornaments which hide from us the full truth
about ourselves and others.
If we delve more deeply into the ultimate metaphysical conditions for the reali-
zation of just moral punishment and reward, we see how imperfect all human reali-
zation of justice is and can, with Kant, list three conditions in the (divine) judge for

have arisen in any selfish soul, and for the sake of this wish the step to religion has
been taken-then for the first time can this ethical doctrine also be called a doctrine
of happiness, because it is only with religion that the hope of happiness first arises.
41 See on this Dietrich von Hildebrand, "Zurn Wesen der Strafe," in Dietrich von Hildebrand, Die
Menschheit am Scheideweg, hrsg. v. Karla Mertens (Regensburg: Habbel, 1955), pp. 517-533; by the
same author also, "Uber die christliche Idee des himmlischen Lohnes," in Philosophisches Jahrbuch
der Gorresgesellschaft, 32. Jg. (Fulda, 1919), pp. 1-14; reprinted in Dietrich von Hildebrand, Die
Menschheit am Scheideweg, hrsg. v. Karla Mertens (Regensburg: Habbel, 1955), pp. 107-126.
42 Augustine, Con! 1, 19: "iussisti enim et sic est, ut poena sua sibi sit ornnis inordinatus animus" (CCL
27, pp. 11115; Corpus Augustinianum Gissense a C. Mayer editum).
43 See Max Scheler, "Zur Rehabilitierung der Tugend," in Max Scheler, Vom Umsturz der Werte (Bern-
MUnchen: Francke-Verlag, 1955).
162 CHAPTER 3

perfect moral reward;44 these conditions apply also to punishment: (1) perfect knowl-
edge and even omniscience (to judge the exact measure of guilt and merit and the
appropriate punishment or award), (2) omnipotence (to carry justice out unimpeded-
ly), and (3) infinite, unrestricted goodness (the perfect embodiment of the moral
world order) to be entitled and 'justified' to punish and reward morally in an ulti-
mate way.45
In punishment, there is also a moment of atonement and, when it is freely ac-
cepted, of expiation and of cleansing from moral evil (Suhne). Many fascinating
questions arise here. Reward and punishment should not be the primary motives for
moral acts, nor should their threat be the primary means of moral pedagogy, or the
idea of 'reward' misinterpreted in the sense of eudemonism. 46 They follow a far
deeper principle of 'moral justice' and 'dueness' which to explore in depth would
lead us beyond the scope of the present work. All this has its deepest reason in a
further mark of moral values and disvalues.

3.12. Moral Goodness Expresses in an Essentially New and Higher Sense the Idea
of Value as Such (Good in a New and More Proper Sense to Which Extramoral
Senses of 'Goodness' Are Merely Analogous)

In virtue of all these characteristics, moral values are values in a higher sense, which
express more purely the idea of value and goodness than others. If we say that an
animal's health or life are good, we realize that we use the term 'good' in a relative-
ly poor analogous sense compared with the manner in which we use it in reference
to moral values. And even human health and human life are not good in that primary
sense in which only morally good acts are good. No one is a good human person
simply because she is healthy or alive. Similarly, the concept of evil, when applied
to diseases, does not mean 'evil' in any similarly powerful way as the moral sense of
'evil'. All five immanent goods medicine serves do not fulfill the idea of value itself

44 See Immanuel Kant, Kritik der praktischen Vernunft, A 253.

45 See, for example, the impressive text in hnmanuel Kant, Kritik der praktischen Vernunft (1788), V,
131, Amn., and ibid., V, 140:
Ich versuche nun diesen Begriff an das Objekt der praktischen Vernunft zu halten,
und da finde ich, daB der moralische Grundsatz ihn nur als mllglich unter Vorausset-
zung eines Welturhebers von hochster Vollkommenheit zulasse. Er muI3 allwissend
sein, urn mein VerhaIten bis zum Innersten meiner Gesinnung in allen mllglichen
Flillen und in aile Zukunft zu erkennen; allmiichtig, urn ihm die angemessenen Fol-
gen zu erteilen; ebenso allgegenwiirtig, ewig u.s.w. Mithin bestirnrnt das moralische
Gesetz durch den Begriff des hOchsten Guts, aIs Gegenstandes einer reinen prakti-
schen Vernunft, den Begriff des Urwesens als hochsten Wesens, welches der phy-
sische (und hOher fortgesetzt der metaphysische), mithin der ganze spekulative Gang
der Vernunft nicht bewirken konnte. Also ist der Begriffvon Gott ein ursprUnglich
nicht zur Physik, d. i. fUr die spekulative Vernunft, sondern zur Moral gehOriger
Begriff, und eben das kann man auch von den Ubrigen Vernunftbegriffen sagen, von
denen wir als Postulaten derselben in ihrem praktischen Gebrauche oben gehandelt
haben.
46 See on this Dietrich von Hildebrand, "Zurn Wesen der Strafe"; by the same author, "Uber die christIi-
che Idee des himmlischen Lohnes"; and Metaphysik der Gemeinschaft. Untersuchungen fiber Wesen
und Wert der Gemeinschcift.
 SUPERIORITY OF MORAL VALUES 163

as only moral goodness does; they are also in this sense of the term not good without
qualification. This insight renders it clearer why the physician or nurse must never
promote the goods of health and life by performing acts that possess moral disval-
ues. Moral goodness is good in a new and higher sense of goodness than extramoral
goods, and moral evil is evil in a more terrible sense of evil than any extramoral evil.
In German, two different words (schlecht and bOse, das Ubel and das Bose) indicate
this difference which is so great that one might claim that between the two senses of
good and evil (the moral and the extramoral one) there is not even analogy properly
speaking but that we find in moral goodness a radically new sense of this term.
One could compare this case with Aristotle's and Thomas's observations on the
difference between 'being' in the proper sense-substance-and accidental being. In
at least as deep a sense as the one in which substance is most properly speaking be-
ing (and its accidents are 'beings' only in a secondary sense), moral goodness is
'good in the proper sense'. And as the term 'being' is used only analogously for sub-
stances which stand in themselves in being and acts or accidents which inhere and
are only in them,47 so the term 'good' is used only analogously and weakly when it is
used for extramoral goods.
Here, it is worth noting, with Thomas Aquinas, that while a human person is a
being primarily because she is a substance, she is not good absolutely speaking sim-
ply because she is a human being (for this reason the person is, in virtue of her being
a substance, good only secundum quid, and in virtue of her acts good without quali-
fication). Only because of her morally good acts she is good absolutely speaking.
This shows a certain reversal of the order characteristic of being as such in the case
of goodness and moral goodness. For while accidents possess being only secundum
quid and someone is a man and a being (ens) absolutely speaking primarily because
of his substantial being, in the case of goodness a man is called good primarily in
view of accidents and acts, not for being substantially speaking human, as Thomas
observed in De Veritate and elsewhere. 48

47 In my Essere e persona, chs. 8-9, I tried to show that being a person, which includes also being a
substance of rational nature, is still far more properly speaking being than just substance.
48 Thomas Aquinas, Quaestiones Disputatae de Veritate, in Opera Omnia (ut sunt in indice thomistico
additis 61 scriptis ex aliis medii aevi auctoribus), 7 Bde, ed. Roberto Busa S. J. (Stuttgart-Bad Cann-
statt, 1980), vol. ill, pp. 1-186, q. 21, a. 5, co:
Ad cuius evidentiam sciendum est quod, ut ex dictis patet, sicut multiplicatur esse
per substantiale et accidentale, sic etiam et bonitas multiplicatur; hoc tamen inter
utrumque differt, quod aliquid dicitur esse ens absolute propter suum esse substan-
tiale, sed propter esse accidentale non dicitur esse absolute: unde cum generatio sit
motus ad esse; cum aliquis accipit esse substantiale, dicitur generari simpliciter; cum
vero accipit esse accidentale, dicitur generari secundum quid. Et similiter est de cor-
ruptione, per quam esse amittitur.
De bono autem est e converso. Nam secundum substantialem bonitatem dicitur
aliquid bonum secundum quid; secundum vera accidentalem dicitur aliquid bonum
simpliciter.
Unde hominem iniustum non dicimus bonum simpliciter, sed secundum quid, in
quantum est homo; hominem vera iustum dicimus simpliciter bonum.
See also Thomas Aquinas, Quaestiones Disputatae de Malo, q. I, a. 2, co:
Sic ergo licet homo secundum hoc ipsum quod est homo, sit quoddam bonum, non
tamen ex hoc ipso est bonus homo, sed id quod facit bonum unumquodque est pra-
164 CHAPTER 3

Also this profound truth, and the new and higher sense of goodness found in
moral goodness, is frequently overlooked in the praxis of medicine. One treats such
goods as the life or death of patients, their sickness or health, as if life and health as
such were higher goods than the moral values in the person. Thus, physicians fre-
quently advice women to commit the immoral act of killing their unborn babies,
even against their conscience, when they can thereby improve their health condition.
Such physicians forget that, while human health and human life are morally relevant
and impose moral obligations on us, and while medicine should serve these goods,
they are nevertheless not as high goods as the moral goodness of the acts in which
we relate properly to life or health. For this reason, we should rather die than com-
mit a morally evil act, as Socrates taught. 49 A proper ethics, and especially a proper
medical ethics, can only be built on this insight into the absolute primacy and higher
meaning of goodness (when compared to the good of a life being saved or a patient
cured from his disease) embodied in moral goodness.

3.13. Moral Goodness, As Long As It Really Exists, Cannot Be Abused Like

Intellectual, Aesthetic, Temperamental and Other Values

Good without qualification can also be understood in the sense that moral goodness
cannot be 'abused' by their subject50 like other talents that turn terrible when abused.
Moral values can become the object of pride and immoral acts, but as long as they
exist, they cannot become part of moral evil as a brilliant mind can. This involves a
new and more pure sense of goodness found in moral goodness, which is that which
is good unconditionally speaking and not only good depending on how it is used
(such as wit, courage, self-control, etc.). While one could challenge this intuition
posing the question whether not pharisaism and its pride of one's own virtues or a
prideful boasting in one's superior humility constitute a form of 'abuse' of moral
values even at a deeper level than the abuses of intelligence, one could reply to this
objection in the following way:
In the first place, the moral qualities in the person change through this abuse in a
very different way from that in which intelligence is vitiated by moral evil; in fact,
they cannot be abused in the same sense of the term, so much so that contrasting all
other values which can be abused to moral values which cannot be abused remains
valid.
Intelligence does not cease to be intelligence by its abuse per se (even though it
may become affected and perverted by the stupidity resulting from pride), whereas
the moral value in the person is changed immediately into evil by the abuse of phari-
saism. The 'abused' moral value does not remain morally good or continue to be-
stow moral goodness on the subject. Thus, as long as the morally good quality and

prie virtus eius. Virtus enim est quae bonum facit habentem, secundum philosophum
in II ethic.
Similarly in Quaestiones Disputatae de Virtutibus, q. I, a. 7, ra 2: "unde solus ille dicitur esse
bonus homo simpliciter qui habet bonam voluntatem."
49 See Plato, Gorgias, 469 b-c; 488 e-489 a; Apology, 40 b-c.
50 Of course, morally good people may be 'abused' by other persons in different ways by counting on
their moral integrity.
 SUPERIORITY OF MORAL VALVES 165

intention (Gesinnung) remain in the person, they cannot be abused as such. Authen-
tic moral values could of course become a temptation to give proud responses to
them, like the monk who got angry when accused of pride and said, "Humility, that
is precisely my forte!" But even here the relationship between moral values and
pride is different-also because of the unity of the person and because moral values
belong primarily to the person as a whole, not to isolated acts, and therefore disap-
pear in the measure in which morally evil pride takes over a person.
We have reached the conclusion: Moral values cannot partake in evil or cease to
be good as long as they truly exist. Let us examine this more closely: If the Pharisee
'abuses' moral values (in quite another sense of the term 'abusing'), we are faced
with different possibilities: (a) either what had appeared as moral virtue was all
along no genuine virtue but an insincere moral masquerade of vice (this is what
Christ suggests in his speeches against the Pharisees); (b) or what might have been
genuine moral goodness is replaced by the moral evil of pride and ceases to exist
(pride corrodes the moral value), (c) or if some moral value remains in the Pharisee,
it remains good and is not turned evil; in this case only the pride is evil and refers to
the authentic morally good act as to its object (also here a partial corrosion of the
moral substance of moral values, however, is inevitable).
This meaning of the unrestricted goodness of moral values, because they cannot
be abused as other values can, has no direct bearing on medical ethics except in il-
lustrating an important and deep sense in which the absoluteness and unrestricted
value of moral goodness should be estimated, as by any person, so also by medical
professionals.

3.14. Moral Values Are Absolutely Speaking Good in that They Never Must Be
Sacrificedfor Any Other Value, because They Are (a) Incomparably Higher and
(b) Should Absolutely and 'First' Be Sought For

Another important sense of the unrestricted meaning of moral goodness is precisely

its absolute and unconditional value which becomes apparent in a special way in the
negative sphere of moral evil: moral evil, injustice, must never be committed, as
Socrates sees so clearly in Plato's Crito:
SOCRATES: And if we find that we should be acting unjustly, then we must not take
into account either of death, or of any other evil that may be the consequence of remain-
ing here, where we are, but only of acting unjustly ...
Ought we never to act unjustly voluntarily? Or may we act unjustly in some ways,
and not in others? Is it the case, as we often agreed in former times, that it is never
either good or honorable to act unjustly? Is not what we used to say most certainly the
truth, whether the multitude agrees with us nor not? Is not acting unjustly evil and
shameful in every case, whether we incur a heavier or lighter punishment in conse-
quence?
Ifwe ought never to act unjustly at all, ought we to repay injustice with injustice, as
the multitude thinks we may?
CRITO: Clearly not ...
SOCRATES: Then we ought not to repay injustice with injustice or to do harm to
any man, no matter what we might have suffered from him. And in conceding this,
Crito, be careful that you do not concede more than you mean. For I know that only a
166 CHAPTER 3

few men hold, or ever will hold, this opinion. And so those who hold it and those who
do not have no common ground of argument. 51

Moral evil (injustice) cannot be justified by anything. This is certainly not true
for extramoral goods where we cannot only always say, ''this is a lesser or greater
evil than that other one," but where we can frequently add, "therefore it is better that
these lower extramoral goods perish than that other higher ones are prevented from
existing, and it may be admissible to allow extramoral evils to happen in order to
prevent worse evils." And as long as the destruction of extramoral and morally rele-
vant evils is not bearer of intrinsically morally evil acts, it is even acceptable to sac-
rifice actively these extramoral goods for other higher ones.
Extramoral goods and evils per se, i.e., when they are not object of moral or im-
moral acts, can be weighed, even human lives; we can say, it is better to jump out on
the left side of a ship to save five children's lives who fell off the board of the ship
in a storm than on the right side where we can only save one child. When a morally
evil act is at stake, its disvalue is far worse, it possesses quite another kind of ugli-
ness than any other evil. But what counts more in our context and is even more as-
tonishing: we must never commit moral evil for any extramoral good such as health
or life.
This insight is particularly important for medical ethics. Think of the case of a
gynecologist who easily wants to sacrifice the moral value of his own act for the
comfort or even subjective wishes of his patients.
Moreover, this absoluteness of the moral values even forbids that we 'sacrifice'
our own moral innocence or commit immoral acts for the sake of higher moral
values. When we are faced therefore with a morally evil act, we must not perform it
for any reason whatsoever. The moral sphere possesses, in another way than human
life and human dignity per se, such an unconditional value that it forbids us ever to
perform moral evil:
There is also an absolute individual directedness in morality, a "Tua res agitur,"
an absolute appeal to the unique acting subject here: I should never commit a moral
evil, and in this no one can substitute me nor can I perform morally evil acts in order
that moral good may come of it in another, for example by saving a better person's
life, who is prone to realize much more moral good than I in my life will.

3.15. Moral Goodness as a Source of the Value of the Person as Such: Only the
Person Herself Can Be the Primary Bearer ofMoral Values, Never Impersonal
Beings, and also Personal Acts Can Be Morally Good Only in a Derivative Sense

3.15.1. Only Persons as Opposed to All Impersonal Beings Can Be Morally Good
Only persons can be morally good and evil: also this is an arch-evidence; no stones,
no plants, not even animals can be morally good. It is an essentially necessary fact,
an eternal truth. This has to do with the essential marks of the person, above all with
the intellect and freedom of the person, which are indispensable conditions of moral
values, as well as with the relationship of the person as subject of free acts to these

51 Plato, Crito, 49 a ff.

 SUPERIORITY OF MORAL VALUES 167

acts themselves. But here we are more interested in another insight into the essence
of moral values:

3.15.2. Only the Person Herself Can Be the Primary Bearer ofMoral Values-
Personal Acts Can Be Morally Good Only in an Analogous Sense

It is never the will per se, the intellect per se, or some other quality in the person
which is distinct from the person herself that are properly speaking morally good in
the person, but it is the acting or the contemplatively free person herself, who alone
can be good or evil. In other words, moral values do not primarily belong to some-
thing in and of the person but to the person herself, even if the subject becomes
bearer of moral values only through his free acts. 52 In this respect, the above quote
from Kant's Groundwork ("It is impossible to conceive anything at all in the world,
or even out of it, which can be taken as good without qualification, except a good
will") is false. For it is not the will as such which is morally good but the acting and
willing person. This became already clear through the elaboration of one of the
senses in which moral values alone justify the thesis that they are good without qual-
ification.

3.15.3. Moral Goodness Makes the Person as Such Good in a Deeper Sense
Compared with Which all Other Meanings of the Goodness ofthe Person Are Just
Analogous
Moral goodness is likewise 'good without qualification' in the sense that moral
goodness not only makes the person as such good and is thus 'good in an unre-
stricted' sense, not only in certain respects making her good as actor or as philoso-
pher. Rather, moral goodness makes the person as such good in a deeper sense com-
pared with which all other meanings of the goodness of the person are just analog-
ous. The moral goodness of a person is not just something good in her but touches
her very being. Interestingly enough, this is even truer of moral goodness than of the
inalienable ontological dignity and value of the person: moral values belong essen-
tially and inalienably to the vocation of each person but not to his or her actual be-
ing. For this value, as Thomas says, makes a man good only 'secundum quid', not
'simpliciter'. Other goods (such as a brilliant mind) are very good, but they do not
make the person as such and as a whole good.
Of course, also here we would have to differentiate: while it is true that each and
every moral value belongs to the person as such and makes her good, not all moral
values do so in the same way. In the first place, we might distinguish deep moral
values and more superficial ones, as we distinguish between serious moral evil and
lighter one. The latter does not yet make the person as such evil. And even the se-
rious moral evil (intended in the religious sphere by the classical notion of 'deadly
sin') does not necessarily make the person as a whole evil. Only the worst types of
external immoral acts (such as brutal murder, rape, etc.) may do this.

52 This thesis and insight are central to Karol Wojtyla, The Acting Person. See also John F. Crosby, The
Seljhood of the Human Person.
168 CHAPTER 3

More profound is the superactual reality ofmoral qualities in the person as it be-
longs to the sphere of moral values, which are rooted in lasting attitudes, in the mor-
al virtues and moral vices. By 'superactual' we mean all those cognitions and acts
which last throughout time in the person even when they do not occupy her actual
consciousness, but which simultaneously constitute a constant background of our
conscious life, such as love or belief. 53
Deeper still than such superactual 'categorial attitudes' such as justice, honesty,
etc., which may also characterize a person in a lasting way as good or evil, lies the
sphere of the fundamental moral attitude, of the ultimate moral stance of the person,
the Grundhaltung,54 or fundamental option. 55 It is evident that only here the full force
of the insight that moral goodness alone lifts the person qua person up, while moral
evil disfigures the person in the most profound sense, applies. 56
The unrestricted sense, in which moral goodness is good, then indicates that
moral values alone constitute man's ultimate goodness qua human person. This is
also, we may submit, the reason why Plato calls moral goodness the proper good of
the soul. 57 This is an entirely new sense of 'unrestricted good'.
This insight is very important for the physician in order to see that in himself and
in his patient he must above all and more desire to see moral values become real
rather than bestow any extramoral goods on his patient or on himself. For it is not
health or life or freedom from pain that makes the patient good unqualifiedly but
only moral virtue. If the physician sees that only moral values make the person qua
person good, he will also recognize the next point, which is very important for his
acting rightly in medicine.

53 For a detailed analysis and unfolding of his philosophical discovery of the sphere ofsuperactual acts
see Dietrich von Hildebrand, Sittlichkeit und ethische Werterkenntnis; the same author, Ethics; the
same author, Das Wesen der Liebe.
54 This notion was unfolded in Dietrich von Hildebrand, Sittlichkeit und ethische Werterkenntnis. It in-
fluenced also Bernhard Hiuing, Das Gesetz Christi, 3 Bde (1. Aufl. 1954; 8. Aufl. Miinchen und Frei-
burg: Erich Wewel Verlag, 1967).
55 The later tenn of fundamental option (Fundamentaloption) is ambiguous for different reasons to
which we will return later in this work; therefore, it must not be simply equated with that of Grund-
haltung (fundamental moral attitude). See Josef Seifert, "Grundhaltung, Tugend und Handlung als ein
Grundproblem der Ethik. WUrdigung der Entdeckung der sittlichen Grundhaltung durch Dietrich von
Hildebrand und kritische Untersuchung der Lehre von der 'Fundamentaloption' innerhalb der 'rein
teleologischen' BegrUndung der Ethik," in Clemens Breuer (Hg.), Ethik der Tugenden. Menschliche
Grundhaltungen als unverzichtbarer Bestandteil moralischen Handelns. Festschrift fiIr Joachim
Piegsa zum 70. Geburtstag, pp. 311-360.
56 See on this question Dietrich von Hildebrand, Sittlichkeit und ethische Werterkenntnis; and by the
same author, Ethics, ch. 27, "The Three Spheres of Morality."
57 See Plato's Gorgias and Politeia X.
 SUPERIORITY OF MORAL VALVES 169

3.16. Moral Values Are the Absolute and Highest Good for the Person: Moral
Values Belong to the Unum Necessarium and the Three Modes ofParticipation in
Values' Account for Three Ways in Which Moral Values Are the Highest Objective
Goods for Persons
Related to this but really distinct is another sense in which moral goodness alone is
'good without qualification'. Moral values are the proper good of the person and the
highest good for the person, the unum necessarium, the condition of the person's ul-
timate good and happiness, which embraces many other goods besides moral good-
ness, such as happiness and the existence and love of other persons. The person can
be in three ways related to moral values, and in each of these ways in which she can
participate in them, they also become an objective goodfor her: 58
(a) The person can be the bearer of moral values, and in consequence of this they
are high objective goods for her.
(b) Moral values can become the obj ect of her knowledge or frui, and in this re-
spect also, and even primarily, the moral values of other persons and especially the
infinite moral holiness of God become an obj ective good for her.
(c) Moral values can be participated in by bringing them into existence, by mak-
ing them be. This is directly possible only within the moral agent himself. While
many other values can be created or brought into being directly in a given person
also by a person outside that person herself, this is impossible in the moral sphere.
Here only the person of the agent herself can become the source through which mor-
al values arise in her. Nevertheless, through education, spiritual direction, through
example, and in many other ways a human person can also contribute to the realiza-
tion of moral goodness in others. And by becoming the cause of moral goodness in
others whom she formed as model, parent, teacher, or physician and friend, she par-
ticipates in a unique way in their moral values.
This meaning of the unrestricted sense in which only moral values are good does
not touch only the aspect of the intrinsic value-importance of moral values and our
different ways of participating in these intrinsic values, but also their character as
objective goods for persons. 59
Moral goodness, when possessed by a person (but in other forms also when par-
ticipated in the two other ways of participating in value described above), is (of all
goods and values within the person)60 the highest objective good for the person; as
the unum necessarium it is in a sense the good for the soul. Because it is, of all val-
ues that reside within the person, the highest good of the person, making the person
herself good in the supreme sense, it is also the highest good for the person. In it-
self-qua morally good-supremely good, it is also good for the person, and indeed
even one decisive factor and ground for the absolutely highest objective good for the
person: her immortal fate. 61 Why is this so?

58 See Dietrich von Hildebrand, "The Modes of Participation in Value," in International Philosophical
Quarterly, vol. I, no. 1 (New York, 1961), pp. 58-84.
59 Ibid.
60 This does not exclude that other persons or God are still higher objective goods for the person; but
also they can be such only when moral values exist within the person.
61 In a Christian and Jewish as well as Islamic perspective for her eternal salvation.
170 CHAPTER 3

Plato in the Gorgias gives as main argument why it is better for man to suffer in-
justice than to commit it: that the moral value itself is higher and more beautiful than
freedom from suffering or life as such, and that the ugliness of moral evil is far
greater than that of suffering injustice or dying a cruel death. Because the doing in-
justice is intrinsically a greater evil, uglier and more shameful in itself, it must also
be a greater evil for the soul of man. Plato thus uses the insight that moral goodness
is a good in itself in an unrestricted sense as the ground of it being also the greatest
good for the soul. He does not argue the other way around: from moral evil being
the greatest objective evil for man (for example by being followed by punishment)
to its also being the greatest evil per se. Plato's is quite another argument than the
one from moral values being a means to happiness and to the intellectual vision of
God and only thereby (indirectly, as means) having a relation to our highest objec-
tive good. Even less is it the argument from punishment that will follow moral evil.
In fact, Plato argues that the unpunished crimes, because in them the person of the
evildoer has no connection to the beauty of justice at all, not even by being punished
justly, are the worst ofall evils, not only in themselves, but also for man.
While Plato here gains an absolutely stunning insight into the deepest reason why
moral evil is the greatest evil for the soul and moral goodness the greatest good for
the soul (of all values and goods within the person save the all-encompassing good
which includes moral goodness but cannot be reduced to it), this does not exclude
the truth that moral goodness is, of all goods within the person, the highest good for
the person also due to some further marks of morality (especially its link to reward).
Moral goodness thus is, of all goods within the person, the highest objective
good for the person for many reasons.
To say that justice is a higher objective good for man than life presents us with
the problem of the apparent incommensurability of the 'fundamental human goods'
so much emphasized by Finnis and Grisez. 62
Now, of course, it is hard to compare the two goods of life and of moral good-
ness with each other, because both are indispensable in different senses as well as
truly incommensurable with each other in many respects: The good of knowledge is
even more fundamental in a sense than moral goodness because it is a condition of
all other intellectual, moral, and spiritual goods. Nevertheless, the fundamental hu-
man goods are not incommensurable in all respects. There is a common and univer-
sal point of view of goodness as such, of value as such, which allows and forces us
to say: That which makes a man most unambiguously and profoundly precious is
neither knowledge nor play nor happiness but moral goodness. Therefore, this must
also make moral goodness the greatest objective good for the person. And in this
sense moral values alone, of all values within the person, are truly the highest objec-
tive goodfor the person, the unum necessarium. (This does not exclude the possibil-
ity that there can be higher goods for the person which are gifts or transcendent to
the person herself such as grace or supernatural goods of the kind some religions
teach us to exist, but also these presuppose and include moral values.)

62 See John Finnis, Fundamentals of Ethics (Oxford: Clarendon Press, 1983); see also the same author,
Natural Law and Natural Rights.
 SUPERIORITY OF MORAL VALUES 171

One could argue that Plato and Plotinus, when they claim in this absolute sense
that moral goodness is the proper and highest good of the soul, more so than happi-
ness, first confuse here the 'objective' and the subjective meaning of eudaimonia
and do not take sufficiently into consideration the dimension of experience (of Er-
lebniszugewandtheit) of the objective good for the person. Even a totally uncon-
scious person who has done good would remain the bearer of this goodness and real-
ize it, but this cannot be called the highest good for her absolutely. For it presup-
poses at least her continued existence. Moreover, its character as good for her cer-
tainly presupposes also some experience of that peace and happiness and joy which
comes from the possession of these values, at least at some time in the future or in
eternity.
Hence this conscious participation in the moral value is not simply a pure conse-
quence of the higher value of moral goodness per se. For this reason, a metaphysics
of the person which shows that moral values are the highest goods not only in them-
selves but also for the person, will have to show that happiness and the joy which
normally come from moral goodness, will actually be given sometime to the good
man. Otherwise only a purely objective sense of happiness is maintained which does
not take into account the subjectivity of the person and that dimension of happiness
that is inseparable from the experiencing of joy.
If we consider the dimension of having to be experienced (Erlebniszugewandt-
heit) of many objective goods for the person, we might also ask ourselves whether,
in their contemplation, the moral values of other persons inasmuch as they are mor-
ally good, are not in a certain sense conceivably a higher source of happiness than
our own moral goodness. This certainly is in some very real sense the case in the
contemplation of God but also in the joy in the moral values of other human persons
because they are much more clearly given as objects of an explicit frui. This is so
because of the other-directedness of the moral life and of love but also because hu-
mility forbids us to 'enjoy' our own virtues as much as we can delight in those of
other persons whom we love, respect highly, or venerate (though we will experience
good moral qualities of our own person in quite another inner experience and peace
of conscience in which we can never experience the moral values of other persons).
Yet even the joy over moral qualities in other persons presupposes a certain
goodness in ourselves, otherwise we might even suffer from seeing the good of oth-
ers (for example, by becoming envious), such that the vision of the good is happi-
ness only for the virtuous soul, whereas the evil soul will even suffer more upon the
sight of the good. 63

63 This idea leads Dostoyevsky and a great number of philosophers and theologians to the idea that even
eternal suffering of hell is not an externally imposed punishment but an inner consequence of the evil
person being confronted with the vision of the good. This is not only a view developed by Christian
and other religious mystics (St. Catherine of Genoa says in her Treatise on Purgatory that she has
clearly seen this truth in her mystical visions) but traces of it can also be found in Plato who thought
that the 'incurably evil' not only deserve but necessarily will suffer hell. See Josef Seifert, "Salvezza e
condanna come problemi filosofici: riflessione sui Gorgia di Platone," Revista Teologica di Lugano
m,2 (1998): 265-289. According to some audacious thinkers, hell is still a mild punishment for the
evil man because his seeing the goodness of God, while remaining fixed in evil, would be a more ex-
cruciating hell still than being banished from God's sight. Consider the passages in Dostoyevsky's
Crime and Punishment on Marmeladov's greatest suffering upon looking at his daughter Sonya's
172 CHAPTER 3

Yet also the joy which comes to the person who is bearer of moral goodness and
the way in which this goodness in her is a source of happiness is quite unique. Think
of the words (and the music!) of Florestan in Beethoven's Fidelia: "0 sufter, sufter
Trost in meinem Herzen: meine Pflicht, ja meine Pflicht hab' ich getan (0 sweet,
sweet consolation in my heart: my duty, ay, my duty I have done)." If we consider
the uniquely close form of participation present in moral values which are linked to
the free center of the person, we understand why even 'participation' is here too
weak a word.
It is clear that all these forms of participation in moral values are open to physi-
cians and nurses. And it is no doubt part of the fullness of their moral life to aim at
all of these forms of participation in moral values.

3.17. Moral Values Are Goods 'in the Unrestricted Sense' by Being Pure
Perfections
Morally good qualities are 'good without qualification' also in the sense that moral
values are 'pure perfections', i.e., that their possession is absolutely better than their
non-possession because they are not intrinsically limited: 64 the ratio formalis of mor-
al qualities reveals that they are 'pure perfections' which admit of infinity and are
absolutely better to possess than not to possess. 65 Let us briefly investigate this cru-
cial notion of 'pure perfections':
Anselm of Canterburt6 in the 11 th and the great Duns Scotus67 in the 14th centu-
ry have elaborated the notion of pure perfection which refers to those attributes of

loving eyes and silent response to her father's alcoholism and stealing her money which 'forces' her
into prostitution.
64 Kant implies this clearly when he says that neither in this world nor outside it we find anything that
could be called good unqualifiedly except a good will, and that means the good will as bearer of moral
perfection. This can only be said if evidence of moral goodness as pure perfection is presupposed by
Kant. For otherwise there could be a higher and more unqualified sense of 'goodness'. That moral
perfection is not essentially limited and its possession absolutely speaking better than its non-posses-
sion does not apply to all moral perfections: it is not true of essentially human moral perfections such
as modesty or correctness in one's profession, but it does apply to the good will as it underlies not
only all moral actions but also all moral virtues and the fundamental morally good attitude. It also ap-
plies to many moral virtues such as justice or truthfulness. The innermost essence of moral goodness
and its source in what Kant refers to in our text by the term 'good will' (even ifhe has a limited un-
derstanding of the good will by restricting it to the sphere of action [HandlungJ ) are pure perfections.
See on this notion Josef Seifert, "Essere persona come perfezione pura. II beato Duns Scoto e una
nuova metafisica personalistica," in De Homine, Dialogo di Filosojia, II (Rome: HerderlUniversita
Lateranense, 1994), pp. 57-75.
65 See on this Josef Seifert, Essere e persona, ch. 5.
66 whose name and decisive contribution is not even mentioned in Leo Sweeney, S.1., Divine Injinity in
Greek and Medieval Thought (New York/San FranciscolBernlFrankfurt a. M.lBerlinlWienlParis:
Peter Lang, 1992). If the book were called: Some Studies on Divine Injinity in Greek and Medieval
Thought, a title that would suit the book better since it appears to be a collection of papers, one would
have less reason to demand that the name of Anselm be mentioned. This is hard to comprehend given
the fact that Anselm possibly made the most original and significant contribution towards the under-
standing of divine infinity by the discovery ofthe pure perfections. More sorely missing in Sweeney's
book is the proper recognition of the metaphysics of pure perfections (perfections absolutely speak-
ing) as the sole ground for a rational concept of divine infmity and the understanding that the objec-
tive reality of these pure perfections is necessarily required for this divine infinity itself to be reality.
 SUPERIORITY OF MORAL VALUES 173

which it is absolutely better to possess them than to possess anything incompatible

with them or not to have them for any reason whatsoever.
These attributes include two major groups: the so-called transcendentals and the
pure perfections.

a. Transcendentals
Under 'transcendentals', medieval philosophers understood all those properties and
principles of being that transcend the limitations of the categories and of the differ-
ent classes or genera of being and which characterize all beings as such. 68
Edith Stein has in an original way expounded all seven of these transcendentals. 69
What are they?
1. Being (ens) and existence.
2. Essence (res).
3. One (unum) or the inner unity which, like the other transcendental properties
of being, can be realized on countless different levels and in most diverse de-
grees of perfection.
4. Something (aliquid). Each being has some inner identity and is thus neither
nothing nor something else. 70
5. True (verum). Every being (and every state of affairs rooted in being) must
possess an openness to the intellect's knowledge. Another dimension of this
truth of being can also be understood as the correspondence of a thing to its
true idea or eternal form, or its adaptation to the divine ideas of each generic
and individual being.
6. The good (bonum) is the value or positive importance of all being. Duns
Scotus criticized sharply and, I think, correctly the view of the good that it
depends just on the appetitus rather than characterizing being in itself (in se).
Later Dietrich von Hildebrand saw the primary form of the good (of value) as
an objective preciousness belonging to things themselves. 71
7. The beautiful (pulchrum).
Now, all these characteristics, which every being must have, are also pure per-
fections. This leads us to the more important and central notion here, that of pure
perfection as such, which allows us to understand an entirely new dimension of the

67 Although Scotus is treated briefly by Sweeney, ibid., pp. 553-558, only extremely abstract notions of
Scotus on infinity and some of his criticisms of Thomas Aquinas are mentioned and rejected. Scotus's
most significant contribution towards understanding divine infinity, the critical unfolding of the char-
acteristics of the pure perfections, is not even mentioned.
68 In contradistinction to Kant's subjectivization of the transcendental and his interpretation of it as the
subjective conditions of our own experience as well as of the objects of experience, the medieval no-
tion of the transcendentals is part of an objectivist ontology.
69 See Edith Stein, Endliches und Ewiges Sein. Versuch eines Aufstiegs zum Sinne des Seins, especially
pp.263-301.
70 Recently, Giovanni Ventimiglia has shown in various works the central role which the transcendental
aliquid as difference plays in St. Thomas's metaphysics and how here the conception of difference as
imperfection was overcome. I cannot agree, however, with all aspects of Ventimiglia's interpretation.
71 See Dietrich von Hildebrand, Ethics, chs. 1-7; 17-18.
174 CHAPTER 3

insight that moral goodness (which certainly is not transcendental in the first sense
of the term because not all beings but only persons can possess moral goodness) is
good in an unrestricted sense.

b. Pure Perfections
What, then, is the nature of these pure perfections?
(1) The first mark and core of pure perfections is their being absolutely speaking
good. In 'pure' goods or perfections any inherent limitation is absent. Pure perfec-
tions are such things as being, life, beauty, goodness, knowledge, or wisdom. To
possess any of these is absolutely better than not to possess them.
That it is absolutely better to have or to be some good thing is by no means true
of all good things. It is untrue of all species of plants and animals, of the human and
angelic natures as well as of many general good qualities, which we find in them,
such as having a beautiful face or running fast.72 Anselm says it is better to be gold
than not to exist or to be lead, but it is not absolutely better to be gold than not to be
gold because many higher perfections exclude being gold, such as to be a mind. It is
not even absolutely better to be human than not to be human. For the highest perfec-
tion excludes the traits of human nature. 73
Duns Scotus achieved the most important step in the elaboration of the theory of
pure perfections. 74 What is characteristic of pure perfections is that there can be no
positive quality that is incompatible with them. There can be no positive reason why
the non-possession of a pure perfection could be preferable to its possession. Scotus
arrives at a definition of pure perfections: a pure perfection is one which is simply
and absolutely better than anything incompatible with it. 75
(2) Each pure perfection admits of infinity. We can know of many attributes
that they are not essentially limited and that they admit of infinity. We can even dis-
cover more than that: pure perfections are only truly themselves when they are infi-
nite,76 unlike mixed perfections which, being limited by their essence, necessarily
exclude infinity. All pure perfections admit of infinity; indeed they are only fully
themselves when they are absolutely infinite. Any finite being is not fully being, any
limited justice not fully justice, etc.

72 The discovery of the pure perfections, too, can be traced back to the greatest pre-Socratic theologian,
Xenophanes, who insisted that one must not attribute to God hands and beauty of faces, but only pure
perfections such as power and knowledge. See H. Diels-W. Kranz, Die Fragmente der Vorsokratiker,
3 Bde, 6. Aufl. (Berlin, 1951-52),21 B 14,21 B 21, 21 B 23, and others.
73 Let me make here a footnote not as philosopher but as Christian. What the philosopher can see here is
true but does not exclude the merciful inclusion of the human nature into the divine nature by the re-
demptive deed of Christ who assumed human nature, but this happened without Christ's losing his di-
vine nature which alone is infinite in perfection and which can never be human.
74 See Duns Scotus, Quaestiones Quodlibetales, q. 1; q. 5; T. Oxon. 1 d. 8, q. 2; Ordinatio 1 d, q. 3. See
also John Duns Scotus, God and Creatures. The Quodlibetal Questions, trans. with an introd., notes,
and glossary by Felix Alluntis and Allan B. Wolter (Washington: The Catholic University of America
Press, reprinted with Princeton University Press, 1975), (1.2 ff.), pp.6 ff., (1.20 ff.), pp. 11 ff,
(5.1 ff), pp. 108 ff., (5.19 ff.), pp. 114 ff., (5.31 ff), pp. 119 ff.
75 I tried to show in Essere e persona that also certain limited subjects, not only their natures, as Scotus
believed, can be incompatible with some pure perfections.
76 Only for this reason one can say, "God alone is good, wise, just, living, etc."
 SUPERIORITY OF MORAL VALUES 175

This notion of 'absolute perfection' cannot be derived from any other form of
infinity nor can it be sufficiently characterized by the terms 'infinity' or 'unlimited-
ness' as such (the Greek terms Apeiron and Aoriston mean also 'unlimited'.r
For these we find also in the finite spheres of space, numbers, etc. Absolute infinity
of perfection, which can solely be understood through the pure perfections, is an ir-
reducible datum and worlds apart from all other infinities within the finite world. It
does not help to speak here of 'unlimitedness' instead of 'infinity', to liberate one-
self from the need of distinguishing clearly between the infinite and the indefinite,
the absolutely infinite and the finitely infinite. For these differences do not concern
words but things themselves; moreover, the term 'unlimited' has the same different
types of meaning as the term 'infinite'. It lends itself even more rather than less to
be applied only to a potential infmity or to infinities within the finite order of things.
While these perfections absolutely speaking of being, unity, life, goodness,
knowledge, freedom, power, justice, wisdom, or love always are limited on earth,
this limitation does not belong to their essence. On the contrary, their innermost na-
ture resists any limitation whatsoever. They are life, being, justice, goodness them-
selves only when they are infinite. To be able to understand this is perhaps the high-
est achievement of all rational knowledge and the condition of any rational or relig-
ious knowledge of God. 78
(3) An important epistemological point regarding the metaphysics of pure per-
fections was made by Thomas Aquinas, who said that we can know that these per-
fections are without inherent limit and therefore that that which is signified by the
names of being, goodness, etc., is indeed unlimited--even though our mode of un-
derstanding and signifying them is limited. 79
(4) They are all mutually compatible, which can be demonstrated from the first
mark: for if A and B were pure perfections but incompatible with each other, it
would be absolutely better and at the same time not better to possess the given pure
perfection A, or B. It would be better to possess A because of its character of pure
perfection, and better not to possess it because it would contradict B which is a pure
perfection and therefore absolutely better to possess.
(5) They are all irreducibly simple (simpliciter simplex, indefinable). The pure
perfections are never just a case of another quality. They have their unmistakable
identity and are urphenomena or Urelements. 80

77 Sweeney (Divine Infinity, pp. 15-28) gives good arguments for apeiria and aoristia being synonyms
in Plotinus and in other authors. He fails to distinguish clearly the three utterly different philosophical
meanings of these terms: (a) the indefmite, (b) the potential or actual infinite within limited spheres of
being; (c) the absolutely infinite.
78 Therefore, the audacious statements of Augustine are justified: "This good and that good: take away
the 'this' and 'that', and regard good itself, if thou canst. Thus wilt thou see God, not good by a good
other than Himself, but the good of all good." God is goodness in its utmost infmite purity and he is
being, The I AM WHO I AM HIMSELF, he is life itself, justice itself, wisdom and knowledge itself,
and not just as an abstract idea but as a living reality. De Trinitate VIII, iii, 4.
79 See the references to the respective texts of Aquinas and their discussion in Josef Seifert, Essere e
persona, ch. 5.
80 We prescind here from a further mark of pure perfections, their communicability to more than one in-
dividual subject, which would require a more profound discussion which is not necessary in our con-
text because moral values are clearly communicable to more than one subject.
 176 CHAPTER 3

This metaphysical intuition into the character of moral values as pure perfections
which are not limited to finite human beings but are better absolutely speaking and
even in an absolute divine being is also presupposed in the well-known atheistic ob-
jection against God that the evils in the world prove that God cannot be merciful and
just and that therefore ''there is no God," and in the reply of 'theodicy' to this ques-
tion. For this atheistic objection as well as the reply of theodicy presuppose the in-
tuition that moral values are pure perfections and that therefore any idea that God be
amoral or immoral, or above moral values without possessing them is absurd.
Against this, most of all the moral goodness of God must be defended: id quo melius
nihil cogitari possit also includes the moral goodness which constitutes the inner-
most dimension of divine holiness and can never be substituted by the tremendum of
holiness. 81 And for the same reason, the atheist is correct when he affirms: "If God is
not morally good, there is no God."
Kant, too, gained this profound insight into the character of moral values as pure
perfections. This insight was absent in Aristotle who believed that God is above
moral virtues and possesses only intellectual ones. Some of the greatest ethicists
from Plato on, however, saw this character of justice and moral values as pure per-
fections. But in praising the good will as supreme value and as a pure perfection
'greater than which' nothing can be without possessing moral goodness, we are con-
fronted with the problem of the 'seat' and source of moral value. Answering this
question leads us to further essential intuitions into moral values, and into the char-
acter of the person and of moral goodness as pure perfection.
One might well pose the question why these purely metaphysical and abstract-
sounding investigations into the character of moral values as pure perfections are
relevant for medical ethics. The answer to this question is the following: as soon as
this sense of their unrestricted goodness is not admitted, not only other goods such
as health or happiness (which certainly are pure perfections) will be placed higher
by the physician than moral values but also no meaningful concept of God will be
possible. Hence the seventh good medicine ought to respect and to serve and the
crucial role of its recognition in order to exclude euthanasia and many other medical
actions will no longer be recognized.

3.18. Moral Values Are Unconditionally Good because They Are Never Just
'Means' towards Ends (Happiness). They Are Dominated by a Principle ofDueness
and Appropriateness and Arise 'on the Back' ofActs (a Critique ofEudemonism)

Clearly, what is morally good is not just good as a means to bring about a certain ef-
fect. The moral goodness of an act cannot be reduced to a cause of some good con-
sequences. We shall return to this insight when we will discuss in the last chapter of
this volume the errors of utilitarianism and consequentialist ethics.
Moral values are dominated by a principle of dueness and appropriateness and
arise 'on the back' of acts but still ought to be willed also for their own sake (be-
cause of the inner justice of the will itself).

81 Also in Anselm the deepest meaning of 'maius' is a moral one. Compare my Gott a/s Gottesbeweis,
ch. 11.
 SUPERIORITY OF MORAL V ALVES 177

This principle of dueness and the call to give the appropriate (value-) response
also distinguish moral values sharply from what they appear to be in the conception
of Aristotle, namely means towards happiness. Even less are they means towards
other goods, or can be judged in their moral rightness or wrongness in terms of their
consequences, as consequentialist or teleological ethics teaches. 82 Moral values are
essentially never just means, they are to be considered and willed as ends in them-
selves. That the moral subject wills them for their own sakes is even necessary for
them to be moral values at all. This is deeply seen by Anselm: moral values must be
willed propter rectitudinem voluntatis ipsam. They must never be regarded just as
means towards happiness. A morally good act corresponds and responds properly to
a morally relevant good that calls for a due response and to the moral goodness of
the act itself.
This due-relation is a relation sui generis and entirely different from, and abso-
lutely irreducible to, a means-end relation. 83 Any good endowed with objective value
calls for an affirmation propter seipsum. In this sense of first seeking the justice of
the kingdom of God the 'appearing on the back' of acts {'auf dem Rucken Erschei-
nen') found in moral values is an essential characteristic of morality.
While moral values arise in the analyzed sense 'on the back of the act' because
they involve a transcendent interest in some good endowed with value, they can be
and ought to be willed for their own sake and Max Scheler is very wrong when he
sees pharisaismjust in that element. 84
This reason why moral values are 'unconditionally good', is a reason extremely
important for medical ethics, as we will see when discussing this point extensively
in chapter 6.

3.19. Link of Morality to Religion and to God

Socrates, in the Apology, relates the good act to the 'obedience' to God (presence of
God in moral ought):
Men of Athens, I am devoted to you, and I love you; but I shall be obedient to the God
more than to you, and as long as I am breathing and able to, I will not cease to look for
wisdom, and to exhort yoU. 85

The importance of this motive for the realization of the moral value of an action
becomes especially clear whenever it is explicitly rejected,86 for example in an atti-

82 See the critique of this view below, in chapter 6. See also Robert Spaemann, "Uber die Unm6g1ichkeit
einer rein teleologischen Begrilndung der Ethik"; see also my "Absolute Moral Obligations towards
Finite Goods as Foundation of Intrinsically Right and Wrong Actions. A Critique of Con sequentialist
Teleological Ethics: Destruction of Ethics through Moral Theology?," Anthropos 1 (1985), pp. 57-94,
and my "Ontic and Moral Goods and Evils. On the Use and Abuse of Important Ethical Distinctions,"
in Anthropotes 2 (Rome, 1987).
83 See on this Dietrich von Hildebrand, Ethics, chs. 17-18; Josef Seifert, Essere e persona, ch. 9.
84 See against this, Dietrich von Hildebrand, Ethics, ch. 19. See also on a sevenfold motivation of moral
acts Josef Seifert, Was ist und was motiviert eine sittliche Handlung?
85 Plato, Apology, 29 d.
86 D. v. Hildebrand has shown this clearly in Die Menschheit am Scheideweg, pp. 56 ff.
178 CHAP1ER3

tude of resentment. 87 As Max Scheler has shown, a moral action loses its moral value
entirely if it closes itself to this ultimate motivating ground and object, and rejects it
explicitly out of ressentiment. 88 Kant's express rejection of this motivating ground
amounts to a philosophical destruction of the substance of the moral act. 89 This be-
comes especially clear as soon as we think also of the fact that the validity of the
motivation of the moral action by its own moral value remains preserved only as
long as this value is intended, implicitly at least, in its transcendent openness to the
absolute good. Kant sees this in a beautiful passage but still undermines this insight
in the last analysis through his immanentism in which God serves only a moral func-
tion and is deprived of any being and autonomous existence independent of human
morality itself. If the moral value is, as is done in Kant's principle of autonomy, ex-
plicitly made absolute in the sense of being expressly alienated from its ultimate
calling as a glorification of God, the living embodiment of all moral goodness and of
all values, an application of this principle to the moral life would lead to a destruc-
tion of the moral value of an action and to a perversion of the moral act. An action
which is in this way explicitly cut off from the motive of a response to God carries a
moral disvalue; ultimately, even a diabolical moral disvalue of rebellion against
God; it is an attempt to make oneself into God.
There is also a purely objective glorification of God in the morally good act: an
objective praise of God, a new sense of glorification through moral goodness, differ-
ent from an explicit praise of God in a prayer of adoration or praise.
For medical ethics this aspect of moral values has a particular relevance when it
comes to the limitations of metaphysical human rights and to the recognition of the
seventh (second transcendent) good medicine ought to serve, as we have explained
in chapter 1. We will return amply to the special significance of this point for medi-
cal ethics in volume II, when discussing assisted suicide, abortion, euthanasia, and
other acts.

3.20. Moral Values Constitute the Most Direct Link between Morality and Religious
Spirituality: Distinction between Philosophical and Theological Assertions
Newman calls morality and especially moral conscience ''the creative principle of
religion"90-not in a nihilistic Nietzschean sense but in the sense that in it there is a
natural human consciousness linked to the religious sphere. The link between mor-
ality and religion could be investigated in depth and detail, but here we thematize
only some aspects of their relation. If we were to make in the following assertoric or
apodictic assertions about the essential relation between morality and supernatural
virtues, implying the real existence of the religious world, we would make religious
or theological affirmations. But we wish to speak from a purely philosophical per-

87 M. Scheler has analyzed this attitude of resentment in detail in his monograph, Das Ressentiment im
Aujbau der Moralen, in Max Scheler, Vom Umsturz der Werte (Bern/MUnchen: Francke-Verlag,
1955), pp. 96-107.
88 See M. Scheler, Das Ressentiment im Aujbau der Moralen.
89 See I. Kant, Groundwork, pp. 111-112, Critique of Practical Reason, p. 241 ff., Metaphysics of
Morals, A 109.
90 See John Henry Cardinal Newman, An Essay in Aid of a Grammar ofAssent.
 SUPERIORITY OF MORAL VALVES 179

spective, expressing the insight that there is an essential link between morality and
religious life and supernatural virtues, if these exist. Moreover, if there is something
like divine grace, it must be related somehow to the moral sphere. In other words: of
all natural values and disvalues only moral values and disvalues are capable of
standing in the type of direct relationship to the sphere of divine grace and union
with God which religions attribute to morally good and evil acts; therefore, even
atheists call certain moral evils 'ungodly'. The idea that by sin (by immoral acts) we
diminish or entirely lose divine grace, and risk losing the ultimate religious human
good (salvation), is in one way or another a common belief of most religious faiths.
But there is also a purely rational philosophical insight hidden here. We can gain
this philosophical ethical insight also from the opposite side: such a belief that there
is a unique relation between morality/immorality and God as well as religion consti-
tutes even from the side of a negative anti-religion an essential aspect of Satanism
which uses immoral acts or horrible crimes as expressions of this anti-theistic reli-
gion and rebellion against God. The assumption of most religions, and even of neg-
ative anti-religions, that the morally good and evil are intimately related with reli-
gious realities and God makes philosophically perfect sense, whereas it would make
no sense at all to claim that intellectual values per se (great intelligence) would in-
crease grace or the chances of salvation or have the special religious significance at-
tributed to morally good and evil acts. Of all natural values and disvalues these ob-
jects of religious belief (grace, supernatural holiness, or sin) can be internally tied up
only with the moral life, and they can solely 'work on it' in a unique way, transfigur-
ing it and raising it onto a new and higher order. 91 In other words, the essence of the
relationship of morality to religious spiritual dimensions also has a philosophically
knowable aspect.
Historically speaking, this aspect of the relationship between moral and religious
values has even been seen in some cultures more clearly by philosophers before it
had become part of religion. The inherent rational evidence of this relationship ex-
plains why the close connection seen between morally good acts and spiritual reli-
gious goodness and God was not merely accepted by ancient philosophers, espe-
cially by Plato, from existing religions; it was even introduced against the religions
of their time. In Greek religion, the gods were portrayed as morally rather wicked
and corrupt personages engaged in many immoral acts. Xenophanes, Plato, and oth-
er Greek philosophers criticized this position and cleansed existing Greek polytheis-

91 This was seen by philosophers of all ages and of different religions. It achieved a special importance
in the fathers and doctors of the Church. Within phenomenology, the point of analyzing the essence of
religion and of religious data in their purely rational intelligibility became an important development
within philosophy of religion. See Rudolf Otto, The Idea of the Holy. An Inquiry into the Non-rational
Factor in the Idea of the Divine and Its Relation to the Rational, translated by John W. Harvey, 27th
Printing (LondoniOxfordlNew York: Oxford University Press, 1982); the same author, AujSiitze zur
Ethik. See also Max Scheler, "Probleme der Religion," in Max Scheler, Vom Ewigen im Menschen; in
English: On the Eternal in Man, trans!. Bernard Noble (Hamden: Archon Books, 1972); for an analy-
sis of specifically Christian virtues of charity and others see Dietrich von Hildebrand, Transformation
in Christ. On the Christian Attitude of Mind, last edition with a new sub-title: Transformation in
Christ. Our Path to Holiness (Reprint of 1948. New Hampshire: Sophia Institute Press. 1989); and his
Das Wesen der Liebe, ch. 11.
180 CHAPTER 3

tic religions from these immoral elements. 92 Additionally, Plato recognized that the
religious Orphic idea of purification (kiijbarsiV) couldn't possibly lie in mere ex-
ternal factors such as the food one eats or does not eat, or in cleansings through
water, but only in moral virtues such as justice and love oftruth.93
Thus, philosophers even preceded the positive religious teachings in this regard
and freed existing religions by means of pure reason from those imperfect forms and
comprehensions in which some of them taught ways to realize the ultimate religious
goods and virtues without moral goodness.

3.21. The Unity ofMoral Values

Another particularly striking feature of moral goodness is the unity of the sphere of
moral values and virtues. This 'unity' of the moral sphere (of virtue), which Plato
discusses in the Meno (71 e if.), has many meanings and dimensions. Let us exam-
ine the most important of these.

3.21.1. 'One Moral Value '-Goodness

The unity of one value (of the morally good) can signify that there is one general
moral value (moral goodness) of which all other moral values are subspecies; this
kind of unity is absent, or at least not so clearly present, in aesthetics, where not all
aesthetic values (for example the comic, the grotesque, or the 'elegant') are
subdivisions of beauty. 94

3.21.2. 'No Division ofLabor , in the Moral Life

Moral values also possess unity in the sense that the division proper to aesthetic or
intellectual values is not applicable here; we cannot be specialists for some, neglect-
ing others, as in other spheres.95 All moral values are required from each, notwith-
standing the fact that there is a uniqueness of moral callings and individual situa-
tions. This impossibility of a 'division of moral labor' is a direct outgrowth of the
obligatory character of the moral ought but applies, in some sense, to the non-oblig-
atory acts as well. We must not and ultimately cannot specialize in some moral val-
ues, leaving others unrealized. This is quite unlike aesthetics where we can and may
ignore the values of painting, concentrating on beautiful music, etc. Kant sees this in
some of his remarks on the categorical imperative. 96

92 See H. Diels-w. Kranz, Die Fragmente der Vorsokratiker, Bd. I; see also Plato, Republic, 2.362 c fr.
93 Plato, Phaedo, 69 b---c.
94 See Dietrich von Hildebrand, Asthetik, 1. Teil, in Gesammelte Werke, Band V (Stuttgart: Kohlham-
mer, 1977; 1989 Ubemommen vom Eos Verlag, st. Ottilien), ch. 1.
95 On all of these traits of moral values cf. Dietrich von Hildebrand, Ethics, ch. 15.
96 See Immanuel Kant, Grundlegung zur Metaphysik der Sitten. See also my book on Was ist und was
motiviert eine sittliche Handlung? on the universality of the object ofa moral act.
 SUPERIORITY OF MORAL VALUES 181

3.21.3. 'Existential Moral Unity'

We can also refer to an existential and inner moral unity in the sense that moral
efforts in one area strengthen also the moral life in others. Also this is not found in
aesthetic values. The authenticity of moral goodness in one area strengthens also the
moral qualities of a person in other areas, and the moral purity of a person in a cer-
tain sphere, such as honesty, is also threatened or even in jeopardy and entirely lost
if other spheres of morality are not developed. For then we destroy even those moral
values to which we aspire. A totally merciless man like Shylock in Shakespeare's
The Merchant of Venice also makes the reality and virtue of his (cruel and merciless)
justice most questionable, and he loses the properly moral goodness qua person
bestowed upon a person by justice.

3.21.4. The Unity ofthe 'Root' ofAll Moral Goodness: the 'Oneness of Virtue ,
All goodness in persons seems to come from one fundamental root, from one funda-
mental attitude. (There are not many virtues in the sense that each would have an in-
dependent life or source in the person: there is one virtue only, of which the others
are parts, as Socrates says in Plato's Meno.) Yet there are many spheres of acts in
the person that are bearers of moral values. Whether we identify this single root of
the entire moral life in a Fundamentaloption, a fundamental moral attitude, or in
love and charity, is a new question, which we cannot turn to in this brief chapter but
to which we shall return in a later context.

3.22. The Superiority of Moral Values over All Others and the Crucial Importance
of This Insight Expounded in This Chapter for Medical Ethics

In the light of its essential characteristics it becomes much clearer that and why for
every man and for every physician and nurse the striving for the realization of moral
perfection is far more important than the efforts dedicated to the realization of any
extramoral good. Even those acts that intend the saving of life or the restoring of
health are primarily good because they are bearers of moral value and not because
they are causes of life and health. They remain therefore morally equally good when
they are not successful in saving life or restoring health, as Kant so well expresses in
general terms:
A good will is not good because of what it effects or accomplishes-because of its fit-
ness for attaining some proposed end: it is good through its willing alone-that is, good
in itself. Considered in itself it is to be esteemed beyond comparison as far higher than
anything it could ever bring about ... Even if, by some special disfavour of destiny or
by the niggardly endowment of stepmotheriy nature, this will is entirely lacking in pow-
er to carry out its intentions; if by its utmost effort it still accomplishes nothing, and
only good will is left (not, admittedly, as a mere wish, but as the straining of every
means so far as they are in our control); even then it would still shine like a jewel for its
own sake as something which has its full value in itself. Its usefulness or fruitlessness
can neither add to, nor subtract from, this value. 97

97 Immanuel Kant, Groundwork, p. 62. With his thesis that only the will is a bearer of moral values,
Kant does not do justice to the metaphysical relation between moral values and the person, for the per-
son herself is the primary bearer of moral values, not acts. On the other hand, Kant also suggests a
182 CHAPTER 3

Moral values disclose themselves, as we have seen in studying the senses in which
'moral values alone' are good in an unrestricted sense, as essentially and incommen-
surably superior to all extramoral goods including life or health. And therefore any
medical ethical position that sees only the (certainly morally relevant) goods of life,
health, soothing of pain, but not the morally good and evil themselves, and for this
reason allows patients, nurses, or physicians to act in immoral ways to promote
extramoral goods such as research, medical knowledge, health, or even human life,
is profoundly erroneous. This should be the clear conclusion from the preceding in-
vestigations of this chapter.

3.23. Moral Values Are Characterized as 'Goodness without Qualification '-Its

Relationship to Happiness and to the Supreme Good

From Socrates on, ethicists have recognized that moral values rank still higher than
the great goods of life or health that medicine serves and that it is better even to suf-
fer death than to commit injustice. Kant calls the 'good will', i.e., the will as bearer
of moral values, "good without qualification," and thereby states something very
profound about morality, the truth of which has emerged more clearly through our
study of the different distinguishing marks of moral values. Let us read his great text
in which he expresses many insights into eternal and absolute truths about morality,
forgetting as it were his whole epistemology in the Critique of Pure Reason, which
would have forbidden him to make such statements valid "outside the world of ap-
pearance." Only an objectivist epistemology and therefore only a critique of Kant
can justify these insights: 98
It is impossible to conceive anything at all in the world, or even out of it, which can be
taken as good without qualification, except a good will. Intelligence, wit, judgement,
and any other talents of the mind we may care to name, or courage, resolution, and con-
stancy of purpose, as qualities of temperament are without doubt good and desirable in
many respects; but they can also be extremely bad and hurtful when the will is not good
which has to make use of these gifts of nature, and which for this reason has the term
'character' applied to its peculiar quality. It is exactly the same with gifts offortune.
Power, wealth, honour, even health and that complete well-being and contentment with
one's state which goes by the name of 'happiness', produce boldness, and as a conse-
quence often over-boldness as well, unless a good will is present .... Moderation in af-
fections and passions, self-control, and sober reflection are not only good in many
respects: they may even seem to constitute part of the inner worth of a person. Yet they
are far from being properly described as good without qualification (however uncondi-

limitation of moral values to the will in the narrower sense, that is, to the will which intervenes
through actions. This would, however, neglect the virtues of a person as independent areas of moral
goodness (even the most profound area) as well as that other area of moral goodness which we find in
the case of taking an internal free stand. This restriction of morality implicit in Kant's ethics has been
overcome convincingly by Dietrich von Hildebrand. See his Die Idee der sittlichen Handlung, and
Ethics, especially pp. 316 sq. and pp. 342 sq. If, however, the word 'will' is used in the same meaning
as 'freedom', then the sphere of morality reaches indeed only as far as the will.
98 On such an epistemology cf. AdolfReinach, "Concerning Phenomenology." Cf. also Dietrich von Hil-
debrand, What Is Philosophy?; D. von Hildebrand, "Das Cogito und die Erkenntnis der realen Welt.
Teilveroffentlichung der Salzburger Vorlesungen Hildebrands: 'Wesen und Wert menschlicher Er-
kenntnis' "; Josef Seifert, Erkenntnis objektiver Wahrheit; the same author Back to Things in Them-
selves.
 SUPERIORITY OF MORAL VALVES 183

tionally they have been commended by the ancients}. For without the principles of a
good will they may become exceedingly bad; and the very coolness of a scoundrel
makes him, not merely more dangerous, but also immediately more abominable in our
eyes than we should have taken him without it. 99

Kant is alluding in the last sentences to the so-called cardinal virtues. Even in
comparison with these 'cardinal virtues', Kant sees, moral values are good without
qualification, while the cardinal virtues are not; three of them can be called moral
virtues only to the extent to which they participate in originally and really morally
good and value-responding qualities of persons. Otherwise, they would possess no
moral character at all. This holds true at least of prudence, fortitude, and temper-
ance. They are morally good only if they are prudent moral goodness, moral good-
ness with fortitude, and temperate moral goodness or love. A physician who is cou-
rageous in inflicting tortures on a prisoner while incurring great dangers from the
members of another political party is not morally good because his courage is whol-
ly divorced from a morally good end and in fact serves an evil purpose; therefore, a
courageous evil physician is morally even more evil than a physician who carries
out immoral deeds cowardly. Similarly, the exercise of temperance or prudence di-
rected chiefly at earning or saving more money is not morally good but morally
neutral at best. Among the four cardinal virtues, only justice possesses intrinsically
and essentially a moral value and therefore is by its essence a moral virtue.
For this reason, we reject, with Kant, the claim inspired by Aristotle's Nicho-
machean Ethics that prudence (mronhsiV) is the 'mother of all virtues'. In reality,
prudence is an essentially subordinated and derivative, though important, virtue, a
virtue that concerns the choice of the right means to an end, and it becomes a moral
virtue only when the end is good. Therefore, prudence is no virtue at all if it stands
in the service of some evil, as Kant points out, but it is an important moral virtue
when it seeks and wills all means that effectively lead to the desired good.

99 I. Kant, Groundwork of the Metaphysics ofMorals, pp. 61--62. The German original reads:
Es ist iiberall nichts in der Welt, ja iiberhaupt auch auJ3er derselben zu denken mog-
lich, was ohne Einschrlinkung filr gut konnte gehalten werden, als allein ein guter
Wille. Verstand, Witz, Urteilskraft, und wie die Talente des Geistes sonst heil3en
mogen, oder Mut, Entschlossenheit, Beharrlichkeit im Vorsatze, als Eigenschaften
des Temperaments, sind ohne Zweifel in mancher Absicht gut und wiinschenswert;
aber sie konnen auch auJ3erst bose. und schadlich werden, wenn der Wille, der von
diesen Naturgaben Gebrauch machen soli und dessen eigentiimliche Beschaffenheit
darum Charakter heiSt, nicht gut ist. Mit den Gliicksgaben ist es ebenso bewandt.
Macht, Reichtum, Ehre, selbst Gesundheit, und das ganze Wohlbefinden und Zufrie-
denheit mit seinem Zustande, unter dem Namen der Gliickseligkeit, machen Mut und
hiedurch ofters auch Obermut, wo nicht ein guter Wille da ist ... MaBigung in Af-
fekten und Leidenschaften, Selbstbeherrschung und niichteme Oberlegung sind
nicht allein in vielerlei Absicht gut, sondem scheinen sogar einen Teil vom inneren
Werte der Person auszumachen; allein es fehlt viel daran, urn sie ohne Einschran-
kung fur gut zu erklaren (so unbedingt sie auch von den Aiten gepriesen worden).
Denn ohne Grundsatze eines guten Willens konnen sie hOchst bOse werden, und das
kalte Blut eines Bosewichts macht ihn nicht allein weit gefahrlicher, sondem auch
unmittelbar in unseren Augen noch verabscheuungswiirdiger, als er ohne dieses
dafilr wiirde gehalten werden.
Immanuel Kant, Grundlegung zur Metaphysik der Sitten, BA 1,2.
184 CHAPTER 3

In this way, physicians are morally virtuous when they prudently, and not rashly
and without thinking, use the means that lead to restoring the health of their patients.
And their prudence is more virtuous still when they also use all means and ways that
will lead them to achieve higher moral perfection. Thus prudence is an important but
subservient moral virtue that only becomes a moral virtue when it is part, or in the
service, of a primary virtue such as love or justice or any adequate response to mor-
ally relevant good.
Only the idea, to be criticized in chapter 4, that we must will the end necessarily
and therefore can only choose among means, can explain why such a fundamental
role was assigned in ancient and medieval philosophy to prudence, not only as an
intellectual (dianoetic) but also as a practical virtue of the prudent choice, and why
its subordinate character that becomes virtuous only from without, namely when it is
embedded in a higher value-responding virtue, could have been overlooked, though
it seems to me that some medieval philosophers, contrary to what is attributed to
them, have recognized this clearly.lOo
Justice, on the other hand, is essentially an elementary moral virtue because its
object and aim, to form true and appropriate judgments about and on persons, to
reach a due response to them, to respect the just and the rights of persons, are essen-
tially morally good and morally relevant, wherefore the attitude, inner response, and
action which is just, are essentially morally good. 101
Kant describes in the above passage-with some explanations added-the 'good
will', i.e., the will as bearer of moral values, as 'good without qualification'. But
what does this 'goodness without qualification' mean? Only by a return to 'things
themselves'-to the moral data themselves-have we become able to understand the
truth of this assertion more adequately. Only a critical return to moral data and
things themselves can provide the criteria to judge Kant's assertions.
This insight that only moral goodness is 'good without qualification' does not
exclude another and more comprehensive sense of goodness that goes beyond moral

100 Though Thomas Aquinas, with Aristotle, indeed assigns prudence a fundamental character such that
many attribute to him the opinion that prudence is the mother of all virtues, Thomas holds on the con-
trary that love (charity) alone can be called the mother of all virtues for two reasons: because it has the
highest object and orders and commands all other virtues.
Nulla autem virtus imperat universal iter omnibus virtutibus, nisi caritas, quae est
mater omnium virtutum; et habet hoc tum ex objecto proprio, quod est summum bo-
num, in quod immediate fertur, tum etiam ex subjecto, scilicet ex voluntate, quae
aliis viribus imperat; et ideo inter virtutes sola caritas dicitur communis finis om-
nium rectarum voluntatum.
Thomas Aquinas, In Sent. II, d. 38, q. 1, a. 2, ra 5. Thomas repeats this teaching often, adding that
caritas is not only the mother, but also the motor (motivating force), form, and root of all other
virtues. He never calls prudence the mother of all virtues but discusses the thesis of Gregor the Great
that obedience is the 'mother of all virtues', saying that this can be held only in a completely different
sense, inasmuch as obedience can be the beginning of humiliation that disposes a person in the
direction of virtues. He assigns to prudence a very foundational but nevertheless subordinated role. In
In Sent. III, d. 27, q. 2, a. 3, ra 3, he says:
Ad tertium dicendum, quod prudentia principalis est in virtutibus moralibus, inquan-
tum est directiva omnium; et ideo ad rationem pertinet: sed caritas est principalis per
modum imperantis et conjungentis fini et informantis; quod pertinet ad voluntatem.
101 We must forego in this context a more detailed critical analysis of the so-called cardinal virtues.
 SUPERIORITY OF MORAL VALUES 185

goodness alone and includes also happiness and all other goods. This all-comprehen-
sive good of course deserves even more fully the title of the 'good in the unrestricted
sense'. Not to see this clearly would constitute a rigoristic weakness in ethics. We
therefore conclude with the observation that while a one-sided insistence on moral
goodness alone (without seeing that the highest good also includes supreme happi-
ness and other goods) is blameworthy, traditional Aristotelian ethics is marked by
another and far worse one-sidedness: namely to overlook the primacy of moral
goodness with respect to happiness or even the degradation of morality to a mere
means towards happiness.
Only by preserving the Kantian and Platonic intuition into the unique absolute-
ness of moral goodness will we be able to preserve an adequate notion of happiness
itself and of that all-comprehensive good which goes beyond moral goodness but
contains morally good acts as its most central core.
While not moral goodness alone and in isolation but the all-encompassing good
which includes happiness is the supreme object of human hope and desire, moral life
in general and medical action in particular must always remain based on the intu-
ition that moral virtue lies at the root of all other goods and at the center of value in
the unrestricted sense. In fact, in many of the above senses it remains true that no
other aspect of the encompassing good but the good will alone, or better said the
moral life that gives rise to moral goodness, is 'good in the unrestricted sense'.

CONCLUDING REMARKS
While ethics deals primarily with the moral value itself and its sources in the world
and in the person, and while thus its understanding presupposes that of human na-
ture, it can also become a window that allows us to look into what the human person
is in the mirror of moral values. Thus ethics properly speaking can lead back to phi-
losophy of the human person.
After this brief exposition of the main characteristics of moral values which dis-
tinguish them profoundly from all other values, our next theme will be a detailed in-
vestigation into one of the most basic anthropological and personological precondi-
tions of all ethics and bioethics and into the very root of the arising of moral values:
freedom.
Understanding freedom better is not only indispensable for medical ethics and
ethics in general, but also for understanding two basic theses of this book:
(a) that a practice of medicine without understanding and freely serving the
goods which are the objective goals and ends of medical action suffers from a dead-
ly philosophical disease, is not medicine, and even turns into anti-medicine;
(b) that the goods which medicine ought to serve are not at all willed necessarily,
as Aristotle and Thomas Aquinas claim, but are the object of the most foundational
and fIrst free and dramatic choice of each physician and nurse.
 CHAPTER 4

THE FREEDOM OF CHOICE

FOR OR AGAINST
THE BASIC GOODS AND ENDS OF MEDICINE
Physicians, Nurses, and Other Health Professionals as Agents
in the Drama of Freedom

Freedom as well as the moral drama of the hwnan person rooted in it are so central
for ethics and bioethics that we dedicate to this topic a separate chapter.
This is also necessary in order to see more in depth why we have said in chap-
ter 1, above, that the seven 'ultimate goals' of medicine are not willed by necessity,
as Aristotle and Thomas Aquinas held, but are the object of a free and truly dramatic
choice.
In a world in which the good itself, and therefore also the ultimate ends of medi-
cine, are not willed by necessity but have to be chosen freely, however, the moral
life of the person and the role of freedom in it, as well as the task of ethics, are pro-
foundly different from their function in a world in which these goals and the good
are willed by necessity and freedom is restricted to the role of just choosing, based
on the intellect's distinction between real and apparent goods, the best means to
reach its end fixed in advance.
When discussing the essence of moral values in the last chapter, we encountered
the necessary state of affairs that moral values necessarily presuppose persons and
their freedom. Without freedom the object of ethics and bioethics would collapse.
But freedom is not only inseparable from morality, it is also inseparable from per-
sonhood.
In order to bring this to evidence, it seems to be indispensable to achieve four
things:
(1) A nwnber of important metaphysical and epistemological insights need to be
gained and argued for in order to understand that the real existence of freedom in the
ultimate, metaphysical sense is possible (and not contradictory in itself) and absolu-
tely inseparable from the personhood of any person, whether finite or divine.
(2) The great moral drama of hwnan freedom and the fact that free choice ex-
tends to the final goals of free acts, something which to understand clearly we found
most important for medical ethics, call for a philosophical analysis of freedom.
(3) Freedom must not be conceived too narrowly so as to situate it in external ac-
tions only instead of grasping its seat in the core of the being and attitudes of the

187
188 CHAPTER 4

person; the bearers and spheres of freedom in the subject, and their unity, require at
least a brief elucidation in order to overcome a false separation between external
moral actions which realize states of affairs in the world and fundamental moral atti-
tudes.
(4) The highest act of human freedom, in which also the full being and meaning
of what it means to be a finite person is actualized, needs to be shown not to consist
in a creation, and not even in volitional actions, but in a cooperative dimension of
freedom, an investigation that completes the study of the third and fourth dimen-
sions and roots of human dignity investigated in chapter 2.
The reader alone can be judge whether I will succeed in the following to accom-
plish these four difficult tasks, at least in form of a sketch.
But a main reason for including a separate chapter on human freedom in a book
on the foundations of medical ethics remains the need to fulfill the task of waking up
physicians and other health workers to realize the tremendous extent and weight of
their free choice and the need to understand, and to serve freely, the true ends and
goods of medicine.
Physicians and nurses, just as all other persons, are faced with the need to
choose, and increasingly so in a society which is less and less regulated by intersub-
jectively and legally accepted moral codes. In order to understand the drama and
need of a conscious free commitment to the ends of the health professions, we have
to attempt now a better understanding of the nature of freedom and of the drama of
the moral choice between entirely different kinds of 'good'.

1. TOWARDS A METAPHYSICS AND EPISTEMOLOGY OF FREEDOM

Before discussing the question of the extent of the choice of the human will, how-
ever, we need to prove the existence of human freedom. This question is in principle
very different from the question of the essence of human freedom. And yet it is of
fundamental importance for ethics because without knowing it, ethics has not secure
application to human persons and would move in a pure world of essences and pos-
sible worlds. Already for this reason of the existential concern of ethics, epoche-
even in the objectivist sense of bracketing the question of real existence in order to
concentrate on the necessary essence of things---can only be a partial but not a uni-
versal method of phenomenological and of any adequate philosophy that returns to
things themselves. I

I This has been well expressed by Tadeusz StyczeIi. in his "Premessa di Tadeusz StyczeIi.: Karol Woj-
tyla: un filosofo della morale agli occhi del suo discepolo," in: Karol Wojtyla, Metajisica della per-
sona. Tufte Ie opere jilosojiche e saggi integrative, a cura di Giovanni Reale e Tadeusz StyczeIi., (Mi-
lano: Bompiani, 2003), p. CXI, where he explains Wojtyla's critique of the Schelerian method of
epoche in ethics. See also Karol Wojtyla, Valutazioni sulla possibilita di costruire i'etica cristiana
sulle basi del sistema di Max Scheler, introd. Jaroslaw Merecki, ibid., pp.249-436; Josef Seifert,
Back to Things in Themselves, and "Phllnomenologie und Philosophie als strenge Wissenschaft. Zur
Grundlegung einer realistischen phllnomenologischen Methode - in kritischem Dialog mit Edmund
Husserls Ideen tiber die Philosophie als strenge Wissenschaft."
 FREE CHOICE AND THE ENDS OF MEDICINE 189

1.1. Freedom in the Strong Metaphysical Sense Is Absolutely Inseparable from

Personhood 2

Freedom belongs so essentially to personhood that no being can be called a person if

she is determined from without, by physical forces, other persons, or even by her
own nature-rather than by the free center of the person, by the person herself. This
insight refers to the pure essence of personhood and would retain its truth even if no
human being were a person. It is a truth of a purely essential order, true in the real
and in any possible world.
Certainly, the actual ability to use freedom is not inseparable from personhood
and not given to embryos and newborn babies, unconscious or comatose patients,
and is absent in all human beings during sleep and in certain types of grave mental
retardation. But to be a person entails the fundamental metaphysicalfaculty offree-
dom, a capacity in principle to perform free acts. 3 As faculty or power, freedom re-
sides on the level of the substantial being of the person or, more precisely, is insep-
arable from the substantial spiritual being and essence of the person. While the per-
son can, in sleep, unconsciousness, mental sickness, addiction, etc., be unable to ex-
ercise this faculty actually, while the faculty itself still remains, this faculty of free-
dom remains nevertheless ordained to be exercised in conscious actualizations.
Moreover, only in these actualizations of freedom we encounter and experience free-
dom and understand its existence even prior to, and apart from, its actualizations.
From free acts and actualizations alone we gain the metaphysical insight into the
subject of freedom, the person; and only through experiencing free acts we under-
stand the existence of the free power and free potentialities that must exist, as we
comprehend clearly and distinctly, prior to all their actualizations in free acts.
Also this distinction between faculty (power) of freedom, and the potentiality it
entails, from the actualized freedom and ability to use freedom remains crucial for a
proper anthropological foundation of medical ethics, when it comes to the actual
personhood and dignity of embryos and of comatose patients, whose actual person-
hood can only be maintained on the basis of the distinction between the faculties and
ontological potentialities of a being and their actualization.
But what is freedom? Freedom is one of those arch-data (urphenomena) that can
neither be defined in terms of something else nor be reduced to something besides
themselves. Freedom includes, however, many dimensions and traits which can be
analyzed and some of which we will discuss.

2 Parts of the original text ofthis chapter, in an altered version, have been given as a lecture delivered at
the Fifth World Congress of Christian Philosophy in Lublin (Catholic University), Poland, on August
22, 1996, under the title: "To be a Person-to be Free." Published in: Zofia J. Zdybicka, et al. (ed.),
Freedom in Contemporary Culture. Acts ofthe Fifth World Congress of Christian Philosophy, Catho-
lic University of Lublin, 20-25 August 1996, vol. I (Lublin: The University Press of the Catholic Uni-
versity of Lublin, 1998), pp. 145-185.
3 The notion ofJaculties (powers) was very well developed by the scholastic philosophers, especially by
Saint Thomas Aquinas. See also John F. Crosby, "Evolutionism and the Ontology of the Human Per-
son." The author makes an important distinction between Vermogen (faculty, power) and Fiihigkeit
(capacity, actual ability). On the notion of the substantial being ofthe person cf. also my Essere e per-
sona, chs. 8-9.
190 CHAPTER 4

Freedom involves a special form of self-possession distinct from the self-posses-

sion achieved in awakened conscious life or in self-knpwledge. It is the self-posses-
sion of being given dominion over one's own being, of one's being being given into
one's own hands, so to speak.
Freedom is not only a freedom from determining causes, an 'I can but I do not
need', but also the power of self-determination. Precisely this moment of self-deter-
mination makes free acts utterly different from chance-events (which, if they exist-
ed, would also not be determined from without).4
Free self-possession is only possible in and through the free agent's capacity of
self-governance and self-determination. To the free determining and governing one-
self corresponds also the person's being governed and determined by herself.
Linked to this self-determination of freedom is also the amazing creative power
freedom entails, the freedom to generate acts and to initiate actions which only exist
because we freely want them and which would not exist if we did not want them to
be. Aristotle expresses this powerfully when he says that man is the lord over the be-
ing or non-being of his own acts. s Aristotle calls the free agent first principle, cause,
lord, and master of the action.
But it would be completely wrong to conceive of freedom solely in terms of self-
determination, self-governance, self-possession, and free engendering of acts that
only exist because we want them to exist, which would also be true of entirely arbi-
trary free acts. On the contrary, freedom can only be understood if its transcendent
dimension, its relation to objects, and above all to other persons in their intrinsic val-
ue is understood. Freedom essentially entails, above and beyond self-determination,
the power to engender from oneself acts of responding and taking stances towards
objects and other persons, of fulfilling oughts and obligations, as well as the capaci-
ty of serving goods and other persons6 and of self-donation.7 In this consideration
freedom is not just a freedom from determining causes but afreedom for those goods
and beings that are its object.
Freedom is also intimately connected with the life of the intellect and involves
the capacity of opening one's mind in knowledge to receive information, of loving

4 See the interesting discussion of many meanings of 'chance' in Aristotle's Physics. One might believe
that if determinism is false "then one's acts are a result of chance." Against this one could argue that
the alternative between either determinism or human acts being the result of chance, and the ensuing
logical argument that from the falsity of determinism it would follow that all acts are the product of
chance, is not only logically incorrect (because there are other possibilities), but it is also false. For
free self-determination differs totally from chance in the sense of uncaused events.
5 See Aristotle, Eudemian Ethics II, vi, 8-9; 1223 a 3 ff.: "hoon ge kurios esti tou einai kai tou mee
einai" ("and he is lord of their [his actions'] being and non-being.") See also Aristotle, Nichomachean
Ethics III; and Magna Moralia, 87 b 31 ff., especially 89 b 6 ff.
6 See William Desmond, "Freedom beyond autonomy," in: Zofia J. Zdybicka, et al. (eds.), Freedom in
Contemporary Culture. Acts of the V World Congress of Christian Philosophy, Catholic University of
Lublin 20-25 August 1996, vol. I (Lublin: The University Press of the Catholic University of Lublin,
1998).
7 On the concept of self-donation see especially Karol Wojtyia, Liebe und Verantwortung; and Dietrich
von Hildebrand, Das Wesen der Liebe, chs. 1-7,9,11.
 FREE CHOICE AND THE ENDS OF MEDICINE 191

the truth, of cooperating freely with the process of knowledge, and of consenting
freely to that which is known, as well as the capacity of accepting gifts. 8
Freedom includes likewise the power to start a causal chain of events and to ini-
tiate activities and actions that lead to the realization of states of affairs. Moreover,
free agents alone can relate to moral oughts and realize moral values.
For all of these manifestations of freedom to be actually what they present them-
selves to be in our experience and knowledge of freedom, freedom in the metaphysi-
cal sense must exist. Any being the content of all of whose acts would be determined
by fate, or by any conceivable cause outside the given free person herself, even by
God, would be deprived of freedom and therefore also lack personhood. We would
have before us a complicated marionette or at best an animal, but not a person. 9 To
be a person, whether finite or infinite, whether human, angelic, or divine, necessarily
entails freedom. To say this is not a mere matter of definition but the formulation of
a synthetic a priori truth founded ontologically, namely on the essence of person-
hood which possesses a necessary link to freedom.lo
Different from understanding such essential and universal facts, as we pointed
out above, is the knowledge of the actual existence of freedom in us. Also actual
versus potential existence of freedom in us has different meanings, as we have seen
and found to be important for understanding the first kind of human dignity.
Human freedom does not have to exist in actu all the time nor does it exclude
many dependencies on conditions, situations, etc. It does not exclude either that cer-
tain external and irrational moments of action (for example, the question at which
exact time we decide to go to town, etc.) may be due to unconscious causes such as
commands given to a person under hypnosis. But the elementary fact of freedom re-
mains intact and is presupposed in all dependencies of our will on other conditions
and partial causes, and is clearly given to our experience and knowledge.
But before saying more on the actual existence of human freedom, let us return
to some questions pertaining to the intelligible essence of freedom. That person and
freedom are inseparable is one of those innumerable 'eternal truths' intended by

8 See on this Paola Premoli De Marchi, Etica dell'assenso. I distinguished in my Erkenntnis objektiver
Wahrheit, I, ch. 3, a conviction and assent which are the inevitable consequences of knowledge and an
assent which is a theoretical response and contains an element of freedom. Such a free assent in our
convictions and judgments plays a great role in Tadeusz Styczei's ethics. See on this also the idea of
real assent in John Henry Cardinal Newman's The Grammar ofAssent as well as the notion of 'freie
Anerkennung' in Tadeusz Styczei's paper delivered during the Fifth World Congress of Christian Phi-
losophy in Lublin, 1996.
9 To the objection that also determined persons would deserve respect and belong to 'the kingdom of
ends', I would reply (a) that the other essential attributes of a person's being (for example intellect)
would also become impossible without freedom because they are held together objectively with free-
dom in the necessary essence of personhood, and (b) that if, per impossibile, human beings would re-
tain their intellect, feelings, etc., without freedom, while they would still deserve respect, would not be
persons because personhood is inseparable from the vocation to free acts and love which constitute the
raison d'etre of personhood and without which the perfection, vocation, and drama of being a person
and many other attributes of the person remain impossible.
10 See on this epistemology Adolf Reinach, "Uber Phiinomenologie"; Max Scheler, Der Formalismus in
der Ethik und die materiale Wertethik; Dietrich von Hildebrand, What Is Philosophy?; Josef Seifert,
Erkenntnis objektiver Wahrheit; Fritz Wenisch, Die Philosophie und ihre Methode.
 192 CHAPTER 4

Augustine's tenn 'rationes aeternae'.l1 A being who would not be free, and who
could not, at least potentially, use his freedom, could not possibly be a person; for in
a being deprived of freedom also the other essential marks of personhood would col-
lapse. Freedom in the strong metaphysical sense of real and ultimate freedom, and
not only some subjective experience of freedom, belongs even to the very core of
the essence of personhood. 12
To say this, and not to restrict this remark to human persons only but to extend it
to all persons, implies one of the crucial discoveries of metaphysics which justifies a
brief deviation from a purely ethical discourse in order to grasp the ontological foun-
dations of freedom so important for medical ethics, as we have found in the first sec-
tion of chapter 3 dedicated to medical ontology.
Also the reader who is primarily interested in bioethics, and therefore might be
tempted to skip the following section on the ontology of freedom, might do well to
consider, however, that many philosophical themes that are not related directly to
bioethics prove in the long run essential for it.

1.2. A Metaphysical Detour for Those Readers Who Are Interested in the Ultimate
Foundations of Medical Ethics: Some Elements ofa Metaphysics ofHuman
Freedom and Answers to Objections against the Existence ofHuman Freedom

As we have discussed in chapter 1 and will see later and in volume II of this work,
when discussing euthanasia and other issues of medical ethics, there are important
questions of medical ethics which are not independent of whether or not God exists
and of whether or not he alone possesses certain rights over human life and death,
which no human person may arrogate to herself. But God enters medical ethics not
as a mere abstract anonymous absolute being of any sort and description, on which
all contingent beings (i.e., beings whose existence is not necessary) depend, but only
as a personal being who alone has any relevance for ethics. Moreover, to be con-
cerned with the concrete medical ethical issues or to be 'Lord over life and death,'
God has to be a personal being and therefore free. Hence the question of whether
freedom can be attributed in a real, and not only a poetic and metaphorical, sense to
God, belongs to the crucial metaphysical foundations of medical ethics and of ethics
in general.
But freedom can solely be attributed to God if it is not a mere inner-worldly hu-
man quality but if it rightly can be attributed to God. But this is only possible if free-
dom belongs to what one might call a 'pure perfection', that is, a quality that is not
essentially limited but absolutely speaking good and only for this reason attributable
to God who cannot stand 'above' freedom and above good and evil but embodies
freedom and moral goodness in the highest possible immeasurable measure. For this
reason, at least a short investigation of whether freedom, and hence also personhood,
belongs to the absolute being is part of the metaphysical foundations ofbioethics.

II For example, in his De Libera Arbitrio II, or in his famous Quaestio "De Ideis" (contained in the 83
Questions on Diverse Subjects).
12 See on this notion of the 'core of the essence' some works by Roman Ingarden, Jean Hering and oth-
ers on 'essences' as well as my "Essence and Existence, "and Sein und Wesen, ch. \, where I discuss
these works as well as the issue of essence at length.
 FREE CHOICE AND THE ENDS OF MEDICINE 193

I will try to defend the following thesis: Freedom (as well as personhood) is a
pure perfection and thus not an essentially limited 'categorial' attribute l3 valid only
for the world or for human persons. It is thus a 'transcendental' in the Scotist sense
of this term, although freedom does not exist in all beings. 14 In other words, the
'transcendental' character of an attribute can not only be constituted by the fact that
no entity can be without it, as is the case with the traditional so-called 'transcenden-
tals' (being, essence, something, unity, truth, goodness, and beauty). These are abso-
lutely universal properties of finite and infinite beings, and of entities of all cate-
gories and ontological regions, precisely in virtue of being properties that belong
analogously to everything that is. For this reason, these 'transcendentals' in the tra-
ditional sense, i.e., those properties which are coextensive with being, are the objects
of extremely abstract concepts in which one prescinds from all the differences be-
tween stones, frogs, human persons, angels, works of art, God-all of which possess
these 'transcendental properties', although only in an analogous sense. In virtue of
the infinity of their extension, the content of these transcendental properties of being
(if one .does not consider them with a view to their higher, archetypal, or absolute
embodiment, but in their transcendental character coextensive with being) is very
small-in order to remain applicable to stones, cows, persons, anQ God. Of course,
the 'abstract object' of the transcendental notions of 'being', 'unity', 'truth', etc., is
never real in its abstractness as correlate to the logical content of the transcendental
concepts. Rather, these transcendental properties can only be realized in concrete en-
tities and on different levels of being.
But when we turn to moral goodness, etc., we do no longer consider goodness in
its transcendental character that is coextensive with being. And yet, also freedom
and moral goodness are transcendentals in the sense of not being essentially limited,
in the sense of being pure perfections.
What is most significant about these transcendental properties then is not the fact
that they are coextensive with being but rather the fact that they are free from the
limitations andfinitudes that belong to certain regions of being only. What accounts
for the really significant 'transcendental' character of an attribute is the fact that it is
a 'pure perfection' (either because of its absolutely universal character of the tradi-
tional transcendentals or for other reasons). This all-decisive character of 'pure per-
fections' is the only point of view which Duns Scotus's revolutionary doctrine ofthe
transcendentals accepts as criterion for transcendentality, which gives rise to a new
concept of 'transcendentality' that identifies at the same time the chief reason for the
significance of the traditional 'transcendentals ': namely, that they are free from the

\3 I use this tenn 'categorial', now commonly used to designate some restricted sphere of being and acts,
equally in a restricted sense, although also some so-called 'categories', for example substance, are
likewise 'pure perfections'. Therefore, this use of 'categorial' in contradistinction to 'transcendental'
is misleading. This difficulty can be solved and the respective unclarity removed by distinguishing
two ontological meanings of 'transcendental' (both opposed to Kant's subjectivist use of the tenn)
and, with Duns Scotus, four kinds of 'pure perfection'. We will develop this in the main text. See
Allan B. Wolter, The Transcendentals and their Function in the Metaphysics o/Duns Scotus (St. Bo-
naventure New York: Franciscan Institute Publications, 1946).
14 This would be considered a condition of a 'transcendental' by Thomas Aquinas. See Thomas Aquinas,
Quaestiones Disputatae de Veritate, and Allan B. Wolter, op. cit. See also Josef Seifert, Essere e
persona, ch. 5.
194 CHAPTER 4

inherent ontological and axiological limits of regional, purely categorial or 'region-

al'ls attributes of being.
This all-decisive character of the traditional transcendentals, and of other attri-
butes, as pure perfections can be characterized in the following way: (a) that it is ab-
solutely better to possess them than not to possess them, for whatever reason;16
(b) that all these attributes (pure perfections), in logical consequence of this their
first and evident characteristic, must be compatible with each other (for otherwise a
contradiction would follow: Pure perfection A, for example being, would be both
absolutely better to possess, because it is a pure perfection, and absolutely better not
to possess, because it would be incompatible with the possession of pure perfection
B, for example wisdom); and that (c) they, and only they, admit of absolute infinity,
nay, are even only themselves when they are infinite (each finite form and limit tak-
ing away from the fullness of what formally constitutes them, from their ratio for-
malis). For our purposes here we may prescind from other marks of the pure perfec-
tions.17
In all of these respects the pure perfections (which Anselm of Canterbury formu-
lated for the first time quite clearly18 but which the Pre-Socratic Xenophanes had for
the first time identified as a crucial topic for metaphysics and philosophy of God)
differ from the 'mixed perfections' or the essentially limited beings and natures.
These (such as being gold or having any other specific character of animals, plants,
or creatures) are only good from a certain point of view, they are often incompatible
with each other, and they do not admit of absolute infinity.
Precisely for this reason only the pure perfections, and all of them, are truly tran-
scendental, i.e. they transcend all limits of the single spheres and limiting categories
of being, in virtue of their character as pure perfections. Now, while all transcen-
dentals in the traditional sense are also pure perfections, because their being in all
spheres of being guarantees their character as pure perfections, not all pure perfec-
tions are transcendentals in the traditional sense. Life and all essential characteris-
tics of personhood are not transcendental in the traditional sense but are also pure
perfections and thus free of the inherent limitations of finite beings, a fact that con-
stitutes the most essential feature also of the traditional transcendentals, in fact, their
very transcendentality consists chiefly in this very fact. Not above all because of
their character as 'universal properties of all beings' but because of their nature as
pure perfections the traditional transcendentals (those co-extensive with being in
Scotus's terms) are without any limits and can therefore be truly attributed to God.
Again: This character of being free of all inherent and essential limitations and
therefore attributable to God constitutes the most significant reason for their tran-

15 This notion is used by Edmund Husserl. See Edmund Husseri, Ideen zu einer reinen Phiinomenologie
und phiinomenologischen Philosophie I, Husserliana Bd. 3, ed. H. 1. Van Breda, hrsg. v. W. Biemel
(Den Haag, 1950).
16 On this whole topic of the pure perfections and for the reasons, discovered by Scotus, why this addi-
tion is necessary, cf. Allan B. Wolter, The Transcendentals and their Function in the Metaphysics of
Duns Scotus. Cf. also my Essere e persona, ch. 5.
17 Such as their 'simply simple' (simpliciter simplex) character and their participatability to more than
one single subject or hypostasis. Cf. on this also my "Essere persona come perfezione pura."
18 In his Monologion, ch. 15.
 FREE CHOICE AND THE ENDS OF MEDICINE 195

scendentality, so much so that we could follow Scotus and define transcendentality

solely in these terms.
This great revolutionary discovery of Anselm, in the refmements added by Duns
Scotus's teaching on the transcendentals (which are only implicit in Saint Thomas's
treatment of the divine names, where, however, some other refinements of Anselm's
discovery, touching the id quod and id quo distinction, are found), is the condition of
the possibility of a personalist metaphysics. For only a metaphysics of the pure per-
fections, and their clear distinction from the transcendentals which are coextensive
with being, allows us to attribute to God not only the most universally shared prop-
erties of being, goodness, etc., but also life (which is not shared by all beings) and
above all personhood, freedom, knowledge, wisdom, justice, and love (which exclu-
sively persons possess). While these higher attributes of life and personhood, inclu-
ding freedom, are not common to all things, they are nevertheless absolutely better
to possess than not to possess, as the great Anselm put it,19 and therefore they are
just as attributable to the absolute being and to the divine persons as the transcen-
dental properties that are coextensive with being. A metaphysics which would re-
gard personhood and freedom only as categorical inner-worldly properties would de-
stroy the foundations of a personalist metaphysics and imply an agnosticism regard-
ing the absolute being, and at any rate provide no metaphysical justification for the
fact that the human person, and not abstract being or goodness as such, is the imago
Dei.
All of this can only be understood and accepted in its truth on the basis of an im-
plicit or explicit metaphysical intuition of the following content: The pure perfec-
tions whose possession is absolutely speaking better than their non-possession for
whatever reason, include-besides such transcendentals which are common to all
beings--others which belong only to some innerwordly beings and to God (such as
life or freedom), and still others which are exclusively divine perfections such as
omniscience or necessary real existence. And these are not less 'transcendental' than
those which are coextensive with being but are, on the contrary, the noblest kinds of
the transcendentals, namely the ones in which the universal 'co-extensive' transcen-
dentals (of goodness, being, etc.) find a much higher embodiment and which are
nevertheless in their own nature (of justice, life, personhood) irreducible to the more
universal 'co-extensive' ones. And for this reason of their nobility, not because ofan
inherent limitation, the intrinsically highest and noblest pure perfections cannot be
shared or possessed in a limited form by all beings but only by the higher ones
which alone can possess those pure perfections which lower beings cannot even par-
ticipate in. In other words, personhood and freedom are not categorial contractions
and limitations of being because they are not found in all things, but they are pure
perfections which are fully themselves only in their infmite divine gestalt and be-
long for this very reason much more fully and literally speaking to God than to us,
whether they are co-extensive with being or not: God alone Is HE WHO IS, Being in
the purest sense, but also he alone knows, and is wise and just in the fullest sense.
The absolute fulfillment of the ratio formalis of all of these attributes, which are

19 Ibid., ch. 15.

196 CHAPTER 4

pure perfections, is only found in God. They are not intrinsically limited as all spe-
cies of plants and animals, and as even human and angelic natures.
Only this rational metaphysical intuition, when it is applied to the highest pure
perfections found in the world, namely to personhood and personal attributes such as
freedom, allows us to attribute these to God and to grasp, with Julio Teran Dutari
and Erich Przywara the relation of the human person to the supreme being as a Frei-
heitsentsprechung (as a dialogical interrelation of free subjects).
But not only God, also the human person is free, even though in a more limited
mode. In fact, every person is free and would not be a person without being free, an
insight the full metaphysical weight of which only a more extensive metaphysics of
pure perfections could show fully.20 But even in showing through this brief analysis
that freedom and personhood belong to the absolute Being, who must embody all
pure perfections in the supreme degree, we have laid an important foundation of
medical ethics.

1.3. The Nature and Real Existence ofHuman Freedom Can Be Known with
Indubitable Certitude
We have seen that human freedom is an absolute condition of morality. Freedom
alone allows the person-in actuality or at least in principle-to elicit free acts, to
determine herself in different ways and on different levels of her being, and to re-
spond in different manners to objects and persons. Above all, only freedom permits
the realization of the highest objective values in the universe, which cannot exist,
not even in God, except through freedom.21 Moral values and justice, whose essen-
tial link: to freedom Anselm expresses clearly in his magnificent formulation of jus-
tice as rectitudo voluntatis propter se ipsam servata (rightness of the will preserved
for its own sake), also in God require necessarily freedom and cannot exist except
through freedom: "One has ... to know that justice cannot exist except in the will if
justice is rectitude preserved for its own sake.',zz The highest morally good acts, jus-
tice, love, mercy, and countless others, though they are also dependent on many fac-
tors which are not within our free power,z3 can absolutely not exist without the free
acts or free cooperation of persons.
But freedom, as it is a condition of all moral values, is relevant for ethics not
only as to its essence but also as to its real existence in the human person. Therefore,
the question of the real existence of human freedom is decisive for ethics. To this
question we now turn.
Not only the intelligible essence of freedom, also its real existence in us is
known to us with certitude. Freedom is not a mere hypothesis or assumption. No, we

20 See also Josef Seifert, Gott als Gottesbeweis.

21 These various rational insights into the pure perfections and their relation to God constitute also the
basis of a truly personalistic interpretation of the ontological argument and of the content of id quo
maius nihil cogitari possit, which I tried to present in my Gott als Gottesbeweis, ch. II.
22 Cf. Anselm of Canterbury, De Veritate I, and the same author, De Conceptu Virginali et de Originali
Peccato ill; ii, 143, 16-17, where he says: "Sciendum [...Jest quia iustitia non potest esse nisi in vo-
luntate, si iustitia est rectitudo voluntatis propter se servata."
23 such as human models which inspire us or divine grace.
 FREE CHOICE AND TIlE ENDS OF MEDICINE 197

both understand what constitutes freedom and know indubitably the truth that we are
free. Augustine 24-as Rene Descartes2S or Hans Urs von Balthasar6 after him-as-
serts the truth that nothing is more evident to us than our freedom: Our very exist-
ence and conscious life are not more indubitably given, though perhaps more easily
understood, than our freedom. And indeed we know of our freedom with the same
type of immediate and reflective evidence with which we know of our own exist-
ence. 27 The awareness of our own free will-a knowledge that is so evident that it
cannot be deception-is part of the evidence of the cogito as unfolded by Augus-
tine. 28 And the existence of free will in us is so evident that its evidence in a certain
sense is more primary and indubitable than that of all other evident truths given in
the cogitO. 29 For even if we could be in error about all things, which is impossible,
Augustine says, it would still remain true that we do not want to be in error, and of
this free will we can have certain knowledge:
Likewise if someone were to say: "I do not will to err," will it not be true that whether
he errs or does not err, yet he does not will to err? Would it not be the height of impu-
dence of anyone to say to this man: "Perhaps you are deceived," since no matter in what
he may be deceived, he is certainly not deceived in not willing to be deceived? And if
he says that he knows this, he adds as many known things as he pleases, and perceives it
to be an infmite number. For he who says, "I do not will to be deceived, and I know that

24 Augustine, De Libero Arbitrio IT; De Civitate Dei V.

2S Rene Descartes, Discours de la Methode, in (Euvres de Descartes, ed. by Charles Adam & Paul Tan-
nery, vol. VI (paris: J. Vrin, 1982), pp. 1-78; Meditationes de Prima Philosophia, in (Euvres de Des-
cartes, ed. by Charles Adam & Paul Tannery, vol. vn (paris: J. Vrin, 1983), pp. 1-561.
26 See Hans Urs von Balthasar, Theodramatik II: Die Personen des Spiels, 1: Der Mensch in Gott (Ein-
siede1n: Johannes Verlag, 1976), pp. 186 ff. See also Balthasar, TheoLogik, Wahrheit der Welt, IT,
A. Wahrheit als Freiheit I (Einsiede1n: Johannes Verlag, 1985). In the Italian translation of this work
by Guido Sommavilla: Verita del Mondo. TeoLogica, vol. I (Milan: Jaka Book, 1987), see pp. 96 ff.
See also Hans-Eduard Hengstenberg, Grundlegung der Ethik (Stuttgart: Kohlhammer, 1969),
pp. 11 ff., where he analyzes a similar ineluctable givenness of moral good and evil, a sort of cogito-
argument for the givenness of good and evil.
27 Investigating this matter more closely, we could distinguish between the evident givenness of freedom
on different levels: (a) in the immediate inner conscious living of our acts; (b) in what Karol Wojtyia
calls 'reflective consciousness' (which precedes the fully conscious self-knowledge); (c) in explicit
reflection and self-knowledge properly speaking in which we make our personal freedom the explicit
object of reflection; (d) in the insight into the nature of freedom, an insight which grasps the necessary
and intelligible essence of personhood, which is realized in each and every person; and (e) in the clear
and indubitable recognition of our personal individual freedom, an evident knowledge which depends,
on the one hand, on the immediate and reflected experience of our being and freedom, and, on the
other hand, on the essential insight into the eternal and evident truth of the connection between free-
dom and personhood.
28 See Ludger Holscher, The Reality o/the Mind. St. Augustine's Arguments/or the Human Soul as Spi-
ritual Substance (London: Routledge and Kegan Paul, 1986). See also the discussion of this in Josef
Seifert, Back to Things in Themselves, chs. 4-5.
29 Of course, this priority is not to be understood absolutely: for without the evidence of our existence
and thinking activity also our freedom and will could not be given. Nevertheless, Augustine's remark
is valid secundum quid, in the following sense: that if we assumed, per impossibile, that all other
truths given in the cogito would be doubtful, we could still be certain that we would freely want and
wish to avoid error and to reach the truth.
198 CHAPTER 4

I do not will this, and I know that I know this," can also continue from here towards an
indefmite number, however awkward this manner of expressing it may be. 30

And again:
On the other hand who would doubt that he lives, remembers, understands, wills, thinks,
knows, and judges? For even if he doubts, he lives; if he doubts, he remembers why he
doubts; if he doubts, he understands that he doubts; if he doubts, he wants (wills) to be
certain; if he doubts, he thinks; if he doubts, he knows that he does not know; if he
doubts, he judges that he ought not to consent rashly. Whoever then doubts about any-
thing else ought never to doubt about all of these; for if they were not, he would be un-
able to doubt about anything at all. 31

The evidence of this knowledge cannot even be refuted by any and all possible
forms of self-deception because these imply or presuppose already the evidence of
free will. l2 It is not possible in this context to discuss all the possible objections
against the evidence of this thesis and thereby bring more fully to evidence the indu-
bitable knowledge we can gain regarding our freedom.

1.4. Some Metaphysical Difficulties and Apories in Admitting Human Freedom and
Another Metaphysical Side-Trip to Support Additional Evidence o/the Truth o/Our
Knowledge that We Are Free

We have seen that the actual existence of freedom in us as well as the nature of free-
dom, and likewise the necessary state of affairs that moral values presuppose free-
dom in an ultimate metaphysical sense of the term, present themselves to our intel-
lect with indubitable evidence. And they are indeed so evident that no doubt of them
is justified; if we just look at the datum of freedom, both the real existence and the
nature of freedom as condition of all moral values disclose themselves to our intel-
lect clearly, lucidly, and indubitably.
Nevertheless, human freedom, Le., a freedom that necessarily includes the capac-
ity for free self-determination, poses profound metaphysical riddles precisely be-
cause it appears in a finite person; and these puzzles regarding freedom are so great

30 Augustine, De Trinitate XV, xii, 21 (The Trinity, translated by Stephen McKenna [Washington, DC:
The Catholic University of America Press, 1970], pp. 48~82):
Item si quispiam dicat, errare nolo; nonne sive erret sive non erret, errare tamen eum
nolle verum erit? Quis est qui huic non impudentissime dicat, Forsitan falleris? cum
profecto ubicumque fallatur, falli se tamen nolle non fallitur. Et si hoc scire se dicat,
addit quantum vult rerum numerum cognitarum, et numerum esse perspicit infi-
nitum. Qui enim dicit, Nolo me falli et hoc me nolle scio, et hoc me scire scio; jam
et si non commoda elocutione, potest hinc infinitum numerum ostendere.
31 Augustine, The Trinity X, 15.
Vivere se tamen et meminisse, et intelligere, et velle, et cogitare, et scire, et judicare
quis dubitet? Quandoquidem etiam si dubitat, vivit; si dubitat, unde dubitet, memi-
nit; si dubitat, dubitare se intelligit; si dubitat, certus esse vult; si dubitat, cogitat; si
dubitat, scit se nescire; si dubitat, judicat non se temere consentire oportere. Quis-
quis igitur aliunde dubitat, de his omnibus dubitare non debet: quae si non essent, de
ulla re dubitare non posset.
l2 Cf. D. von Hildebrand, "Das Cogito und die Erkenntnis der realen Welt"; Josef Seifert, Back to
Things in Themselves.
 FREE CHOICE AND THE ENDS OF MEDICINE 199

that they could call into question our certitude if we made the evidence of the
knowledge of our freedom dependent on the solution of these apories. But the sheer
existence of innumerable difficulties does not justifY a single doubt if our evidence
is clear enough.'J Even if, however, a solution to these puzzles is as little required as
a condition of letting ourselves be fully convinced by the mentioned evidence, as the
solution of all puzzles our sense perceptions pose to the intellect is a condition of
trusting our seeing a train which we avoid in order to save our lives, the intellect
wants to find some answer to these puzzles.
Human freedom, the necessary condition of all moral values, is one of those
amazing miracles of being which, the longer you think about them and marvel at
them, the more incomprehensible they become. By the astonishing traits of human
freedom numerous and apparently insoluble apories are raised which seem to chal-
lenge the very existence and non-contradictoriness of freedom if we cease to look at
the evidence of the nature and existence of freedom and begin to ponder these diffi-
culties which our mind is too weak to solve entirely.
Aristotle formulates one of those metaphysically absolutely astonishing features
of freedom when he says, as we recorded before, that due to our freedom we are "the
lords over the being and the non-being of our actions."34 Is it not a prerogative of
God to be Lord over the being and the non-being of a thing? Does being lord over
being and non-being not imply some-exclusively divine-creation from nothing,
some absolute fiat (there shall be ... ), which brings forth the being of something
from nothing?
Does Aristotle attribute to the human will then the bringing forth of an act by a
simple inner word of a fiat, without the person being determined to such a fiat by
any cause other than her free center itself? Can there even be in any finite person
such a god-like quality as to be the lord over the being and non-being of something?
The answer imposes itself on us: While we cannot create from nothing and have re-
ceived both our being and our free will, freedom, inasmuch as it becomes an abso-
lute beginning of free acts of the person, is truly a god-like attribute of man which
can be described in terms of St. Augustine's remarks on the free will: "for if we will,
it is; if we will not, it is not . .. "J5 Kant, too, when he expresses the profound puzzle
of such an absolute beginning of causality in freedom, refers to this relationship-
mentioned by Plato--between the essence of freedom and a first mover.36 But it cer-
tainly does not constitute a valid objection against freedom that it has a character
truly analogous to God's creating entities from nothing, at least as long as the essen-
tial distinction between limited human and infinite divine freedom is maintained.

33 This has been stressed by John Henry Cardinal Newman.

34 Aristotle, Eudemian Ethics II, vi, 8-9; 1223 a 3 ff. See also Aristotle, Nichomachean Ethics III; and
Magna Moraiia, 87 b 31 ff., especially 89 b 6 ff. Aristotle could hardly be more explicit on freedom
as he is in these texts, calling the free agent first principle, cause, lord, master ofthe action.
35 (Emphasis mine). The full text reads: "for we do many things which, if we were not willing, we
should certainly not do. This is primarily true of the act of willing itself-for if we will, it is; if we
will not, it is not ... "
Augustine continues a little further down: " ... Our wills, therefore, exist as wills, and do them-
selves whatever we do by willing, and which would not be done if we were unwilling." Augustine,
The City of God.
36 Kant, Critique of Pure Reason, B 478.
200 CHAPTER 4

But the admission of an astonishing creative power of human freedom and the
discovery that even immense difficulties do not justify a doubt of evident data such
as freedom, while they provide some relief to our puzzle-plagued mind, does not
solve all the metaphysical difficulties posed by this creative character of freedom.
The difficulties in fact greatly increase when we take into account the mysterious
difficulties that accompany the relationship between human freedom and human de-
pendence on causes. Does not every change require a cause? But if this is true, the
free act that involves a change also requires a cause-which in turn seems to contra-
dict freedom. Does not a real and ultimate beginning of causality in the free agent
himself contradict the principle of causality, which states that "every contingent be-
ing and every change must have an efficient cause through the power of which it is
or comes to be"?
This difficulty remains disturbingly puzzling even if we do indeed have a good
reply: the absolute beginning of causality in the free agent only apparently contra-
dicts the principle of causality.37 For in reality, there is absolutely no contradiction
here; on the contrary, free action is an archetypal case of efficient causality and the
only type of cause which can provide a beginning and absolute explanation of effi-
cient causality because it does not refer to another more primary cause which pro-
duces it. Thus it certainly does not refute freedom that it fulfills the principle of effi-
cient causality in an exemplary way and constitutes a prime example of efficient
causality and the only ultimate explanation thereof, without which all other efficient
causes remain unintelligible because they send us eternally back to another cause
that causes them and can never explain any beginning and principle of efficient cau-
sality.38
But while the principle of causality in no way contradicts freedom, certain deep
problems of an ontology of freedom in its relation to causality remain. Because these

37 Kant is so puzzled by this apparent contradiction that he thinks that we are led to an antinomy here,
having both to assume freedom and having to deny it at the same time. He writes on this enigma of
freedom:
We must therefore admit ... an absolute spontaneity of causes, by which a series of
phenomena ... begins by itself; The transcendental idea of freedom is ... that of the
absolute spontaneity of action, as the real ground of imputability; it is, however, the
real stone of offence in the eyes of philosophy, which finds its insurmountable diffi-
culties in admitting this kind of unconditioned causality ... a faculty of spontane-
ously originating a series of successive things or states ...
I. Kant, Critique of Pure Reason, B 472, 474, 476. See on the solution of the Third Antinomy
Josef Seifert, Uberwindung des Skandals der reinen Vernunft, and also "Das Antinomienproblem als
ein Grundproblem aller Metaphysik: Kritik der Kritik der reinen Vemunft."
38 The self-moving of free acts and free subjects, this having the source of motion within the subject-
person of action herself, makes truly that free acts stand within one's own power, instead of being
moved from the outside, caused by another cause, impressed also Plato so much in the Phaedrus that
he said that such a self-moving soul must be beginningless, not deriving its motion from another
source but being its absolute origin. And he goes on to describe the soul as if it were beginningless,
eternal, the absolute source of movement, divine (Platon, Phaedrus 245c 5 ff.). Nevertheless, in the
semi-creationism proposed by Plato in the Timaeus, Plato holds that also the human soul is created by
the demiurg. See the justification of the demiurg as an important element of Plato's metaphysics (and
not a myth as most interpreters thought) in the second volume of Giovarmi Reale and Dario Antiseri,
Storia dellajilosojia antica (Brescia: Editrice La Scuola, 1997; now also in Polish), and in Giovarmi
Reale, Verso una nuova interpretazione di Platone, 20th ed. (Milano: Jaca Book, 1996).
 FREE CHOICE AND THE ENDS OF MEDICINE 201

problems are, on the one hand, crucial for the foundations of an ethics, and, on the
other hand, lead us beyond our ethicallbioethical discussion, I will put them in small
print and the reader who is exclusively interested in the ethical questions, may skip
this part of our analysis.

While the above and, I take it, correct statement of the principle of causality in no wise
contradicts freedom, the false Kantian formulation of it that claims that "each change follows
upon another change according to a necessary law" and leads Kant to the construction of an
opposition between causality and freedom in the Third Antinomy of the Critique a/Pure Rea-
son, does. For the alleged principle that "every change follows upon another change accord-
ing to a necessary law" applies perhaps to physical and chemical reality but certainly not uni-
versally and not to persons. If it were to apply to persons and human acts it would indeed con-
tradict freedom, but the following upon each other according to necessary general laws, which
is characteristic of causal sequences in the material universe, in no way is of the essence of ef-
ficient causality, which is much more perfectly embodied in free acts. 39
But the metaphysical difficulties associated with human freedom are far from being over-
come by these insights. For the kernel of the difficulties is precisely how this more perfect
form of being a free efficient cause of acts can be compatible with our total dependence on
natural causes responsible for our generation and growth and with the metaphysical cause
which our being requires because of its non-necessity. For this our radical dependence on
causes precisely seems to forbid the existence of freedom in us. How can a totally dependent
and therefore completely god-unlike being be so god-like as to be free?
The extent to which this self-engendering of acts, this being the principle of actions and of
causality, is god-like becomes apparent when we consider that it is almost unthinkable that
man be both a creature and free. This leads us to a real and profound objection against free-
dom that does not touch the relationship between freedom and the principle of causality but
between freedom and the total dependence of the human person on divine creativity. How can
a radically dependent creature be free? Must not omnipotence, if it creates us, completely
cause our being and everything that is in us? Is not such a creaturely dependence on God,
then, a contradiction to freedom? Is not even the foreknowledge of-free acts incompatible
with freedom, as Cicero holds in De Natura Deorum? Again and again in the history of phi-
losophy, atheism or at least the denial of fundamental properties of the divine being went
hand in hand with the acknowledgment of freedom-precisely because freedom is so god-like
and appears to be impossible in a creature. 40
Augustine is profoundly concerned as well with the problem of atheism as consequence of
freedom. He has to introduce many distinctions between different kinds of necessity and to
develop his fine philosophy of the 'order of causes' in order to explain this puzzle how free-
dom can exist in a creature whose acts are foreknown by God and who is nonetheless free. 41
Soeren Kierkegaard likewise struggles in his philosophical diaries with this problem of how
God can give freedom to that which he creates. Kierkegaard solves this enormous difficulty,
which we could truly call a (philosophically given) 'mystery of metaphysical freedom', in a
beautiful way by saying that omnipotence does not extinguish human freedom. On the contra-
ry, precisely this-the creation of freedom-requires omnipotence. No finite power could cre-

39 See my detailed exposition of this in Josef Seifert, Uberwindung des Skandals der reinen Vernunft.
Die Widerspruchsfreiheit der Wirklichkeit - trotz Kant.
40 Thus the radical skeptic Cameades and the atheist Epicurus were great philosophers of freedom, in-
sisting on man's sovereignty and independence from the gods. They were atheists in part precisely in
order to save freedom. Something similar could be said of one motive of Sartre's atheism.
41 Augustine, The City ofGod V, 8-11, especially V, 9. See also Augustine, De Libero Arbitrio II.
202 CHAPTER 4

ate a free being. Only all-powerful causality can produce something so tremendous, some-
thing so incredible-a free being:

... all finite power makes dependent; only omnipotence can make independent, can cre-
ate from nothing that which subsists in itself, by omnipotence taking itself constantly
back again ... without abandoning the slightest part of its power ... this is the incom-
prehensible thing that omnipotence cannot only bring into being the most imposing
thing, the world's visible totality, but also the most fragile thing of all, a being that is in-
dependent vis-a-vis omnipotence. Hence that omnipotence, which can lie so heavily on
the world, can also render itself so light that that which became (through it) receives in-
dependence. 42

Another metaphysical puzzle, and even what seems to be a contradiction, appears to fol-
low from freedom: that the free agent both determines himself and does not determine himself
but is instead determined by himself In being the lord over the being and the non-being of his
actions, the free agent has also the equally amazing power of self-determination, of being in a
sense the causa sui. For in engendering acts, in speaking a 'fiat', which is preceded by a caus-
al nothing (i.e., which is not caused and determined by a preceding cause), man both deter-
mines himself and is determined by himself, 'creates himself (his own act)' and is turned
good or evil by himself,43 dominates himself and is being dominated by himself He becomes
as it were subject and object at once, being he who determines and also he who is determined,
he who governs and he who is governed, as Karol Wojtyla so clearly expounds. 44 This most
amazing fact would involve a contradiction indeed were it not clear that it cannot be in one
and the same sense that man determines himself and does not determine himself (but is deter-
mined). But this double aspect of freedom is not a contradiction if the person both determines
herself and does not determine herself (being determined by herselt}---but in different senses.
One could also raise another objection against freedom in terms of the principle of suffi-
cient reason. In effect, the first conscious discovery of this principle of sufficient reason by
Leibniz led him to formulate it in a faulty way that indeed contradicts freedom, at least the
freedom of choice. Correctly stated, however, this principle of sufficient reason states that
"every being (not only contingent ones and changes, as in the case of the principle of [effi-
cient] causality) [or change] must have a sufficient reason---either within or outside itself-
which adequately explains the existence and essence of that being [or change] in all its as-
pects." This principle, which in its correct statement does not contain the idea of a perfectly
good or necessary cause (as Leibniz's interpretation of this principle in the light of the 'best
possible world' thesis) does not contradict freedom because the being of the person and her
free power and will are precisely the sufficient explanation of free action, or at least-in finite
persons-a significant part of the sufficient reason of free acts. 45
Yet also a clear distinction between the principle of sufficient reason and the principle of
causality does not dissolve the apories and astonishing characteristics of freedom. For who

42 Soeren Kierkegaard, Papirer VIT, I, 141. See also a similar text in R. Descartes, Principia Philoso-
phiae, in (Euvres de Descartes, publiees par Charles Adam et Paul Tannery, vol. Vill-I (Paris:
Librairie Philosophique J. Vrin, 1982), I, 40 ff.
43 Of course, the positive and the negative cases are very different here: while we can attribute the evil
solely to our own will (and to other evil wills and factors which influence us), any good will (at least
in a supernatural sense) cannot be solely attributed to the human will but is also the work of God and
his grace, as Christians and other theists believe. Nevertheless, there is a specifically creative dimen-
sion of our freedom also and exclusively in the positive use of the will for the good which in a true
sense is the cause of the goodness of the person.
44 Karol Wojtyla, The Acting Person; cf. also the corrected text, authorized by the author (unpublished),
Library of the International Academy of Philosophy in the Principality of Liechtenstein, Vaduz.
45 Free acts in finite persons require of course also the action of the infinite divine being.
 FREE CHOICE AND THE ENDS OF MEDICINE 203

can penetrate the admirable nature of this free engendering and this independence and self-de-
pendence of man as free agent?
But if one delves into the different features of freedom, one will find no evidence for the
non-existence of human freedom but the clear evidence of man's spiritual and substantial soul
as a necessary condition of human freedom. For it is absolutely impossible that any material
tissue of the brain, any product of natural or evolutionary processes could be free. A free act
can only proceed from an indivisible, spiritual person, from man's soul as a spiritual and sub-
sisting (substantial) reality. No neurons in the brain or epiphenomena of brain processes can
explain freedom. 46

1.5. Did Neurological Evidence Refute Freedom?

Another metaphysical and scientific problem, and even an apparent impossibility and contra-
diction inherent in the idea of human freedom relates to the seeming a priori and empirical
impossibility that human beings, who depend on physical events in their brains, could be free.
For in the physical and biological world all changes do seem to be dependent on preceding
events that determine them. Moreover, such a dependence of free acts on preceding brain
events seems to be confirmed by empirical experiments that had been designed precisely to
demonstrate empirically the existence of human freedom but then seemed to speak against
freedom, at least against any positively initiated free acts.
Benjamin Libet (preceded by Komhuber & Deecke, 1965, and Kornhuber, 1984) has done
famous neurological experiments, some interpretations of which called freedom into question
and proposed a certain deterministic philosophical interpretation of the empirical results Libet
and others obtained in their experiments. 47
While Libet himself originally intended to defend the empirical evidence of human free-
dom, he ended up by believing that by them one can only gain evidence of a purely negative
or controlling role of human freedom. 48 He arrived at the following conclusion:
I have taken an experimental approach to the question of whether we have free will.
Freely voluntary acts are preceded by a specific electrical change in the brain (the
"readiness potential", RP) that begins 550 msec. before the act. Human subjects became
aware of intention to act 350-400 msec. after RP starts, but 200 msec. before the motor
act. The volitional process is therefore initiated unconsciously. But the conscious func-
tion could still control the outcome; it can veto the act. Free will is therefore not ex-
cluded. 49

In the light of this summary of his main results, Libet affirms freedom, but merely as a
reasonable (and never scientifically falsified) hypothesis. Thus he defends freedom, but not as
an evident truth as we sought to establish it, nor does he affirm its (in my opinion unre-
nounceable) positive role of initiating free acts. Rather, he affirms freedom (a) only hypothet-
ically and (b) only with respect to its controlling, modifYing, and vetoing function that may
change human acts or prevent that they occur but does not positively bring them into exist-
ence.

46 See on this Josef Seifert, Leib und Seele; see also my Das Leib-Seele Problem und die gegenwiirtige
philosophische Diskussion.
47 See Benjamin Libet, "Do We Have Free Will?," in: Robert Kane (ed.), The Oxford Handbook ofFree
Will (Oxford: Oxford University Press, 2002), pp. 551-564.
48 See also Benjamin Libet, Anthony Freeman, and Keith Sutherland (eds.), The Volitional Brain. To-
wards a Neuroscience ofFree Will (Thorverton: Imprint Academic, 1999).
49 See Libet, "Do We have Free Will?", ibid., p. 551.
204 CHAPTER 4

Libet's experiments involved freely chosen, deliberate and intent-full actions, during and
before which the electric events in the brains of the acting persons were examined carefully. If
one interprets the outcome of these experiments correctly, I argued elsewhere,50 Libet and
others provided a series of empirical evidences for freedom by means of modern brain re-
search. These evidences throw not only further light on the distinction between mind and
brain but also prove an active influence of the mind and of inner mental activity on the body
and on the brain.
Libet, Eccles, and others proceeded from our immediate experience that we can influence
and in fact engender many of our bodily actions through our conscious activity, for example,
when we speak or when we perform other volitional bodily activities. We are convinced that
these actions proceed from freedom. We presuppose this in daily life whenever we hold
someone morally or legally responsible. 51
In order to verify this assumption empirically, various experiments with persons who
moved their limbs willfully have been conducted. These experimental studies showed an em-
pirical result that the philosopher of freedom could have expected but that is nevertheless
highly remarkable. Upon acting voluntarily-to be more precise: within a half second (550
ms) preceding a conscious voluntary action of a person who, for example, actually moves her
finger-"observable and completely new modular brain-patterns of excitation and motion"
are built up, which proceed slowly from the so-called 'readiness potential,.52 When these mo-
tion patterns reach a certain measure of coordination and neural excitation, the bodily motion
actually takes place.
Now, at first sight and at a rather commonsensical interpretation, this observation gives
witness to freedom. For even the most careful screening of the brain of persons who allowed
such experiments to be conducted could not discover any preceding patterns of motion and
uncommon degrees of excitation in brain cells or modules of neurons until the free action had
been decided to take place. In a word, there was not any excitation preceding free acts that
could have explained the arising of the 'readiness potential' (RP) and especially those excita-
tory patterns that preceded and accompanied the bodily motions and movements. Moreover,
this build-up of the RP took place at the same intervals exactly when (before) the physical ac-
tion took place and in no way randomly with the experience of the free act following such a
random arising of the RP.
At this point, however, we have to address the argument against any positive human ini-
tiation of free acts (and in favor of a merely controlling and negative vetoing power of free-
dom), which Libet himself draws as conclusion from his experiments. As we have noted,
Libet felt forced by the results of his investigations to restrict the role of freedom to a mere
Veto and to a very limited controlling or steering influence on positive volitional decisions
and actions. The arising of positive free acts and movements itself would be neurologically
conditioned and biologically or chemically caused; so-called free acts would be born in the
brain and in unconsciousness and explicable neurologically, while they could be vetoed or
modified by free will.

50 See Josef Seifert, Das Leib-Seele Problem und die gegenwiirtige philosophische Diskussion.
51 Cicero and Augustine insisted on this very forcefully. See also the interesting witness of this fact of-
fered by a materialist determinist, who writes that whenever he punishes his child, he assumes the
child's freedom, and thus contradicts his theory according to which freedom is just an illusion. See the
article of Hubertus Breuer on Daniel Wegener, "Gedankenschranken", Gehirn und Geist. Das Maga-
zinfor Psychologie und Hirnforschung, 112003: 52-54.
52 See Sir John Eccles, The Human Mystery, pp. 214-217. See also Karl R. Popper and John C. Eccles,
The Self and its Brain, pp. 283-285, 291, 293, 364, 365, particularly the phenomenological grasp of
the phenomenon of the freedom of will, p. 275 ff., 472 ff.
 FREE CHOICE AND THE ENDS OF MEDICINE 205

The experiments of Libet and similar other ones, however, show in reality only the fol-
lowing: consciousness of the will (decision) to act precedes the actual acting by about 200
milliseconds. The so-called readiness-potential, however, begins 550 milliseconds prior to the
actual acting and before the consciousness of 'now acting'. Also the actual consciousness of
acting occurs only ca. 250 milliseconds after the beginning phases of the readiness potential.
These facts then need an interpretation and explanation, which only thought and philo-
sophical distinctions, and in no way empirical experimental evidence can provide.
Libet philosophically interprets the empirical results he obtained by acknowledging only
the possibility of a vetoing or controlling, but not of a positively initiating, role of free will as
being compatible with the outcome of his experiments. It is clear, however, that this interpre-
tation of his experiments entails a number of philosophical assumptions that are not results of
empirical research. Moreover, they are partly unclear and partly clearly erroneous. They are
subject to a number of criticisms such as the following ones:
A. We have to criticize first of all quite generally Libet's interpretation of the outcome of
his own experiments for being based on extremely vague methodological ideas concerning the
nature, certainty obtained, and role of philosophical methods, and concerning nature and role
of the scientific empirical method he uses.
Moreover, the autonomy, or dependence on philosophical premises, of empirical tests of
freedom are not clear in his writings. Do these empirical 'tests of freedom' depend on philo-
sophical insights and distinctions, as I would assert? Do they thus depend (a) already on gath-
ering, or only (b) on interpreting empirical evidences? Libet also fails to see what the general
role and limits of empirical and of philosophical research are in the exploration of freedom.
We can call all this a lack of philosophical foundations of the method of scientific knowl-
edge and of its interpretation. This general lack of epistemological clarity has many concrete
effects that need to be criticized.
B. For example, how can we test empirically in terms of milliseconds when exactly a con-
scious deliberate act begins---such as wanting to exclaim at the exact point in time at which a
fast -moving second hand oof a clock reaches 12: 1O:4? Perhaps we can measure by millisecond
the moment of the actual onset of physical movement, but the conscious act is wholly
different if we are not behavioristically confused. Measuring the exact time of initiation of the
will and of the conscious act to exclaim, however, is necessarily imprecise and could easily
explain the few milliseconds of the RP's preceding the physical action and the time the
examined person gives as the time of her conscious will to act. Even Libet confesses: "Ini-
tially that seemed to me an impossible goal.,,53 But later he believed he could overcome this
inexactitude by using clocks that had a sweep-second hand that moved much faster and bigger
than usual clocks (oscilloscopes).54 But how could the use of such clocks allow an exact
temporal measurement of so many free and conscious acts which neither the person in the
experiment nor Libet distinguish, as we shall see (under critique C)?
But with this inevitable inexactitude of measuring the arising of human actions by milli-
seconds Libet's whole philosophical interpretation of his experiments collapses because it
measures entirely different conscious and physical acts without distinguishing them and with-
out being aware of the clear impossibility of such a temporal localizing them in terms ofmilli-
seconds. The beginning of the first of the described conscious acts could exactly lie at or be-
fore the beginning of the build-up ofthe RP!
C. The serious inexactitude of measuring the onset of personal acts is particularly and
further evident when we consider that Libet partly entirely fails to distinguish clearly the great
variety of conscious acts found in the context of any free movement, partly distinguishes them

53 See Benjamin Libet, "Do We Have Free Will?", p. 553.

54 See Benjamin Libet, ibid., pp. 553 ff.
206 CHAPTER 4

in a very insufficient way. Let us then briefly distinguish the following series of entirely
distinct conscious acts that enter into any conscious action55 :
(I) There are the purely inner deliberations which nonnally precede free acts56 and which
seem to have no noticeable effects on the emergence of brain activity examined by Libet, be-
cause these acts precede and accompany the observation of the hands of the clock long before
deciding to exclaim and before the beginning of the readiness potential.
(2) There exists, in our example, the conscious act of free intention to callout at loud
voice when the hand will have reached the agreed upon second on the clock. Since this act
precedes the build-up of the readiness potential (RP) by far,57 it also seems to fail to have any
noticeable effect on the brain activity although it is clearly a free act and precedes the action
as well as the build-up of the RP.
(3) There is the act of concretely planning to shout at all, when to shout. Also this last
planning which in some ways concretizes the preceding free intention to shout precedes the
build-up of the RP by far and seems to faiJ to produce any remarkable physiological effects on
the brain although it is (a) clearly a free act and (b) an act that precedes the build-up of the
RP.
(4) There is also the act of starting to prepare to shout (getting ready to act). Why could
not precisely this free act that clearly precedes the action itself cause the readiness potential
(which would exactly correspond to the name RP)? And why could this free act of getting
ready to act not produce the readiness potential and precede, for example by one half second,
the actual shouting?
(5) There is likewise the act of concentrating very hard from the time on when the clock's
hand shows the preceding seconds or milliseconds, in order not to miss the previously agreed
upon moment for acting. Why should not this act of concentration have brain effects, some-
thing which seems clearly to be confirmed by brain research and by physiological tests of
chess players while they reflect on their next moves as well as by other persons who perfonn
the 'activity' that we nonnally describe as 'getting ready' (so important for 100 m runs or
other sports).
(6) Ther<: is furthennore, as a clearly distinct moment, the free act of the free concrete de-
cision to act within the next half second, for example, the decision of actually carrying out the
chess move (already decided on just before) on the chess board, or of shouting out loud after
seeing (in the next half second) the second-hand of the clock indicate the previously decided
second on the clock in which exactly we intend to start to act. This concrete decision to act
itself, since it involves a free energy geared towards moving and shouting, likewise precedes
the action and could easily contribute to the build-up of the readiness potential, as feelings of
anguish in the face of threats, etc., do. They give rise to all kinds of changes in brain activity;
why should then not a 'getting ready' lead to a Bereitschafispotential (RP)?
(7) Distinct from all these free acts is the reflective consciousness that I now want start to
shout or that I do indeed intend to move my hand, which is an entirely different cognitive act
that bends back on, and becomes aware of, my intentions to act.

55 Traces of much simpler distinctions are found in Benjamin Libet, "Do We Have Free Will?", p. 560:
We should also distinguish between deliberations about what choice of action to
adopt (including planning of when to act on such a choice) and the fmal intention
actually 'to act now' ....
56 For its careful analysis see Adolf Reinach, "Die UberJegung: ihre ethische und rechtliche Bedeutung
(1912/13)", in: AdolfReinach, Siimtliche Werke. Kritische Ausgabe mit Kommentar, Bd. I: Die Wer-
ke, Teil I: Kritische Neuausgabe (1905-1914), Teil II: Nachgelassene Texte (1906-1917), pp. 279-
311.
57 See on this Benjamin Libet, "Do We Have Free Will?", p. 560.
 FREE CHOICE AND THE ENDS OF MEDICINE 207

And this cognitive act of reflection,58 at least at a time at which I become fully con-
sciously aware of it, may well be preceded in time by the inner free acts themselves-before I
become reflectively aware of them. Libet et al. in no way make these distinctions and hence
fail to design their experiments with free acts as precisely as possible so as to take into
consideration this wealth of different acts any or all of which might contribute to the RP.
(8) Different from all these acts is the actual beginning of the conscious deliberate con-
crete action of actually shouting or actually moving my hand in order to carry out a move (a
free act which itself unfolds in, and takes some, time).
(9) No doubt only milliseconds later I begin to become aware of, in reflection, that I have
begun to act or that I have executed a free action.
(10) The acts of expressing this reflective awareness in language, in some motion of the
hand or in some words, in which I speak of my free acts, again certainly are preceded by the
movement of the hand or my shouting themselves.
If these entirely different conscious acts, which partly follow, partly accompany each
other in time, are not clearly distinguished by a scientist or by a person who seeks to answer
the question as to when a person began to act freely, how should it be possible for him or her
to identifY exactly the time when he or she began to act freely and how should a scientist de-
sign experiments that, albeit only roughly, seek to establish the respective time spans or mo-
ments during which these different free acts took place?
Libet gains many important empirically supported pre-philosophical insights into free-
dom, but his opinion that the results of his experiments refute positive freedom is based on an
entirely insufficient empirical ground, precisely because he ignores the many free acts that
precede the reflective awareness of a person that she actually started to act. This makes Lib-
et's claim that his experiments allow only the admission of a negative veto-role of freedom
entirely unfounded. If there is approximately half a second (550 milliseconds) from the start
of the build-up of the RP (readiness potential) in the brain to the actual motion-an action that
is preceded in time by so many free and cognitive acts-or to the moment in which I become
reflectively aware of the fact that I act (an act that again precedes the actual motion by 200
milliseconds), then how should Libet's experiments contradict the freedom of the positive ini-
tiation of these acts?!
Alone the difference between a pre-reflective and a reflexively given acting (which latter
precedes the action by only 200 milliseconds), let alone the possible effect of the intense free
concentration and psychological getting ready to act that certainly precede the actual doing
and could very well be responsible for the build-up of the readiness potential, could easily
suffice to account for the antecedence of the RP by 250 milliseconds.
D. Moreover, Libet seems to fail entirely to see the basic point of his experiments that
have been so much better understood and explained by Popper and Eccles. 59 The central evi-
dence of Libet's experiment precisely shows that, within whatever temporal preceding by mil-
liseconds, the free decision to act at a certain time and the actual acting at this time, or also
the preceding and accompanying free acts, make burst forth a tremendous new energy in the
brain. And if the person suddenly decides not to act at the given or previously decreed time,
nothing happens and no physiologically wholly unexpected energies will emerge in the neu-
rons!
Thus all empirical evidences appear to corroborate the opinion that the modular patterns
of motion occur in form of a sudden appearance, quite independently of any preceding brain-
state and precisely, only, and exactly then when the person on whom the experiment is per-

58 Karol Wojtyia has shown that reflective consciousness is again quite different from the reflection
properly speaking. See Josef Seifert, "Karol Cardinal Karol Wojtyla (Pope John Paul II) as Philoso-
pher and the CracowlLublin School of Philosophy."
59 See Karl R. Popper and John C. Eccles, The Self and Its Brain.
208 CHAPTER 4

formed wants to become active. In other words, these experiments confIrm in a fascinating
manner that on the level of the brain exactly that happens which we should expect from the
experience and philosophical understanding of conscious life: namely, that on the occasion of
each volitional motion an objectively existing and also experientially noticeable 'breaking in'
ofthe order of the mind and volition into the world of the body takes place and that the source
of such bodily and physical-physiological changes does not lie in the brain itself but in the
will of the person, in the spontaneous activation of the free center of the person. Empirical
brain science thus confIrms the most natural experience of a free dominion of the mind over
the body, a phenomenon Kant recognized, calling it 'causality through freedom' but which,
for quite invalid reasons and confusions in his notion of causality,60 he believed had to be de-
nied for the world of appearances. Had he known the newest empirical results of brain re-
search, and at the same time freed himself more entirely from the philosophical grounds of his
'physical determinism' (for the sake of a transcendental doctrine of freedom), Kant might
have been delighted over such an empirical confIrmation of 'causality through freedom', of
the power of the subject over the body.
Similar evidences were presented when persons were observed when they spoke, when
they solved mathematical problems, when they were asked to remember certain past events,
etc. 61
In all of these cases of activities it seems to emerge clearly as an empirical fact of brain-
science that in consequence of voluntary action the eruption of physiologically completely in-
explicable spatio-temporal patterns of motion in the modules of brain takes place, an eruption
that is completely inexplicable through the preceding physiological events or causes and that
can only be explained as an irruption of the power and freedom of the mind into the world of
the brain. This is not so for other conscious experiences. For example, in the case of experien-
cing pain because of having cut one's fInger or in sensation an explanation of the newly de-
veloping brain events through physiological reality is possible and, at least partially, even the
only reasonable explanation. Here no irruption of new immaterial causes into the order ofthe
brain takes place, but immanent physiological causes clearly give rise to the respective brain
events. Physical pain and other experiences here are the consequences of preceding nerve and
brain events (although such a causal explanation cannot exhaustively do justice to physical
suffering or provide a sufficient understanding of it).
In the light of a phenomenology of freedom the mentioned empirical facts also witness
the philosophically evident link that exists between the free and self-conscious center of the
person and her body. Thus the truth of inner experience of really initiating bodily movements,
and thereby the truth of 'causality through freedom', as Kant describes this fact quite fIttingly,
which, however, he believes to be empirically absolutely indemonstrable, since in the world
of appearance strictly causal determination would rule, can be verifIed or at least corroborated
through the empirical brain research of the newest date. 62 If nothing in the brain explains the
overwhelming excitation and the newly arising patterns of motion that occur suddenly and in
complete dependence on the person's decision and will to act now rather than later or earlier,
then it seems to be also from a purely scientific standpoint the most reasonable assumption to
assume exactly what our conscious experience has always taught us: namely, that as free
subjects we are indeed the cause of voluntary bodily movements; that the mind here truly has
an effect on matter.

6{) See Josef Seifert, Uberwindung des Skandals der reinen Vernurift. Die Widerspruchsfreiheit der
Wirklichkeit - trotz Kant.
61 See Karl R. Popper and John C. Eccles, The Self and its Brain, ch. E 4, E 8.
62 Of course, such a 'verification' always presupposes certain philosophical insights and cannot be
gained entirely without their help, for example not without various insights which refer to the essence
of freedom, of causality, of their mutual relationship and of the subject of freedom.
 FREE CHOICE AND THE ENDS OF MEDICINE 209

E. To recognize this fact has, however, immense consequences which Kornhuber and
Libet may fail to appreciate fully but which especially Libet clearly hints at; he even devel-
oped a theory to explain these consequences speculatively, by reference to quantum mechan-
ics. 63 With Eccles and Popper we have then to assume that, as they express themselves, there
exists a fundamental openness of WORLD I for WORLD 2. The brain is open with respect to
receiving input and influences from the mind and thereby the matter of the brain is open to
communicate with a reality that is distinct from the brain and that the brain does not only in-
fluence but from which it also can receive influences. Modern natural science reconfirms the
words that Socrates spoke in Plato's Phaedo about the reasons why his limbs and nerves re-
mained in jail: namely because of his knowledge and free decision to do justice, and not for
physiological causes (98b f£). These Socratic words sound just like the newest scientific find-
ings:

... as if in the same way he should give voice and air and hearing and countless other
things of the sort as causes for our talking with each other, and should fail to mention all
the real causes, which are, that the Athenians decided that it was best to condemn me,
and therefore I have decided that it was best for me to sit here and that it is right for me
to stay and undergo whatever penalty they might order. For, by the dog, I fancy these
bones and sinews of mine would have been in Megara or Boeotia long ago, carried
thither by an opinion of what was best, if I did not think it was better and nobler to en-
dure any penalty the city may inflict rather than to escape and run away. 64

Further evidences for the fact that these words of Socrates relate also to the relationship
between the mind and the brain and to the latter's link to conscious knowledge and free deci-
sion can be obtained from experiments with active memory-retrieval. Our conscious efforts to
refresh memories, our activity of rejecting images that present themselves to our memory
when these images are not the ones that we are looking for, an activity Augustine already has
described in detail in book X of his Confessions, leads to an actual 'opening' of potentially
open modules, to an activation of information that is in a certain way stored or programmed in
the brain and had already been 'filed' there and could have been activated before. This activa-
tion of brain-stored information occurs through what Eccles describes as "playing the brain."
This expression for a using of the brain in a quasi-instrumental manner had been suggested
before by Henri Bergson in his theories concerning empirical discoveries regarding brain-
damaged persons. 65
In the light of these results, the revolutionary character ofEcc1es's and Poppers's concept
of the openness of WORLD I with respect to WORLD 2 emerges clearly. This concept is ob-
viously only revolutionary, however, if you see it in the light of modern science and its deter-
ministic philosophical foundation. For in the quoted Platonic text and in many other authors
after Plato, including Kant, this concept appears to be a guiding principle: Plato refutes,
through the mouth of Socrates, the materialists' negation of freedom by pointing out that the
causes of Socrates' actions did not lie in any of the physiological causes in his body or nerves
but solely in his free will to do what is just and to obey the law, without which decision all his
brain and body would long have been removed from the prison-cell.
F. The 'openness of matter (brain) to mind '-Is the breaking of laws ofphysics an insur-
mountable problem for a philosophy of the mind? The results of these philosophical intuitions

63 Benjamin Libet, "Do We Have Free Will?", pp. 561 ff.

64 Plato, Phaedo, 98 c-99 b. In Kant, however, we find the recognition of this fact only as something ly-
ing beyond the experience and beyond any objectivizing thinking, in the alleged sphere of purely in-
telligible objects and things in themselves in which alone Kant assumes a freedom and causality
through freedom to be possible and seeks to save their reality.
65 See Bergson, Matiere et Memoire. On the newest state of scientific research and theory, regarding the
problem of memory, see Eccles, The Human Psyche, pp. 176 ff.
210 CHAPTER 4

into human freedom as the true cause of human acts and of the mentioned empirical experi-
ments, however, seem to contradict and to violate also the principle of the preservation of
energy and the first laws of thermo-dynamics. For the mind appears here to irrupt into matter
and material events and to engender new energies or to set them free, energies that had not ex-
isted before in the brain or in the material universe. Eccles, Popper and also Wigner, a nobel-
laureate of physics, are even less disturbed by these consequences than Hans Jonas. 66 The
consequences only demand that we develop a new and simultaneously classical physics
(which recognizes objective empirical and also a priori evident laws of 'pure physics' regard-
ing time, motion, space, etc.) and above all that we explore the relationship of physics to psy-
chology and philosophical anthropology. The mentioned natural scientists argue that the em-
pirical facts described above do not contradict the laws of physics which strictly and in their
full extent refer only to the limited sphere of the material (non-living) universe. These empiri-
cal fmdings only refute the idea of a deterministically closed material universe in which any
causal influence, force or energy from a source distinct from the system of the material world
itself would be excluded.
Even more important than the polemics against those interpretations and formulations of
the laws of physics that have their root in a deterministically conc.eived universe is another
observation. The apparent 'openness' of the material universe according to the modem con-
ception of physics, according to which all natural laws are only statistic laws and allow the
possibility of chance and exception, is in no way a sufficient correction of earlier determin-
istic physics. For the openness of the material universe of the brain as well as of the physical
material world which is part of the brain and also of the external physical world with respect
to the mind, insofar as all these parts of the physical world are subjected to free deeds of
human persons, is a completely new and different form of 'openness' of matter to the mind. It
is an openness of the physical world for influences from reason and from freedom, not the
mere fact that the laws of the physical universe, at least in the microphysical world, are only
statistical and not absolute. This relationship between the brain and free subjects is completely
new and different in comparison to the 'openness' of matter in the sense of statistically calcu-
lable exceptions from general rules. A statistical gambling with chances is in a certain way
not less far from the openness of matter with respect to mind in freedom than a strictly deter-
ministically closed material universe.

1.6. Is Freedom Self-Creation?

When we seek to conceive-with J.-P. Sartre-man's freedom in terms of self-creation, we

might be l<:d to the idea of a free spontaneous positing by which man determines things and
himself completely, entirely, creating his own essence and that of things. To be free would
signify to be autonomous in such an absolute way that one neither has ontological presupposi-
tions nor an essence which would not depend on human freedom.
Yet such a self-creating freedom is not only in itself absurd, but human freedom obvious-
ly presupposes many things that do not depend on our freedom, both in the subject and in the
object of a free act. The very existence of the subject of conscious acts as an 'individual sub-
stance of rational nature' precedes any free act. Never could an epiphenomenon or accident of
another thing or a material substance that consists of a multiplicity of non-identical parts be

66 See Hans Jonas, Macht oder Ohnmacht der Subjektivitiit? Das Leib-Seele-Problem im Vorfeld des
Prinzips Verantwortung (Insel Verlag, Frankfurt a. M., 1979). See also my critical evaluation of Jo-
nas's in part excellent critique of epiphenomenalism (supervenience theories of the mind) in Josef
Seifert, Das Leib-Seele Problem und die gegerrwartige philosophische Diskussion, and my What Is
Life?, and Oberwindung des Skandals der reinen Vernunft.
 FREE CHOICE AND THE ENDS OF MEDICINE 211

the subject of free acts. In order to be possible, any free act presupposes ontologically the ex-
istence of its subject as a spiritual entity that stands in itself
In the sense of freely engendering its own existence no entity can be causa sui. 67 More-
over, the essences of things are also pregiven, especially with respect to their dependence on
necessary and eternal 'essential plans' (eide) but also with respect to the contingent natures
which contain meaningful elements that need to be investigated empirically because they lack
absolute necessity: also these empirical sides of nature, whether the product of evolution or
created by some non-human free act, are in no way the product of human freedom. 68
A legitimate sense of self-creation, however, can refer to acts themselves and to the deter-
mination that they bestow on their subject. His existence, however, man experiences as a
given, as a gift which is entirely independent of his freedom and which is presupposed by it.
Moreover, he recognizes that his nature--of being free and of having many other attributes,
such as the ability to know or to perceive, such as the value he possesses and his being faced
with objective goods-is independent of his free self-determination.
Man actualizes certain aspects of his own being and of his own essence (of how he is)
only through freedom. 69 The deepest dignity of the person lies in a vocation70 that needs to be
responded to, and in a value that needs to be acquired and is not simply a possession. 71 Man's
dignity does not consist solely in the inalienable value that he possesses as person, who is
endowed with freedom, but also in those values that can accrue to him only through the good
use of his freedom. This dignity which lies in man's searching for the truth, in his obeying his
conscience, doing justice, etc., man can lose. Its gain depends on man's freedom. In this
sense, then, man 'creates himself to be evil or good' or is himself accountable for being good
or evil, depending on the free stance he takes towards truth and goodness. 72

1.7. Freedom and Its Conditions: Individual Being, Cognition, and Value

Among the pregiven conditions of freedom is also the uniqueness of each person. There is
something unique, irreplaceable and insubstitutable in the free subject. Yes, man can have
twins and conceivably even countless 'clones', other human beings who are just like him in
all gifts and in appearance. 73 But in his own freedom, each man possesses, at the very bottom

67 Fichte's idea of a free self-creation of the subject of free acts, ofa free self-constitution and self-posit-
ing to which the lowes its own being, proves absurd when we contemplate the intelligible structure of
free acts. Cf. Johann Gottlieb Fichte, Grundriss des Eigenthiimlichen der Wissenschaftslehre (1795),
139: "ein Satz, der im theoretischen Theile der Wissenschaftslehre postulirt wird, nach dem Grund-
satze: nichts kommt dem Ich zu, als dasjenige, was es in sich selbst setzt."
68 On the decisive difference between necessary and contingent essences see Dietrich von Hildebrand,
What Is Philosophy?; see also Josef Seifert, Sein und Wesen, chs. 1-2.
69 On the distinction between what-being (ti einai) and how-being (poion einai) see my "Essence and
Existence", ch. 1; and my Sein und Wesen, ch. 1.
70 This concept of 'vocation' plays a central role in Urs von Balthasar's conception of the person.
71 This reminds of Gabriel Marcel's statement: "etre une personne n'est pas une possession, mais une
conquete" (to be a person is not a possession but a conquest). See Josef Seifert, "Dimensionen und
Quellen der Menschenwiirde," in: Walter Schweidler, Herbert A. Neumann, Eugen Brysch (eds.),
Menschenleben - Menschenwiirde. Interdisziplinares Symposium zur Bioethik (HamburgIMUn-
chenlLondon: LIT Verlag, 2003), pp. 51-92.
72 In the case of goodness, man does not simply create himself or his goodness, as we shall see. He par-
takes in goodness and there are many aspects of morally good acts which involve gifts, too. Therefore,
even with respect to moral goodness we can speak of 'self-creation' in a very restricted sense only.
73 In reality, I know from very close friendships with various 'identical twins' that they are profoundly
different in appearance and personality, which becomes clear when one knows them well; and this
would just as well apply to 'human clones'.
212 CHAPTER 4

of his being, something which is inalienably his, which nobody else can ever actualize for
him, and which he can use in such ways as to determine himself in radically different fash-
ions, by becoming good or evil.
Thus the experience of freedom and of the abyss of concrete, individual life of the spirit
refutes any averroist or transcendental idealist system which regards the free subject as some
universal spirit, as some logical synthesis or unity, as one ego common to all. No, the individ-
ual thisness, the haecceitas of the person, appears most deeply in her freedom and in the tua
res agitur freedom involves. Therefore, it is not by chance that one of the greatest philoso-
phers of freedom, Duns Scotus, was also one of the most profound philosophers of individual
thisness. 74
Yet not only the subject is presupposed for freedom but also some object. We arrive here
at two essentially necessary truths which are not constituted by freedom and which link free-
dom to consciousness, as well as to knowledge of objects. "Nothing is willed (desired) that is
not first conceived"-this scholastic principle speaks first of what Husser! and Brentano
would call the intentionality of the free act, its directedness to some object in the way of will-
ing, which presupposes intentional acts of knowing or at least ofthinking directed at the same
object. Two things are implied here: First, I cannot just will as I can feel a headache or be
drowsy, i.e., as a subjective non-intentional state which is not directed to anything over
against itself. Just as I camlOt perceive without perceiving something, know without knowing
something, so I cannot will without my act being directed at something which stands over
against myself or, being in me, still appears as object of my free acts-for example, when I
work on improving my behavior. But apart from this meaningful conscious directedness of
my willing itself at something the scholastic principle also teaches a second thing: namely,
that this something cannot be originally given through willing itself but that willing presup-
poses some other act (here designated as thinking or as knowing and identified by Brentano as
Vorstellenlimagining, representing)75 in which alone the object of willing can become origi-
nally accessible to the mind. 76
In formulating the fundamental dependence of will on knowledge or thought, the Medie-
vals sometimes use another proposition, namely "nothing is willed that is not first known,,77
In so speaking, the medieval philosophers indicated more than that each act of volition pre-
supposes some awareness of an object, however erroneous. They implied that volition presup-
poses knowledge, cognition ofthat which is. And it proves indeed impossible that our relation
to an object in a free act, however much prey to deception we are, consist of nothing but illu-
sion and error. For in each error and deception we know something and know some truth-for
example, that we exist or that we perceive such and such objects which appear to be such and
such, or that those things at which our will is directed possess some true value, or that we
should look for truth. But also all concrete rational human actions and commitments presup-
pose, in different degrees, some knowledge of being and value. For instance, when we defend
a slave from being sold or mistreated, we have some understanding of the true dignity of the

74 On individuality see also Francisco Suarez, Metaphysical Investigations V (On Individuality). On this
and other metaphysical aspects of freedom see likewise Josef Seifert, Essere e persona, ch. 9.
75 See Franz Brentano, Psychologie vom empirischen Standpunkt, Bd. 1-2, ed. O. Kraus, unveranderter
Nachdruck der Ausgabe von 1924 (first edition 1874), (Hamburg, 1955). Also in English translation
as: Psychology from an Empirical Standpoint (1973).
76 It cannot be our task here to enter more deeply into the kind of acts that are presupposed by willing.
77 "Nil volitum nisi cogitatum"; "nil volitum nisi primum praecogitatum"; "nil volitum nisi praecogni-
turn."
Cf. on this also Thomas Aquinas, Summa Contra Gentiles, lb. 1, cap. 5, no. 2: "Nullus enim desi-
derio et studio in aliquid tendit nisi sit ei praecognitum."
 FREE CHOICE AND THE ENDS OF MEDICINE 213

person in contradistinction to the lower value of a lifeless thing or that of an animal. We have
some knowledge ofthe good.

We found some of the preceding more abstract epistemological and metaphysical

reflections useful for understanding better some of the most elementary conditions
and foundations of a philosophical recognition of freedom. A clear recognition of
freedom, however, is of crucial importance for all ethics, and therefore also for med-
ical ethics. But now we turn to the more concrete ethical dimensions of human free-
dom which to discuss is indispensable in a work on the foundations of medical eth-
ics because they alone can explain not only the dramatic choice physicians and other
health professionals have to make but also what are the sources of a rapidly spread-
ing philosophical disease of medicine and what are the means of its cure.

2. ETHICS, FREEDOM, AND MOTIVATION

The Drama of the Physician's Freedom Can Only Be Understood in the Light of the
Free Choice of the End and Not Only ofthe Means

2.1. Categories of the 'Good'

We have seen that even in evil and largely irrational human acts some true knowl-
edge is presupposed. Willing presupposes the subject's relation to an object, but also
to at least some truth and value.
Precisely the close relationship between freedom and knowledge, however, could
lead us to believe that the knowledge of the goods medicine should serve forces us
to follow this knowledge in our freedom. Socrates said, "Nobody commits knowing-
ly an injustice." But then there is no free choice for the physician as far as the essen-
tial goals of medicine are concerned and the drama we alleged in chapter 1 does not
exist.
Sharing some of the same assumptions with this Socratic position, but wishing to
liberate freedom from the apparently necessary dominion of knowledge of the good
over it, someone could think that truth, as well as any value in the object of free acts,
enslaves the human person. Truth and value are then thought to constitute limits to
human freedom and appear to threaten the person's autonomy. Thinkers who be-
lieved this have attempted to completely separate freedom and the principles which
exert influence on it from the object and its motivating power; they have postulated
that the source of free acts lies in the subject alone and in no way in the object. This
thought dominates Kant's ethics and is present also in Fichte's idea that the other
(the non-I) only fails to limit freedom if it is posited (gesetzt) by the subject,78 In its
most radical form, Sartre has defended such a view offreedom. 79

78 Johann Gottlieb Fichte, Grundlegung des Naturrechts (1796) II, ill 8:

Es ist in mir bei diesem Geschiifte die Vorstellung der Freiheit. Ich setze in der glei-
chen ungetheilten Handlung zugleich andere freie Wesen. Ich beschreibe sonach
durch meine Einbildungskraft eine Sphiire fur die Freiheit, in welche mehrere Wesen
sich theilen. Ich schreibe mir selbst nicht aile Freiheit zu, die ich gesetzt habe, weil
ich auch noch andere freie Wesen setzen und denselben einen Theil derselben zu-
schreiben muss.
Fichte, Das System der Sittenlehre (1798) II, IV 68:
214 CHAPTER 4

All of these opinions on freedom and on its liberation from submission under
goods entail a radical misunderstanding of freedom, however. Far from destroying
human freedom, truth and authentic values on the object-side liberate it. Each ration-
al action presupposes a certain state of the world, the existence of certain bonds or
the absence thereof, certain values, etc. Thus each human action by its nature has a
connection to truth. Truth is, as Karol Wojtyla the philosopher says, ''the internal
principle of human action."80
As truth does not destroy or threaten freedom, so values also do not. Kant's idea
that freedom is only autonomous if its entire source proceeds from the subject and if
it does not depend on any object, is profoundly wrong. He fails to see that not all in-
fluences from values and objects threaten freedom or are like mere causes taking
some effect in the subject. There are indeed such influences that are hostile to free-
dom, such as drug-addiction or psycho-terror. But truth and true values liberate free-
dom. We do not create but discover them and they are not dependent on our free-
dom. They are to be found and are pregiven to the subject in the world and in the na-
ture of things. But when we find them, they do not oppress us or deprive us of our
freedom, but renew and liberate us. They give a meaning, 'purpose', and end to hu-
man actions; they liberate freedom to itself and render possible the deepest dimen-
sions of it.
This finds a concrete application in the medical service to patients. The call to re-
spond to patient needs and the obligation to save lives, to restore health, to fight dis-
ease, etc., are not hostile to the freedom of physicians and nurses. They give mean-
ing to their freedom. Without being faced with the different goals and goods we de-
scribed, the physician's freedom would be empty and lack any 'why' of medical ac-
tion. And such a 'why' cannot derive from a mere arbitrary decree or decision of the
free will but must stem from the nature of reality. Only truth and true values will
make us free.
For only in response to truth and to true goods can freedom be fully freedom, can
freedom be meaningful rather than senseless arbitrariness. Only in response to the
good can free acts embody value, can freedom have a 'why' for the sake of which
we act.
This axiological dimension of freedom-its link to truth and to value-forces us
to consider a new essentially necessary truth about freedom: the object of a free act
does not stand in front of us as totally neutral and indifferent, but as 'important', i.e.,
it is raised out of the sphere of the wholly indifferent. 81 Otherwise there would be no
reason to will it.
This importance can be positive or negative importance. A purely negative im-
portance as such, however, cannot motivate our affirming will but only our rejecting

Weil ich frei bin, setze ich die Objecte meiner Welt als modificabel, schreibe ich mir
einen Leib zu, der durch meinen blossen Willen nach meinem Begriffe in Bewegung
gesetzt wird, nehme ich Wesen meines gleichen ausser mir an, u. dergl.
79 See Jean-Paul Sartre, L 'Etre et Ie m~ant (Paris, 1943); "Descartes und die Freiheit," in: Rene Des-
cartes, Discours de la methode (franz.-dt.); mit einem Vorwort von K. Jaspers und einem Beitrag von
J .-P. Sartres (Mainz: Internationaler Universumverlag, 1948).
80 Karol Wojtyla, The Acting Person, chs. 1 ff.
81 Cf. Dietrich von Hildebrand, Ethics, ch. 1.
 FREE CHOICE AND THE ENDS OF MEDICINE 215

or some other form of 'negative willing', i.e., of saying in some way 'no' to some-
thing. If we call therefore any positive importance 'good', an object attracts our will
always sub specie bani, under some aspect of the good, as Thomas Aquinas says:
Quidquid agitur, sub specie (ratione) bani agitur.82 We always want something
which stands before us either as positively important-this is a necessary condition
in order for us to will it affirmingly-or as negatively important, which is required
for us to reject it, to will that it not be, or to flee it.
Yet if we follow Aristotle's and Thomas Aquinas's teaching that all men desire
the good in the sense of something that stands before us as desirable or as positively
important, and if we then interpret this good which 'all men desire' as their happi-
ness, do we then not lose freedom? Does not then the knowledge of the good deter-
mine freedom by necessity? If our will wants the good, which is identified with hap-
piness, by necessity, freedom can only have the role of executing what the intellect
shows us to be good. Morally evil choices are then simply based on error and igno-
rance and Socrates is right in asserting that no man commits injustice or another evil
willingly.

2.2. The Drama a/Human Freedom Can Only Be Understood in the Light a/the
Free Choice a/the End and Not Only a/the Means: Categories a/the 'Good' as
Explanation a/This Choice
Even if it is true that we will necessarily some good, the drama of freedom, as it also
faces the physician in his choice for or against life and other goods of patients, defi-
nitely presupposes at least two entirely different points of view of motivation be-
tween which we can choose and which are irreducible to each other. If all men
wanted necessarily the same end and could choose only the means that they deem
best for this end, freedom or at least the drama of freedom would be impossible.

82 See, among numerable other passages, Thomas Aquinas, Summa Contra Gentiles, 2.27:
For it behoves the will to be proportionate to its object. Now the object of the intel-
lect is a good understood, as stated above. t2 Hence the will has a natural aptitude to
extend to whatever the intellect can propose to it under the aspect of good.
Voluntatem enim suo obiecto proportionatam esse oportet. Obiectum autem volunta-
tis est bonum intellectum, ut patet ex supra dictis. Voluntas igitur ad quaelibet se
nata est extendere quae ei intellectus sub ratione boni proponere potest.
See also Thomas Aquinas, Summa Theologica, Complete American Edition in Two Volumes,
trans!. by Fathers of the English Dominican Province (New York: Benziger Brothers, without year), 1-
Iiae, Q. I, co:
I answer that, Man must, of necessity, desire all, whatsoever he desires, for the last
end. This is evident for two reasons. First, because whatever man desires, he desires
it under the aspect of good. And if he desire it, not as his perfect good, which is the
last end, he must, of necessity, desire it as tending to the perfect good, because the
beginning of anything is always ordained to its completion; as is clearly the case in
effects both of nature and of art. Wherefore every beginning of perfection is or-
dained to complete perfection which is achieved through the last end. Secondly, be-
cause the last end stands in the same relation in moving the appetite, as the first
mover in other movements. Now it is clear that secondary moving causes do not
move save inasmuch as they are moved by the first mover. Therefore, secondary ob-
jects of the appetite do not move the appetite, except as ordained to the first object
of the appetite, which is the last end.
216 CHAPTER 4

Also some followers of Aristotle (who had asserted such a thing) admit this, for ex-
ample Cornelio Fabro, who criticizes this Aristotelian idea (defended also by Thom-
as Aquinas), according to which the good determines the will. Fabro attributes to
other aspects of the ethical thought of Thomas Aquinas also the view that the will
can choose between ultimate ends, specifically between a perverse and a good end. 83
And the older distinction common to many scholastics between the bonum utile, the
bonum commodum and the bonum honestum, between which we can choose, goes in
a similar direction. Kant, in his distinction between acting from inclination (Nei-
gung) andfrom duty (Pflicht) formulates for the first time quite clearly two radically
and incommensurably distinct points of view of human motivation, a truly epochal
ethical discovery.
Yet in my opinion, there are so many confusions regarding this matter in Kant,
that one can say that a viable distinction between fundamentally different categories
of the good (of importance), between which the drama of human freedom unfolds,
we owe to Dietrich von Hildebrand. 84 He identifies three types or categories of im-
portance. First, Hildebrand distinguishes between the objective value and the merely
subjectively satisfying. There is an abysmal distinction between them, which shows
that the 'good' that all men desire is not univocally and not even truly analogically
'good'. What are those distinctive marks between the intrinsically good-to which
Hildebrand's notion of 'value' refers-and the merely subjectively satisfYing?
(1) First, value-importance (such as the value of human life) is objective and in-
trinsic; the merely subjectively satisfying (for example, sexual pleasure or the pos-
session of money to 'buy pleasure') is relative to the subject. Some persons like
chocolate or money, others not. That which possesses objective value, in contrast, is
precious in and of itself. The dignity of man is such a value which does not derive
from any relationship to our inclinations, drives, instincts, appetitus-but belongs to
the person by her own nature. Value in this sense is, above all, a preciousness in
itself which does not consist in the ability of an object to satisfY or to fulfill us but is
an intrinsic positive importance that raises a being out of the neutral, of the indiffer-
ent. We express linguistically this character of bonum in se, which already Duns
Scotus has contrasted with the Thomist understanding of bonum being good only ad
aliud (good as relational to appetitus) in that our language does not allow us to say
of such values as the dignity of the person or justice that they are dignity for me, or
justice related to my desires. No, they are dignity and justice as intrinsic values, as
intrinsic preciousness of things.
The physician and nurse who are confronted daily with patients, born and unborn
human beings who possess personal dignity, are thereby constantly addressed by the
call issued by such intrinsic goods.
In sharp contrast, the merely subjectively satisfying of the cigarette depends on
our likes or dislikes. For a non-smoker, the smoke of cigarette may be disagreeable,
something negatively important. For the smoker it is subjectively satisfYing. This

83 Cf. Cornelio Fabro, Riflessioni sulla Liberta (Rimini: Magggioli, 1983), pp. i-xi, 13-132.
84 In thinking about the Socratic problem and the Aristotelian-Thomistic thesis that all men desire the
good, as well as on Max Scheler's theory according to which each evil act consists in a preferring the
lower good to the higher, Dietrich von Hildebrand arrived at one of his most stunning discoveries, that
of the three categories of importance.
 FREE CHOICE AND THE ENDS OF MEDICINE 217

positive or negative quality depends on the pleasure or displeasure it gives to a sub-

ject.
Whereas the quality of the subjectively satisfying or of the subjectively dissatis-
fying may be grounded in the nature of the object-such as in the case of the good
taste of some excellent wine, some Marzipan of Toledo, or a warm bath when one is
cold-it can also be entirely divorced from the true nature of the object, such as
when the torture and blood of his victim fill the sadist with intense satisfaction.
(2) Objects endowed with the two mentioned kinds of importance address them-
selves quite differently to the subject. The good insofar as it is endowed with intrin-
sic value addresses a call to us. It appeals to our freedom to conform to it, to give it a
due response. In fact, this call addressed to us by beings endowed with intrinsic val-
ue reveals the innermost meaning of freedom. For example, we ought to respect a
human person in virtue of her dignity, regardless of whether this person is old or
young, pretty or ugly, born or unborn. When we treat a person like a thing, like an
animal, or even as a slave, we contradict this call issuing forth from the dignity of
persons. The same is true when we deliberately kill an innocent human being. Ob-
jective values do not leave us in our arbitrariness but call us to conform our wills,
hearts and actions to them.
At the same time, they address themselves specifically to our freedom because
no machine and no animal governed by instincts but only a free subject can say yes
to values, can properly relate to goods endowed with intrinsic preciousness.
Quite the reverse, the merely subjectively satisfying addresses itself to us not
with a call to give it a due response, but with an enticement; if it is illegitimate, it se-
duces us. As long as it is legitimate, we are entirely free to follow its invitation or
not to follow it. We cannot speak here of a call, let alone an obligation. While not
demanding a response from the person and not addressing a call to her, however, the
merely subjectively satisfying has a tendency to dethrone our freedom, to enslave us.
Just think how a passion for gambling, for sexual satisfaction, for money or power
can dominate and enslave a man or a woman. Thus the true meaning and possession
of freedom in the moral sense becomes first possible through the response to goods
endowed with intrinsic value.
(3) Thirdly, the subject relates quite differently to the object in the case of a good
endowed with intrinsic value as opposed to a merely subjectively satisfying object.
The intrinsic good is object of a certain self-donation, of a certain conforming
ourselves to it, of our giving it a response due to it. We subordinate ourselves to an
object endowed with intrinsic value in love, in admiration, in the concern for truth
and justice, or in the adoration of the infmitely holy God.
Such a gesture of subordination to things endowed with intrinsic values is clearly
seen in the commitment of nurses and physicians to persons, starting with the greet-
ing of patients, in which they recognize their intrinsic dignity as persons, up to the
self-sacrificial care nurses or physicians give to patients in situations of infectious
diseases where they risk their lives to care for others.
In contrast to such a self-donation in medical care, any such giving of oneself is
missing in the case of the merely subjectively satisfying. There we appropriate the
object to us, we consume it, we use it, as the French expression 'je me rejouis de"
shows, which means both 'to use' and 'to take pleasure in', a fact on which Karol
218 CHAPTER 4

Wojtyla has put his finger in an admirable way.85 This attitude is found in a perverse
form in medical staff who regard patients only as means to earn money or are even
willing to sacrifice the lives of born or unborn human persons entrusted to them just
in order to provide money to please their pleasures.
(4) Fourthly, the two kinds of importance show a radically different type of gra-
dation. Objective and intrinsic values are gradated according to a principle of hier-
archy. They rank: higher or lower in an axiological sense. Thus the human patient's
dignity exceeds incommensurably the value of animals. Denying a crucial case of
such hierarchy, Peter Singer's attempt to unsanctify human life and'to claim that
healthy pigs have higher value than gravely handicapped humans is a profound
error. 86
The merely subjectively satisfying, however, possesses only degrees of intensity.
We can apply to pleasure per se only Aristipp's criteria: (a) How intensive is it?
(b) How easy is it to get by? (c) How long does it last? (d) Which bad after-effects
does it have? Even Aristipp's radical hedonism, however, cannot be defended with-
out reintroducing some objective value. For when he praises the wise man for his
wisdom, Aristipp admits some intrinsic goodness of wisdom and would not say that
the fool's actions are equally good. 87 Likewise, Gorgias, Polos, and Callicles in
Plato's Gorgias, who hold similar views, cannot help but admitting-upon being
questioned by Socrates-that there are some pleasures which are not good.
(5) While both values and the merely subjectively satisfying have a relation to
joy and happiness, their relationship to happiness is quite different: That which pos-
sesses intrinsic value can render us happy only when we give ourselves to it. The
true happiness bestowed on us by values presupposes that we participate in the in-
trinsic value of a thing or of a person. This happiness is the joy that only a thing of
objective value can bring about. It is the radiance of value in the soul that perceives
it. We can gain this happiness and win our soul only when we give ourselves, when
we lose our souls. Happiness is a superabundant gift. Also this can be seen beauti-
fully in medicine in doctors and nurses who receive profound happiness in their self-
donation.
In contrast, merely subjectively satisfying objects we use for our satisfaction.
They are means to our pleasure. Moreover, our subjective satisfaction is quite com-
patible with the knowledge that the importance of the object depends on its capacity
to please us. This ego-centered 'happiness' has a completely different character than
the authentic happiness, which is a gift of our contact with things possessed by in-
trinsic nobility and value.
This again is evident in medicine. A nurse who does not care about her patients
but only desires her own egocentric pleasure will experience perhaps intense satis-
faction but never be enriched by the authentic and profound happiness which the

85 See Karol Wojtyla, The Acting Person, where an outstanding critique of hedonism explains this
linguistic peculiarity of the French and Polish language. See also my "Karol Cardinal Wojtyla (Pope
John Paul II) as Philosopher and the CracowlLublin School of Philosophy." See likewise the discus-
sion of this paper through Georges Kalinowski and Tadeusz Styczei in Aletheia IV (1987).
86 See Peter Singer, "Unsanctifying Human Life."
87 See Giovanni Reale and Dario Antiseri, Storia della filosofla antica, vo!. I. See also Dietrich von Hil-
debrand, Ethics, ch. 3.
 FREE CHOICE AND THE ENDS OF MEDICINE 219

nurse who gives patients loving care will experience. The same is true for physi-
cians.
We thus see: there are profoundly distinct senses of the good, radically different
kinds of positive importance that address themselves to quite different centers in us.
What is more, there is no common denominator among them; they are not pur-
sued under the same point of view of motivation, for instance under the point of
view of the question: "What is intrinsically better?" A physician can take money to
torture a person without believing at all that this act is objectively better than to re-
fuse it.
This difference can in no way be reduced to that of the real and of the apparent
good. It is possible that a man wrongly believes that a thing possesses intrinsic
worth and thus he can prefer the apparent good to the real good; but in this case he
acts sub specie of the same kind of goodness.
In the situation of the dramatic choice of the nurse or physician between serving
the good of a child or killing it to make money, we are faced with an entirely differ-
ent situation: The subjective satisfaction wealth can provide, may be pursued entire-
ly independently from the belief that it is intrinsically better to pursue it at the cost
of a human life. The 'good' in the two senses we distinguished can be pursued in
complete independence from each other: someone can pursue what satisfies his con-
cupiscence or pleases his pride entirely without any concern whatsoever whether his
acts are in harmony with what is good in itself. It is this fact that accounts for the
drama of moral choices and regards the end ofhuman acts.
We may proceed to show a third category of importance, which is indispensable
for understanding such acts as gratitude, forgiveness, or love, as well as for under-
standing happiness. 88 This third sense of the good can be described as the 'objective
good for the person'. It shares with the subj ectively satisfying that it is essentially a
goodfor someone; it addresses itself to a person and is a goodfor her. It shares with
value the objectivity, however. It lies objectively in the true interest of a person,
constitutes an objective 'pro' for the person, serves her true happiness and fulfill-
ment, and is verily a gift for her. In desiring happiness, as distinct from mere subjec-
tive pleasure, we truly desire the objective goods for us. In gratitude, we respond to
such gifts for us, and in the intentio benevolentiae of love we desire the objective
good for the beloved person. Inasmuch as it makes humanly and ethically a decisive
difference whether we pursue just our own objective good or that of others,89 we
could even speak here of two entirely different categories of 'good': the objective
good for my own person and that for another person.
The objective good for the person, be it my own or another person, is not di-
vorced from intrinsic value. On the contrary, each value, when it is profoundly un-
derstood or when the person embodies it, also addresses itself to her as her gift and
source of happiness. The justice of Socrates is of intrinsic value but also a great ob-
jective good for him. The beloved person is precious in herself but also a source of
happiness for those who love her, etc., so that we could call love in different senses

88 See on all of this Dietrich von Hildebrand, Ethics, chs. 1-7; 17-18.
89 This was brought out admirably in chapter 7 of Dietrich von Hildebrand, Das Wesen der Liebe.
220 CHAPTER 4

an Uberwertantwort, an act that goes in various senses beyond an adequate value re-
sponse to an objective good. 90
Understanding the irreducible diversity of these three categories of importance,
we also understand the drama of human freedom. Human freedom does not unfold
just in relationship to the means for the good or to practical judgments, while we
would have to will the end, the good, by necessity.
No, given the profound difference of the three categories of importance, given
the three fundamentally different meanings of the 'good', we understand now the
depth and drama of man's freedom in deciding which of these different kinds ofim-
portance becomes the one dominant in his life. A person can choose each of these
fundamentally distinct goods; she can also isolate them and choose one of them in
indifference to the others. Thus she may choose her own satisfaction in indifference
to the intrinsically valuable. She can rob a man, wanting to enjoy his wealth and the
pleasure going along with his possessions, without even asking herself whether her
action is intrinsically better or not. A man can rape a girl because this satisfies his
lust or his sadistic desire for power and humiliation of others, without having to be-
lieve that his action is in itself better than not raping the girl. He can even lead
warfare against the good because he sees it obscuring his own power and greatness.
In so doing, he does not pay a bit of attention to the question whether or not his ac-
tion is good in itself, nor does he have to believe it is, as if he always acted sub ra-
tione of the intrinsic value.
Thus man can do the evil, clearly seeing that it is evil, as Ovid put it: "Video
meliora proboque; deteriora sequor" (I see the better and approve it; but I do what
is worse). Man can, contrary to Socrates' view, knowingly do injustice; in effect, he
is only unjust if he commits injustice knowingly. In fact, he can resent and hate jus-
tice and all that is intrinsically good.
Man cannot only be indifferent to that which is intrinsically good but also--and
most amazingly-towards the objective good for himself. Man can gamble or give
himself to his lust, knowing well that this leads to his sickness, to his moral destruc-
tion, or even believing that this might lead to his eternal damnation. Yet he can
choose the road to his evil or to his own perdition because he can pursue that which
satisfies him subjectively now and fulfills his will to power-and, in so doing, he
can be indifferent not only to intrinsic value but even to his own objective good.
Dostoyevsky has described this repeatedly in his novels and short stories. Think of
Marmeladov's conversation with Raskolnikov in Crime and Punishment, where it is
evident that Marmeladov knows fully well that to steal the money he needs to buy
alcohol from his own daughter Sonya, whom his alcoholism and the resulting hun-
ger of the family has driven to despair and who earned this money by prostitution
(which she hates but sees as only means to save her starving family), is utterly evil.
Yet he acts in this way. Or think of Dostoyevsky's Story ofa Funny Man in which
the same phenomenon of choosing a course of action one knows clearly to be evil is
powerfully described. Thus even the objective good for ourselves we do not neces-
sarily will. On the contrary, we can very well engage in alcohol, in drugs, in adultery
and rape, in deceit and lies, knowing perfectly well that this does not lead us to true

90 See Hildebrand, Das Wesen der Liebe, chs. 5-10.

 FREE CHOICE AND THE ENDS OF MEDICINE 221

happiness. Therefore, the self-love that consists in desiring our true happiness, our
salvation in God, is a rare and very meritorious and difficult moral act.
The drama of freedom presupposes, apart from the three categories of impor-
tance, also the ability of isolating them from one another, the capacity of absolutiz-
ing the merely subjectively satisfying and of taking it outside of its legitimate place
which it possesses only as long as it is integrated in the right order of goods and in
the overall response to what is intrinsically valuable. Socrates' famous thesis that no
one acts knowingly wrong is thus proven wrong.
In order to understand the drama of human freedom, we must not only consider
objective values such as aesthetic values of beauty in nature and art or intellectual
values such as the thorough knowledge of a language. These also demand a due re-
sponse-but they do not impose moral obligations on us. Only when we are faced
with such goods that do not only address a general call to respond to them adequate-
ly but issue a moral call, we are faced with the whole depth and the drama of human
freedom. The dignity of the person, her life, the elementary objective goods for her,
such as her clothing and food, or the basic intellectual development of a person,
truth, etc.-these are not themselves moral values. Nobody is in the moral sense
good or evil for having or not having them. Nevertheless, these values and goods are
morally relevant. They issue moral calls and obligations to us and for this reason are
called 'morally relevant' goods or evils, as we have seen. 91 They involve a directed-
ness to our conscience; they issue quite another serious call than aesthetic values or
even an obligation. They demand that we respond to them with our freedom.
Most morally relevant goods are related to the person or some aspect of a per-
son's being and therefore intimately related to medical activity. In view of the cen-
trality of the morally relevant good of the person who is endowed with intrinsic dig-
nity it becomes understandable why some formulations of the fundamental moral
norm refer only to the person, such as Kant's various personalistic formulations of
the categorical imperative92 and the personalistic principle of Polish personalist eth-
ics: "persona est affirmanda propter seipsam" (the person ought to be affirmed for

91 See above, ch. 3, and Dietrich von Hildebrand, Ethics, ch. 19.
92 See especially the fourth one of the following eight versions of the 'categorical imperative':
1. "Act only according to that maxim by which you can at the same time will that it should become
a moral law" (Immanuel Kant, Foundations of a Metaphysics of Morals, p. 44; Grundlegung zur
Metaphysik der Sitten, II. Teil).
2. "Act as though the maxim of your action were by your will to become a universal law of nature"
(ibid., p. 45).
3. "Act in such a way that the maxim of your will can be taken at the same time as principle of a
universal law" (Kant, Kritik der praktischen Vernunjt, § 7).
4. "Act so that you treat humanity, whether in your own person or in another, always as an end and
never as means only" (Foundation, p. 54).
5. In the third formulation of the principle, i.e., Kant also expresses the idea of "the will of every
rational being as a will giving universal law" (ibid., p. 57).
6. "The principle of every human will as giving universal laws in all its maxims" (ibid., p. 57).
7. "Act with reference to every rational being (whether yourself or another) so that it is an end in
itself in your maxim" (ibid, p. 64).
8. "Act by a maxim which involves its own universal validity for every rational being" (ibid.,
p.64).
222 CHAPTER 4

his or her own sake), or "persona est amanda propter seipsam" (the person ought to
be loved for her own sake).93
If we respond adequately to morally relevant goods,94 we realize moral values.
These involve quite another unconditional sense of 'goodness', as Kant says and as
we have seen in chapter 3, above. Here we may briefly summarize our main results,
relating them to freedom: Moral values presuppose necessarily human freedom.
Without it, they cannot possibly exist. Yet while this bond is evident, it is not analyt-
ically but synthetically true that it exists. Theologians such as Calvin admitted guilt
and sin without admitting freedom. It follows from the essence, not from the mere
definition, of moral values that they presuppose freedom. 9s Also this is an absolutely
necessary truth, a veritas aeterna. Moral values are therefore linked to responsibil-
ity; we are accountable for our moral goodness or evilness. They appeal to moral
conscience and deserve punishment or reward. All moral values, at least all obliga-
tory ones,96 should be realized by every person; the partial value-realization and spe-
cialization that is natural in other spheres of value, such as aesthetic or intellectual
values, is here inappropriate, as we have seen already. Moral values have a higher
rank than other values and are the highest objective goods for the person. Moral val-
ues most properly are the good of the soul, moral evil is most radically opposed to
the good of the soul, as Plato states. 97 In morality in its highest perfection lie the ul-
timate existential calling of man and the only ultimate fulfillment of the being of the
person qua person. For this reason all moral values are also morally relevant, i.e., we
ought to strive for their realization above all in ourselves but also in others. Moral
values also imply the most direct relationship to God and to religious values. None
of these features belong to the other values. 98
We now see that the drama of human freedom lies precisely in choosing either
morally evil pleasure, pride, and concupiscence in contempt of the call of moral val-
ues---or choosing to conform our lives to the call of moral and morally relevant
goods."" Unfortunately, neither that which is good in itself (such as the person of the
patient endowed with intrinsic dignity), nor that which is objectively good/or other

93 See Karol Wojtyla, Liebe und Verantwortung; Tadeusz Styczeil, Andrzej Szostek, Karol Wojtyia, Der,
Streit urn den Menschen. Personaler Anspruch des Sittlichen (Kevelaer: Butzon und Bercker, 1979).
"4 I cannot deal here with many other types of morally relevant importance. See on this Hildebrand,
Moralia.
9S See Aristotle, Magna Moralia, 87 b 33 ff: "For this is the most important condition for virtue, free-

dom. To put it simply, free is that which we do without being forced to do it." Cicero, Augustine, and
most philosophers recognized the necessary link between freedom and morality.
96 This addition is to exclude two things: (a) an ethical rigorism which does not allow for a sphere of
'optional' moral goodness or of a heroism which is not required from all; (b) the opinion that finite
persons can absolutely speaking realize all moral values (whereas the absolute perfection of justice,
mercy, etc., can only be found in God).
97 Plato, Politeia X.
98 Kant calls the morally good will the only thing that is 'good without qualification'. We have identified
in chapter 2 many meanings of this statement.
99 St. Augustine sees this when he speaks, in The City of God, of the two ultimate principles of good and
bad acts and of the Two Cities: "arnor Dei usque ad contemptum sui" (love of God even to the point
of contempting oneself) and "arnor sui usque ad contemptum Dei" (love of self even to the contempt
of God).
 FREE CHOICE AND THE ENDS OF MEDICINE 223

persons (the true physical and encompassing good/or patients), nor even our own
objective good (true happiness) are desired by necessity. They must, as we can now
understand in the light of the categories of importance we distinguished, be chosen
freely.
Physicians and nurses may lose their jobs or their acceptance in medical schools
or in schools for nurses, if they refuse steadfastly any collaboration with acts such as
abortion. loo At least, they have to forgo a bigger income they could gain by partaking
in abortion or abortion industry. They might even risk their professional career if
they abstain from moral evils.
This choice between what is just and right in itself and what is more satisfying
subjectively, is a dramatic and difficult one. In criticizing sharply the idea that "the
good is what all men desire" so as if the intrinsic good or even the objective good
for our person, let alone that for other persons, were desired and willed by necessity,
we do not deny that there is both a natural ordination to intrinsic goodness and to the
objective good for the person, and even a natural tendency in the human person driv-
ing her towards these goods. And this thirst for the good and for happiness as an in-
eradicable inclination, which is the condition even for suffering from its privation, is
indeed a 'necessary directedness of will and desire' to their ends (when the end of
the will is understood not as the object of rational choice but as the end of the will's
'natural inclination'.) But at the level of our personal and free relationship to reality
we need to choose these goods freely and can choose perverse ones, an insight of
which Cornelio Fabro shows that we can find it also in Aquinas. 101
Thus we conclude: while there remains also in doctors and nurses an inclination
to the good and to their and their patients' true happiness, physicians and medical
staff can also choose grave moral evils to gain subjective advantages. Each of them
has to choose freely the ends and ultimate goals of his or her acts.

3. BEING FREE IS NOT RESTRICTED TO THE SPHERE OF ACTION BUT

ENCOMPASSES MANY SPHERES OF HUMAN WILLING
3.1. Different Levels o/Human Freedom-Actual and Superactual, Direct and
Indirect Freedom, Affective Responses, Other Gifts and Cooperative Freedom
All of us, but especially those who, as medical professionals, live an extremely ac-
tive life, can easily be seduced into reducing their freedom to their action or into
failing to recognize that there are other spheres of moral acts. But human freedom is
in no way only given in actions.
To believe so or to cut off the sphere of human actions from the underlying and
more fundamental forms of human life can have tragic consequences, cutting off the
active life of medical professionals from its true roots and from a far more funda-
mental level of freedom.

100 In Zurich, as mentioned above, applicants are not even accepted into nursing school if they do not sign
to be ready to collaborate with abortion.
101 Cf. Cornelio Fabro, Riflessioni sulla Liberta, pp. i-xi, 13-132.
224 CHAPTER 4

The opposite danger also exists: an insisting on 'fundamental moral options'

with the implication that a good benevolent attitude permits us to perform any con-
crete actions, as long as its consequences are judged preponderantly positive.
In order to overcome both of these errors, and to understand the nature of free-
dom and the different kinds of acts that it renders possible, we must first distinguish
two quite different dimensions or perfections of freedom.lo2 The first one unfolds in
relation to the important object; it involves a free 'yes' or a free 'no' spoken to it. It
is the freedom to respond, to take a stance, affirming or rejecting an object or state
of affairs. This dimension of freedom is involved when physicians or nurses take a
stance on issues of life and death, dedicate themselves to promote the wellness of
their patients, and decide to mitigate suffering.
The second dimension of freedom consists in the will being able to engender free
acts which aim at something outside themselves, and to initiate new causal chains,
thereby also becoming the lord over our external actions and being able to initiate
activities which then might lead to the realization of states of affairs which we real-
ize in the outside world, after 'affirming' (willing) them freely in an inner response.
The second dimension of freedom may also lead to the making or creating of ob-
jects, works of art, etc., which are not reducible to states of affairs, the proper ob-
jects of human action. Physicians and nurses continuously realize this dimension of
freedom whenever they operate on a patient, administer drugs to them, etc.
The first perfection of our will is deeper and has a much wider scope than the
second. It encompasses also all purely inner responses, including those directed to
objects that we can in no way change,103 such as God. But we can take also a loving
and generous or an envious attitude towards a more gifted person than we are. We
can freely respect and affirm in love such a person, or reject her in hate and envy.I04
Also a grave disease or illness we can freely and humbly accept or rebel against it.
The second dimension of human freedom chiefly refers to free actions in the
strict sense, i.e., to acts which aim at the realization of states of affairs which are not
yet real but can be realized through me (the object-sphere of prattein, of acting in
the narrower sense of this term) or to objects which we can make or produce
(poiein). In such actions and productive acts that are geared to the real world outside
of ourselves, we initiate those activities that bring about the intended states of affairs
or objects of making.
Both dimensions of freedom involve the mysterious inner power to engender acts
without any preceding cause and without our nature forcing us to act. This essence
of freedom is common to all free acts and actions.

102 See Hildebrand, Ethics, ch. 20 tr.

103 Hildebrand, in his Ethics, failed to see clearly the independence of this fIrst perfection of human
freedom from the second and the central and all-encompassing role of free responses not only with
respect to non-realized states of affairs which can be realized through me, but with respect to all kinds
of morally relevant goods. Cf. Josef Seifert, Was ist und was motiviert eine sittliche Handlung? In his
later work, Hildebrand corrected this mistake of his Ethics: Hildebrand, Moralia.
104 We do not refer here to the affective response of love, envy, or hatred, which we cannot freely engen-
der. But there is also a free affirmation of the person as a whole which we can call a volitional dimen-
sion or form of love. The full reality of love requires both the free response to the person and the af-
fective response of love, which in tum can be sanctioned by the free will.
 FREE CHOICE AND THE ENDS OF MEDICINE 225

The first perfection of the will, the responding one, involves not only freedom as
an unforced consent (we can freely affirm a good without choosing properly speak-
ing), but it also includes the freedom of choice.
In the light of our distinctions between the different senses of the good we see:
Free choice is not restricted to the choice of the proper means to achieve the good as
final end: We do not want with necessity as final end the intrinsic good or the happy
life or the realization of moral values and the adequate response to the truth and es-
pecially to morally relevant goods such as the health or life of patients. Unfortunate-
ly, we can fail to will the first and most important objective goal of our freedom-to
conform our lives to the truth and to true goods. For we can choose a life of subjec-
tive satisfaction in indifference towards truth and towards intrinsic values and mor-
ally relevant goods, and even in indifference towards our own objective good. Thus
we can choose between ultimate ends, between good and evil, between the love of
God up to the neglect of self and the self-love up to the contempt of God, as Augus-
tine puts the object of this dramatic choice in The City a/God. This choice between
the ultimate ends is the drama of human freedom.
In order to understand human freedom, we must understand the further truth that
freedom has many dimensions above and beyond its role in external action. There is
first the impossibility of reducing the first dimension of freedom, its responding
character, to that free response of willing which is an integral part of external action
only and which presupposes something that is not yet real but can be realized
through me. Also when I read a book or watch a movie, or become witness of crimes
or suffer events that I cannot change, I can take purely inner stances, freely affirm-
ing the good, rejecting the evil, praising God or cursing him. These are not external
actions but free inner responses possible even when I am perhaps unable to respond
in any external action. I can direct such inner free responses to individual goods or
evils, such as to a person to whom I forgive a wrong, to an abortion or euthanasia
which I might be forced to witness or to know of, to a scene of torture which I have
to see in a concentration camp, or to whole general spheres of values, such as to
moral values as such, to the dignity of the human body, to all human rights, etc. A
sphere in-between purely inner free stances and actions aiming at realizing states of
affairs outside me is the whole world of language.
Besides such actual free responses, which I experience here and now and direct
to an object, there are also superactual free responses in a person. These continue to
exist in us even when we do not actually experience them or think of them. As we
know many things superactually even when we do not think of them, such as the
French word for horse, so we find also that concretely lived free acts and responses
do not exhaust themselves in our actually experiencing them. Both our responses to
individual beings (such as our love for our wife or child) and to general types and
whole spheres of value, such as attitudes of reverence, the virtues of justice, of puri-
ty, etc., can last in the form of superactual acts. They manifest themselves in our
emotions, feelings, concrete responses and actions, etc. All virtues and vices are su-
peractual acts. They profoundly influence the concrete actual consciousness of a per-
son and are as it were a basso continuo that accompanies the actual melodies of our
daily life.
226 CHAPTER 4

Finally, there is the so-called fundamental moral option for or against all morally
relevant goods, for or against God and the whole world of values. This response has
the most universal scope of objects at which it is directed. This attitude may also be
called the general moral attitude. This most general attitude, however, is not called
so because in itself it would be an abstract entity, but it is 'general' in at least three
distinct ways: (1) It is really or potentially present in all other morally good or evil
acts; (2) it has the most general morally relevant good as its object: both in the sense
that it responds to all morally relevant goods and in that it responds to the supremely
concrete and yet all-encompassing good: God. Moreover, (3) it is called to become
superactually real in the person and thus receives the character of lasting foundation
of a person's moral life, which is a condition for fulfilling its character of underlying
the entirety of a person's individual responses and moral acts and being general in
this sense.
Certainly, the general moral response to the world of morally relevant goods can
also exist in us merely momentarily as a stance we take at a certain moment towards
the whole world of values. But it is intended to achieve a superactual reality in our
soul and deserves the name attitude (rather than momentary stance) only when it has
become superactual. It also can and should have a special depth in different senses,
and not only in that of the superactuallife of the person: It can be more or less firm-
ly rooted in the person, it can qualitatively be more or less deep, play a greater or
lesser role in our lives, last more or less long in its identity throughout time, as op-
posed to fast-changing attitudes, etc. The fundamental moral attitude, especially
when it is freely sanctioned, constitutes in a sense the backbone of our moral life and
is the fountain of concrete actions. Being also strengthened and formed by them, it
possesses utmost significance in any adequate philosophy of virtue and ethics. It
must not be regarded as unconscious, however, though it is more hidden to our re-
flection than concrete intentions.
The fundamental moral attitude (option)'OS does have both a content and an
object, though its content can be extremely 'thin' and formal such as when the good
general moral attitude of an atheist or skeptic has only the form of not wanting to do
anything in truth forbidden him, and if he is ready to obey all moral obligations if
they exist and if he will know them. The atheist and skeptic can in this way be mor-
ally good, submitting in this formal and abstract way to the truth (while leaving open
the content and knowability of truth and feeling unsure whether perhaps in truth ev-
erything is permitted, as Nietzsche thought). Yet the will to submit to truth in
thought and action remains always a decisive element of the person's fundamental
morally good attitude. For all moral imperatives bind in the name of truth, andjudg-
ments which make a claim to truth are presupposed everywhere in our moral life.
And nothing is permitted except if it is in truth permitted.

105 This notion of fundamental moral option, apart from being interpreted in many false transcendental
idealist senses as unconscious, free of content, formal, never experienced, etc., is today also frequently
divorced from an understanding of its foundational role for the sphere of action. Chiefly because of
this 'teleological' (consequentialist) misunderstanding we avoid this term for the fundamental moral
attitude. Also this term refers only to one of the elements related the fundamental moral attitude,
which Hildebrand called 'the fundamental moral intention'. It is not possible here to distinguish all
these elements and acts. Cf. D. von Hildebrand, Sittlichkeit und ethische Werterkenntnis.
 FREE CHOICE AND THE ENDS OF MEDICINE 227

The good fundamental moral attitude may take on much more content, however.
It may be based on a clear recognition of the truth and its basic contents and refer
specifically to morally relevant goods that are understood to exist. It may thus take
the essentially different form of a clear general will to respond adequately to the
morally relevant goods and also of the general will to be morally good.
This general will to be good constitutes a new and very important element of the
fundamental moral attitude, which is another value-responding attitude towards the
unique and specifically moral value to be realized by me.
The fundamental moral attitude as the 'general will to be good' refers to the
'bonum est faciendum' in the sense of the sphere of moral values and disvalues in
the person herself. The acceptance of the call to realize moral values in our own per-
son was thought by Max Scheler to be impossible or at least to involve pharisaism:
To be interested in my own moral goodness would, according to him, fail to accept
the principle that the moral value 'rides on the back of my actions'. It would be a
self-centered attitude and involve a turning away from the morally relevant object of
the good of our neighbor. But this is not true although it is true that the genuine in-
terest in the other's good, in the morally relevant good, is indeed a condition of au-
thentic morality. A careful phenomenology of the fundamental moral attitude forces
us to recognize a two-fold directedness of the Grundhaltung-to all morally relevant
goods and to the realization of moral values in us.
It would be unobjective not to want to be good ourselves if it is recognized that
moral values are higher than even all morally relevant ones which are not them-
selves moral values, as we have seen in chapter 3.
Parents have to be interested also and primarily in the moral goodness of their
children, Socrates is committed to further the moral virtue of his fellow-citizens.
As it would be morally wrong to be disinterested in moral values as such, it
would be most illogical not to be interested in their realization in us. That this inter-
est as such has nothing to do with pharisaism or egocentricity in morality is seen
when we understand that the general response to moral values in us and in others
must be first of all a value-response, not just a response to the objective good for us.
Thus it would be illogical in the highest degree not to be interested in our own
moral goodness as if that were any less important than the moral values in others.
We must distinguish the egocentric or pharisaic interest 'only in our salvation' or
even in a purely subjectively satisfying aspect of glorifying ourselves and of enjoy-
ing our superiority through moral values from the value-response to moral values.
Only the former is pharisaism while the latter is an integral part of the fundamental
good moral attitude.
In the 'general will to be good' we find a second and radically new moment,
namely the awareness that moral values cannot be realized by us primarily in the
world or in other persons but only in ourselves. Only over ourselves we have this
kind of control that permits us to realize them directly. Therefore, the general 'will
to be good' refers not to the moral goodness of others but to our own. It also accepts
the kind of irreplaceable character of our own person and the primary way in which
their call is directed to our own self, in the sense of a special absoluteness of the
moral obligations being addressed to us in such a way which forbids us ever to say
that "we should commit a moral evil so that another one avoids an even greater
228 CHAPTER 4

one." Such a moral weighing of goods is excluded in this self-directedness of the

'general will to be good' which recognizes the unique insubstitutable "Tua res agi-
tur" in the moral imperative. We will return to this important foundation for ethics
in general and medical ethics in particular in chapter 6.
By saying that this will to be good, too, has to have a value-responding character,
we do not exclude that it should involve also an interest in our own (or anybody
else's) objective good/or the person. On the contrary, the objective good for persons
including our own constitutes a dimension of morally relevant goods that must be re-
sponded to in order for our attitude to be truly morally good. It is more problematic
to determine whether a general moral attitude would still be good if we were inter-
ested only in our own salvation and if the will to be morally good did not include
any response to the intrinsic value of morality. Imagine that someone were to say,
for example: "I do not care a bit for moral goodness as such but 1 know: 1 shall be
damned if 1 am not good. Therefore, and therefore alone (to win my salvation and to
avoid punishment), 1 shall be good. Otherwise 1 would not give a damn for justice
and goodness." Would this still be morally good? It appears to be so only in the
most rudimentary way, and even this only by involving still a certain unconscious
response to the value of one's own person and possibly even to moral goodness be-
cause of its intrinsic value. I06
This leads us to a further insight into the true nature of the fundamental moral at-
titude in this sense: it ought to preserve the hierarchy within the motives of moral
acts, and the hierarchical relationship between morally relevant goods and moral
values, intending the realization of justice and other morally good acts first of all be-
cause of their intrinsic moral goodness.
The element of the fundamental moral attitude directed to all morally relevant
goods and moral obligations differs from the more general commitment to truth in
being one step more concrete by being based on the recognition that there are some
morally obligatory and morally relevant things besides 'whatever truly binds us' as
such. It concretizes the Grundhaltung towards truth also by going one step further
beyond the moral relevance of truth itself and by recognizing some other morally
relevant goods.
We could further distinguish the morally required and obligatory Grundhal-
tung lO7 to submit to all morally obligatory goods, and the 'optional' Grundhaltung
that lies in the determination to follow also moral invitations. The first one would be
possessed by a physician or nurse who reject in principle any moral wrong in order
to please their patients' or superior's will. The second fundamental moral attitude
would be more perfect: it would also involve a fundamental willingness, for exam-

106 If someone is not at least implicitly motivated by the inherent preciousness of moral values but ex-
cludes this in the form of a radical disinterest or even hatred for them, the interest in his own objective
good is either not even possible any longer or-if it is possible-is deprived of any moral value. One
could express this also in terms of the traditional distinction in theology between repentance out of
love and out of fear. A repentance out of fear with the total exclusion of any love would seem to be
not only imperfect but no repentance at all. A repentance motivated by fear but not rejecting all love is
imperfect.
107 Strictly speaking obligatory is the fundamental moral intention to respect all morally obligatory goods
and to acquire this Grundhaltung, but since the general superactual attitude is not within our direct
free power (but only the indirect one), it cannot directly be morally obligatory to have it.
 FREE CHOICE AND THE ENDS OF MEDICINE 229

pIe of a nurse or physician, to dedicate their lives far beyond the obligatory to the
promotion of health. Such persons may dedicate years of work and their spare time
to do research on how to cure cancer or leprosy. They may go to distant African
countries at a low pay in order to alleviate suffering there, etc., as Mother Theresa
and her Sisters of Charity did in India and many places, and as many 'physicians
without borders' in Europe and many physicians in countries plagued by poverty do.
This attitude goes far beyond merely fulfilling one's moral duties.
Born from the encounter of subject and morally relevant object, besides 'moral
invitations' to perform free sacrifices or heroic acts such as Maximilian Kolbe's giv-
ing his life for a family father, also moral obligations arise which possess another
moment of absoluteness and make a direct appeal to our conscience. This difference
is evident in cases in which the same morally relevant good (a human life) is at stake
without any obligation for us entering into the picture (for example, when we see
human persons as shoppers in a supermarket where their lives do not impose special
or actual moral obligations on us). The universality of the object of the fundamental
moral attitude reveals itself also in the response to all obligations as new moments
compared with the morally relevant goods (for example, a human person or life).
For this moral obligation and law requires, as Kant saw (though he falsified the ob-
ject of this insight profoundly by claiming that pure reason gives this law to itself), a
new and unconditional respect (Achtung), possessing itself a new absoluteness that
calls quite logically for a new moment of obedience in the fundamental moral atti-
tude. This element within the fundamental moral attitude is not explicable through
the commitment to objective goods such as human life that are morally relevant but
do not deserve in themselves this absolute subordination and obedience owed to the
moral obligation itself. IDS Inasmuch as the objective moral obligations are always
mediated through our knowledge and conscience, and bind us in this form of being
recognized and acknowledged by the subject, one could also describe the fundamen-
tal moral attitude as the determination to follow always one's conscience.
Likewise, the fundamental openness to non-obligatory moral calls can exist on
many levels of qualitative depth and purity: (a) it can exist to some more or less lim-
ited degree as in most morally good human persons; (b) it can also exist in form of a
heroic and in a certain sense unlimited morally good attitude to respond as far as
possible not only to all morally obligatory goods but also to all non-obligatory
goods and indeed to choose the more perfect goods before the lower ones. Such an
'unlimitedly morally good attitude' towards non-obligatory goods we find in
st. Theresa of Avila who reports in her Life (Autobiography) having vowed to do al-
ways that which appeared to her morally more perfect. Similar attitudes are found in
Father Kolbe, Janusz Korczak, Mother Theresa and others.
The fundamental moral attitude can be differentiated also according to the under-
lying ethical knowledge (the purity and depth of ethical knowledge, its closeness to
the moral data, etc.) as well as in accordance with the different degrees of the depth
of the will and the volitional affirmation of the morally relevant goods. There are
also many degrees of moral consciousness informing and characterizing the funda-
mental moral attitude. Its scope is still immensely universal, but with each specific

IDS See my Was ist undwas motiviert eine sittliche Handlung?

230 CHAPTER 4

understanding of concrete morally relevant goods it becomes more conscious and is

enriched and expanded with respect to its content and object.
If a person accepts the existence of God as an infinite personal being most
worthy of love (as an id quo maius nihil cogitari possit), the good fundamental mor-
al attitude may assume much more content still and exist in the form of the unam-
biguous love of God and love of neighbor. From the perspective of a Christian or
Jewish faith, whose meaning can be explored by pure philosophy, the fondamental
moral attitude receives a far higher and more dense inner content. When the truth
about the world and God revealed by Christ is accepted, a completely new sublime
quality of the fundamental moral attitude and of the virtues informed by caritas
comes to exist. \09
As there exists a necessary essential connection of moral values and moral con-
science with the absolute Being, the fundamental moral attitude is also one of obe-
dience and of surrender to God. Socrates already expressed this by saying in the
Apology: "I respect you, Athenians, but I have to obey God more than you." This
obedience to God constitutes a new personal reference point discovered quite natu-
rally in the very nature of the moral ought but much more clearly present and
grasped when the existence of God is known and consciously responded to. The
"Thou shalt ..." of the moral ought involves in its essence and at its root a moment
which finds explicit expression in the Old Testament: "For I am the LORD your
God: ... and ye shall be holy; for I am holy:"1 \0 The reference to the absolute divine
personal being is not only found in the Bible but discovered in other essential marks
of morality: in responsibility, punishment, etc. Cardinal Newman thought in his
Grammar of Assent that this datum prior to all religion is the 'creative principle of
all religion' .III SO much did he recognize that it precedes all positive religion.
There are countless degrees and forms of the fundamental moral attitude when it
assumes the explicit form of being directed to God: a fundamental attitude of obedi-
ence to God, a desire that his will be done, the solemn affirmation of his holiness in
adoration, etc. The climax of this God-centered core of the general morally good at-
titude lies in the explicit religious acts of the love and desire of the glorification of
God.
Is then an atheistic morally good attitude possible? I think that yes. An atheist
can very well have the general morally good attitude related to truth: "I search to
live a life under the guidance of truth-at least if truth exists; I will respect all values
I can discover." But the good general attitude of the atheist is morally good only if
the atheist is open in principle to God, i.e. if his attitude has the following, 'truth-
searching' form: iiI affirm all morally relevant goods that I recognize. If God does
exist and were known to me, he would be the supreme object of my moral attitude

109 See on this the phenomenological analyses of Dietrich von Hildebrand in his Transformation in
Christ. On the Christian Attitude of Mind, and in the same author, Ethics, as well as the same author,
Das Wesen der Liebe, in: Dietrich von Hildebrand, Gesammelte Werke ill ( Regensburg, 1971),
ch. 11.
110 The full text is: "44 For I am the LORD your God: ye shall therefore sanctify yourselves, and ye shall
be holy; for I am holy:" Lev. 11:44. See also Lev. 11:45; 19:2; 20:26; 21:8, and also 1 Peter 1:16: "16
Because it is written, Be ye holy; for I am holy."
III See John Henry Cardinal Newman, An Essay in Aid of a Grammar ofAssent.
 FREE CHOICE AND THE ENDS OF MEDICINE 231

and I would embrace the Holiest as the ultimate motivating ground and supreme ob-
ject of all moral acts." Any moral attitude such as described in Thus spoke Zara-
thustra by Nietzsche: "if there were a God, how could I bear not to be one. There-
fore there is no God" could only be evil. If the atheist rejected explicitly and in prin-
ciple God even if he were to find that he exists and embodies all goodness, in the
sense of Nietzsche's word, the moral attitude of such an atheist would be evil. Simi-
larly, if the atheist were to set up his moral goodness against God, such as Goetz in
Sartre's Le diable et Ie Bon Dieu, all his acts would lose any moral value for the rea-
son of embodying diabolical pride and revolt against the absolute Good.
But on the other hand, the fundamental morally good attitude towards truth and
the good might even demand atheism, not objectively but subjectively, if someone
had an image of God according to which God, if he corresponded to this image,
truly would deserve to be rejected in the name of an eternal moral order and in the
name of evident moral values. Such a conception of God which would justify the re-
jection of God includes the widespread deterministic image of a God who would
condemn angels and men to eternal punishment for their sins although these sins and
the fact that they do evil would solely depend on God's own will against whose de-
cree the creatures could in no way act. An acceptance of such a God would be mor-
ally evil, at least if one understands properly what one believes in such a determinist
interpretation of sin and hell: that God is thereby turned into the devil and cause of
all evil. Therefore, a rejection of such a God who would correspond to this false im-
age is morally demanded. It is also clear that, when we presuppose the objective
goodness of God, this element of the morally good attitude, the response to God, dif-
fers very much depending on the vagueness or clarity of someone's metaphysical
conception of God. This element of the morally good attitude towards God reaches
from a vague 'openness to God' as the atheist or agnostic can even possess it, to the
fervent and unconditioned love of God.
Many authors thought that the fundamental morally good attitude is restricted to
a very formal abstract level, or even is a-thematic in the sense of having no object at
all.
This is the 'transcendental' conception of the 'fundamental option' found in Karl
Rahner and other authors and is, in my opinion, in contradiction to the nature of in-
tentional consciousness that must have an object, reducing the fundamental option to
an irrational state of consciousness. Of course, if a-thematic were to mean the super-
actual character of this attitude that continues to exist even when I do not actually
perform and live it, it would be quite correct to attribute this to the fundamental
moral attitude. If the term meant that this attitude could never be actualized in con-
sciousness, it would again be a false assertion because all superactual attitudes can
and should become actually conscious from time to time. The same would apply to
the thesis that the fundamental moral attitude can never become the theme or object
of reflection. Superactual realities differ wholly from the sphere of the subcon-
scious. 112
This view contains the truth that rarely we live fully consciously this fundamen-
tal moral attitude; normally it is not the theme of our acts but remains a background

112 See the discussion of the superactuality of virtues in Dietrich von Hildebrand, Ethics.
232 CHAPTER 4

for conscious life. It is also true that we cannot identify it in reducing it to particular
objects or sphere of goods because it refers to all of them. Nevertheless, in reality, as
we now see, the fimdamental moral attitude, by proceeding from most universal, all-
embracing objects such as truth, value, God, can assume very rich and concrete ob-
jects, embracing them all in their wealth of content and branching off into the dif-
ferent concrete virtues which respond to single spheres of morally relevant goods
such as rights Gustice) or property (honesty), or the dignity and 'sacredness' of the
body and human sexuality (chastity and purity), and giving rise to responses to still
more individual goods. Also the morally good attitude towards God is, if we under-
stand God as supreme embodiment of all pure perfections, directed to an extremely
concrete and living reality, the archetype of all individual thisness and qualitative
concreteness: the perfect justice, love, goodness, wisdom, and all-encompassing
perfection.
At least to receive its full meaning, the general free moral attitude must also exist
superactually, i.e. to say its reality in us cannot be restricted to the times when we
consciously live it, think of it. This attitude is not meant to endure merely a few mo-
ments but to become a lasting and formative basis of our moral life. At this point we
have to consider a more general and very important fact: a person's rational life, her
knowing and willing, can extend far beyond the limits of the moment and of the
short islands of the present. It can last, without being subconscious, as a continuous-
ly present reality or as a background of actual consciousness, reaching deeply into it.
The superactual attitudes are rather supraconscious and constitute the background
and form of conscious human life. Not all human experiences allow for such a su-
peractual existence. But to many, such as to 'knowing some object' and 'knowing
that' (which refers to states of affairs), or to love, it belongs essentially that they
exist only really if they are superactual and not restricted to short islands of time.
We do not just love truth or a person from 4 p.m. to 8 p.m. Both general moral atti-
tudes and responses to individual persons, such as the love of our child or spouse,
can be superactual. Thus, starting from the most general fimdamental moral option
for or against morally relevant goods as such, for or against God, for or against truth,
the life and formative influence of superactual free acts extend to concrete attitudes
towards individual persons. Our moral life is deeply formed by such superactual re-
sponses and attitudes. Such attitudes can also open our intellect and contribute much
to our value-perception or lead to value-blindness.113 Thus they exert an enormous
influence on our moral life.
Drawing the conclusion for our topic, we see that to be free is not restricted to
external actions directed towards realizing not-yet-existing states of affairs in the
world, nor to free responses to individual beings. Freedom entails also general vir-
tues or vices that relate to whole spheres of morally relevant goods and the most
fimdamental moral attitude. Thus freedom is situated at the very core of the being of
the person that can be actualized only through freedom. Also for the moral life of
physicians and nurses, for the background and form of their dealing with patients,
the fundamental moral attitude or fundamental option is of decisive importance.

113 See on all of this the important work of Dietrich von Hildebrand, Sittlichkeit und ethische Wert-
erkenntnis.
 FREE CHOICE AND mE ENDS OF MEDICINE 233

4. COOPERATIVE FREEDOM AND THE AFFECTIVE DIMENSION OF THE

GIFT OF SELF AS AN IMPORTANT ELEMENT OF MEDICAL ETHICS
In the following, we are going to discuss a dimension of ethics that is important for
physicians and nurses. For the fullness of the moral life and of the kindness and lov-
ing affIrmation towards patients, whose suffering makes them more receptive for
kindness and feelings of sympathy, requires gifts which do not stand within our
power. No nurse can force herself by her freedom to feel feelings of loving sympa-
thy or even produce at will a heartfelt smile. That our moral life requires a dimen-
sion of gift and grace is thus not solely a content of faith and theology but applies
also to the order of nature and is experienced here. Similarly, it is clear that we can-
not directly realize superactual attitudes by a simple fiat. We can engender freely
general moral intentions, yes, but they neither immediately take root in the person
nor acquire instantaneously the personal depth proper to superactual acts. Likewise,
we cannot, by a simple fiat of our will, bring about affective responses such as grief
or love, joy, compassion, or repentance, however appropriate also these affective
and spiritual affections are to their objects. 114
Yet the fact that such feelings and attitudes do not stand in the direct power of
our will does not imply that we have no freedom or responsibility with respect to our
superactual attitudes or to our spiritual affective responses such as love, repentance,
or grief. We come to recognize here two further important manifestations of free-
dom: (I) the indirect role of our free acts, and (2) cooperative freedom.
(1) A single free action of helping someone lies within the power of our direct
freedom (in spite of the diffIculties and limitations we may experience with respect
to its actualization), and has an immediate and direct effect in the world and on our
conscious life. Yet each action has also indirect effects on the person; it will influ-
ence and gradually change our superactual attitudes and the kind of emotional re-
sponses (love or hatred, warmth or envy and bitterness) we give to others. This ap-
plies to good as well as to bad actions. There are many other forms of indirect influ-
ence of our freedom. When we meditate on our lives, for example, instead of acting
thoughtlessly and without the necessary reflection, we will influence our lives indi-
rectly. Yet this act of meditation itself we can command, we can take time to think
about the purpose of our lives instead of hunting for pleasure after pleasure, or of
going from noise to noise, diverting ourselves in the negative sense described by
Pascal.I 15 Thus we come to understand that our freedom has an enormous indirect in-
fluence distinct from direct freedom by which we bring about free acts. Through all
the single free acts of a nurse who is polite with patients, asks compassionately how
they are, practices patience when they are demanding, the affective life and general
attitudes of that nurse will gradually change and be deeply modified.
(2) Even more amazing is what Hildebrand terms 'cooperative freedom'. We
cannot directly bring about with our freedom superactual attitudes towards persons
or values, though such attitudes result indirectly from many free actions, nor can we
immediately evoke affective responses of repentance, compassion, or love, which

114 On the spiritual fonus of affectivity see Dietrich von Hildebrand, The Sacred Heart; 2nd ed.: The
Heart.
lIS Blaise Pascal, Pensees no. 139 (136). See also Seifert, Schachphilosophie, pp. 90-105.
234 CHAPTER 4

arise in our nature without participation of our freedom. And yet these affections are
morally and humanly speaking adequate to their object or to the human or divine
person to whom they are addressed. We should feel love for persons, experience
compassion, joy, or delight. And yet we cannot produce them, though indirect free-
dom exerts great influence on the arising of emotions, virtues, and vices. But when
we are given affective responses or superactual attitudes, we also have another im-
portant capacity: namely that of cooperative freedom, of relating freely and in a par-
ticularly intimate way to those realities in us that arise without freedom. We can
conspire freely with the tears of repentance that arise in us or suppress them, we can
disavow freely feelings of anger or hatred towards a disagreeable person, or we can
identify ourselves with them. We can cooperate with emotions of love and form
them freely from within by sanctioning them. Hildebrand calls this use of freedom
cooperative freedom. With this concept, we touch upon what constitutes the very
heart of human freedom. Recognition of cooperative freedom even modifies what
we have said about freedom at the beginning of this chapter, describing freedom in
terms of our being 'the lords over the being and the non-being of our acts'. This
characterization of freedom in terms of autonomy and creation does not describe
adequately many aspects of freedom such as the freedom in the grateful receiving of
gifts, in gratitude as such, and in cooperative freedom. 116
In many cases, of which the highest (according to Jewish or Christian faith) in-
volve divine grace, we find in our soul gifts and experiences of joy or love that arise
in us without depending on our freedom. Yet inasmuch as such movements of our
soul are adequate or inadequate to their object, good or bad, we must not let them
arise in us without involvement of our freedom. When they are bad, we ought to dis-
avow them, thereby not immediately eradicating them but 'decapitating' them, as it
were. We can freely speak a 'no' to our feeling of intense envy, when we realize its
evilness and inappropriateness. This is not an act of repression but, on the contrary,
an act of conscious confrontation with ourselves. By disavowing feelings of envy,
the person disassociates herself from them. Thus they become movements of the
soul for which we are no longer responsible in the way in which we are responsible
when we let envy grow in us without taking such a free stance.
Much more profound is the interpenetration of freedom and affective re-
sponses---or other non-free experiences and gifts in us-in the positive case. When a
deep love or feeling of repentance is granted to us-a feeling or movement of our
soul that we never could have given to ourselves---our freedom is not condenmed to

116 See W. Desmond's paper "Freedom Beyond Autonomy" read at the Fifth World Congress of Chris-
tian Philosophy in Lublin. See also Balduin Schwarz, "Uber die Dankbarkeit," in. 1. Tenzler (ed.),
Wirklichkeit der Milte. Beitrage zu einer Strukturanthropologie. Festgabefor August Vetter zum 80.
Geburtstag (FreiburgIMiinchen 1968), pp. 677-704; the same author, "Der Dank als Gesinnung und
Tat," in J. Seifert (ed.), Danken und Dankbarkeit. Eine universale Dimension des Menschseins (Hei-
delberg: Carl Winter Universitatsverlag, 1992), pp.15-26; "Some reflections on gratitude," in
B. Schwarz (ed.), The Human Person and the World of Values. A tribute to Dietrich von Hildebrand
by his friends in philosophy (New York, 1960), pp. 168-191; "Refiexions sur la gratitude et I'admira-
tion," in Entretiens autour de Gabriel Marcel, sous la direction de Jeanne Parain-Vial et Paul Ricreur
(Neuchiitel: Editions de la Braconniere, 1976), pp. 229-241 (also ibid., "Diskussion," pp. 242-248).
See also Balduin Schwarz (ed.), Dankbarkeit ist das Gedachtnis des Herzens. Aphorismen (Miinchen:
Don Bosco Verlag, 1992).
 FREE CHOICE AND THE ENDS OF MEDICINE 235

remain outside such gifts. It can join in with the gift. We can freely sanction our af-
fective response or an attitude of our will of which we recognize that it has gift-char-
acter and does not stand simply in our power. By such a free sanctioning of these
acts, we integrate them into our free life. Analogously, we can appropriate and ac-
cept into our freedom all intentional and good acts that arise in our soul, including
our acceptance and conviction of the truth. Also in the sphere of the intellect we can
integrate by a free sanction, and affirm from within, convictions that arise organ-
ically and without being free acts from our cognition. Newman spoke in a similar
vein of a real assent. Given the rationality of the conviction and its character as a
theoretical and adequate response to reality (states of affairs), we can also sanction it
or add to convictions resulting simply from knowledge (being convinced by the ob-
ject known) convictions that have the character ofJree real assent.1l7 We can speak a
free 'yes' to truth, a response that takes on a new role when it is not merely based on
evident knowledge but on probable knowledge or on faith.ll8 We can turn an act or
experience that is given to us as a gift into a free act by freely sanctioning such gifts.
Gift and freedom interpenetrate each other here. We might speak, with Dietrich von
Hildebrand,ll9 following a great and original discovery of his, anticipated by other
thinkers, in particular by Saint Francis de Sales,120 of a spiritual wedding of our will
with our affections and with other noble movements or acts in us, including the free
assent to truth. By affections which well up in us as gifts, such as deep emotions of
compassion and charity, which enrich the relationships between medical staff and
patient, our will is enriched and allowed to partake as it were in the wealth of those
affections and of other movements of the soul which possess gift character. Thus the
deepest dimensions of freedom do not actualize themselves simply by the free center
of the person alone. They are not even only formed by, as well as dependent on, the
value of the object that gives purpose and meaning to our freedom.
Rather, the deepest dimension of human freedom requires a gift which precedes
it and in cooperation with which alone freedom can attain its supreme dignity. 121
This is true in a special way of the deepest act of freedom realized only in love and
in the gift of Self, in which we give to the other not only a response or something in
ourselves, do not only perform acts, but give our very self to the other. This self-
donation in love requires, in its fullness, on the human level, also the gift of the af-
fective response to the beloved person. 122

117 This played a great role in Stoic philosophy of the judgment.

118 Dietrich von Hildebrand did not discuss the role of freedom in theoretical responses such as convic-
tions which he regarded as not free in his Ethics, ch. 17.
119 See Dietrich von Hildebrand, Ethics, ch. 25, pp. 316-337.
120 See Andreas Laun, "Die mitwirkende Freiheit bei Dietrich von Hildebrand und die geistliche Lehre
des hI. Franz von Sales," in Aletheia V (1991), pp. 258-264. Also in the same author, Fragen der
Moraltheologie heute, pp. 216-220. See likewise A. Laun, Der salesianische Liebesbegriff - Nach-
stenliebe - heilige Freundschaft - eheliche Liebe (Eichstatt: Franz-Sales-Verlag, 1993), pp. 91 ff.
121 While this is a purely philosophical distinction based on the data of affective experiences, it is clear
that this philosophical distinction is of the highest importance for an understanding of the Catholic
theological teaching on justification.
122 This fact, which is evident on the level of affective experiences and general attitudes and convictions,
is in addition a matter of belief on the level of Jewish or Christian faith where we understand the su-
preme act of freedom to lie in a free acceptance of, and cooperation with, divine grace. Faith is then
236 CHAPTER 4

5. CONCLUDING REMARKS ON THE FUNDAMENTAL MORAL CHOICES

IN MEDICINE

On all of these levels, the moral life of the human person involves a fundamental
free choice between good and evil-and between quite different types of 'good' (of
positive importance). No physician and nurse should believe that he or she wills the
good by necessity. They have to choose it in the depth of their soul again and
again-both when it is difficult and when it comes easy. Therefore, they ought to
ask themselves again and again whether they freely embrace the goals and goods of
medicine. They should examine themselves as to whether they truly and fully com-
mit themselves, in the spirit of the Hippocratic Oath, to the good of their patients, to
the seven goods of medicine, and to all the morally relevant goods they have to do
with day in and day out, including truth.
They have to speak again and again an unwavering free 'yes' to the intrinsic val-
ue and dignity of their patients, to the value of each human person even when she
causes lots of trouble, is ungrateful, or is plagued by pain. Physicians and nurses
need to speak this 'yes' in their most encompassing fundamental moral attitude but
also on the level of the distinct virtues. Their free concrete stances and choices will
gradually lead them to conduct a life of the virtues of kindness, of assuming full
moral responsibility for their actions--or to not taking the care for patients serious-
ly, to engaging in vices of avarice or recklessness, which are unworthy of their pa-
tients and lead to acts that endanger the health and lives of their patients.
The drama of free choice that manifests itself in the general attitudes and virtues
or vices of medical staff is still much more concrete and actual in the concrete inner
stances and responses to patients they have to take daily here and now.
And of course, free choice refers quite especially to the external and as it were
physical actions of physicians or other persons involved in health care. To the im-
portance of the sphere of concrete incarnate actions in medicine and the criteria of
their rightness and wrongness we will return in the last chapter.
On all of these levels the free yes or the no to human dignity, to truthfulness and
justice, to all morally relevant goods, is possible and is given into the hands of each
doctor, each nurse, each secretary, each health care taker. On all levels of their medi-
cal professional lives each member of this profession needs to choose freely: may he
and she choose life, not death; health and care, not neglect; virtue and not vice.

conceived as a free act of 'faith in', and submission to, God and a consequent 'belief that' what he re-
veals to us is true. Even more profoundly, the supernatural love of caritas, without which we cannot
speak a 'totus Tuus', requires, according to this faith, the gift of grace, confIrming on a religious level
a profound natural experience and philosophical insight into the broader cooperative role of human
freedom. In this ultimate sense, then, 'to be free' means to cooperate with gifts, and without using our
freedom in cooperation with such gifts we can never attain the highest perfection to which the person
is called nor fulfIll what it means 'to be a person' .
 CHAPTERS

RATIONAL JUSTIFICATION OF AN OBJECTIVE AND

PUBLICLY ACCEPTABLE BIOETHICS
A Critique of Ethical Relativism, Skepticism, and Nihilism
and an Answer to Engelhardt

1. SHORT SUMMARY OF THE RESULTS GAINED IN THE PRECEDING

CHAPTERS AND OF THE PROBLEMS TO BE TREATED IN CHAPTER 5

In the first four chapters of this work I have attempted to sketch outlines of a philos-
ophy of medicine, general ethics, and medical ethics and defended a number of con-
tent-full ('material') goods and ends which medicine should serve. For medicine to
serve these concrete and content-full goods I have declared not only to be desirable
but constitutive of medicine qua medicine.
The essences of these goods contain many contingent elements open only to em-
pirical medical science, and in this respect their exploration belongs to the field of
empirical medicine. But these goods also possess, in their core, necessary and highly
intelligible natures which are open only to specifically philosophical analyses that
were presented in the first chapter only in a succinct form, but shall be expanded, es-
pecially that of the nature and value of human life' and of health/ in volume II of the
present work.
In chapter 2 we investigated the dignity of the human person as a universal basis
of a rationally founded global medical ethics and as a true 'universal of medical eth-
ics' .
In chapter 3, we came to distinguish the morally relevant goods, which constitute
the ends of medicine, from moral values themselves. Ethics qua ethics, and thus also
medical ethics, needs to reflect on the entirely new and axiologically speaking
higher essence and rank of moral values, which are higher values also in comparison
with all those noble morally relevant goods whose realization medicine should
serve. And by serving and adequately respecting morally relevant goods, which are
not themselves moral goods, such as life or health, we realize moral values in our
acts. Moral values themselves exceed in their rank all extramoral but morally rele-
vant goods including human life. This was the stunning result of Socrates' and also

, For a further elaboration of this topic see Josef Seifert, What is Life?
2 See also Josef Seifert, "Moral Goodness and Mental Health."

237
238 CHAPTERS

of Kant's ethics, and a proper understanding and phenomenological investigation of

medical ethics and of concrete imperatives governing human actions has recon-
finned these general ethical results.
Chapter 4 on the essence of freedom seemed necessary for a book on the founda-
tions of ethics of medicine in view of the unique significance of the freedom of the
will for the constitution and existence of these highest human values, namely, moral
values, which alone constitute the unum necessarium within fundamental human
goods and must be recognized in their singular importance. An investigation into
freedom and the different categories of the 'good' and 'important' have allowed us
also to see clearly the drama of free choice with which physicians and other medical
professionals are faced today vis-a.-vis the goals of medicine and the goods medicine
should serve.
Let us now turn to the great topics to be treated in this chapter: The nature and
value of human life, of human health, and of the other fundamental goods in whose
service medicine qua medicine stands and in which medical ethics is founded, are
given to us unquestionably as trans-cultural and highly intelligible, and at the same
time as content-full and 'material' (non-fonnal) in the sense that they possess a rich
qualitative nature from which many very concrete moral imperatives and obligations
follow.
The systematic investigation of these goods and of their universal and concrete
moral implications turned out to be ultimately a philosophical task. Therefore, a cen-
tral part of authentically medical science does not belong to natural science but to
philosophy, as Theophrastus Paracelsus and many other great physicians and philos-
ophers of medicine saw very deeply. Thus, philosophical and ethical studies should
be part of the curriculum of any physician and nurse, especially today when the un-
derstanding regarding those high morally relevant and moral goods without respect
for which medicine degenerates to a criminal activity can no longer be taken for
granted.
While religious believers, particularly adherents of the monotheistic religions,
and specifically Christians, believe that Divine Revelation of the reality and of the
immensity of the love of God for man gives us a far more secure and sublime grasp
of the goods medicine ought to serve, the fundamental essences of these goods are
open to universally shared human experience. Given that a religious worldview is
shared only by a dwindling number of members of our pluralistic society, the ques-
tion whether the foundations and basic contents of bioethics are open to human rea-
son rather than being a private matter of belief of religious faith-communities only
assumes in our secularized society a higher significance than this question held ever
before in history.
I argue in this book and will specifically argue in this chapter that universally ac-
cessible moral experience and pre-philosophical Sachkontakt, as well as rational
philosophical intuition and analysis are sufficient to gain authentic ethical knowl-
edge. In consequence of this, the nucleus and essence of the goods medicine ought
to serve and of the moral obligations and acts related to them, however richly their
content may be shaped by cultural traditions or distorted by culturally and his-
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 239

torically changing substitutes for true morality/ is trans-cultural and intelligible in

principle for all meri and women of good will.
To insist on this has been called a 'natural law ethics',4 which I passionately de-
fend although I see many problems with the concrete ways in which different con-
ceptions of this 'natural law' were affected by errors of naturalism, of eudemonism
and of other considerable distortions. 5

2. THE PHILOSOPHICAL PLAGUE AND AIDS OF MEDICINE TO BE

DISCUSSED-IN THIS CHAPTER AND THEIR CURE

The position that we can attain to a rational and objective bioethical knowledge has
been challenged dramatically in our time by many authors who defend varieties of
an ethical skepticism and relativism which undermines any authentic ethics and bio-
ethics. 6 We can call value relativism and skepticism the most deadly philosophical
diseases of medicine, a true philosophical plague of medicine because they deny the
entire basis of medical ethics.
In the following, I wish therefore to present first a critique of general relativism
and skepticism, which inevitably leads also to ethical skepticism or relativism, and
to some specific forms and arguments of, and against, ethical relativism and skepti-
cism. 7
Then I will turn especial attention to one of many dramatic challenges that ex-
erted a particular strong influence in the field of bioethics, the book of my personal
friend but on many points my philosophical foe; H. T. Engelhardt, Jr. In his very in-

3 See on this Dietrich von Hildebrand, with Alice Jourdain, Graven Images. Substitutes for True Moral-
ity (New York: David McKay Company, 1957; 2nd ed. Chicago: Franciscan Herald Press, 1976).
4 A newer form of a natural law ethics can be seen in a 'non-formal ethics of values' , which constitutes
a revolution of traditional natural law ethics, even surpassing the great work ofG. E. Moore, Principia
Ethica. We encounter this new ethics in different forms in personalistic works such as Max Scheler,
Der Formalismus in der Ethik und die materiale Wertethik; Karol Wojtyia, The Acting Person; see
also Josef Seifert, Was ist und was motiyiert eine sittliche Handlung?
5 See on this Andreas Laun, Die naturrechtliche Begriindung der Ethik in der neueren katholischen Mo-
raltheologie (Wien: Wiener Dom-Verlag, 1973); also by the same author, "Die naturrechtliche Proble-
matik von heute in der wertethischen Sicht Dietrich von Hildebrands," in Die naturrechtliche Begriin-
dung der Ethik in der neueren katholischen Moraltheologie, pp. 160-230 See likewise Burkhardt
Ziemske (Hrsg.), Staatsphilosophie und Rechtspolitik. Festschriftfiir Martin Kriele zum 65. Geburts-
tag (MUnchen: Verlag C. H. Beck, 1997); Wolfgang Waldstein, "Vorpositive Ordnungselemente im
Romischen Recht," 6st. z. off. Recht 17 [1967]. See also Josef Seifert, "Zur Erkenntnis der Men-
schemechte und ihrer axiologischen und anthropologischen Grundlagen," in Josef Seifert (Hrsg.), Wie
erkennt man Naturrecht? (Heidelberg: Universitlitsverlag C. Winter, 1998), pp. 65-106.
6 Several authors have recognized this. See, for example, Courtney S. Campbell, ''The Crumbling Foun-
dations of Medical Ethics," Theor Med, 19 (2) (January 98): 143-152. This author sees three books
that demonstrate these crumbling foundations of medical ethics: Peter Singer'S Rethinking Life and
Death. The Col/apse of Our Traditional Ethics (Oxford: Oxford University Press, 1995); Tristram En-
gelhardt's The Foundations of Bioethics; and Jonathan Moreno's Deciding Together: Bioethics and
Moral Consensus (Oxford: Oxford University Press, 1995).
7 See on this John F. Crosby, "Refutation of Skepticism and General Relativism." See likewise Martin
Cajthaml, Analyse und Kritik des RelatiYismus.
240 CHAPTER 5

fluential work on bioethics and in other writings," he challenges any content-full bio-
ethics and philosophical natural law ethics, on two distinct counts: on the one hand,
the very possibility of a rational and content-full ethical knowledge is disputed by
him; on the other hand, he questions in particular any legitimate role of such a philo-
sophical bioethics for the contemporary public world of our pluralistic and secular
society. The fIrst reason for his position is epistemological; the second belongs to his
political and social philosophy, and to his libertarian philosophy of the role of the
state.
Seeing that a medieval structure of society, in which religion formed the public
life, has ended and that many a dream of the excessive rationalists of the enlighten-
ment, who thought that they could found a society in which morality would prevail,
on reason alone, has failed, he turned to a radical so-called 'postmodern' ethical
skepticism, whose foundations we will have to examine carefully.
Engelhardt not only believes, what is obviously correct, that the dominant role of
a single religion in society has at least de facto ended. Nor does he just hold the
equally correct belief that the ideology of the enlightenment (which thought that, by
means of mere education and democracy, and according to some authors even with-
out moral virtues, human reason alone will prove sufficient to temper all human pas-
sions and to guarantee a lasting just and peaceful order) has been proven wrong by
the horrors of the last century. Engelhardt also infers what is not at all obviously
true: namely, that also the conviction regarding the existence and intelligibility of
natural law itself is a mere fantastic dream of the enlightenment which has collapsed
in recent history and that human beings are not capable of any moral virtues except
on the basis of religious life and faith.
He thus adopts the view current among many that we live in a postmodern age in
which neither faith nor reason can provide a public moral order and in which a radi-
cally libertarian laissez-faire 'public ethics', with its principles of permission and of
agreement, should dominate. 9
Historically speaking, Engelhardt regards-mistakenly, I believe-the natural
law ethics based on reason as a specifIcally modern phenomenon, as a dream of the
enlightenment and as a late consequence of the distorted rationalism attributed by
him to Catholicism and to Saint Thomas Aquinas. He therein fails to recognize, I
submit, the long and venerable tradition of natural law ethics from antiquity to the
present, and above all the objective and evident existence of what has been called,
not without ambiguities, 'natural law' .10

8 See H. T. Engelhardt, Jr., The Foundations of Bioethics. See by the same author, The Foundations of
Christian Bioethics, (Lisse: Swets & Zeitlinger, 2000).
9 On the notion of postmodemity used by Engelhardt see ibid., pp. 8 ff.
10 See on this Wolfgang Waldstein, Operae Libertorum. Untersuchungen zur Dienstpjlicht freigelasse-
ner Sklaven (Stuttgart: Steiner-V erlag-Wiesbaden, 1986); see by the same author, Das Menschenrecht
zum Leben (Berlin: Duncker & Humblot, 1982). See likewise Martin Kriele, Recht Vernunft Wirklich-
keit (Berlin: Duncker & Humblot, 1990), pp. 71-235. See also Burkhardt Ziemske (Hrsg.), Staats-
philosophie und Rechtspolitik. Festschrift for Martin Kriele zum 65. Geburtstag. See my paper in this
work: Josef Seifert, "Die vierfache Quelle der Menschenwiirde als Fundament der Menschenrechte,"
pp. 165-185. Engelhardt also overlooks that his denial of any ethical natural law content and his re-
striction of any content-full morals to religious faith-communities contradicts the repeated assertions
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 241

In his thematic and systematic philosophy, he raises many philosophical objec-

tions to ethical objectivism. H. T. Engelhardt's challenge of the rational foundations
of ethics does not only concern his own specific and influential position, but his ar-
guments and our replies likewise touch the positions of many other authors.
In view of the central question of the non-relativity and objectivity of ethics and
of the many influential critiques of value-objectivism, it is essential for our project
of a philosophical bioethics to be critically propounded, to examine this challenge
very carefully, examining Engelhardt's concrete position and discussing some other
positions and more general arguments in favor of ethical relativism and nihilism as
well.
One might characterize Engelhardt's position as a general philosophical and pri-
marily ethical skepticism and relativism linked to an ontological and fideist objecti-
vism. II If this position can be proven wrong, it no doubt turns out to be another phil-
osophical disease of contemporary medicine distinct from the philosophical plagues
of a total ethical skepticism and (ontological) value relativism which Engelhardt
does not hold. A position, however, which recognizes content-full ethical knowledge
solely for the domain of religious groups but denies it for any public ethics might be
called in a certain sense a philosophical AIDS of medicine because it undermines
the philosophical immune system and the natural resistance of the human intellect to
the philosophical plague of value relativism that divorces medicine entirely from its
pregiven goals and threatens the very existence of medicine. As we shall see, Engel-
hardt himself sees the fatal consequences of total ethical skepticism that cannot dif-
ferentiate any more between good and criminal health care and has to conclude that
"the health care provided by Albert Schweitzer and by Nazi death camps will be
equally defensible and indefensible."12 Engelhardt's position, while not denying ab-
solutely the contents of bioethics, deprives the human intellect of any immune sys-
tem against ethical skepticism, relativism, agnosticism, ontological value nihilism,
and the most radical value subjectivism and nihilism. While the position of Engel-
hardt neither denies the existence of objective values nor the human capacity of
knowing them, it restricts knowledge of them to a purely religious domain and there-
by leaves human reason unaided by faith without any immune system against the
most deadly poison of a total corrosion of content-full moral truth as foundation of
medical practice.
Moreover, this position delivers the public forum, secular ethics, the legal order
and politics, at least as far as moral contents are concerned, completely into the
hands of ethical nihilism, and hence infects at least the public world t3 with philo-
sophical HIV-a philosophical human immune insufficiency virus. A radical ac-

of a natural law accessible to every human being, made in the Old and New Testament (and also in the
Koran).
II See T. H. Engelhardt, Jr., The Foundations o/Christian Bioethics. That Engelhardt's position entails
relativism and nihilism, was also pointed out by Michael J. Wreen in his "Nihilism, Relativism, and
Engelhardt," Theor Med 19 (I) (January 1998): 73-88. This author holds, however, that Engelhardt
himself is an ethical universalist, a claim with which we cannot agree except on an extremely formal
level, which, however, can also not be defended successfully from Engelhardt's own principles.
12 T. H. Engelhardt, Jr., The Foundations 0/ Bioethics, p. 65.
13 Contrasted by Engelhardt with the private world ofthe believer.
242 CHAPTERS

quired immune insufficiency syndrome for the medical ethics of the public world is
the inevitable consequence.
Our relevant task of propounding a cure for this philosophical disease is still
manifold. A fIrst step in such a cure is taken when three central problems of ethics
are clearly separated which Engelhardt's work does not sufficiently distinguish:
(1) Our fIrst task is to clarify the question whether an objective moral knowledge
is possible or whether there is no way of knowing any objective principles and foun-
dations of ethics--epistemological and metaphysical skepticism or relativism, and
even nihilism resulting from the second alternative. This most fundamental question
touches both general skepticism and relativism as applied to ethics, and specifIcally
axiological or ethical forms of skepticism and relativism.
(2) The second problem is whether such an objective knowledge of moral princi-
ples and contents, if it exists, will be solely based on religious faith and a life of ho-
liness, as Engelhardt suggests, or can be attained also in a secular society-indepen-
dently of religion. The question is whether human 'nature' or 'reason unaided by
faith' is capable of knowing, at least to some extent, moral goodness and evilness as
well as morally relevant goods which explain content-full moral imperatives.
An affirmative answer to this question, as we shall give it, must be sharply dis-
tinguished from the claim that everybody will consent with the content of such
knowledge, and even more sharply from the thesis that all must have an adequate
theoretical understanding of morality. Concrete moral intuitions and theoretical un-
derstanding of ethics are not only different but can occur in mutual independence of
each other. For example, it is not at all necessary that a person who fails to see phil-
osophically the inexplicability of moral values in terms of consequences of human
actions only, fails to possess a good concrete understanding of morality. He can
have a purely consequentialist or eudemonistic theory of ethics, which I regard as
fundamentally flawed, but have excellent pre-philosophical ethical intuitions into the
absoluteness of moral imperatives which cannot be reduced to what a consequential-
ist or eudemonistic theory permits. Already for this reason one cannot deduce from
the diversity of philosophical theories about morality that there is no (pre-philosoph-
ical) moral consensus possible. For most people are far more intelligent than their
theories. 14
Besides, the assertion that there is a natural knowledge of moral values does not
at all imply that this knowledge be not in any way dependent on certain moral pre-
conditions. To attain natural ethical knowledge, above and beyond the most elemen-
tary one, which any consciously awakened human person possesses, could, in spite
of its objectivity and objective evidence, still require several conditions of such a
knowledge, including moral ones, such as the moral conversion (metanoia) or the
virtuous life, of which Plato and Aristotle spoke as of conditions of ethical knowl-
edge. Such moral preconditions of, and many obstacles to, ethical knowledge have
been investigated in ancient thought but in even greater detail in a phenomenological

14 Many thinkers including Kant have insisted on this. Engelhardt, however, concludes, without suffi-
cient examination of a moral common sense and without any cogent argument or appeal to evidence,
from the moral diversity and from 'the diverse moral understandings' and theories of morality that no
objective ethical knowledge is possible. See H. T. Engelhardt, Jr., The Foundations of Bioethics,
pp. vii ff., 3 ff.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 243

ethics of value knowledge and of value blindness. IS Hence, the fact that no broad, let
alone general consensus and knowledge of 'natural law' can be reached is per se no
valid objection at all against its existence or intelligibility. To claim that things are
otherwise would make many untenable assumptions. For it is quite possible that for
moral values to be known adequate efforts must be made by a person, and certain in-
tellectual and most of all moral conditions must be fulfilled by him or her. Thus, our
second problem is neither whether there is a broad consensus in ethics nor whether
ethical knowledge has moral preconditions, but whether natural (philosophical) and
content-full ethical knowledge exists at all.
(3) Our third problem belongs to political and legal philosophy: Would such a
true and rational ethical knowledge, or also religious ethical knowledge, as long as it
is not shared by all or at least by a majority, be sufficient to found a bioethics whose
application in the secular public realm by physicians, legislators, statesmen, etc.,
would be acceptable? Would it be a bioethics that we, who recognize its truth, can in
good conscience propose for others in our pluralistic state when we do not entertain
hopes that fundamental human rights and moral and legal demands issuing from
them, let alone more subtle bioethical truths, will meet with a broad general consen-
sus? In other words: Is truth, even naturally knowable truth, a sufficient basis for law
and public ethics in a pluralistic society? Or do we have to build our system of law
and public life merely on such principles as tolerance, agreement, or consensus-
and without concern for the objective truth about value and ethical contents?
The attempt to solve these three questions is the task of the present chapter.

3. ARE TRUTH AND GOODNESS RELATIVE?

3.1. Relativism, Skepticism, and Their Consequences-a Radical Philosophical

Plague of Medicine
"Man is the measure of all things, of those that are that they are and of those that are
not, that they are not."16 With these famous words, the Sophist Protagoras expressed
the idea that all being, truth, and goodness are relative to man, and he seems to have
meant 'to each individual man', not only to society or to mankind.17 (In the last anal-
ysis, also the assertion of the relativity of truth to the human species is equally relati-
vistic. 18) From Plato on to the present,19 this view was often criticized, and quite co-

IS See Plato, Politeia VI-VII; Aristotle, Nichomachean Ethics I, 1. See also many works on the sources
of errors from antiquity to Antonio Rosmini. Many of them are summarized in Balduin Schwarz, Der
Irrtum in der Philosophie. Untersuchungen fiber das Wesen, die Formen und die psychologische Ge-
nese des Irrtums im Bereich der Philosophie, mit einem Oberblick fiber die Geschichte der Irrtums-
problematik in der abendliindischen Philosophie (MUnster, Aschaffenburg, 1934), itself one of the
best treatises on the question. See also Dietrich von Hildebrand, Sittlichkeit und ethische Werterkennt-
nis.
16 See this homo-mensura principle stated and critically examined in Plato, Theaetetus, 170a ff.
17 See Giovanni Reale and Dario Antiseri, Storia dellafilosofia antica, vol. I, pp. 231-232. Reale argues
that all sources prove that Protagoras defended individual relativism.
18 See Martin Cajthaml, Kritik des Relativismus.
19 See Plato, Theaetetus, 170a-179b; Gorgias; Aristotle, Metaphysics N; Augustine, Contra Academi-
cos; the same author, De Libera Arbitrio. For a critique of relativism in our time see, for example,
244 CHAPTERS

gently, and yet-there are few ordinary people and even fewer philosophers who are
not affected by relativism in one form or another.20 But what is relativism and what
are its consequences?
The idea that being and truth are relative implies that a proposition is not true or
false in its relationship to facts or states of affairs that objectively exist but that its
truth and falsity would depend on man. There are four possible forms of relativism
regarding the nature and reference point of this relativity: (1) Truth, being, and
goodness could exist only 'for me individually' (this is the position of 'individual
relativism'). (2) Being, truth and goodness could be relative not to individuals but to
a certain culture, historical epoch or group of humans. (This is the position of cultu-
ral or historical relativism and could be attributed to Hegel, Dilthey, or the herme-
neutical school of Gadamer, though to each in a very different way.21) (3) Being,
truth, and goodness could also be relative to man in general. (This position can be
called, partly depending on its concrete form, 'specific', 'anthropological', 'tran-
scendental', or psychologistic relativism, a view which one might attribute to Kant,
to many post-Kantian philosophers, and-tragically because he was one of the great-
est critics of this form ofrelativism22-to the later HusserI.) (4) Truth could be made
relative to any subject as such including superhuman subjects: we could call this po-
sition purely transcendental relativism. (We prescind from this position in the
following, because it is hardly defended by anyone, although almost all arguments
we put forward against the first three forms of relativism apply to it as well.)
Truth would, under the assumption of relativism, be relative to the experience,
structure, judgment, or consensus of many or all human beings, or to the private
opinion of an individual. Nothing would, under this assumption, be true in itself,
objectively so.
The idea that the good is relative can either be just an application of truth-
relativism to goodness, or it can form a specific axiological or ethical form of relati-
vism, limiting relativism just to values (admitting, for example, objective knowledge

C. S. Lewis, The Abolition of Man (New York: The Macmillan Co., 1947, 7th printing, 1970); Diet-
rich von Hildebrand, Ethics, ch. 9; Edmund Husserl, Logische Untersuchungen; Alexander Solscheni-
zyn, Macht und Moral zu Ende des Zwanzigsten Jahrhunderts, hrsg. v. Rocco Buttiglione und Josef
Seifert (Heidelberg: Universitatsvedag C. Winter, 1994).
20 Hussed noted this in Logische Untersuchungen, but fell himself later into a transcendental relativism.
See Walter Hoeres, "Critique of the Transcendental Metaphysics of Knowing, Phenomenology and
Neo-Scholastic Transcendental Philosophy," Aletheia (1978) 1,1, 353-69.
21 See also Bernhard lrrgang, Praktische Ethik aus hermeneutischer Sicht (paderbornlMiin-
chenlWienlZiirich: Ferdinand SchOningh, 2003), pp. 14 ff. lrrgang thinks that the most central contri-
butions of hermeneutical ethics are the insights into the historicity of human knowledge and into the
circular nature of interpretation:
Zentrale Erkenntnisse der philosophischen Hermeneutik sind die Einsicht in die Ge-
schichtlichkeit des Verstehens und die Erkenntnis der Zirkelstruktur des Erkennens
(ibid., p. 15).
Both of these ideas can refer to authentic data that can be well explained but can also express fun-
damental errors. See Josef Seifert, "Truth and History. Noumenal Phenomenology (phenomenological
Realism) defended against some claims made by Hegel, Dilthey, and the Hermeneutical School," in
Diotima XI, Athens 1983, pp. 160-181; the same author, "Texts and Things," in Annual ACPA Pro-
ceedings (1999), vol. LXXII, pp. 41-68.
22 See Edmund Hussed, Logische Untersuchungen.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 245

in science or mathematics), or only to moral values (not denying, for example, the
obj ectivity of aesthetic or intellectual values).
Ethical relativism can also take a completely different form, which would be per-
fectly compatible with the recognition of the objectivity of truth even about the
good. 23 This form of ethical relativism consists in the view that the only type of ex-
isting goodness is the subjectively satisfying or dissatisfying. Of that sort of 'good-
ness' or positive importance (the agreeable or the disagreeable) all of us accept that
it is relative, as we have seen in the preceding chapters. Eating Gorgonzola cheese,
for example, is pleasurable to one person and hateful to another. Value-relativism
would then mean that all goodness including moral goodness depends on subjective
taste and that all goods are just what subjectively is liked or disliked by a given
subject.
The question whether truth and goodness are relative is immensely important. In
a sense it is more important than any other question. For absolutely everything is dif-
ferent depending on whether or not truth and goodness are relative. If truth and
goodness were relative, things and acts would neither have being nor value in them-
selves; even Hitler would then only appear to you evil or worse than Mother The-
resa, but the opposite opinion would be just as correct. If the good were relative in
the second sense, the crime of your mother or sister being raped and mutilated
would be merely unsatisfactory for the victim or for you but the deed committed by
the soldier who perpetrates these crimes would be just as justified or unjustified as
your outrage. If there were no objective truth, nothing would be what it is but only
be taken to be this or that. If even not all truth but only truth about values, or the val-
ues themselves, were relative, all values you have acquired through your education,
all learning, all skills, everything would be bare of real value and just as good as
their opposites. Hell on earth would be equally justifiable as any just order.
Some thinkers, who do not hold relativism of truth or values, hold metaphysical
value skepticism, i.e., a position that denies any knowledge of objective values.
Many so-called postmodem thinkers who do not relativize truth but deny its exist-
ence or any possibility of knowing it hold an ethical skepticism. 24 An utter nihilism
would result from relativism as well as from metaphysical skepticism, as also H. T.
Engelhardt, Jr. admits. Engelhardt writes, in what I regard as the most impressive
passage in his book, exceedingly well about the enormous weight of the question as
to whether moral values can be known:
One must appreciate the enormity of the failure of the Enlightenment project of discov-
ering a canonical content-full morality. This failure represents the collapse of the
Western philosophical hope to ground the objectivity of morality. This failure bears
against theories of justice and accounts of morality generally. It brings all secular bio-

23 In the first case, no judgment about the good would be objectively true but only 'true for someone'.
According to this position, relativism would just declare ethical truth, with all other truth, relative.
24 One way of defining 'postrnodernity' is the following: the stage in the history of philosophy that
marks the end of a naive sanguine rationalistic optimism of enlightenment (which neither one of the
great Medieval or ancient philosophers held). Another one is in terms of deeming impossible any ob-
jective rational ethical knowledge. These two meanings are at times distinguished by H. T. Engel-
hardt, Jr. but most often merged in a way which I regard dangerous because such a merging of two
entirely different concepts of post-modernity gives rise to serious confusions. See H. T. Engelhardt,
Jr., The Foundations ofBioethics.
246 CHAPTERS

ethics into question. If one cannot justifY a particular morality, one cannot justifY claims
of immorality. All appears to become a matter of taste. Indeed, if one cannot disclose
some lines of conduct as canonically immoral, then the health care provided by Albert
Schweitzer and by Nazi death camps will be equally defensible and indefensible. If one
cannot discover an objective method to decide when the morally deviant are also mor-
ally wrong, then the action of the morally heinous and the saint will be equally justifi-
able or lacking in justification, at least in general secular terms. One stands on the brink
of nihilism. 2S

Moreover, any resistance to such atrocities as Nazism or to any hellish political

system would become rationally groundless and unjustifiable. Even though the
opinion is voiced again and again that moral objectivism paves the road for evils
such as National Socialism, the very opposite is true. Engelhardt comes close to this
view that radical value skepticism is a condition of democracy when he says that
even taken-for granted rules such as ''not to torture and kill the unconsenting inno-
cent for sport" have, in secular morality, ''the character of the arbitrary and conven-
tional."26 We shall see later that Engelhardt's own solution to these nihilistic conse-
quences and his thesis that democracy presupposes a public order built on skepti-
cism and relativism, in which persons adhering to private moral standards live as
'moral strangers' in a 'public universe', cannot be defended. For precisely each
democratic order rests on non-negotiable human rights and truths. The recognition
of objective truth about values does not lead to totalitarianism and oppression, al-
though of course the cruelties of the Inquisition and the oppression of religious free-
dom can be committed in the name of objective truth about values, but not because
of the appeal to objective moral values but because of a lack of understanding their
true nature and demands which include the call to respect freedom. Totalitarian
ideologies and regimes such as communism, Nazism, and fascism, however, were in
no way based on the objectivity of moral values but built on a radical relativism.
Precisely the opposition and rationally justified resistance to them required the rec-
ognition of objective truth. 27
If there were no truth independent of subjective beliefs about human rights,
about God, soul, justice, injustice, all things would only be what you think or con-
ceive them to be. Thus, radical relativism or skepticism of truth lead also to radical
skepticism or relativism of value. Radical value skepticism and relativism, however,

2S See the section entitled "At the brink of nihilism," in his The Foundations ofBioethics, pp. 65 ff. En-
gelhardt's "way out of nihilism" (ibid., pp. 67 ff.) is more than doubtful as we shall see below in this
chapter.
26 See H. T. Engelhardt, Jr., The Foundations ofBioethics, p. 37.
27 See for example Dietrich von Hildebrand, Memoiren und AujSiitze gegen den Nationalsozialismus
1933-1938, hrsg. von Ernst Wenisch (Mainz: Matthias GrUnewald Verlag, 1994). Cf. likewise Rocco
Buttiglione, Augusto del Noce. Biografia di un pensiero. See also N. Leser, J. Seifert, K. Plitzner
(Hrsg.), Die Gedankenwelt Sir Karl Poppers: Kritischer Rationalismus im Dialog (Heidelberg: Uni-
versitatsverlag C. Winter, 1991), especially pp. 31-74, and "Diskussion," pp. 75-82; see also Josef
Seifert, "Ideologie und Philosophie. Kritische Reflexionen tiber Marx-Engels 'Deutsche Ideologie' -
Vom allgemeinen Ideologieverdacht zu unzweifelbarer Wahrheitserkenntnis"; "Die Philosophie als
Uberwindung der Ideologie," in AI di Iii di occidente e oriente: Europa, a cura di Danilo Castellano
(NapolilRomalBeneventolMilano: Edizioni Scientifiche Italiane, 1994), pp.27-50; "Frieden und
Transzendenz," in Arnold Buchholz (ed.), Kant und der Frieden in Europa. Ansiitze zur geistigen
Grundlegung kiinftiger Ost-West-Beziehungen. Bericht tiber eine Tagung der Ostsee-Akademie (Tra-
vemiinde 12. bis 15. Mai 1991) (Baden-Baden: Nomos Verlagsgesellschaft, 1992), pp. 165-184.
 AN OBJECTIVE BIOETIllCS-ANSWER TO ENGELHARDT 247

are inconceivably horrible in themselves; and from them also follows that none of
the horrors and atrocities in history could justifiably be recognized as evil.
Similar to relativism and yet different from it is skepticism which does not assert
the relativity of truth but simply holds that man cannot know any truth and should
abstain from any judgment (in a complete skeptical epoche'), which would be episte-
mological skepticism, while the thesis that there is no truth would be metaphysical
skepticism in a special sense of this term (dogmatic skepticism in the sense of the
negation o/truth).

3.2. The Evident Falsity and the Internal Contradictions o/General Relativism and
Skepticism
Aristotle has shown28 that relativism and skepticism, if defended consistently, must
also extend to the first and most evident principle upon which all truth and being
rest, the principle of contradiction: nothing can be and not be at the same time and in
the same sense. It can also be formulated differently: "Nothing can have an attribute
and not have the same attribute in the same respect and at the same time," or: "No
state of affairs can be and not be at the same time and in the same respect," or: "A
state of affairs S is P cannot coexist with the contradictorily opposite state of affairs
S is not P." To deny and to doubt also this principle, Aristotle tells us, involves three
consequences, which no person is prepared to draw: 29
(1) The relativist could not say anything any more. For whenever he speaks and
asserts anything, including his relativism, he recognizes the fact that the state of af-
fairs he is asserting involves that its opposite is not the case. If he doubts or denies
the principle of contradiction, however, he cancels everything he says. Even doubt,
St. Augustine shows, is impossible without the truth of the principle of contradic-
tion: for if I doubt whether or not there is objective truth, I understand the incompa-
tibility of the two alternatives between which I waver back and forth in doubt.
Aristotle cites a famous ancient skeptic, who understood that in his doubt itself
and in anything he would say about his skeptical doubt or about the reasons that mo-
tivated it, he still presupposed the principle of contradiction and many other truths;
and hence he remained completely silent in the end. But in spite of his remarkable
consistency, Aristotle says, this skeptic named Cratylus30 still was not a rigorous
skeptic who doubted everything including the principle of contradiction. For Craty-
Ius still made certain signs with his finger when he meant or wanted one thing and
thus still excluded that at the same time the opposite could be the case. Only a vege-
table that does not think, Aristotle adds, could cease to recognize this principle.
(2) Secondly, Aristotle tells us, if the relativist and skeptic were correct, he could
not distinguish anything any more from anything else. We cannot distinguish a man
from a trireme, a stone from a living organism, if we are skeptics or relativists, be-

28 Aristotle, Metaphysics N (Gamma).

29 Aristotle, Metaphysics N, 1006 b 13 ff.
30 See Aristotle, Metaphysics N, ch. 5, 1010 a II ff. Aristotle tells us that Plato was first in contact with
this Cratylus. See Aristotle, Metaphysics I, ch. 65. See on Cratylus's interesting views on philosophy
of language and their critique also Plato, Craty/us.
248 CHAPTERS

cause any distinction implies that objectively A is not B and thus not simultaneously
B, and that this is neither doubted nor relativized. 31
Other philosophers have emphasized that even doubt presupposes this insight.
For the radical doubt of all truth implies that it is not certain whether or not there is
truth. I doubt all truth, that is, I am uncertain of whether or not it is.
But if this is the case, Augustine explains in an earlier version of his cogito, I
grasp at the foundation of doubt also the universal principle which Aristotle calls the
'first and most certain of all principles', namely, the principle of contradiction. For if
it were not impossible that one and the same thing, A, possess and does not possess
existence, or a predicate b, then the meaning of doubt would be entirely undermined.
Doubt, in order to be meaningful at all, presupposes the absolute validity of the prin-
ciple of contradiction. I grasp that either there is truth or there is no truth, but both
cannot occur at the same time and in the same sense. If they could both be, A and its
contradictory opposite, then doubt would not make sense any more. In Contra Aca-
demicos (his early and purely philosophical dialogue, written by him as a 'pagan
philosopher' prior to his conversion to Christianity) Augustine presents a critique of
skepticism, a view he himself had once adopted. Augustine shows in addition that
infinitely many true disjunctive propositions follow from the truth of the principle of
contradiction:
Count, if you can how many there are: ... if there is one sun (only), there are not two:
one and the same soul cannot die and still be immortal, man cannot at the same time be
happy and unhappy; ... we are now either awake or asleep: either there is a body which
I seem to see or there is not a body. TIrrough dialectic I have learned that these and
many other things which it would take too long to mention are true; no matter in what
condition our senses may be, these things are true of themselves. It has taught me that, if
the antecedent of any of those statements which I just placed before you in logical con-
nection were assumed, it would be necessary to deduce that which was connected with
it.32

Hence the most radical skeptic sees that a thing cannot be and not be in the same
sense and at the same time. The unfolding of this knowledge would make us under-
stand how many additional evidences it implies, and how all the things Husserl's
Logical Investigations and Pfander's Logik unfold about the essence of the principle
of contradiction, about the distinction between its ontological and its logical sense,
about the difference between the principle of contradiction and a mere psychological
law, about the immediate knowledge in which it is given, about the difference be-
tween its evident objective truth and its mere presupposedness by thinking, and so
on are contained within and are implicitly recognized in the most radical doubt.
They form part of the nucleus of indubitable truth without which the person cannot
live intellectually and perform any conscious act at all, including doubtingY

31 Aristotle, ibid., 1007 b 18 if.

32 Augustine, Contra Academicos II, xiii, 29.
33 See on this also Edmund Husser!, Logische Untersuchungen; Alexander Pflinder, Logik; Mariano
Crespo, "En tomo a los estados de cosas. Una investigacion ontologico-formal," Anuario Filosofico,
XXVIIIlI (1995), 143-156; and by the same author, Para una ontologia de los estados de cosas esen-
cialmente necesarios. Tesis doctoral (Departamento de Metafisica y Teoria del Conocimiento. Univer-
sidad Complutense, Madrid 1995). See also Josef Seifert, Back to Things in Themselves. See also Lud-
ger Holscher, The Reality o/the Mind.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 249

(3) Thirdly, neither the relativist nor the skeptic could perfonn any rational ac-
tion any more. For whenever he acts and avoids, for example, falling into a ditch, he
knows and recognizes that to fall into it and not to do so are objectively distinct. 34
In addition, any radical skepticism and relativism contradicts itself. The very
statement that truth is relative claims to be adequate to the actual state of affairs and
thus claims absolute truth for itself. For if the facts are as they are judged in the
judgment, the judgment is true not merely for someone but in itself. The relativist
also presupposes truth, as well as the knowledge of truth, when he defends himself
against the objection of irrationality.
Something similar applies to the skeptic. For to be a skeptic as well as to be a
relativist, I have to have some reasons. But in giving these reasons, I presuppose that
at least these are true and that to hold that truth is knowable, or that it is absolute and
objective, is a false or a badly founded opinion for some reasons. But then, in order
to deny all truth or to doubt it, I assert and claim to know some truth about the rea-
sons of the rationality of skepticism or of relativism.
Even the subtlest fonns of relativism and skepticism, as we might attribute them
to Hume or to Kant, who denied that we could know things in themselves, are con-
tradictory. For they assume that at least our activity of thinking or of constituting the
world through our subjective categories takes place objectively, and that it is in itself
true that we do not know anything that exists in itself. It is thus impossible to know
only appearances without knowing some being in itself, at least the fact of just see-
ing appearances which, in order for Kant's position to be true, cannot itself be a
mere appearance. 35
Relativism, unlike skepticism or universal doubt, also contradicts the evident
structure and essence of truth. For the truth of a proposition rests on its conformity
and adequation to a state of affairs. If! say, "there is no God," this judgment is only
true if actually there is no God. If I say that Napoleon actually lived, this is only true
if it is indeed the case that he is not a mere piece of fiction. But then truth or falsity
depends just on the facts and their relation to my assertion, not on my subjective
opinion. And in this case, a proposition can only either be true--and then it is true in
itself and hence also for the whole world and for all angels and for gods36---or it is

34 Aristotle, Metaphysics IV, 1008 b 13 ff. See also Josef Seifert, "Wahrheit als Orientierungspunkt fur
menschliche Entscheidungen," Prima philosophia, vol. 7 (1994) H 3, pp. 289-305; "Demokratie,
Wahrheit und Gerechtigkeit. Cicero und das Problem des Pluralismus," in H. Schuschnigg, D. Guts-
mann, H. Starhemberg (eds.), Konig und Volk. Demokratie im Wandel der Zeit, Maximiliana vol. VI
(WienIMllnchen, Amalthea Verlag, 1992), pp. 27-51.
35 See Dietrich von Hildebrand, What Is Philosophy?; D. von Hildebrand, "Das Cogito und die Erkennt-
nis der realen Welt." See also Josef Seifert, Back to Things in Themselves.
36 See Edmund Husserl, Logische Untersuchungen, Prolegomena, ch. 5 ff., e.g. ch. 7, § 36:
Was wahr ist, ist absolut, ist "an sich" wahr; die Wahrheit ist identisch eine, ob sie
Menschen oder Unmenschen, Engel oder GOtter urteilend erfassen. Von der Wahr-
heit in dieser idealen Einheit gegenUber der realen Mannigfaltigkeit von Rassen,
Individuen und Erlebnissen sprechen die logischen Gesetze und sprechen wir aile,
wenn wir nicht etwa relativistisch verwirrt sind.
Saying this, as Adolf Reinach and Edmund Husserl, does not imply that I deny that there is only
one true God but that even if there were many gods, truth being objective, it would also be true for
them.
250 CHAPTERS

false if it asserts what is not the case. But then its falsity is not just false 'for me' but
in itself.
Even if the object of a true proposition is a mere subjective state or feeling, the
truth about the fact that I have a headache, or that I have dreamt about a duck, or that
I held an error, is objective.
The objectivity of truth, and its misinterpretation in any form of relativism, is not
only self-evident but also undeniable because any negation of it presupposes it,
which is not the case with all evident truths but only with those that are inevitably
presupposed. 37 In the negation of all objective truth we encounter inconceivable fal-
sities and internal contradictions. Thus, while indeed most people hold relativistic
philosophies, no one actually even can think relativism, let alone hold it consistent-
ly.
St. Augustine and Descartes, and many others with them, have pointed out that
also the indubitable knowledge regarding the existing world refutes any relativism
and skepticism. They have added that we also understand that even if we were in er-
ror about everything else, we could never be in error about our very existence be-
cause to be deceived one has to exist. Thus, at least this must be objectively true
even if everything else were false.
Moreover, everybody who doubts also understands (intelligit) that he doubts and
many other truths:
On the other hand who would doubt that he lives, remembers, understands, wills, thinks,
knows, and judges? For even if he doubts, he lives; ifhe doubts, he remembers why he
doubts; ifhe doubts, he understands that he doubts; if he doubts, he wants to be certain;
if he doubts, he thinks; if he doubts, he knows that he does not know; if he doubts, he
judges that he ought not to consent rashly. Whoever then doubts about anything else
ought never to doubt about all of these; for if they were not, he would be unable to
doubt about anything at all. 38

But if this is true, then many, and indeed infinitely many other things are also
true: for example, that I am living, that I am perceiving (seeing, hearing, smelling,
touching, feeling), that I am thinking, that I am doubting, and that all of this is true,
and that each of these truth-judgments are true, and so on ad infinitum.
Max Scheler observes that there is an even more fundamental indubitable knowl-
edge than the one contained in the cogito: our first primordial evidence is that some-
thing is rather than nothing. 39 Also this evidence is absolutely indubitable and refers

37 See Edmund Husser!, Logische Untersuchungen, I: Prolegomena, chs. 5-9. See also Giovanni Reale
and Dario Antiseri, Storia della filosofia antica, vols. I and 2, on the undeniable truths (verita innega-
hili) in ancient philosophy.
38 St. Augustine, The Trinity. See also the beautifully written Latin original:
Vivere se tamen et meminisse, et intelligere, et velie, et cogitare, et scire, et judicare
quis dubitet? Quandoquidem etiam si dubitat, vivit; si dubitat, unde dubitet, memi-
nit; si dubitat, dubitare se intelligit; si dubitat, certus esse vult; si dubitat, cogitat; si
dubitat, scit se nescire; si dubitat, judicat non se temere consentire oportere. Quis-
quis igitur aliunde dubitat, de his onmibus dubitare non debet: quae si non essent, de
ulla re dubitare non posset.
39 Max Scheler, "Vom Wesen der Philosophie und der moralischen Bedingung des philosophischen Er-
kennens," in Max Scheler, Vom Ewigen im Menschen (Erkenntnislehre und Metaphysik), Schriften
aus dem NachlaB Band II, herausgegeben mit einem Anhang von Manfred S. Frings (Bern: Francke
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 251

to some truth that is presupposed even by the skeptical doubt. Countless other evi-
dences of indubitable knowledge of objective truth could be added.

3.3. Critique ofEthical Relativism and Skepticism

By the falsity of universal relativism it is not yet excluded that all values and partic-
ularly moral values would be relative. With regard to them, it does not seem to in-
volve us in contradictions to deny that objective moral values exist. Especially if I
say that just as I dislike cigars and others love them, so things are not just or unjust
objectively, but are only felt so subjectively.

3.3.1. Actual Contradictions ofEthical Relativism and Skepticism

But we can argue against ethical skepticism and relativism on many grounds. First,
we may ask: Can this opinion be upheld without contradiction to other opinions of

Verlag, 1979), pp. 61-99; pp. 93-94; "The Nature of Philosophy and the Moral Preconditions of Phil-
osophical Knowledge," in On the Eternal in Man, translated by Bernard Noble, 2nd ed. (Hamden,
Connecticut: Archon Books, 1972), pp. 67-104; pp. 98-99:
For this reason every inquiry into the nature of philosophy must also begin with this
problem of the order offimdamental self-evident insights.
But the first and most direct self-evident insight is that already postulated in es-
tablishing the sense of the expression 'doubt about something' (about the being of
something, the truth of a proposition, etc.): put in the form of a judgment it states
that there is something (in general) or, to put it more acutely, that there is not noth-
ing-the word 'nothing' here denoting not simply the not-being-anything or non-
existence of a thing, but that absolute nothing whose negation of being does not 'as
yet' discriminate in the negated being between thusness (So-sein), or essence, and
existence (Dasein). The situation that there is not nothing is at one and the same
time the object of the first and most direct self-evident insight and the object of the
most intense, the ultimate philosophical wonder, though I grant that this emotional
response cannot come to fruition until it has been preceded, among the emotional
acts conducive to the philosophical attitude, by the adoption of that humility which
abolishes the taken-for-granted, self-evident character of being as a fundamental fact
and even undermines it as an obvious fact. This insight, then, is evident to me with
invincible clarity, no matter where I tum my attention, whatever I look upon and
however it be more closely determined according to secondary categories of being-
whether it be quality or existence, noumenal or phenomenal, a real or objective non-
real entity, an object or subject, an ideal or a resistant object, valuate or value-neuter
'existential' being; whether it be substantial, attributive, accidental or relational;
possible, necessary or actual; timeless, purely durational, past, present or future; true
(as e.g. a proposition), valid or pre-logical; purely mental and fictive (like the wholly
imaginary 'mountain of gold' or a merely imagined feeling) or extra-mental or both
mental and extra-mental. Choose where you will, with every example within one or
more interlinked and overlapping 'kinds' of being, as with every one of these cate-
gories themselves, the clarity of this primary insight is such that it outshines every-
thing which can in any conceivable way be brought into comparison with it. But
whoever has not, so to speak, looked into the abyss of absolute nothing will indeed
completely overlook the eminent positivity inherent in the insight that there is some-
thing and not rather nothing; he will begin with one or other of the perhaps no less
self-evident insights which are, nevertheless, posterior and subordinate in self-
evidence to this insight ...
See also Max Scheler, "Theory of the Three Facts," in Max Scheler, Selected Philosophical Es-
says, transl. by David R. Lachterman (Evanston: Northwestern University Press, 1973).
252 CHAPTER 5

the value-skeptic or of the value-relativist himself? Does not the moral relativist ob-
ject when he is asked to contradict his own convictions for money's sake and to
teach for money the opposite of his convictions? Or would he not hold that to state
his (relativistic) opinion is some duty he has towards truth and would he not thus re-
introduce some objective moral standard? Would not even the most radical ethical
relativist object ifhe were cheated?
I am reminded here of the story of Moritz Schlick, a famous ethicist of our cen-
tury. After he told his colleague that all moral categories are relative and that to say
that a thing is unjust is only to express one's feelings towards it, he got a letter from
the Rector of the University of Vienna. Turning pale upon reading it, he said to his
colleague: "Read this, is it not a terrible injustice committed against me?!"40 Schlick
also condemned the Nazi-crimes. Thus, he forgot all his theories and gained the evi-
dent insight that justice and injustice belong to actions and are not just imagined by
us or relative to us.

3.3.2. Inevitable and Inherent Contradiction in Ethical Relativism and Skepticism

Apart from the many actual contradictions of the sort found in Schlick or in Plato's
Gorgias, where Gorgias, Polos, and Callicles cannot fail to admit some ethical
truths, which contradict their own relativistic beliefs, there is a deeper and more in-
evitable contradiction found in these positions. In the last analysis, radical ethical
relativism and skepticism are even inconceivable and unthinkable without contradic-
tion. Why? Because even the most radical ethical skeptic or relativist presupposes
some values, such as that he should not assert any untruth (as he believes an objecti-
vist position to be untrue), that it is therefore preferable to be a relativist or skeptic,
etc.
Without the objectivity of these value judgments he could not defend his position
rationally, but to hold these value judgments is to fall into contradiction to the eth-
ical positions of skepticism and relativism. Hence, it is impossible to hold relativism
and to deny the objectivity of truth about some values without falling either into
contradictions or into absurdities:'
Moreover, in stating the above things about relativism, we recognize some objec-
tive truth about relativism and about the evils that follow from it, truths which T. H.
Engelhardt, Ir. states so well in the statements quoted above.

3.3.3. Critique ofEmotivist Ethical Relativism

Schlick and Stevenson also tried to explain moral values through subjective feeling-
reactions to things.
Furthermore, do not the feelings of which many philosophers say that they ex-
plain moral qualities, which would arise by our projecting our feelings into things,
already presuppose these qualities to enkindle our feelings? Injustice is not expli-

40 On this story, see Dietrich von Hildebrand, Memoiren und AuJsatze gegen den Nationalsozialismus
1933-1938.
4' See my attempt to prove this in detail in Josef Seifert, Back to Things in Themselves.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 253

cable through our feelings because in order to feel outraged, we must first perceive
the injustice of an act. 42
Moreover, our feelings are frequently quite different in quality from the good or
evil qualities on the object-side, as C. S. Lewis showed so well. For when we say,
"this is sublime," we do not have sublime feelings but rather opposite ones, namely,
feelings ofhumility.43

3.3.4. Critique ofPositivist Forms ofEthical Agnosticism

The kind of immediate knowledge ethics requires can include sense perception but
certainly does not· rest chiefly, or in as important a sense as chemistry, physics,
zoology or medicine, on it; for neither the moral values themselves nor their bearers,
the personal acts, can be seen, heard, touched, or in any other way be grasped
through the senses, except for their physical expression in the human body. But even
here only the purely external side of human actions and the physical side of the ex-
pression of moral acts and attitudes in the body are perceived through the senses; our
understanding of the expression of moral qualities in what we see or hear transcends
the sense-data and sense perceptions as such. It grasps something of entirely invi-
sible and spiritual nature.
The specifically ethical intuition is in the first place an immediate knowledge ob-
tained through some form of intellectual intuition which can again be of different
kinds and has different elements: ethical knowledge begins with our knowledge of
other persons and of our own personal lives and acts.
All of us possess an inner experience of our own consciousness, knowledge, in-
tentions, acts, and their objects, and we can pay heed to them and describe our dif-
ferent affective, intellectual, and volitional experiences and our different acts which
are consciously lived by us from within.
But we also possess at the origin of our moral experience an experience of the
inner life and acts of other persons, far more complicated to explain than the experi-
ence of our own conscious life because we have neither an immediate inner aware-
ness nor a direct and immediate introspection into other persons' conscious lives.
Our ethical knowledge is in no way reducible to the immediate intuitive forms of
cognition of our own and other persons' conscious acts. Rather, both our own and
other persons' acts have an intelligible general form and essence, which allows us to
identify clearly the general moments of free acts, the indispensable elements of acts
such as forgiveness or gratitude, the different relations between persons, etc. The
general essences of these acts are not contingent and accidental but necessary and
intelligible. Therefore, our mind can comprehend here much rather than merely de-
scribe accidental individual experiences and mixtures of experiences: it can rise to a
true and immediate knowledge of the pure essences of the mentioned data.

42 See J. Barger, "The Meaningful Character of Value-Language."

43 C. S. Lewis, The Abolition of Man, pp. 14 ff. See also the fme book by Michael D. Aeschliman" The
Restitution of Man: C. S. Lewis and the Case Against Scientism (Grand Rapids, Mich.: Eerdmans,
1983), pp. 75 ff.
254 CHAPTER 5

It is important to note here that Kant's and Engelhardt's restriction of ethical val-
ue intuitions to completely formal and content-less imperatives and principles44 is
untenable and contradictory in itself (because even Kant uses the content-full per-
sonalistic formulation of the categorical imperative, which presupposes a grasp of
the intrinsic dignity of persons in virtue of their essence and existence, and Engel-
hardt presupposes the equally content-full values of freedom, tolerance, non-vio-
lence, peaceful dialogue, etc.). But we clearly gain also many intuitions in the spe-
cific content-full and non-formal values45 that are rooted in persons, animals, differ-
ent acts and virtues of persons, etc. 46 .
Moreover, in many of these essences, especially those with which ethics is con-
cerned, such as love or justice, we perceive a perfection hardly ever found in con-
crete individual experiences; therefore, we can say that the justice, kindness, love,
etc., which we encounter in ourselves and in other persons is quite imperfect.
Without justifying this type of knowledge of the essences of specifically personal
acts and experiences, we can never ground ethics as a science. Take an empiricist's
position that will recognize solely Basissatze (basic sentences) known through sense
perception. It is clear that on such a basis only a non-cognitivist ethical standpoint is
possible, because the sentences the truth of which sense perception informs us of can
at best found a theory of different patterns of bodily behavior but never found ethics
as a science, granted that the evidence of the natures of personal acts cannot be seen,
smelt, etc., but must be understood with some other intellectual power.
The best an ethics of this sort can reach will be a system like that ofMackie,47 ac-
cording to which indeed ethics presupposes objective values, but these are quaint
and queer objects, because they are not given to the senses, and therefore entirely
unknowable. A fine ethical perception, such as that of Mackie, coupled with a purely
empiricist theory of ethical method, has to claim that our moral life rests on entirely
irrational assumptions of something (of intrinsic values) that cannot be known be-
cause its existence can never be verified or falsified by sense perceptions.
But even in defending this non-cognitivist ethical standpoint, the purely positiv-
ist or empiricist ethics involves itself in insurmountable self-contradictions. For also
the assumption of objective values, which Mackie attributes to our ethical
experience, cannot be perceived by the senses; neither can its alleged non-cognosci-
bility be verified or falsified by sense perceptions. Moreover, this position is contra-
dictory also because any denial of non-sensory acts of cognition of data which can-
not be verified or falsified through sense perceptions is contradictory because it it-
self presupposes what it denies. For example, Mackie asserts that in our moral expe-
rience we make truth claims for our judgments on objective values; but these (ac-

44 See Immanuel Kant, Kritik der praktischen Vernunft (1788); see also H. T. Engelhardt, Jr., The Foun-
dations of Bioethics; see the same author, "The Foundations of Bioethics and Secular Humanism:
Why Is There No Canonical Moral Content?" in Brendan P. Minogue, Gabriel Palmer-Fernandez, and
James E. Reagan (eds.), Reading Engelhardt. Essays on the Thought ofT. H Engelhardt, Jr., pp. 259-
285.
45 Materiale Werte.
46 I cannot offer here a detailed critique of ethical formalism. See on this Max Scheler, Formalism in
Ethics and Non-Formal Ethics of Values; see also Dietrich von Hildebrand, Ethics.
47 J. L. Mackie, Ethics: Inventing Right and Wrong.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 255

cording to Mackie unfounded) truth-claims and their existence in our moral experi-
ence cannot be experienced by the senses but must be understood as something en-
tirely immaterial. This ethics furthermore makes actual truth-claims for itself; but
neither these nor the presupposed actual truth of its propositions nor the validity of
its logical underpinnings and implications and of the logical reasonings used by
Mackie and the valid forms of them can ever be known by the senses. Thus the en-
tire ethics of Mackie would have to be disqualified as queer or quaint or as meaning-
less utterances, as Carnap said, if there were not an immediate intellectual knowl-
edge different from sense perception and in no way queer. 48 Thus, Mackie necessari-
ly presupposes what he denies; and this is true for any attempt to negate undeniable
truths which one inevitably reintroduces as soon as one denies them. 49

3.3.5. Immediate Evidence of Morally Good and Evil and of Other Values-Value-
Seeing (Wertsehen) as a Method ofEthics
Prescinding from inevitable internal contradictions and from contradictions to the
experienced data inexplicable in terms of ethical relativism, is it not much more
simply evident that moral values are objective? Is it not evident that child-abuse in
its sexual and non-sexual forms is evil? That medical experimentation on political
prisoners without their consent is morally wrong, etc.?
Ethics as a rational science not only presupposes intelligible data not accessible
through sense perception but only through a sort of intellectual intuition (an insight
that we might also call 'categorial intuition') that is not less immediate than sense
perception. This would not be specific to ethics because also logic, general ontology
or mathematics as authentic sciences presuppose this. 50
Rather, ethics presupposes in addition an immediate knowledge of the essence of
those things that are morally relevant and of their importance, which gives rise to
moral obligations or calls. Ethics requires a further method of an insight adapted to
the different essences of those acts which are bearers of moral values, into the condi-
tions of moral values in the subject and into their objects, etc.
While also deductive logical reasoning plays an indispensable role in ethics as a
science, certainly the immediate intellectual grasp of these things, which are urphe-

48 See John Finnis, Natural Law and Natural Rights, ch. 2.

49 See on this Giovanni Reale and Dario Antiseri, Storia dellafilosofia antica, vol. 2. See on the critique
of less sophisticated forms of denying the objectivity of ethical knowledge John Barger, "The Mean-
ingful Character of Value-Language: A Critique of the Linguistic Foundations of Emotivism." Barger
criticizes there A. J. Ayer's emotivism and the precriptivist dimension in C. 1. Stevenson's value phi-
losophy. According to Stevenson, value language "is emotive so as to be persuasive" (Barger, op. cit.,
p. 78). Barger's critique aims at showing Ayer's and Stevenson's misinterpretation of value-language
itself. It is thus a linguistic critique of emotivism, to serve as preface to a properly ethical and ontolog-
ical critique of their standpoint. Nevertheless, it contains already in its present form many insights into
the objectivity of values themselves and of their claim to objectivity, in the light of which the misin-
terpretations of emotivists can be seen. See also my critique of non-cognivist ethics in Josef Seifert,
"Zur Begriindung ethischer Normen. Einwande auf Edgar Morschers Position. Ein Diskussionsbei-
trag," in J. Seifert, F. Wenisch, E. Morscher (eds.), Vom Wahren und vom Outen. Festschrift zum
achtzigsten Geburtstag von Balduin Schwarz (Salzburg: St.Peter Verlag, 1983). "Und dennoch: Ethik
ist Episteme, nicht bloSe Doxa. Uber die wissenschaftliche Begriindbarkeit und UberprUibarkeit ethi-
scher Siitze und Normen. Erwiderung auf Edgar Morschers Antwort," in ibid.
50 See Josef Seifert, "Wissen und Wahrheit in Naturwissenschaften, Philosophie und Glauben."
256 CHAPTER 5

nomena irreducible to others, plays a key role. Therefore, phenomenology as an un-

folding of the self-given nature of these things is an indispensable methodological
instrument of ethics as a science.
The intuitive ethical method of an intellectual seeing of values differs not only
from sense-perception, with which it shares the immediacy but not the bluntness of
simply 'observing facts', but also from an intuition into purely logical or formal-log-
ical principles such as the principle of contradiction, which are as necessary and in-
telligible as the essence of moral values. But the Wertsehen (seeing of values), both
concretely in our everyday experience and in an intellectually purer, more distinct,
more precise way in philosophical ethics, differs from other intuitions because it is
the form of grasping that unique urphenomenon which we call value (the good). And
within the broader sphere of knowing values and the good, the seeing of uniquely
moral urphenomena and moral values, which we have tried to identify briefly, dif-
fers in important ways from other sorts of immediate rational knowledge.
This method of ethical value-intuitions and insights into the essence of moral
values is not some irrational feeling of values, which also Max Scheler or Pascal did
not have in mind when they spoke of value-feeling (Wertfiihlen), in order to indicate
the type of immediate intuitive knowledge found in ethics. 51
We should, however, not at all characterize this immediate knowledge of moral
values and of their essences as feelings. For insights into moral values and into their
essences are neither themselves an emotional experience (though deep emotions
flow from the intuitive cognition and even more from the contemplation of values),
nor is our knowledge of moral values a mere witnessing or testimonial deprived of
rigorous rational evidence. Rather, it is a fully rational grasping of moral values, an
insight into them that is not less rational than mathematical or logical intuitions,
though different in kind. Also in ethical insights into moral values the human mind
transcends all mere human subjectivity and grasps the objective essence of things
which informs the intellect, for example, that committing injustice and realizing the
moral disvalue of unjust acts not only differs from evils such as suffering injustice,
but is a greater evil and an evil of an entirely different kind-given in its distinctness
to our mind. 52

51 Though Karol Wojtyia charges Max Scheler with an 'emotionalization of consciousness', Max Sche-
Ier certainly believed, like Pascal before him, that there is also an intentional cognitive feeling of val-
ues, similarly to the immediate feeling in the sphere of our senses. See Karol Wojtyia, "fiber die Mog-
lichkeit, eine christliche Ethik in Anlehnung an Max Scheler zu schaffen," in Karol WojtyialJohannes
Paul II., Primat des Geistes. Philosophische Schriften (Stuttgart-Degerloch: Verlag Dr. Heinrich See-
wald, 1980), pp. 35-326.
52 Ethics as a rigorous science does not only presuppose intuitive knowledge of essences of acts and val-
ues but these intuitions and their objects must also be systematically unfolded as we will see when dis-
cussing the second type of method in ethics.
As all intelligible essences, so also moral data require a careful systematic analysis and clear dis-
tinctions between their different intelligible marks and between them and other values and data.
It would be wrong to believe that all philosophy just has to do with the analysis of necessary es-
sences, rather than also having to analyze less absolutely intelligible but still intelligible natures, such
as needed in some aspects of a philosophy of the human body, of femininity and masculinity, of the
child, or also in the analysis of some phenomena in the arts (essence of baroque) or in philosophy of
history (such as the essence of an epoch). Thus, the investigation we have to conduct will reveal to us
 AN OBJECTIVE BIOETIllCS-ANSWER TO ENGELHARDT 257

The evidence regarding objective moral values does not only extend to individu-
al cases but also to the universal essences of values such as justice and even to the
universal superiority of moral values over others. 53
The evidence of the objectivity of values is not restricted to the sphere of moral
value but refers also to vital values, intellectual values, aesthetic, and other values.
Some of these values are even more easily evident than moral ones. Think of the
value of health, for example: who would doubt that health is objectively speaking
preferable to disease, illness, Aids or leprosy? that pleasure is preferable to pain?
Also some basic intellectual and linguistic values are evident. How can anyone
doubt that there is some value to knowledge, to education, to the mastery of a lan-
guage? And who could deny that a vast and precise knowledge and use of language
is better than linguistic ignorance and analphabetism? Who would doubt, for exam-
ple, that the following radical value-nihilism of some new ecologists of language is
absurd? They claim that no grammar book, dictionary, or teacher have any right to
interfere with the natural process of linguistic development or with the factual use of
language. Spelling mistakes or grammatical mistakes must no longer be corrected
because thereby the teacher would impose his value-system on the pupil, replacing
the pupil's own spelling habits with the teacher's, thus impeding the student from
contributing to the living development of language. Ecological dictionaries should
only indicate majority spellings and the percentage of the population who would
spell father with an 'f rather than with a 'v'. This linguistic relativism goes far be-
yond insisting that each person should use her own judgment about spelling: it
amounts to denying that (so-called) misspelling is any worse than (so-called) correct
spelling. This position is a simple consequence of value-relativism; for if all values
are relative, it is certainly not possible to hold that such things as a correct use of
language would be better than an incorrect way of speaking or writing. This ecologi-
cal linguistic relativism is a consequence of general value relativism, which, while
being itself a harmless application of relativism to something, which indeed is partly
a matter of consensus, nevertheless will be recognized almost universally as absurd.
Yet even this radical linguistic relativism still implies the intuition into some objec-
tive values (though they are distorted), such as that of a natural development of a liv-
ing (spoken) language and of respect for ecological aspects oflanguage.

3.3.6. Refotation ofthe Argumentfor Ethical Skepticism or Relativism from a Lack

ofEthical Consensus-Broad Ethical Consensus Also with Atheists
Many ethical relativists refer to the lack of universal moral consensus to support
their view. They argue that at the most in a closed religious community we find mor-
al consensus, and that therefore the knowledge of values could not be objective nor

the need of identifYing a method in many ways similar to intuition into necessary essences but in other
ways dissimilar to it.
53 See chapter 3 of the present work. Also Kant, although he held that we can only know appearances,
says in his Foundations to a Metaphysics of Morals: "nothing in the world and, indeed, not even out-
side of it, can be conceived that is good in an unrestricted sense except a good will." And Kant cites
the evidence that intelligence, fortitude, and other qualities can become extremely bad when they are
used for evil; only the free and good will is of much higher value than any of its effects and cannot be
perverted.
258 CHAPTER 5

ethics a science. We reply: Would not virtually anyone agree, because it is evident,
that the parents, who cut their child into pieces and froze the corpse in a refrigerator
because the child had wet his bed, are criminals, if they are not wholly mentally ill?
And this agreement would certainly not be a mere factual blind consensus but based
on the lucid evidence regarding the value of human life, of parental love, and other
values.
And would they not agree on countless other moral evidences regarding intoler-
ance, outrages such as the evils and unspeakable atrocities committed in the Bosnia-
war and Kosovo-crisis in the 1990s but also on countless finer points regarding daily
examples of injustice or egoism? Who would fail to recognize the naive egoism of
the man who goes to the Restaurant with his friend and when he is first offered the
choice between a large and a tiny trout, takes the large one and leaves the tiny one to
his friend? There is an excellent Jewish joke regarding this case, where the man who
took the large one is reprimanded by his friend and thereupon asks him: "And which
one you would have taken in my place?" "The small one, of course." "Well, fine
then: you got it!" The deep philosophical insights contained in this joke are most in-
triguing and touch the different role each has with respect to himself and to others.
Thus, this joke can only be found funny because all those who understand it possess
very refmed ethical intuitions. Also on such fine points regarding values we possess
evident knowledge.
Or think of the wide consensus on such content-full principles as the declarations
of fundamental human rights so well documented and interpreted by John Flemingp4
Much more important than the consensus per se is the evident truth of many of those
moral values on which there is consensus, as we have seen above.
To gain insight into an objective moral good and evil and, based on this rational
knowledge, to agree on many of its contents is by no means a mere matter of reli-
gious faith. No, in ancient thought we fmd the most impassioned expressions and
clearest insights into the falsity of the statement of Hamlet that things are not good
and evil except that our thoughts make them so. Socrates insists on the absoluteness
of goodness, and that it is better to suffer injustice than to commit it; Cicero states
that it is a madman's thought (dementis est) that good and evil are relative. He says
that no Senators or princes can change treachery, infidelity, adultery, lies, forgery, or
foul murder, condemnation without trial, etc., into something good because these
acts are evil by their very nature. 55
But not only Cicero who believed in divine beings, also atheists can recognize
the intrinsic goodness or evilness of human acts. As a matter of fact, Ivan Karama-

54 See the quotes from John Fleming in chapter 1 of this work.

55 quodsi populorurn iussis, si principum decretis, si sententiis iudicium iura constitue-
rentur, ius esset latrocinari, ius adulterare, ius testamenta falsa supponere, si haec
suffragiis aut scitis multitudinis probarentur. quae si tanta potestas stultorum senten-
tiis atque iussis, ut eorum suffragiis rerum natura vertatur, cur non sanciunt, ut, quae
mala pemiciosaque sunt, habeantur pro bonis et salutaribus? aut cum ius ex iniuria
lex facere possit, bonum eadem facere non possit de malo? atqui nos legem bonam a
mala nulla alia nisi naturae norma dividere possumus; nee solum ius et iniuria natura
diiudicatur, sed omnino omnia honesta et turpia ... ea [honesta et turpia] autem in
opinione existimare, non in natura posita dementis est ...
De Legibus I, xvi, 43--44.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 259

zov in Dostoyevsky's Brothers Karamazov, while he claims that if there is no God

everything is permitted, invokes himself the absoluteness of the value of each child
and the intrinsic evil of torturing innocent children as proof that there can be no God
because there is no justification not only for the horrible injustices and crimes com-
mitted against innocent children but also for their alleged pennission through God.
Thus, precisely the atheist who denies that an omnipotent and kind God could permit
such evils, presupposes objective and absolute moral values and evils, in the name
of which he protests against God. Without the evidence of absolute moral and mor-
ally relevant values Ivan could never defend his atheistic metaphysics, which rests
on the absoluteness of good and evil. And on these ethical value judgments from
which the atheist proceeds to disprove God's existence, religious persons and all de-
cent mankind will wholly agree, even'ifthey reject his conclusions, which is based
on some further premises.

3.3.7. Arguments against Ethical Relativism from the Observation that Many
Apparently Moral Disagreements Are Disagreements on Facts, Not on Values
There is another reason why the undeniable conflicts of opinion regarding moral
matters are not so profound as ethical skeptics and relativists make us believe. The
real conflicts of moral opinion are often due to different opinions about facts rather
than to disagreements about value. When Indians refuse to slaughter a cow because
they think that the souls of their ancestors live in animals, they presuppose the same
moral judgment as we: do not kill your ancestors! Even most abortionists will dis-
agree more on facts than on values. They deny the personhood or even the human
nature of the embryo and do not say: you may kill innocent human persons. Thus,
they often recognize implicitly the very same value, the sanctity of the life of a hu-
man person, in the name of which we may protest abortion as a crime. 56
Besides, the many undeniable real conflicts of ethical opinion57 do not disprove
the objectivity of the good because moral value-perception, while being objective,
may well presuppose a certain moral disposition to see the good, as we have ob-
served above and as was well stated by Aristotle. 58 Everybody knows that excessive
vanity and pride, lust or greed make people blind for those values which oppose
their irrational passions which, as Cicero puts it, lurk like a wild beast in all of us
and pervert our judgment. 59

56 This is true only to some extent about Peter Singer. Cf. his "UnsanctifYing Human Life." Neverthe-
less, inasmuch as Singer defends an evolutionist account of man according to which a gradual distinc-
tion between animals and human beings makes it possible that higher animals are more similar to nor-
mal human persons than some members of the species man, it is also true about him.
Engelhardt, in his discussion of the abortion debate (The Foundations of Bioethics, pp. 9 if.) as
proof of the unknowability of moral values neglects this argument, which, with others, Max Scheler
and Dietrich von Hildebrand have made. See the latter's Ethics, ch. 9.
57 H. T. Engelhardt, Jr. mentions a few ofthose in his The Foundations ofBioethics, pp. 37 f.
58 See Aristotle, Nichomachean Ethics VI, I 144a12-1144a37, for example:
And this eye of the soul acquires its formed state not without the aid of virtue as has
been said and is plain;
59 Cicero, De Legibus I, xv, 42:
lam vero illud stultissimum, existimare omnia iusta esse, quae sita sint in populorum
institutis aut legibus. etiamne si quae leges sint tyrannorum? si triginta illi Athenis
260 CHAPTERS

3.3.8. Two Arguments against Ethical Agnosticism and Relativism Which Are
Insufficient in Themselves but Constitute Additional Reasons against Ethical
Subjectivism: Evaluation ofDesires and Coherence
There are two very different attempts to reply to ethical relativism and skepticism,
briefly alluded to in the introduction, which appear to us to be quite insufficient.
These replies to ethical subjectivism present some attempt to overcome the philo-
sophical disease of a complete ethical subjectivism and seek to found a kind of 'ob-
jective ethics' either based on the evaluation of subjective desires,6o or based on a re-
duction of ethics to a mere 'logic of norms', to an ideal of ethical consistency.
According to the first of these opinions, some subjective wishes, for example the
wish to commit suicide-because of unrequited love, for example-can be classified
as invalid and as not standing on a par with other desires; and therefore the medical
doctor or society have a right to distinguish between 'objective' (real) and those de-
sires that are 'purely subjective' or even merely apparent; and between the goods re-
lated to them. Confronted with changing and purely subjective desires--expected to
cease after a short time-and with what appears good from their vantage point, med-
ical staff and society at large would therefore have a right to interfere and prevent
the carrying out of such desires which do not satisfy 'conditions of invariance' .61
Along similar lines, some contemporary ethicists distinguish between passing 'sub-
jective values' and real underlying subjective wishes and interests in which they be-
lieve to fmd an objective measure, in contradistinction to superficial actual desires
(for example of mentally ill patients).62 But if this good distinction has no further
foundation and figures as the only standard to be used against a total relativization of
ethical values, the transition from purely subjectively conceived values and valua-
tions to objective norms of action by means of invariance criteria only remains pro-
foundly obscure and even untenable-in spite of assertions to the contrary made by
some defenders of this opinion. 63
For all attempts to derive objective moral criteria from subjective values presup-
pose again objective values of the freedom and autonomy of persons, of the value of
the coherence of a person's desires, etc. Some of the defenders of the possibility of
deriving objective moral norms from a subjectivist notion of value occasionally see

leges imponere voluissent, aut si onmes Athenienses de1ectarentur tyrannicis legi-

bus, num idcirco eae leges iustae haberentur? nihilo, credo, magis illa, quam interrex
noster tuiit, ut dictator, quem vellet civium, aut indicta causa impune posset occide-
reo est enim unum ius, quo devincta est hominum societas, et quod lex constituit una;
quae lex est recta ratio imperandi ac prohibendi; quam qui ignorat, is est iniustus,
sive est illa scripta uspiam sive nusquam.
60 See Julian Nida-RUmelin, "Wert des Lebens," especially pp. 834 ff., 841 if. Cr., for example, p. 841:
"Die entscheidungstheoretischen Kohlirenzbedingungen markieren eine Fonn des Uberganges von
subjektiven zu objektiven Wiinschen bzw. Interessen." Julian Nida-RUmelin defends the position that
the theory of decision, based on the principle of the coherence necessary among an individual's differ-
ent decisions, can provide objective standards of the logic of decision excluding certain contradictions
and incoherences within the sphere of subjective value-decisions.
61 'Invarianzbedingungen'. See Julian Nida-RUmelin, "Wert des Lebens," p. 843.
62 See Julian Nida-Riimelin, "Wert des Lebens," pp. 843 ff.
63 Ibid., pp. 845-848.
 AN OBJECTNE BIOETHICS-ANSWER TO ENGELHARDT 261

this impossibility,64 whereas in other places they try completely to disassociate the
question of the objective value from absolute deontological imperatives.65
Some authors in this trend go much farther than others in the direction of under-
standing the objective nature of moral values or at least of moral value-claims. Thus
Mackie, for example,66 defends the objectivity of moral language as implying the ob-
jectivity of the concepts of 'morally right' and 'morally wrong', while denying any
epistemological justification of this claim to objectivity.
Julian Nida-Rfunelin rejects this error-theory of objective moral judgments
(which are held to be queer and irrational by Mackie). He defends instead67 some
real or potential objective knowledge of objective moral values; this he regards as
enough ground to define his position as 'cognitivism', distinguishing his use of this
term from others. But it remains nevertheless a question whether he goes essentially
beyond Kant's idea of moral 'postulates'68 when he rejects any 'theory-free' core of

64 So Julian Nida-Rilmelin writes very beautiful pages on the objectivity of a person's value and on that
of a work of art regardless of our happiness and subjective reasons for liking these goods because of
their intrinsic value (intrinsischer Wert). After saying that subjective motives to regret the destruction
of a work of art or the death of a person are not the only ones, he writes, ibid., p. 854:
Wenn jemand gestorben ist, dann ist damit eine unersetzliche, unerforschlich kom-
plexe subjektive Welt untergegangen, reich an Erinnerungen und Erfahrungen, faszi-
nierend in ihren Spannungen und Harmonien, vie1fliltig in ihren Ausdrucksformen.
Man kann die Zerstorung eines wertvollen Gemlildes auch dann bedauem, wenn
man es nie zu Gesicht bekommen hat. Urn so mehr kann man die unwiderrufliche
Zerstorung der subjektiven Welt eines Sterbenden bedauern. In beiden Flillen ist die
natllrlichste Erkllirung, daB wir dem Gemlilde und der subjektiven Welt einen objek-
tiven intrinsischen Wert zuschreiben, so wie wir in den Flillen, in denen wir etwas
urn seiner se1bst willen erstreben, dies deshalb tun, wei! wir glauben, daB es objektiv
erstrebenswert sei.
See also the beautiful passage in Julian Nida-Riimelin, "Die Rolle der Person in der Ethik: Die Po-
sition des Utilitarismus" (iiberarbeitete Mitschrift des Vortrags gehalten von Julian Nida-Rilmelin vor
der Katholischen Akademie in Bayem am 17. und 18. Oktober 1994), p. 17, which seems to insist on
the objective character of material (content-full) intrinsic values:
Demgegeniiber impliziert ein nicht-reduktionistischer Personenbegriff, daB die indi-
viduelle Person unersetzbar ist in dem Sinne, daB sie nicht einfach der Maximierung
des allgemeinen Nutzens und Wohlergehens geopfert werden darf, vie1mehr ist die
Person mit unvernuBerlichen Rechten ausgestattet.
65 Julian Nida-Rilmelin, "Wert des Lebens," p. 856. It seems to represent a certain contradiction to
these views when Julian Nida-Riimelin defends more clearly an objectivism in his "Zur Reichweite
theoretischer Vernunft in der Ethik," in Hans FriedrichIRolf-Peter Horstmann (Hrsg.), Vernunftbe-
griffe in der Maderne, Stuttgarter Hegel-KongreB 1993 (Stuttgart: Klett-Cotta, 1994), pp. 727-745,
for example on pp. 740-741. There he clearly defends an objectivism in a strong sense which alone
is adequate to 'objective moral facts' and to 'moral truth':
Eine Eigenschaft ist objektiv, wenn einer Entitlit diese Eigenschaft unabhlingig von
den subjektiven Zustlinden, insbesondere unabhlingig von den Uberzeugungen und
Vermutungen der urtei!enden Person zukommt.
However, while he denies the thesis of consensus and of constructionist theories of truth that the
coherent nature of our conviction 'constitutes' values, he rejects both any form of 'intuitionism' (im-
mediate moral cognitions), ibid., pp. 732 ff., and of epistemological coherentism as methodological
foundations of ethics, ibid., pp. 739, 741.
66 J. L. Mackie, Ethics: Inventing Right and Wrong. See also Jo1m Finnis, Fundamentals a/Ethics.
67 Julian Nida-Rilmelin, "Zur Reichweite theoretischer Vemunft in der Ethik," pp. 730 ff.
68 Julian Nida-Rilmelin, ibid., pp. 737 f.
262 CHAP1ER5

moral intuitions and therefore opts for an epistemology, in whose center we find co-
herence and systematization rather than any intuitive contact with objectively given
moral data. 69 For as soon as coherence is not regarded as simply an aid to, but as a
substitute of, ethical intuitions and inferences based on them, such a thesis will end
necessarily in another subjectivist or non-cognitivist position.

3.3.9. Is There a Conflict between Intuitive Ethical Knowledge and Ethical

Argumentation?
Frequently a false opposition is created between argumentation and systematic ex-
amination, on the one hand, and the admitting of ethical intuitions on the other. The
position that between the two there exists a conflict is false also from the point of
view of coherence, but not only from that point of view.
The point at stake is of crucial significance. 7o To justify objectivism in ethics, we
must admit-besides all logic of ethics-some objective values given to us through
intellectual insights as the supreme form of rational cognition, which is fully com-
patible with, and even the condition of, any form of ethical argument,11

3.3.10. Some Excellent Arguments against Purely Consequentialist Ethics Based on

a Purely Intersubjective Hermeneutical Objectivism, Which Cannot Overcome
Ethical Relativism
Some adherents of the possibility of the foundation of a sort of 'intersubjective ob-
jectivism' in ethics (as it was developed in the Diskursethik of Jiirgen Habermas)72
on a subjectivist foundation reject consequentialist ethics with an excellent argument
taken from the collapse of the moral identity of persons under consequentialist as-
sumptions. 73 Some of these authors seek unnecessarily (and, I believe, contradictor-
ily) to defend this excellent argument against consequentiaiist ethics from the break-
down of the moral identity of the acting person on purely subjective grounds, identi-
fying even-with reference to G. E. Moore-{equally unjustifiably) an objectivist
ethics with a consequentialist one. 74

69 Julian Nida-Rfunelin, ibid., p. 739.

70 See my debates with Edgar Morscher on this in Josef Seifert, "Zur BegrUndung ethischer Normen.
Einwiinde auf Edgar Morschers Position. Ein Diskussionsbeitrag"; "Und dennoch: Ethik ist Episterne,
nicht bloBe Doxa. Ober die wissenschaftliche Begriindbarkeit und Oberpriifbarkeit ethischer Satze
und Normen. Erwiderung auf Edgar Morschers Antwort."
71 See on this also my Back to Things in Themselves, ch. 1.
72 Expounded by Habermas in Strukturwandel der 6jJentlichkeit (1962); Theorie und Praxis (1963);
Technik und Wissenschaft als Ideologie (1968); Erkenntnis und Interesse (1968); Theorie des kommu-
nikativen Handelns (1981); Der philosophische Diskurs der Moderne (1985); Eine Art Schadensab-
wicklung (1987); Nachmetaphysisches Denken (1988).
73 Julian Nida-Rfunelin, Kritik des Konsequentialismus, and especially his lecture "Person und Ethik"
(International Academy of Philosophy in the Principality of Liechtenstein, 22 October, 1996).
74 Julian Nida-Rilmelin, though he tends to hold some absolute values and value intuitions, suggests this
at times, for example when he writes in his "Wert des Lebens," p. 848:
Die interne Perspektive wird zwangslaufig aufgegeben, wenn die moralische Beur-
teilung des angernessenen Umgangs mit Leben nicht von seinern subjektiven, son-
dern von seinem objektiven Wert abhiingig gemacht wird. Das paradigmatische Bei-
spiel dafiir ist die klassische utilitaristische Ethik.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 263

3.3.11. Arguments against an Ethical Relativism Based on the Alleged Relative and
Relational Character ofAll Values-A New Use of the Distinction between Three
Categories of Goodness (of Positive Importance)
We have seen that one form of a specifically ethical relativism is not at all based on
the relativity of truth but on the idea of an inherent relativity of values. The evidence
of objective values as such, and in particular of objective moral values, is clearer to
us when we distinguish the intrinsic preciousness and goodness such as the dignity
of a person or the value of justice from the merely subjectively satisfying, which in-
deed does involve some relation or even relativity.7s Let us remember the contrast
between these two radically different senses of 'good' distinguished in chapter 3,
above:
(1) The pleasurable character of activities such as smoking depends on our sub-
jective likes or dislikes, whereas objective values such as human dignity as source of
human rights are completely independent from anyone's likes or dislikes. It is a ma-
jestic, and entirely objective value.
(2) The merely subjectively satisfying invites and possibly seduces us, but it does
not call for an adequate response and respect as the value of the person whom we
love.
(3) Moreover, when we pursue mere subjective pleasure, we use the object and
surrender it to our wants; but when we give a value response to that which is in itself
good, we serve the good; for example, we affirm the person we love for his or her
own sake. 76
(4) These intrinsic goods endowed with objective value rank higher or lower in a
hierarchy. Pleasure and displeasure have only degrees ofintensity.77
(5) Finally, the mere pursuit of pleasure does not lead to authentic happiness.
Rather, true happiness is only possible as a superabundant gift, when we forget our-
selves and give ourselves to some objective and intrinsic good.
There are also objective gifts for a person, which are relational. When we say:
How good for me that the girl I love married me! then we refer gratefully to a good
that is objectively in our true interest and not merely subjectively satisfying. But this
event is not viewed here as it is in itself. For a great gift for me does not have to be a
gift for another person but perhaps is even a source of her suffering. These objective
goods or evils for persons address themselves to a person, to his or her individual
center. But they are objectively good for her, in her true interest. Moreover, all such
goods for persons presuppose that the person himself or herself is intrinsically noble
and good. Otherwise all such objective goods for persons would be left hanging in
the air.

7S This distinction has been fully discovered in ethics by Dietrich von Hildebrand, Ethics, chs. 1-3, 17-
18.
76 This was beautifully worked out by Karol Wojtyla. See Karol Wojtyia, Liebe und Verantwortung; see
also Josef Seifert, "Karol Cardinal Wojtyla (Pope John Paul II) as Philosopher and the CracowlLublin
School of Philosophy." See likewise Rodrigo Guerra L6pez, Volver a la persona. El metodo filos6fico
de Karol Wojtyla, Pr610go de Josef Seifert, Colecci6n "Esprit" (Madrid: Caparr6s Editores, 2002);
and the same author, Afirmar a la persona por sf misma. La dignidad como jimdamento de los dere-
chos de la persona (Mexico: Comisi6n Nacional de los Derechos Humanos, 2003).
77 See chapter 3 above, where Aristipp's views are discussed.
264 CHAPTER 5

3.3.12. 1ntrinsic Value and Affirmability of the Person

The discovery of intrinsic absolute goods, which demand an adequate response,
might seem to enslave our freedom, but in reality these intrinsic goods liberate us.
For no other purpose of our freedom is as noble as to serve humanity, to serve a God
whom we affirm not only intellectually but with our will and heart as infinitely
good, or to search for a truth which has value in itself and not only for us. Man is a
being made to transcend himself and to conform his will to goods that bear intrinsic
and objective value in them. In no other sphere of life this is so evident as in love.
Love involves serving others, it involves an affirmation of others for their own sake,
an abandoning ourselves and a giving ourselves to them, a saying 'yes' to them in
their intrinsic preciousness.
There is hardly anything greater and more significant than to recognize the ob-
jectivity of the good, to search for its better knowledge, and to respect what deserves
respect, and to love those beings and persons to whom love is owed. Love is not
only the most complete witness to the intrinsic and objective character of the good
but to an intrinsic value that the person qua person possesses. Love does not just re-
spond to something good in a person, as admiration does, but authentic love em-
braces and affirms the other person as a whole and for his or her own sake. Thus, it
sees the faults of the beloved person as unfaithfulness to her true self, the develop-
ment of which to higher and higher values the movement of love and friendship
seeks to promote. 78

4. IS AN OBJECTIVE RATIONAL BIOETHICS POSSIBLE IN OUR

PLURALISTIC SOCIETY?
Engelhardt's Negative Reply to the Second and Third Questions Posed Above and
the Need to Return to Things Themselves
We have posed three questions at the beginning of this chapter: one about objective
knowledge of moral values, the second about the existence of a natural and purely
philosophical knowledge of them, and the third about a publicly acceptable and ca-
nonical bioethics. While we now have given preliminary answers to the first two
questions which we proposed to solve in this chapter, let us nevertheless return again
to these questions from a different point of view, namely, in reference to the posi-
tions of H. T. Engelhardt, Jr., who strongly connects these two questions with the
very different third one concerning the possibility of a canonical and content-full
public bioethics for our pluralistic society.

78 See on this Dietrich von Hildebrand, Das Wesen der Liebe, chs. 1-3. See also Karol Wojtyia, Amore e
responsabilita, in Karol Wojtyia, Metajisica della persona. Tutte Ie opere jilosojiche a saggi integra-
tive, a cura di Giovanni Reale e Tadeusz Styczei (Milano: Bompiani, 2003), pp. 451-777; Rodrigo
Guerra Lopez, Ajirmar a la persona por sf misma. La dignidad como fundamento de los derechos de
la persona. See also Max Scheler, Wesen und Formen der Sympathie. Gesammelte Werke Bd. VII,
6. Aufl. (Bern und Miinchen: Francke Verlag, 1973), pp. 150 ff.
 AN OBJECTIVE BrOETHICS-ANSWER TO ENGELHARDT 265

4.1. The First Reason ofEngelhardt's Allegation of the Incapacity ofPhilosophical

Moral Reasoning: the 'Private Character' of Moral Commitments and the
Ambiguity of This Claim
Hardly anybody will doubt that a human being today, as in times past, can fonn his
own private opinions about questions of bioethics. But a widespread value-relati-
vism, some arguments of which we have already critically examined, adopts the
view that there are no objective standards of good and evil, at least none which
could serve as publicly acceptable, canonical, and content-full measure of bio-
ethics. 79
Regarding the question whether an objective ethical knowledge of moral values
is possible, or whether we are doomed to ethical relativism and skepticism, Engel-
hardt's position is ambiguous, as we shall see. He both implies philosophically, and
rejects for religious reasons (though not entirely), such a general ethical skepticism
and relativism. so He tends to claim that we do possess objective ethical knowledge-
but only on a religious level. Nevertheless, even his speaking about the religiously
grounded 'bioethics of friends' in the plural, and many of his expressions about such
a content-full bioethics of different social groups and of 'truth for them' and 'known
by them', without ever introducing the concepts of moral substitutes and ethical er-
rors, smacks of relativism. 81
Whereas his answer to the question of the existence of objective moral values is
ambiguously affinnative, the question whether we possess any philosophical knowl-
edge of objective moral contents, is clearly answered negatively by him. Therefore,
a fortiori his response to the question about a publicly acceptable objective and con-
tent-full ethics is negative. In ancient and medieval times, he argues, or in funda-
mentalist Moslem countries today, common ethical standards were and are accepted
because of a common religion. In the Western modem world, however, a religion
that could unify our moral experience and provide a basis for our laws does not ex-
ist. Such a common moral and religious experience has disappeared from the world
since the end of the influence on public life of a commonly accepted religion. A
commonly accepted religion can indeed provide a 'content-full' public ethics and
prepositive system oflaw. Think for example of the Mosaic Law or the medieval or-
der in which State and Church were united.
After the collapse of a publicly accepted religion many thinkers of the enlighten-
ment sought to substitute religion by reason in providing a common moral experi-

79 Cf. also Kevin W. Wildes, "Respondeo: Method and Content in Casuistry," Journal of Medicine and
Philosophy, 1994; 19(1): 115-119. Wildes argues against James Tallmon that medical ethics, espe-
cially casuistry, needs contents and a moral vision. Cf. also James M. Tallmon, "Casuistry, Catholi-
cism, Ethics, Medicine, Morality," Journal of Medicine and Philosophy. 1994; 19(1): 103-113.
80 In principle, skepticism, as a radical doubt or as a negation of truth, which still may cling to the notion
of objective truth, must be distinguished from relativism which relativizes the very notion of truth to
the individual, a group, or all men. Engelhardt's purely philosophical position combines both.
81 In general, Engelhardt lacks a philosophical theory of error, as Balduin Schwarz has admirably pre-
sented it. See Balduin Schwarz, Der Irrtum in der Philosophie; see also Dietrich von Hildebrand, with
Alice Jourdain, Graven Images. Substitutes for True Morality; and by the same author Idolkult und
Gotteskult, in Dietrich von Hildebrand, Gesammelte Werke VII (Regensburg: Josef Habbel, 1974).
See also Josef Seifert, Erkenntnis objektiver Wahrheit, Part r, ch. 3.
266 CHAPTERS

ence. But this rationalistic dream of the enlightenment to replace religion by reason
as a formative and commonly accepted ground of public morals was, according to
Engelhardt, never sound to begin with and therefore collapsed even quicker in the
consciousness of mankind. During and after the time of the enlightenment, rational-
ists and sons of the enlightenment claimed to discover, by means of their reason
alone, universally binding values and moral principles. Yet this faith in human rea-
son to provide a universal and ecumenically acceptable basis for the public life
faded over the last centuries. As Tristram Engelhardt puts the problem in his influen-
tial work on bioethics, there does not appear to exist today the possibility of either a
rational or a religious foundation for a public bioethics. 82
Engelhardt distinguishes within our society, which lacks 'a common moral vi-
sion', an 'ethics for friends' from an 'ethics for moral strangers'.83 He wants to 'pri-
vatize' all content-full moral commitments, implying a sort of Hegelian and Dilthey-
an relativism,84 and yet not imply a "qualification or diminution of the significance
and substance of the moral commitments of particular moral communities."85 But
how is this possible if one 'privatizes' morality? And how can even the objectivity
of moral values and imperatives be upheld when they are related only to 'particular
moral communities'?
Now, 'privatization' is. an ambiguous term. It can mean at least two distinct
things: (I) It can intend either that we find in ethics only relative and subjective
'moral commitments of particular moral communities', a position that would in-
volve the ethical relativism we attempted to refute in its cultural and historical form.
(2) Or it can mean that the objective truth known in these communities can only be
known under certain conditions, but is entirely objective.
If this second sense of 'privatization' is his meaning, Engelhardt should contrast
true ethical knowledge, which would exist only in small private communities, and
ethical errors that also can form community life, and abandon the talk of a truth for
and within particular ethical communities.
There exists a very profound and indeed insurmountable problem for Engel-
hardt's position, however. For this second claim of the privacy of an objective ethi-
cal knowledge (towards which we see Engelhardt tending) cannot apply to the many
'private moral commitments' of which Engelhardt is speaking and of which he
makes many of the following statements. Therefore, Engelhardt's assertions in
speaking of the second meaning of "privatization of content-full moral commit-
ments,"86 can apply only to the set of true moral contents and do not allow him to
hold that there exists in general 'a truth of private ethical knowledge'.

82 Engelhardt, H.T., Jr., The Foundations ofBioethics (1986). See also the substantially different second
version of the work: H. T. Engelhardt, Jr., The Foundations ofBioethics, 2nd ed. ( 1996). See also the
same author, The Foundations of Christian Bioethics.
83 Engelhardt, The Foundations of Bioethics, pp. 7 ff. See also the same author, "The Foundations of
Bioethics and Secular Humanism: Why Is There No Canonical Moral Content?"
84 Hegel's influence on the thought ofH. T. Engelhardt, Jr. can be seen in many places, for example in
Engelhardt's The Foundations of Bioethics, p. 9, and especially on pp. 25-26 (note 15). See also En-
gelhardt, Mind-Body. A Categorial Relation (Den Haag: M. Nijhoff, 1973).
85 The Foundations ofBioethics, 2nd ed. (1996), p. viii.
86 He nowhere distinguishes the two, as far as I can see.
 AN OBJECTNE BIOETHICS-ANSWER TO ENGELHARDT 267

Moreover, this one true private ethics alleged by him must be universal in its
validity and not private-in virtue of being true. Thus, the true ethics, accessible ac-
cording to him only to a few (members of the true Church), ought to be opposed by
him to the many moral errors, which alone can be a mere 'private moral commit-
ment' of a particular group. Only ethical errors can be no more than the object of a
shared intersubjective preference or than part of communal convictions. Ethical
truth necessarily transcends communal group-sentiments. Therefore, if Engelhardt
has in mind that particular groups can each know objective ethical truth about the
good, he should cease to speak in general terms of 'private moral commitments'. For
this terminology either suggests that these ethical codes 'are all true' in the sense of
a correspondence theory of truth, and this would be contradictory, because many of
them are contradictory. Or the notions of truth, value, and objectivity are meant all
the time by him only as 'relative' to certain groups, as if truth and value were all
only matters of private or historically and culturally different tastes, and as if truth
could be just true for, and within, a particular community. In this case he would have
to define the essence of truth in terms of a consensus-theory and embrace an all-out
ethical relativism.
Therefore, in case he espouses this second interpretation of his 'private ethics',
which he intends in the following statement, the whole talk of 'friends' and 'stran-
gers' is a relic of unduly re1ativizing ethical truth (in the first sense of 'privatiza-
tion'). To make statements such as "the truth known by and within a particular com-
munity will not be appreciated by moral strangers as having a claim on them unless
they convert and thus cease to be moral strangers"87 unavoidably involves this confu-
sion between the two meanings of 'privatization'.
If Engelhardt's answer to the question of objective absolute truth and value is
ambiguous, his answer to the questions about natural rational knowledge of ethical
contents and of their binding role for society is clear: he denies any content-foll phil-
osophical knowledge of moral properties and eo ipso asserts their incapacity to be-
come publicly acceptable in a pluralist society. Clearly, he makes the claim of the
'incapacities of philosophical moral reasoning', though he fmds this conclusion
reached by him 'abhorrent' .88
Thus, Engelhardt admits the immense significance of this question. 89 Let us
therefore first investigate his further reasons against the objectivity of philosophical
ethical knowledge and for the human incapacity of such knowledge.

87 Ibid., p. viii.
88 Ibid., p. viii.
89 Remember his statements quoted already from H. T. Engelhardt, Jr.'s The Foundations of Bioethies,
2nd ed., p. 65:
One must appreciate the enormity of the failure of the Enlightenment project of dis-
covering a canonical content-full morality. This failure represents the collapse of the
Western philosophical hope to ground the objectivity of morality. This failure bears
against theories of justice and accounts of morality generally. It brings all secular
bioethics into question. If one cannot justifY a particular morality, one cannot justifY
claims of immorality. All appears to become a matter of taste. Indeed, if one cannot
disclose some lines of conduct as canonically immoral, then the health care provided
by Albert Schweitzer and by Nazi death camps will be equally defensible and inde-
fensible. If one cannot discover an objective method to decide when the morally de-
268 CHAP1ER5

4.2. Does Every Claim ofRational Ethical Knowledge either Beg the Question or
Lead to an Infinite Regress?-Critique ofEngelhardt's Second Reason to Reject
Philosophical Ethical Objectivism
On the very first pages of his book, Engelhardt claims that 'secular accounts' of con-
tent-full ethics are subject of the following devastating alternative: either ''they beg
the question, arbitrarily affirm a particular point of departure, or invoke an infinite
regress."9O He rightly states that if this is so, "then the modem philosophical project9l
of justifying a general bioethics fails as well."92
In making this criticism, Engelhardt levels against any content-full ethics exactly
the same objection which Aristotle raises against those who try to prove every-
thing-in ethics, logic, or in any other field-instead of recognizing the fact that be-
sides knowledge by demonstration there is another more certain, more rational and
more foundational form of cognition: immediate intellectual knowledge (intellectual
intuition or noesis).93 After Aristotle, countless other thinkers including phenomeno-
logical logicians have shown the existence of propositions that neither are capable
nor stand in need of demonstration. 94 Therefore, if ethicists who defend a content-
full ethics were, as Aristotle puts it, so uneducated that they believed it possible to
demonstrate every moral claim, then Engelhardt's critique would clearly hold true.
For any ethics that would pretend to demonstrate every proposition it contains by
necessity fails by falling into an infinite regress. For not all claims (neither ultimate
premises and 'rules of evidence' nor the logical 'rules of inference') can actually be
demonstrated. 95 In any attempt to demonstrate all propositions of a given system one
would need to fall back on an infinite chain of demonstrations which never would
prove anything at all, or one would use circular arguments which would beg the
question, either by demonstrating what needs to be proven by premises which pre-
suppose it, or by deriving certain conclusions from premises which stand in need of
demonstration but are introduced without any demonstration. This insight consti-
tutes also the core of Godel's famous principle, which was subject to many false
philosophical interpretations.
But it is clear that not all referring to indemonstrable propositions commits the
logical or epistemological flaw of a 'petitio principii' (begging the question). For all
demonstrations rest on indemonstrable premises that are obtained by immediate
knowledge, either by intellectual intuitions or by sense perceptions or by other per-
ceptions, such as are given in the immediate experience of our consciousness. More-

viant are also morally wrong, then the action of the morally heinous and the saint
will be equally justifiable or lacking in justification, at least in general secular terms.
One stands on the brink of nihilism.
90 H. T. Engelhardt, Jr., The Foundations of Bioethies, p. ix. He repeats the same thesis often, for ex-
ample ibid., pp. 41 ff.
9l This 'project' is in reality very ancient, from Greek philosophy and the Book of Wisdom and Saint
Paul's Letter to the Romans on through Saint Justin Philosopher and Martyr, Saint Clement of Alex-
andria, Augustine, etc., on to the 20th century.
92 Ibid., p. ix.
93 Aristotle, Posterior Analyties.
94 See, for example, AdolfReinach, "Uber Phanomenologie"; see also Alexander Pfander, Logik.
95 All of these can never be demonstrated, in no discipline.
 AN OBJECTNE BIOETHICS-ANSWER TO ENGELHARDT 269

over: Any science and discipline whatsoever presupposes such immediate fonns of
cognition. And nowhere where these are to be found, i.e., cognitions that cannot and
need not be demonstrated, such as sense perceptions, is their invocation or use as
such a 'begging of the question' nor does it involve an infinite regress. If I see with
my eyes the results of a laboratory test, and understand the meaning of what I see, I
cannot prove my vision. Nonetheless, obviously no one is objecting, or even feels
entitled to object, to the chemist, physicist, or medical scientist that he 'begs the
question' by referring to laboratory observations that rest on sense perceptions. If I
feel a headache and tell the physician or psychiatrist this, I do not beg the question,
though I cannot prove having it. If! grasp certain logical laws (such as that the logi-
cal fonn Barbara is valid) or moral values that are evidently grounded in the nature
of acts of a certain kind, I do equally not beg the question simply because I have no
proof-because I possess a far superior immediate intellectual grasp of these laws.
But if one asks why Engelhardt raises the objection of begging the question
against any philosophical foundation of a non-fonnal ethics, then one finds no solid
answer to this query in Engelhardt. 96
Of course, also when introducing premises which stand in need of demonstration
as if they neither needed nor were capable of demonstrations, I may 'beg the ques-
tion' not in the strict logical sense, but in a completely different sense of the tenn: I
can merely arbitrarily claim to possess immediate intellectual knowledge about
theses without actually possessing such knowledge and without there being any
sense- or rational evidence to substantiate my claim. Here we do not properly find a
begging of the question in the sense of the logical mistake of circular argument, but
unfounded claims to evidence or ludicrous pretensions of perceptions or intuitions
where we have none. I beg the question whenever I introduce as self-evident propo-
sitions that stand in need of demonstration.
Thus, Engelhardt could make either one of the following claims:
(1) All non-fonnal ethics actually seeks to demonstrate all of its presuppositions
or does so by methodological necessity. This leads, in view of Aristotle's insights,
either to begging the question or to an infinite regress. The underlying claim that all
non-fonnal ethics seeks to demonstrate all of its propositions lacks any foundation
and would at best apply to wholly uneducated ethicists who would fail to see that
not everything can be demonstrated, or it would presuppose an equally uneducated
critic who would fail to see that all demonstrations rest on indemonstrable proposi-
tions which must derive their evidence from elsewhere (in ethics ultimately from
their intelligible content).
(2) He could also claim that no immediately evident proposition exists, but this
would equally condemn his own position, which, as any other philosophy, presup-
poses immediately known principles and premises.
(3) He could further mean that all philosophical content-full ethical positions
treat propositions that stand in need of demonstration as if they were self-evident.

96 As we shall see, there is only one clearly discernible argument in his work, but it appears to be weak;
another argument may lie in his claim that theses which would have to be demonstrated or at least
argued for are introduced in ethics completely arbitrarily.
270 CHAPTERS

This objection would imply a claim of a universal need to demonstrate content-full

propositions (at least in secular medical positions).
(4) He could restrict the last objection and merely claim that, on the level of pure
philosophy and reason, no content-full ethical positions can be based on immediate-
ly evident principles but that all secular content-full ethical accounts must simply as-
sume, arbitrarily and blindly, their premises, and perhaps likewise their rules of evi-
dence and inference.
AD (1) Now Engelhardt is in no way clear as to which of these claims he is mak-
ing and as to why he makes the claim. Sometimes he clearly makes the first one, im-
plying that all ethical propositions stand in need of demonstration. See the state-
ment: " ... all concrete, secular moral accounts presuppose what they seek to
prove."97 It does not become clear why each concrete ethical position begs the ques-
tion or has to beg the question, if it is defended by an educated person who knows
that not all propositions can be demonstrated, nor why Engelhardt's formal or pro-
cedural ethics which equally presupposes some indemonstrable (and hotly disputed)
premises would not beg the question under the assumption that all ethical knowledge
needs to be demonstrated as the above quote implies. 98
In addition, the introduction of evidence does not mean, as G. E. Moore implies,
that we can only say 'the good is the good', but we can carefully analyze objects of
philosophy, distinguish data from their opposites and from neighboring phenomena,
elaborate their marks, exclude misunderstandings, answer objections, make distinc-
tions, etc., and thus elucidate and bring to evidence these data.
Engelhardt's own position is not exempt from his own objection because it also
rests on foundations deemed evident. Thus, he suddenly abandons the claim implicit
in the above statement that all propositions stand in need of demonstration.
AD (2) Since claim two is unreasonable and would show a lack of logical train-
ing, and would immediately condemn his own position, we can safely assume that it
cannot be his intention to present this objection.
AD (3) If the third objection were a simple application of the first objection to
medical ethics, implying that all ethical propositions would need proof, it would be
both unreasonable and would clearly contradict Engelhardt's own position. For En-
gelhardt himself admits religiously motivated ethical intuitions and denies content-
full intuitions only to 'secular ethics'. He attributes an intuitive knowledge of moral
values and of moral truth to those who have converted and stand in contact with the
divine grace and divine energies. 99
But the third objection could also be interpreted in another way and imply only
that secular medical accounts need to prove all of their claims (presumedly because
there is no immediate ethical evidence about moral contents). In raising this objec-
tion, he refers to the second meaning of 'begging the question' distinguished above,

97 Ibid., p. x.
98 Ibid., p. x.
99 See ibid., p. 14:
Traditional moralities and their communities remain. Their adherents accept
grace ... They know concretely about virtue and character. Some even strive for
sanctity and holiness. They know what is worth dying/or, when, and why. They know
that morality commands, that its content is not chosen. [Emphasis mine]
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 271

which we again differentiated: Engelhardt could pretend that qll secular ethics begs
the question in the sense of claiming as self-evident what needs to be demonstrated.
But as by their very nature assertions about ultimate values can only be known im-
mediately and not by deductions, it is unlikely that Engelhardt seriously makes this
claim.
AD (4) Hence the only remaining way to argue for this Engelhardtean claim is
the fourth one. This also seems to accord with the actual course of his line of reason-
ing in which he does not reproach all ethics but only secular bioethics to beg the
question or fall into an infinite regress. Begging the question would then just mean
claiming moral intuitions that, as secular rational person, one does not and cannot
conceivably possess. But even here Engelhardt does not hold the view that secular
ethics is unable to build on any immediate moral intuitions in absolute radicality.
This cannot be seriously Engelhardt's claim already for the reason that he explicitly
admits what is obvious, namely, that he himself also claims intuitive evidence for his
own secular (philosophical) bioethical positions. Thus, he must assert that not all
secular ethics is deprived of rational and justified evident knowledge but that only
intuitions into concrete moral or morally relevant goods are all arbitrary. In other
words, according to him for his formal and content-less ethics and its foundational
principles one can possess immediate and rational intuition but not for any content.
For in his further explanation of his statement that the only alternative of con-
tent-full secular ethics is either 'question begging' or 'infinite regress', he seems to
restrict the objection to only those forms of secular ethics which are "about the con-
crete moral views"loo of an author or "carry with it a concrete moral perspective." He
admits ethical intuitions of secular ethics of the sort as grounds the formal bioethics
he proposes but denies all content-full ethical intuitions to secular ethics.
Thus, what remains is that he claims that all secular ethics, not because it should
demonstrate value claims, but because-due to an enormous value-blindness in sec-
ular ethicists-it cannot really perceive any value, being struck with utter ethical
value-blindness, makes just arbitrary claims to value knowledge. lol The problem is
that this claim is both (a) wholly arbitrary itseifand (b) logically contradictory.
(a) If this claim is not wholly arbitrary, it must rest on some intelligible reason
for arrogating for himself (his own formal ethics) rational intuitions into the prin-
ciples of a procedural secular ethics, while denying the same type of rational evi-
dence to all positions of content-full ethics, for example to those who hold that evi-
dently in rape a violation of human dignity occurs and that this violation of human
dignity is criminal because it violates a fundamental human high good of sexual val-
ues and the fundamental human right to the respect of one's sexual freedom and in-
tegrity. Now the only apparently intelligible reason Engelhardt offers for his distin-
ction between actual rational immediate knowledge (claimed for himself) and arbit-
rary claims to rational knowledge (attributed indiscriminately to all philosophical
and secular content-fitll value claims), which one can find in his book, consists in
the undoubted statement, with which his book opens, that there is actual ethical dis-

100 /bid., p. x.
101 On this entire matter, see Dietrich von Hildebrand, Ethics, ch. 9 on ethical relativism; see also his Sitt-
lichkeit und ethische Werterkenntnis.
272 CHAPTER 5

sent among people. But how does this undeniable fact prove that no rational claim to
evidence is possible regarding disputed questions such as ethical ones? To consider
the mere fact of dissent a sufficient reason for such a conclusion is both untenable
(nobody claims, for example, that there is no objective knowledge about scientific
facts possible because some are disputed) and leads to a logical contradiction in En-
gelhardt's position. For if there were no rational indemonstrable knowledge wher-
ever dissent reigns, then certainly the positive principles of Engelhardt's own proce-
dural ethics and the negative results of his analysis, namely, the alleged absence of
rational knowledge of content-full ethics, could not make any legitimate claim to
rationality and justification. For both the positive and negative aspects of En-
gelhardt's theory are far more hotly disputed and far less subject of agreement or
consensus than the most central ethical contents with respect to which he seems to
consider dissent as reason for assuming the absence of rational truth-claims in which
one does not arbitrarily 'beg the question'. Hence this argument: "where we find dis-
sent, we encounter incapacity of rational secular truth-claims," completely destroys
any possible justification of Engelhardt's own truth-claims and makes his own posi-
tion equally unsusceptible of rational defense. For on his claims to immediate evi-
dent knowledge of the foundations of the allegedly "only suitable ethics for a secular
society," there is not the least consent. I02 Not only those other members of society,
which he calls the 'moral strangers', disagree with him, but also his 'moral friends',
for example myself Both with his positive and with his negative claims then both
'moral strangers', the atheist secularists, and his 'moral friends', countless Christian
writers and philosophers, disagree. Those who dissent with him on the content of his
allegedly 'only acceptable content-less procedural ethics for a secularized public
world" include countless members of his own religious community who are re-
garded by him as belonging to the narrowest circle of friends, namely, members of
the Orthodox Church and even the most brilliant members of the Catholic Church
who are canonized and are equally revered as Saints by the Orthodox Church, such
as Saint Clement of Alexandria or Justin the Martyr These thinkers clearly think that
content-full ethical intuitions are possible in spite of the phenomenon of moral
dissent, which was well known to them. 103

102 And he makes necessarily claims to rational immediate knowledge---just as necessarily as anyone
else.
103 The First Apology ofJustin, ch. 2:
Reason directs those who are truly pious and philosophical to honour and love only
what is true, declining to follow traditional opinions, if these be worthless. For not
only does sound reason direct us to refuse the guidance of those who did or taught
anything wrong, but it is incumbent on the lover of truth, by all means, and if death
be threatened, even before his own life, to choose to do and say what is right. Do
you, then, since ye are called pious and philosophers, guardians of justice and lovers
oflearning, give good heed, and hearken to my address; and ifye are indeed such, it
will be manifested.
ibid., ch. 3:
For even one of the ancients somewhere said, "Unless both rulers and ruled philo-
sophize, it is impossible to make states blessed." It is our task, therefore, to afford to
all an opportunity of inspecting our life and teachings, lest, on account of those who
are accustomed to be ignorant of our affairs, we should incur the penalty due to them
for mental blindness; and it is your business, when you hear us, to be found, as rea-
 AN OBJECTIVE BIOETIllCS-ANSWER TO ENGELHARDT 273

son demands, good judges. For if, when ye have learned the truth, you do not what is
just, you will be before God without excuse.
ibid., ch. 4:
For as some who have been taught by the Master, Christ, not to deny Him, give
encouragement to others when they are put to the question, so in all probability do
those who lead wicked lives give occasion to those who, without consideration, take
upon them to accuse all the Christians of impiety and wickedness. And this also is
not right. For of philosophy, too, some assume the name and the garb who do noth-
ing worthy of their profession; and you are well aware, that those of the ancients
whose opinions and teachings were quite diverse, are yet all called by the one name
of philosophers. And of these some taught atheism; ...
The Second Apology ofJustin for the Christian Addressed to the Roman Senate, ch. 3:
For I would have you to know that I proposed to him certain questions on this sub-
ject, and interrogated him, and found most convincingly that he, in truth, knows
nothing. And to prove that I speak the truth, I am ready, if these disputations have
not been reported to you, to conduct them again in your presence. And this would be
an act worthy of a prince. But if my questions and his answers have been made
known to you, you are already aware that he is acquainted with none of our matters;
or, if he is acquainted with them, but, through fear of those who might hear him,
does not dare to speak out, like Socrates, he proves himself, as I said before, no phi-
losopher, but an opionative man; at least he does not regard that Socratic and most
admirable saying: "But a man must in no wise be honoured before the truth."
The Dialogue of Justin, Philosopher and Martyr, with Trypho, A Jew bears even more ample evi-
dence of Justin's insistence on the greatness of rational human knowledge of goods and values; the
same is even more true of Clement who goes as far as to claim a covenant between God and the Greek
philosophers and sees the work of pagan (secular) human reason as a high good directly willed by
God.
See also Clement, Epitomes ill, ch. II:
But it is said we do not all philosophize. Do we not all, then, follow after life? What
sayest thou? How hast thou believed? How, pray, dost thou love God and thy neigh-
bour, if thou dost not philosophize? And how dost thou love thyself, if thou dost not
love life?
Above all, see Clement, Stromata, ch. 7, ''The Eclectic Philosophy Paves the Way for Divine Vir-
tue":
The Greek preparatory culture, therefore, with philosophy itself, is shown to have
come down from God to men, not with a definite direction but in the way in which
showers fail down on the good land, and on the dunghill, and on the houses. And
similarly both the grass and the wheat sprout; and the figs and any other reckless
trees grow on sepulchres. And things that grow, appear as a type of truths. For they
enjoy the same influence of the rain. But they have not the same grace as those
which spring up in rich soil, inasmuch as they are withered or plucked up. And here
we are aided by the parable of the sower, which the Lord interpreted. For the hus-
bandman of the soil which is among men is one; He who from the beginning, from
the foundation of the world, sowed nutritious seeds; He who in each age rained
down the Lord, the Word. But the times and places which received [such gifts], cre-
ated the differences which exist. Further, the husbandman sows not only wheat (of
which there are many varieties), but also other seeds-barley, and beam, and peas,
and vetches, and vegetable and flower seeds. And to the same husbandry belongs
both planting and the operations necessary in the nurseries, and gardens, and or-
chards, and the planning and rearing of all sorts of trees.
In like manner, not only the care of sheep, but the care of herds, and breeding of
horses, and dogs, and bee-craft, all arts, and to speak comprehensively, the care of
flocks and the rearing of animals, differ from each other more or less, but are all use-
ful for life. And philosophy-I do not mean the Stoic, or the Platonic, or the Epicu-
rean, or the Aristotelian, but whatever has been well said by each of those sects,
274 CHAPTER 5

(b) Besides alleging in an unfounded (and ultimately contradictory) way that the
factual dissent on moral contents transforms any secular content-full ethics into ar-
bitrary theses, however, Engelhardt also contradicts himself in another way. For the
secular procedural ethics he proposes includes many content-full value statements
that are not at all totally content-less. Now Engelhardt is keen in denying this. He
claims that he propounds a value-free ethics, one that remains "without establishing

which teach righteousness along with a science pervaded by piety-this eclectic

whole I call philosophy. But such conclusions of human reasonings, as men have cut
away and falsified, I would never call divine.
See also ibid., ch. ix, "Human Knowledge Necessary for the Understanding of the Scriptures," in
which the necessity of human (secular) understanding for knowing the Scriptures is taught, and count-
less other passages:
Some, who think themselves naturally gifted, do not wish to touch either philosophy
or logic; nay more, they do not wish to learn natural science. They demand bare
faith alone, as if they wished, without bestowing any care on the vine, straightway to
gather clusters from the first. Now the Lord is figuratively described as the vine,
from which, with pains and the art of husbandry, according to the word, the fruit is
to be gathered.
We must lop, dig, bind, and perform the other operations. The pruning-knife, I
should think, and the pick-axe, and the other agricultural implements, are necessary
for the culture of the vine, so that it may produce eatable fruit. And as in husbandry,
so also in medicine: he has learned to purpose, who has practised the various les-
sons, so as to be able to cultivate and to heal. So also here, I call him truly learned
who brings everything to bear on the truth; so that, from geometry, and music, and
grammar, and philosophy itself, culling what is useful, he guards the faith against as-
sault. Now, as was said, the athlete is despised who is not furnished for the contest.
For instance, too, we praise the experienced helmsman who "has seen the cities of
many men," and the physician who has had large experience; thus also some de-
scribe the empiric. And he who brings everything to bear on a right life, procuring
examples from the Greeks and barbarians, this man is an experienced searcher after
truth, and in reality a man of much counsel, like the touch-stone that is, the Lydian,
which is believed to possess the power of distinguishing the spurious from the genu-
ine gold. And our much-knowing gnostic can distinguish sophistry from philosophy,
the art of decoration from gymnastics, cookery from physic, and rhetoric from dia-
lectics, and the other sects which are according to the barbarian philosophy, from the
truth itself. And how necessary is it for him who desires to be partaker of the power
of God, to treat of intellectual subjects by philosophising! And how serviceable is it
to distinguish expressions which are ambiguous, and which in the Testaments are
used synonymously! For the Lord, at the time of His temptation, skilfully matched
the devil by an arnbiguous expression. And I do not yet, in this connection, see how
in the world the inventor of philosophy and dialectics, as some suppose, is seduced
through being deceived by the form of speech which consists in ambiguity. And if
the prophets and apostles knew not the arts by which the exercises of philosophy are
exhibited, yet the mind of the prophetic and instructive spirit, uttered secretly, be-
cause all have not an intelligent ear, demands skilful modes of teaching in order to
clear exposition. For the prophets and disciples of the Spirit knew infallibly their
mind. For they knew it by faith, in a way which others could not easily, as the Spirit
has said. But it is not possible for those who have not learned to receive it thus.
"Write," it is said, ''the commandments doubly, in counsel and knowledge, that thou
mayest answer the words of truth to them who send unto thee." What, then, is the
knowledge of answering? or what that of asking? It is dialectics. What then? Is not
speaking our business, and does not action proceed from the Word? For if we act not
for the Word, we shall act against reason. But a rational work is accomplished
through God. "And nothing," it is said, ''was made without Him" - the Word of
God.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 275

the moral worth or moral desirability of any particular choices,"104 not providing any
"content-full ethics by which men and women can live their concrete morallives."los
He claims that his Foundations is not a "libertarian manifesto celebrating the value
of freedom," 106 that he does not claim "a value for individual choice, freedom, or lib-
erty,"107 nor for autonomy and self-determination or peace. For this reason he re-
named the 'principle of autonomy' simply 'principle of permission', in order to indi-
cate that no value is at stake but simply "that secular moral authority is derived from
the permission of those involved in a common undertaking."108 Neither God nor rea-
son but only the 'permission of the individuals' is the source of this ethics. Who
wants more, should join a religion, as Engelhardt did.
But considering only for a moment the principles on which Engelhardt builds his
allegedly content-free ethics, we find many ethical contents, i.e., many moral and
morally relevant values presupposed. He speaks of the peaceable communities in
ways that he certainly opposes to the hostile and brutal societies, and decries Nazism
and Stalinism for the reasons of their 'brutality', implying obviously the latter's dis-
value and the former's value. l09 Speaking of the ethics "that should guide individuals
when they meet as public strangers to fashion health care policy,"IIO he obviously
implies a value of such an ethics and of fulfilling such an 'ought'. This is even
clearer when he speaks of the dangers of slaughtering people "in the cause of secular
visions of justice, human dignity, ideological rectitude .. ," of the "grace of ...
peaceable collaboration," etc. III If these are not goods and evils, the whole book
makes no sense. For then it would not claim that even these fundamental goods are
values and hence hell would be just as good as heaven. Also when he states very
well (p. 16) that toleration does not mean to forgo moral condemnation of acts but
"only makes sense in terms of that which one holds wrong or improper," he still pre-
supposes a value of toleration itself. The whole ethos of the book is permeated by
value judgments about respecting persons, their liberty, the need for a peaceful
settlement of disputes, etc. And these imply profound content-full moral and morally
relevant values.

4.3. Natural Ethical Knowledge or Total Value Blindness of Secular Society

But how can he substantiate his claim that human experience and reason are wholly
incapable of knowing any values, while religious persons do have many ethical in-
tuitions? This thesis seems quite unreasonable given the fact that all religious experi-
ence and faith presupposes necessarily some natural knowledge, and given the uni-
versal human moral experience. Engelhardt's radical philosophical postmodemism

104 The Foundations ofBioethics, 2nd ed., p. viii.

105 Ibid., p. ix.
106 Ibid., p. xi.
107 Ibid., p. X.
108 Ibid., p. xi.
109 Ibid., p. 9-10.
110 Ibid., p. 11.
III Ibid., p. 15 f.
276 CHAPTERS

and skepticism also contradict the universal moral experience of mankind and the
well-nigh universal affirmation of fundamental human rights and the evident obliga-
tion to respect them. There is only one discernible argument in his work for this po-
sition: He claims in many passages that the insurmountable dissent is sufficient
proof that there is no objective ethical value knowledge.
Now this may appear plausible and such great minds as Edmund Husser! have
held similar positions. 112 But it is in no way evident that dissent is a sufficient reason
to conclude that there is no objective and scientific knowledge in a field. For in the
first place, we must not forget the common and well nigh universally shared ethical
knowledge over the many disputes and differences. After all, almost all of mankind
would disapprove of a pure kingdom of hell on earth. A mere thought experiment
suffices to show this. In fact, even many of the positions of Engelhardt in his The
Foundations ofBioethics would be rejected by most, for example on infanticide.
If we were to assume that there is no such knowledge, we would attribute to all
members of the secular pluralist society a total ethical value blindness, which can
only be attributed to satanic pride or total concupiscence. In fact, we would attribute
to mankind more than the total value blindness of satanic pride. For also this satanic
pride includes some ethical value intuition at the beginning and even all along in
order to be possible. As Bonaventure says,l13 it belongs to the dignity of the person
even of the devil to know eternal truths about the good; otherwise he could not reject
it and become evil. Moreover, if we consider the common forms of ethical value
blindness: (1) the blindness of subsumption and its clear conditions, (2) the moral
blindness of dullness because of frequent morally evil deeds which are not repented,
(3) the constitutional or the passion-conditioned partial moral value blindness, we
see that each of them explains moral dissent without any relativism. It takes fully in-
to account the fact stressed by Engelhardt that ethical value knowledge presupposes
a morally good life and virtue or metanoia, but it explains this dissent and these
moral conditions of ethical knowledge without any relativism or radical fideism. 114
If we take further into account, regarding the substitutes for true morality,"5 the
strange mixture of historically and culturally determined factors and errors with ob-
jective ethical intuitions, we even understand far better that moral dissent rests on

112 See Edmund Husser!, "Philosophie als strenge Wissenschaft," in Edmund Husser!, Aujsatze und Vor-
trage (1911-1921), Hrsg. Thomas Nenon und Hans Rainer Sepp, Husserliana Bd. XXV (Dord-
rechtIBostonlLancaster: M. Nijhoff, 1987), pp. 3-62. See also a critique of these arguments in Josef
Seifert, "Phanomenologie und Philosophie als strenge Wissenschaft. Zur Grundlegung einer realisti-
schen phanomenologischen Methode - in kritischem Dialog mit Edmund Husser!s Ideen tiber die Phi-
losophie als strenge Wissenschaft." See also "Philosophy as a Rigorous Science. Towards the Founda-
tions of a Realist Phenomenological Method-in Critical Dialogue with Edmund Husser!'s Ideas
about Philosophy as a Rigorous Science" (in Russian), and my "Philosophy as a Rigorous Science.
Towards a Foundation of the Method of Realist Phenomenology in Critical Dialogue with Husser!'s
Idea of Philosophy as a Rigorous Science" (in Czech).
113 See Bonaventura, Quaestiones Disputatae de Scientia Christi, in Bonaventure, Doctoris Seraphici
S. Bonaventurae Opera omnia, edita studio et cura PP. Collegii a S. Bonaventura, ad Claras Aquas
(Quarracchi) ex Typographia Collegii S. Bonaventura, 10 volumina (1882-1902), vol. V.
114 See Dietrich von Hildebrand, Sittlichkeit und ethische Werterkenntnis.
115 See Dietrich von Hildebrand, with Alice Jourdain, Graven Images. Many of the ethical disagreements
which H. T. Engelhardt, Jr. adduces against objective ethical knowledge (H. T. Engelliardt, Jr., The
Foundations ofBioethics, pp. 43 ff.) can be thus explained.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 277

the foundation that all humanity, even the worshippers of false Gods, as Saint Paul
says, know objective moral values and their eternal essences. 116 Thus, there is no
total moral value blindness in society, and even where it exists, it is never as total
that it would not still presuppose the ethical intuitions even Satan possesses in order
for it to be possible that he be evil.

4.4. Does Engelhardt Have any Theory ofError? On the Inner Distinction between
Ethical Knowledge and Ethical Errors, and between Ethical Theories and
Immediate Ethical Cognitions as Ground ofRejecting Skeptical Conclusions from
Ethical Dissent in Society

Moreover, the way in which Engelhardt concludes from ethical dissent to the ab-
sence of objective ethical knowledge implies that he puts all opinions on a par, and
considers them subject to 'totally equal rights'. But in reality, it is clear that we must
not treat all sides in a dispute as if they were equal. There are rational and irrational,
rash and considerate judgments. There are blind judgments and others based on evi-
dence. There is above all a marked and essential distinction between true knowl-
edge, especially knowledge in the narrower sense, and error. In error we find always
elements of opinion that go beyond knowledge, convictions and judgments that
leave the purely receptive transcendent gesture of knowledge.
We must not treat them as equal; and if we cease to do so, we will develop a
theory of error and its causes, and contrast it with true knowledge. In fact there is a
profound inner distinction between authentic ethical knowledge and judgments
based on ethical blindness or ethical errors.1I7 The ethical knowledge, as any other
knowledge, is an intentional receptive and transcendent discovery of something, and
not a partially blind opinion. For this reason, as Socrates in Plato's Gorgias, Aris-
totle, Augustine, Descartes, and many others saw, knowledge is always true. There
are no conflicting ethical intuitions as Engelhardt assumes, but the conflict is always
between two errors or mere opinions, or between error and knowledge. Genuine in-
tuition never contradicts any other genuine intuition, neither our own nor that of
someone else. Error never is knowledge, and only truth can be intuited.
There is also no infinite chain of intuitions necessary to gain certainty about evi-
dent facts such as that I live and exist, or such that a person possesses value or that
the principle of contradiction holds. I 18
Moreover there is a difference between not seeing that something is good or evil,
and seeing that it is good or evil. From not seeing that something is evil I cannot in-
fer logically that it is not evil, as I cannot infer from having no signs that patients in
the PVS (Persistent Vegetative State) are conscious, that they are not conscious. I 19

116 H. T. Engelhardt, Jr. presupposes them as well in his The Foundations of Bioethics chapter on such
principles as beneficence, pennission, and justice, ibid., pp. I'02-134.
117 See Balduin Schwarz, Der Irrtum in der Philosophie; Josef Seifert, Erkenntnis objektiver Wahrheit, I,
ch.3.
118 See the claims of H. T. Engelhardt, Jr. in his The Foundations of Bioethics, pp. 42--43, contradicting
this.
119 See on these distinctions Alice von Hildebrand-Jourdain, "On the Pseudo-Obvious," in Balduin
Schwarz (ed.), Wahrheit, Wert und Sein. Festgabefiir Dietrich von Hildebrand zum 80. Geburtstag
278 CHAPTERS

Once we recognize the inner essential distinction between (ethical) knowledge,

the receptive grasp of value, and mere opinion and error, we also understand that no
error is possible without some preceding knowledge. Therefore, the existence of er-
ror proves knowledge, and does not refute it. For nobody can embrace ethical errors
without possessing some ethical knowledge. In any example of ethical error one can
show how the very notion of good and evil, and many other elements in this error or
underlying cognitions are correctly seen, and how the error as such precisely de-
viates from such evident ethical cognitions implied and presupposed by it.
Another crucial distinction is that between different theoretical accounts of mor-
ality and the immediate experiential ethical knowledge. The falsity on the level of
theory does not exclude that the direct ethical intuition of a person is correct.
Thus, we must (1) not overlook the rich ethical consensus, and (2) not fail to see
the many reasons that explain dissent without relativizing truth or denying ethical
knowledge (the intrinsic distinction between error and truth, between theoretical and
existential ethical errors, etc.).120 Moreover, we (3) have to see that truth is quite in-
dependent of consensus and (4) just have to turn to the evident ethical insights that
we possess, in order to see that it is untenable indeed to claim that secular society is
wholly deprived of content-full ethical insights. Hence the argwnent of Engelhardt
in favor of postmodern radical ethical skepticism is not valid.

S. IS THERE A PUBLICLY ACCEPTABLE CONTENT-FULL BIOETHICS?

We have seen that Engelhardt is a champion of negating any content-full public bio-
ethics or natural law ethics and theory of fundamental human rights as basis of our
legislation. But even if he were to agree with us in our critique of his views regard-
ing these issues, and ifhe came to hold that objective ethical intuitions are available,
he would still disagree with us on their positive role in public ethics and in legis-
lation and society at large. Let us therefore turn more closely to an examination of
the way in which this author analyzes the problem of the role of philosophical ethics
in the pluralistic society ofa 'public world', and of how he seeks its solution. 121 Tris-
tram Engelhardt's 'bioethics for a public world', which differs sharply from his own
private Christian bioethics, responds to this situation, in which allegedly neither
faith nor reason can reach a true basis for public ethics and law. While Engelhardt
admits the continued existence of a 'private ethics' and of objective truth as the
foundation of the 'true religiously founded ethics' ,122 he believes that after the col-
lapse of the public power of religion and after the historical apparentness and evi-
dence of reason's inability to provide a solid 'content-full' ethical foundation for
public life, we are faced with a situation where a defensible ethics for a public world
can only rest on agreement.

(Regensburg: JosefHabbel, 1970), pp. 25-32. The example regarding PVS I take from an investtiga-
tion into PVS by D. Alan Shewmon.
120 On a broader basis see my critique of this in Josef Seifert, "Zur Begriindung ethischer Normen"; "Und
dennoch: Ethik ist Episteme, nicht blosse Doxa."
121 A stay of several months of Prof. and Mrs. Engelhardt in Liechtenstein in the Fall of 1997 provided an
opportunity for me to discuss the contents of this chapter personally with the author.
122 Which he identifies with orthodoxy.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 279

This view involves some variety of a consensus theory of truth (a sort of 'per-
mission-theory of truth'), at least oflegally and politically relevant truth, and an eth-
ical skepticism which seems a necessary condition of Engelhardt's being led to pro-
pose for the public life in our states and secular hospitals a purely politically
grounded public ethics and value system based on consensus, toleration, or permis-
sion. He thinks that because a religious world view has broken down in the public
world of our societies and applies only to small groups, and because any effort to
found a universal rational basis of 'content-full' ethics for all men has sorely failed,
we are left today with the need for a culturally and democratically changing bio-
ethics as formative for our public life in secular society.
Moreover, society should agree on tolerating and permitting differing and oppos-
ing ethical views. After the eclipse of enlightenment's dream of reason and the dis-
appearance of faith we have no other alternative. What else can remain as founda-
tion if neither faith nor reason can provide a publicly acceptable basis for 'content-
full' ethics? His answer is: either dictatorship and totalitarian imposition ofa minori-
ty's views on society, which he rejects, or democratic agreement, which he pro-
poses. An acceptable bioethics for the public space in which we live is restricted to
positions that meet with a broad consensus or at least a broad basis of mutual per-
mission and toleration, even within our pluralist world.
Evidently, in order to do so, the public ethics has to be characterized by a lar-
gesse d'esprit and give a lot ofliberty to individuals and groups to do as they please.
It has to be an ethics of permissiveness: abortion on demand, euthanasia, and infanti-
cide, as well as the public expression of homosexuality in form of state-recognized
homosexual marriage-like communities have to be allowed in a libertarian secular
society, and the universally accepted ethically binding contents of moral and politi-
cal consensus have to be based on an extremely general common denominator or
better, on such general, very liberal and vague guidelines that if possible all groups
and individual members of our society agree on them. Since such agreement refers
according to him only to few contents, for example to the rejection of sexual abuse
and torture of children, only very few contents will appear outside the zone of the
'tolerable' .
As far as possible, the contents of such a content-full public ethics has to be kept
to such a minimum that all social groups in a pluralistic state abstain from imposing
their private standards to the public life and the common ethical contents and stan-
dards in secular society remain at a minimum level. Any contents such as many nat-
ural laws and fundamental human rights as recognized in the Declaration of Inde-
pendence are threatened by the lingering demons ofthe French Revolution or ofNa-
zism, which acted in their name. To avoid such excesses, nothing but consensus and
toleration/permission should provide the basis of public life.
The United States Constitution, which Engelhardt interprets as abstaining from
any natural law position, can serve as an extremely successful model for such a
modem pluralistic society in which private moral codes of certain groups in society
are not imposed on anyone else. According to it, if it is more and more applied, the
standards of a public morality derive only from limited consensus but more from
agreement, permission, and toleration, and therefore can be kept such that, as far as
humanly tolerable, within them anything is legally and ethically permitted which
280 CHAPTERS

any members or groups within this pluralistic society might choose to adopt as their
life-style. Engelhardt proposes "a public ethics for moral strangers" (that is, for indi-
viduals who do not participate in 'a common moral vision') when they meet on the
marketplace and in the public cultural space of a pluralistic, non-coercive society,123
while he himself holds a 'private ethics' which he accepts for the sphere of his own
personal life and which condemns abortion and infanticide as horrible crimes. This
position leads him to an almost schizophrenic opposition between his private ethics
and the public secular ethics and laws he proposes. 124
Engelhardt would say that any reflections that want to introduce either rational or
religious foundations for bioethical discussions or laws presuppose outdated 'mod-
em' public ethical standards, i.e., standards that seek to recover universal values,
rights, or ontological truths by means of human reason. The hopeless postmodern
relativism and pluralism of present society, however, render this dream of modernity
obsolete, and we should develop postmodern standards in a pluralist society, which
("since we cannot derive moral authority from God or reason") "can only be derived
from the agreement of the individuals who join in a moral undertaking."125
This is an enormously important step, which needs to be examined with utmost
care. For it propounds a very radical position, which contains a number of ambigui-
ties, the first one of which gives rise to a second.

5.1. Ambiguities in the Term 'Canonical' and the Distinction between

Epistemological and Metaphysical Ethical Skepticism

The first of these ambiguities concerns the question of what Engelhardt means by
'canonical'. This term can at least have three different meanings:
(1) The first of them refers to the question of the objectivity of truth and of moral
contents. If moral imperatives were nothing but subjective personal choices, they
would lose a 'canonical' character in the sense of an objectively true and therefore
objectively binding character. Engelhardt does not seem to want to deny this sense in
which both many contents of private and public morality are and remain 'canonical'.
In fact, by rejecting a 'metaphysical skepticism', he appears to preserve, although on
the level of purely private religious convictions, so it appears, the claim to objective
truth of moral values and therefore their objectively right and thus objectively bind-
ing character. The difficulty is to see how he can uphold and substantiate this posi-
tion given his gnoseological skepticism and his rejection of the 'canonical' character
of moral codes in the second and third senses of the term.

123 The Foundations ofBioethics, 1986.

124 He propounds this ethics in several articles in the journal Christian Bioethics. Non-Ecumenical
Studies in Medical Morality. As a matter of fact, Engelliardt states in the preface to the 2nd edition of
his The Foundations ofBioethics, p. x, that the etemal fIres of hell expect those who carry out what he
proposes for 'public ethics', such as abortion on demand:
I am of the fum conviction that, save of God's mercy, those who willfully engage in
much that a peaceable, fully secular state will permit (e.g., euthanasia and direct
abortion on demand) stand in danger of hell's eternal fIres.
125 Engelliardt, The Foundations ofBioethics, p. 33.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 281

(2) The second sense of the 'canonical' character of moral norms requires that
we can know them in principle and that therefore they can be 'canonical' in the
sense of actually binding our consciences. Purely metaphysical objectivity of values
and norms without any knowledge of their objective existence on our part can never
be binding to our consciences and in our private or public moral life. Now it appears
obvious that any position, such as Engelhardt's, which upholds the metaphysical ob-
jectivity and therefore the canonical character of morality in the first sense, if it is
not a wholly arbitrary position, also necessarily requires some knowledge of this ob-
jectivity and therefore some 'canonicity' in the second sense. But how can then En-
gelhardt be a radical epistemological skeptic and yet a metaphysical objectivist? The
answer is simple: he cannot and he is not. His position should therefore be desig-
nated as an exclusively philosophical epistemological skepticism and rather as a cer-
tain type of radical fideism and even better as an "epistemology of an ethical knowl-
edge through private religious experience and contact with divine energies alone"
than an all-out skepticism of any knowledge of objective truth. According to Engel-
hardt, we can know the objectivity of values and norms, but can do so only by faith
and by religious moral experience, never by reason based on natural good will.
Therefore, in order to identify Engelhardt's position exactly, we must distinguish
within the denial of the canonical character of moral values and norms on purely
epistemological grounds again two positions: the first one would deny any and all
knowledge of objective and 'canonical' norms (in sense 1), and this position is con-
tradictory, given the incompatibility between a radical skepticism of all knowledge
of objective truth and the assertion of metaphysical objectivity. It is also not Engel-
hardt's position. For he admits a purely religious knowledge of objective ethical
truth. Thus, his position is one of just denying any rational knowledge of moral val-
ues and ethical norms, of holding a purely philosophical epistemological skepticism,
while simultaneously holding a religious epistemological objectivism.
Now this second kind of epistemological skepticism held by Engelhardt is not
free of ambiguity either.
A. For in the first place, Engelhardt distinguishes within philosophical ethical
knowledge two kinds: (a) one which he calls 'content-full', implying probably
something like what Max Scheler calls non-formal or 'material values';126 (b) an-
other one which he does not call with a common term but which one might call 'pro-
cedural' because it refers only to norms and values which to recognize is necessary
to settle moral disputes in a peaceful and non-violent way. Engelhardt also calls
these universal norms of public society 'formal' in a Kantian sense. Regarding this
second kind of moral and morally relevant values, however, if one considers them
closely, Engelhardt necessarily does assume rational and content-full ethical knowl-
edge. At least he presupposes it, while his general ethical position does not allow in
any way a rational justification of this position. How can one fail to recognize that
the values Engelhardt proposes for secular society, namely, tolerance, non-coercive-
ness, non-violence, etc., are and imply themselves content-full values such as pa-
tience, meekness, respect? And more compellingly, how can one fail to see that they

126 See Max Scheler, Der Formalismus in der Ethik und die materiale Wertethik; Formalism in Ethics
and Non-Formal Ethics o/Values.
282 CHAPTER 5

definitely presuppose such content-full values as the dignity of persons, the value of
freedom and of respect for it, the distinction between good and evil, the preference
of rational over irrational settlements of disagreements, etc.? Also Kant's ethical for-
malism of "Act always in such a way that the maxim of your action can serve as
ground of a general law" never was able to stand alone (without any contents). Kant
could not help introducing non-formal contents and values in his ethics: First, the
absolute content-full value of human dignity as foundation of ethics; after all, Kant's
classical formulation of the respect due to the intrinsic value and dignity of per-
sons 127 gives rise to ethical personalism. 128 Secondly, Kant introduces countless mate-
rial contents whenever he explains how the purely formal version of the categorical
imperative is to be applied: for example truthfulness (forbidding the admission of an
'alleged human right to lie'},129 love of peace, etc. Thus, it is impossible to defend a
formal ethics without admitting some contents, both morally relevant goods and
moral values. As Kant, also Engelhardt necessarily reintroduces what he seeks to
deny: a rational and canonical content of secular ethics. But then we have in prin-
ciple the necessary grounds to build some natural law ethics and to recognize many
truths about abortion, euthanasia, as binding also in an ethics for the public world.
The kind of moral and morally relevant values that Engelhardt admits are also quite
content-full, as we will see. Therefore, the distinction between 'content-full' and
content-less values and norms cannot be upheld, no more than Kant's assertion of
purely formal principles a priori in ethics.
B. Engelhardt distinguishes not only within rational ethical knowledge and 'ca-
nonical contents' related to knowledge the two kinds which we described and which
cannot be upheld in their difference without contradictions, but he also distinguishes
between a (a) rational knowledge of ethical contents, which he denies, and (b) a
religious knowledge of ethical contents, which he affirms. Thus he claims that we
~an know the objectivity and the binding and in this sense also subjectively canonical
sense, or the objectively canonical character (in sense I) of moral norms which in
view of this knowledge become also binding for the subject and his or her con-
science (,canonical' in sense 2), but he claims that this is no rational knowledge but
a purely religious knowledge. Now, such a separation between faith (and religious
experience and knowledge) and philosophical (rational) knowledge of ethical norms
and moral values is, I argue, equally untenable. For it is absolutely impossible to
have grace without nature and to have religious faith which is not totally irrational
and unworthy of the person, without having some rational knowledge of values as
well. This is particularly evident when considering the 'third way' Engelhardt pro-
poses in regard to how we know moral values: a way between 'fideism' and 'ration-
alism' .\30 Faced with the accusation of radical fideism, which admits ethical knowl-
edge 'by faith alone', he adopts a position that admits not only pure blind faith but
also some experience of the divine energies, some light and cognitive contact with

127 See his famous text from his Foundations B 64/65 quoted later in the main text.
128 The ethics of Max Scheler, Formalismus.
129 Cf. Immanuel Kant, Ober ein vermeintes Recht aus Menschenliebe zu liigen (1797), in Kants Werke,
Akademie-Textausgabe (Berlin: Walter de Gruyter & Co., 1968), vo!' VITI, pp. 425-430.
130 See H. T. Engelhardt, Jr., "The Foundations of Bioethics and Secular Humanism: Why Is There No
Canonical Moral Content?"
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 283

moral truth through leading a life of holiness. But this is even less tenable without
admitting some ability of human reason to contact reality and truth and to see val-
ues. As a matter of fact, Engelhardt himself seems to recognize as much when he
unexpectedly claims, after having declared "the failure of the project of grounding a
content-full morality in reason" and the postmodern collapse "of Christianity'S
thousand-year-old faith in reason and the whole edifice built upon it":
Still, the collapse is not so complete as to despoil us of any remnant of a general secular
morality. In this sense, Foundations is optimistic. It does not lead us to the conclusion
that, if God is not recognized, all is allowed. There is still a sparse fabric that we can
invoke when we meet in the midst ofunbelief. 131

But this significant admission abandons clearly the fundamental thesis of Engel-
hardt: his declaration of the end of rationally knowable ethics and his further claim
of the separation between a (in his opinion non-existing) rational and a religious eth-
ical knowledge. Thus, our public ethics would consist of a 'scarce fabric' of ethical
positions that still meet a broad consensus and an enormous amount of opposition
between ethical stances in our pluralistic society in regard to which libertarian tole-
ration would be appropriate. Moreover, if one draws out all the consequences of this
admission and examines the extent to which religious reason presupposes rational
cognitions and to which secular reason in a truth-loving person is open to recogniz-
ing countless concrete ethical contents with reference to torture, violence, sexual
abuse, murder, lies and deceit, unfaithfulness and adultery, etc., one must arrive at
the conclusion that the starkness and radicality of Engelhardt's division between
public and private ethics has to be abandoned entirely.
(3) The third sense of 'canonical' is a social and political one: it does not refer to
the individual person who is able, be it by religious or by secular ethical knowledge,
to know some objective ethical truth which thereby becomes binding and canonical
for him, but it refers to the publicly and universally binding character of ethical
norms as foundations ofpublic medical ethical codes in secular society and demo-
cratic states. In this regard, 'canonical' would refer only to the part of morality that
can be 'inflicted' by law or medical codes on a pluralistic society. This sense of 'ca-
nonical' is clearly distinct from the first two and regards not only the general distin-
ction between law and morality, but also the question to which extent a democratic
society with majorities which are in error and contradict the enlightened minorities
who know the truth allows for applying objective ethics to its 'public space'. This
leads us to further ambiguities in Engelhardt's position.

5.2. Ambiguities Regarding the 'Political Ethics' and the Relationship between
Truth, Private Morality, and Public Ethics

(I) On the one hand, Engelhardt proposes a society and state in which objective
truth and conformity with the reality of the good actually have no more power to
form laws and public ethical codes. Engelhardt proposes this idea in its most radical
form with respect both to reason and to religious faith. He claims that ethical reason

131 H. T. Engelhardt, Jr., "The Foundations ofBioethics and Secular Humanism," p. 280.
284 CHAPTER 5

and rational knowledge possess no actual power at all at the foundation of our legal
systems and public moral codes, at least not when they adopt contents. This
statement seems to be greatly exaggerated, although it is undeniable that in a certain
measure the power of a common bond of ethical and natural law knowledge and of a
generally acknowledged mode of conduct in accordance with it fades in our soci-
eties. But after all, the situation, horrible as it is, is not yet that bad that no broad
consensus on any ethical issues can be expected in present society. After all, we still
agree that rape or sexual abuse of children, oppression of religious freedom, in-
fringement on the habeas corpus right, condemnation without due process, first de-
gree murder, torture, etc., are evil and crimes that should be forbidden and punished
by the law. There was still a worldwide outcry and a profound national ethical con-
sensus in Belgium when the horror of the crimes of child-abuse in the Dutroux case,
the abuse of girls in child-porno and their brutal murder as well as the incompetence
and negligence of some police officers in Belgium in this case, were discovered. 132 In
this way, consensus on, and rational knowledge of, what is legally permissible and
morally right still is possible and dominates thousands and thousands of concrete de-
cisions and laws in our secular society. One could even claim that in some respects
human rights are recognized today more universally than ever before, namely, by
99% of all states.133
Ifwe imagine for a moment that all values given to our reason would be rejected
by society, we would live in a hell on earth, and certainly no society presently is
quite that bad that it would indulge and accept cruel murder, breaking of contracts,
false oaths, torturing and sadistically abusing children, killing one's own parents to
obtain possession of their fortunes, cheating private individuals, communities, or the
state, raping women, etc. We must not, in other words, in consideration of the large
and terrible disagreements in our society regarding abortion, euthanasia, assisted
suicide, etc., conclude that the entirety of the so-called 'natural law' has faded and
that we live in a world of total corruption of morality, of unqualified disagreement
on all moral issues, and of a complete eclipse of reason. Nor should we doubt that if
great rhetoricians, philosophers, poets, and influential politicians, or prophets and
saints were to give our societies real moral guidance, our societies could reach
knowledge of the rationally accessible right and wrong on a much larger scale than
at present.

132 Marc Dutroux committed his horrific crimes between the mid 1980s and the later 1990s. Although he
was convicted in 1989 and condemned to serve a 13 year sentence, he spent only three years in prison
and then was released for good conduct. When immediately after his release further girls disappeared,
police investigators ignored for a long time correct hints and information given by his own mother and
another man. When they searched Dutroux's Charleroi house in which he actually kept at that time
several girls who had been kidnapped by him in order to sell them into prostitution and make porno-
graphic videos of them, the police did not search carefully enough and missed the secret dungeon in
the basement in which the girls were held. During his imprisonment two young girls whom Dutroux
and his accomplice did not care for, died of hunger in their prison This gross police negligence led to
an uproar of the Belgian population (300.000 marched in white robes through Brussels to demand a
change of law) and eventually forced two ministers, a chief Prosecutor, a number of police officers,
and other authorities into resignation. The full Dutroux case will only be opened in March 2004.
133 See the exact figures and report of John Fleming in chapter I, above.
 AN OBJECTIVE BIOElHICS-ANSWER TO ENGELHARDT 285

Therefore, we should (a) not overlook that our societies, as all societies, even
those of murderers or thieves,134 are still held together by an amazingly large sphere
of consensus and shared moral experience and understanding. This understanding
is, moreover, not a mere matter of consensus but composed ofevident tenets of mor-
ality, of different types of pre-positive principles of law, and of other evident
truths. 135
(b) Even less should we overlook that it is our task, each in his own place in so-
ciety, to enlarge the scope of this rational knowledge of ethical contents, fundamen-
tal human rights, etc., and that much more is possible than we presently see. This
could be said also about religion: that it (a) still constitutes in some way a unifying
undergirding element in the public vision of man, and that (b) it could gain such a
power again if we had more missionaries and Saints in our society.
Furthermore, we should never forget that a lack of broad consensus is also found
in religion and that one could therefore, if one meant to reject the possibility of
knowing truth wherever dissent exists, draw the same consequences about religion
and Christian faith as about philosophy and public ethics: namely, that we cannot
reach truth by means of it but that its content should be regarded either as object of
mere mutual toleration of private and irrational opinions, or be determined in the
future pluralistic society by limited consensus on elements of a 'global religion' .136
As Engelhardt would reject these consequences, why does he not also reject the
same consequence in the field of ethics?
(2) But Engelhardt proposes another and even much more problematic thesis
about the 'public world', and in this thesis he seems to use an 'is' to derive an
'ought'. He proposes, namely, that-in the name of freedom and non-coercive-
ness-moral truth accessible to reason or to faith should have no more publicly
binding character. We should neither work for a change of our society nor deplore
the impossibility of restoring 'law and order and a kingdom of truth' in the public
world and condemn it like a prophet. But the non-coercive society of our public
world allows us to accept and to propose, as Engelhardt does, for this public world
ethical codes (such as the permission of infanticide, abortion, euthanasia), which we
(including H. T. Engelhardt, Jr. himself) wholly reject asfalse in our private morali-
ty. But this creates a de jure dominion of untruth in society or means a total relativ-

134 I remind the reader of the amusing story of Cervantes' Don Quixote, in which Sancho Pansa observes
on justice being such a fine thing that even a band of robbers has to respect it when sharing their prey.
135 See on this Wolfgang Waldstein, "Vorpositive Ordnungselemente im R6mischen Recht," esp. 8 ff.;
the same author, Operae Libertorum. Untersuchungen zur Dienstpjlicht freigelassener Sklaven, esp.
pp. 183, 195 f., 196, 398,402 f. See also Waldstein, Das Menschenrecht zum Leben. See also Josef
Seifert, "Demokratie, Wahrheit und Gerechtigkeit."
136 Such a common global basis can be sought in real commonly accepted truths and values. See Josef
Seifert, "Contribution philosophique a une paix interculturelle et interreligieuse," in Arab League
Educational Cultural and Scientific Organization (ISESCO), (ed.), Du Dialogue euro-arabe. Exi-
gences et perspectives, Conference (Tunis: Organisation Arabe pour I'Education, la Culture, et les
Sciences, 2003), pp. 251-256. One can also attempt to base such a universal religious community on a
relativistic basis, an attempt that must fail, I think. See Hans KUng and Karl-Josef Kuschel (Hrsg.),
Erkliirung zum Weltethos. Die Deklaration des Parlamentes der Weltreligionen, 2. Autl (MUn-
chen/Ziirich: Piper, 1996); and Hans Kilng, Weltethos fiir Weltwirtschaft und Weltpolitik (MUnchen:
Piper, 1997).
286 CHAPTERS

ism--even religiously. At the same time, such a position would lead to a schizo-
phrenic attitude in which we propose for public sanction laws regarding abortion,
euthanasia, etc., that 'legalize' actions which we, in our private morality, would re-
ject as awful crimes.
Thus, we see how centrally significant the question of the objectivity and de jure
bindingforce of truth, even ofreligious truth, for society, is. But we also see, since a
purely religious consensus is indeed largely impossible, how dangerous it is to sepa-
rate in a radical fideism reason and faith, personal moral conviction and public so-
ciallife.
Engelhardt's position that 'public ethics' today should come only from a consen-
sus on "agreement of individuals who join in a moral undertaking" is neither logi-
cally consistent nor plausible, however. It is inconsistent because it is obvious that
Engelhardt accepts quite a few moral contents as rational and reasonable within a
pluralistic society, and he obviously does not consider them only as the object of a
broad consensus. He takes, in the first place, the very existence of a non-coercive so-
ciety as an absolute value. Therefore, he would reject any totalitarian regime as in-
trinsically wrong. His moral code contains such values as 'non-coerciveness', 'mu-
tual respect', liberty as absence of attempts to impose private morals on public soci-
ety, and he regards all of these as absolute values on which-in addition-the ma-
jority agrees.
Moreover, with many of the additional values which he introduces not everyone,
and with some of them not even a majority agrees, for example, with his justification
of abortion, infanticide, etc. But this applies even to the more general principles that
he adopts. For all those principles which he defends as ground-rules of an ethics in a
pluralist society happen to coincide with the most liberal standards of a non-coer-
cive, libertarian American society, with which at least some majorities today (for ex-
ample, in Ireland or those states in which abortion and infanticide are outlawed)
would disagree. Thus, Engelhardt presupposes for his position precisely that which
he seeks to deny: namely, rational intuitions into objective values and moral norms
that do not depend on agreement.
In addition, each of the axiological elements which he presupposes as objective
(for example, non-coerciveness) contains a great number of further presuppositions
of ethics, epistemology, ontology, and legal philosophy, such as the existence of
freedom, the dignity grounded in it, the disvalue of violating it, the rational knowl-
edge of all of these things, etc. Moreover, on each of these values presupposed by
him, many individuals disagree even though a majority of Americans today might
agree with him. Either Engelhardt has to abandon these principles and their declara-
tion as rational and binding values for our public world, and regard them, too, as re-
lative, which would lead to a collapse of his entire theory, and then he would have
nothing left as content of a 'postmodern ethics', or he holds them to be absolute val-
ues. But then he contradicts his relativistic epistemology and ethics, which he pro-
poses only for the public world, not for his private moral Weltanschauung. 137

137 See the whole position he and other authors develop in Christian Bioethics. Non-Ecumenical Studies
in Medical Morality.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 287

Engelhardt's position is implausible for another reason. It forgets that man has
always lived in a pluralist society. Disagreements and relativism based on it have ex-
isted since millennia. Why should the power of human reason be trusted less today
than before? There is no evidence to support such a thesis, except perhaps Engel-
hardt's own despair of objective rational knowledge, and his skepticism which hap-
pens to be contradictory and to presuppose-as does any conceivable skeptical
doubt-quite a few really evident truths and some other merely allegedly evident
truths which turn out to be confusions or errors.
If we consider carefully human cognition as such, however, which always de-
mands some reality over against it which it discovers, and if we consider the evi-
dence of the truth, also about values such as the dignity of man, we recognize clear-
ly: this dignity is no matter of mere social conventions and consensus but is rooted
in the very essence of the human person, as Cicero so clearly saw.138 This becomes
evident even when we doubt it. Consider the radical skeptical doubt of all truth, par-
ticularly of ethical truth. Do we not imply even in such a doubt objective value-intu-
itions? Note that we adopt such a doubt in order not to give our consent rashly and
thus in order not to fall into error. Are not in this effort untruth and error given as
objective evils, which we seek to stay away from? Even in such a radical skeptical
doubt we grasp the objective disvalue of untruth, which we seek to steer clear of,
and the value of the truth, for respect of which we entertain our doubt. We recognize
that the knowledge to which we aspire is of greater value than our honest doubt. And
we understand that none of these values are arbitrarily declared by us or by society
but are found in the nature of things themselves.
Not only theists but also atheist moral philosophers such as Leszek Kolakowski
and Tadeusz Kotarbinski have seen clearly that a culture without objective values
and their recognition is impossible-although their attempt at founding them is
hardly tenable from an epistemological point of view. 139 Kolakowski argues against
the view that a pluralist society demands some form of consensus-theory of truth or
ethical relativism:
If we were to give up the idea that there is a differentiation of good and evil independent
of our decision, and one which we find already existing ... then there is no boundary
forbidding on moral grounds to participate in anything, if only it becomes credible that,

138 See Cicero, De Legibus I, vii, 22:

... animal hoc providum, sagax, multiplex, acutum, memor, plenum rationis et con-
silii, quem vocamus hominem, praeclara quadam condicione generatum esse a su-
premo deo; solum est enim ex tot animantium generibus atque naturis particeps ra-
tionis et cogitationis, cum cetera sint omnia expertia. quid est autem non dicam in
homine, sed in omni coelo atque terra ratione divinius? quae cum adolevit atque per-
fecta est, nominatur rite sapientia. est igitur, quoniam nihil est ratione melius homine
et in deo, prima homini cum deo societas ...
See also chapter 2, above.
139 See on this L. Kolakowski's essays from 1955-1968. So he writes: "To save in man that which is
most valuable in him ... is possible only by strong resistance to the temptation of relativism, by de-
fending at all costs the tower of indestructible values" (L. Kolakowski, "Odpowiedziainosc i historia,"
in Pochwala niekonsekwencji. Pisma rozproszone z lat 1955-1968, translated by D. Chabrajska,
vol. II, 27-76 [London, 1989]). See likewise Dorota Chabrajska, "The Axiological Dimension of
Leszek Kolakowski's Theory of Culture" (unpublished draft of her proposed doctoral dissertation,
lAP Liechtenstein, 1991).
288 CHAPTERS

by our participation, we favor some tendency which by its being victorious is also
morally good by definition. 140

We might also quote Solzhenitsyn who writes:

Communism never hid that it rejects all absolute moral concepts and mocks the value-
categories of "Good" and "Evil". Morality for the communist is the relative morality of
the respective class. Depending on circumstances and political situation any action,
even murder, nay even the assassination of hundreds of thousands, can be evil but also
good. This depends on the relevant class-ideology. Who determines class-ideology,
however? The whole class cannot convene in order to say what is good, what evil. A
handful people determines then what is good and what is evil. I must say that in this
respect communism was most successful. For it succeeded to infect the whole world
with this conception of the relativity of Good and Evil. Now-a-days not only commu-
nists are convinced of this. It is regarded today in progressive society as improper and
embarrassing to use seriously the words Good and Evil. The communists were able to
suggest to all of us that these concepts are really old-fashioned and ridiculous. But if
one takes away from us the concepts of "Good" and "Evil", what remains still for us? It
will be some mere vegetating. We will sink down to the level of animals. 141

Solzhenitsyn appeals here to some immediate evidence that Good and Evil are
objective categories.
We have already seen that many think that in the sphere of intellect clear insights
into the existence of good and evil count for nothing if there is no demonstration or
proof for good and evil. We have likewise seen that it is impossible to demonstrate
that something is evil without already presupposing some indemonstrable and evi-
dent value. But why should it be inadmissible to refer, at least in the last analysis, to
indemonstrable but evident values? Do we not attribute the role of an ultimate crite-
rion of truth and falsity to our immediate sense perceptions, which are just as imme-
diate and much less reliable than intellectual insights? Will not any human court
trust the immediate and indemonstrable evidences of his seeing the bloody instru-
ments of murder and even believe the testimony of others who perceived the event?
Why do we then not ascribe the same objective evidence to intellectual intuitions?
Aristotle points out, as we have reminded ourselves before, that demanding proofs
for everything is irrational and that in fact in the sphere of rational knowledge imme-
diate cognitions of essences and principles of things are the primary and most reli-
able as well as the most evident forms of cognition.
Perhaps one distrusts, with H. T. Engelhardt, Jr., these intuitions because of the
lack of consensus about them in our pluralistic society. But evidence does not de-
pend on consensus, and if we consider for a minute the manifold obstacles and pre-
judices rooted in human nature and society which bar the way towards ethical
knowledge, we will easily see that such an intuition as Alexander Solzhenitsyn's in-
to the objective and absolute validity of Good and Evil remains entirely objective

140 See L. Kolakowski, "Kant i zagrozenie cywilizacji," in Czy diabel moze byc zbawiony i 27 innych
kazan, translated by D. Chabrajska (London 1984), pp. 83-120.
141 Drei Reden an die Amerikaner, pp.45-46 (re-translation is mine). These assertions resemble many
statements by Dietrich von Hildebrand in his article "The Dethronement of Truth," in Proceedings of
the American Catholic Philosophical Association, Washington DC, vol. XVII, 1943.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 289

even if the whole society disagrees. i42 Moreover, he is right in saying in his Nobel
Address that art presents powerfully the reality of things everyone sees irrefutably:
the objective reality of the Categories of Good and Evil and of many other things.

5.3. The Needfor Phenomenology in the Clarification and Objective Foundation of

Content-full Ethical Intuitions
In spite of all of this being true, however, a mere appeal to the immediate evidence
of absolute categories of Good and Evil is not enough in philosophy. The work of
the philosopher with respect to such intuitions consists in unfolding the intelligible
traits of their object, in making clear distinctions founded on the experienced data, in
refuting common confusions and mistakes, and thus in leading the listener or reader
to his own discovery of the things themselves.
In our confused and pluralistic society a mere appeal to creeds, dogmas, and text-
books is not enough. What is needed today is a going back to the issues themselves;
what is required is a bringing to evidence of those moral imperatives that are deci-
sive for bioethics and of those goods to which the medical doctor should be dedi-
cated.
Such a going back to things themselves was the special goal of phenomenology,
a goal that, to my mind, few thinkers have more sorely failed to achieve than many
of the authors who call themselves phenomenologist. But this does not prevent me
from holding that a rightly understood and interpreted phenomenological method,
which coincides with the method all great philosophers have used to achieve their
real positive results, i43 is needed today in bioethics.
Phenomenology shall be understood here as a rigorously thought-out and applied
method, and its practice, in the service of a return back to things themselves. Unlike
most phenomenologists, we understand the phenomenological method here as the
best foundation for an objectivist and realist philosophy. A rigorous investigation of
things as they show themselves from themselves i44 permits a return to things in
themselves as a return to the knowable structures and essences of things as these are
independently of our conscious acts. i45
In the light of the aforesaid, we may say: We need a modem bioethics which
does neither create nor invent ethical norms, nor merely repeat a cultural historical
standpoint, but an ethics which derives its principles from the contact with the given
structures of reality. It is not easy to discover these. It takes what Plato calls the hunt

i42 Cf. the English text of Aleksandr Solzhenitsyn's speech upon receiving the doctorate honoris causa
from the International Academy of Philosophy in the Principality Liechtenstein, and the quotes in my
introduction to the text: Alexander Solschenizyn, Macht und Moral zu Ende des Zwanzigsten Jahr-
hundert.
i43 This point I tried to make in Seifert, Back to Things in Themselves, chs. 1-4.
i44 See Martin Heidegger, Sein und Zeit (Frankfurt a. M.: Klostermann, 1977), § 7.
i45 This method was introduced under the name of phenomenology by Husser! in his Logical Investiga-
tions. Many other authors have contributed to its elaboration and some among them have understood
it as a return to the objective essences and being of things, notably Adolf Reinach, Samtliche Werke.
Kritische Ausgabe mit Kommentar, Bd. I: Die Werke, Teil I: Kritische Neuausgabe (1905-1914),
Teil II: Nachgelassene Texte (1906-1917); Bd. II: Kommentar und Textkritik; Dietrich von Hilde-
brand, Was ist Philosophie?; Josef Seifert, Back to Things in Themselves.
290 CHAPTER 5

for being, one of the many images in which he represents in his dialogues the diffi-
culties the philosopher encounters in his quest for truth and the arduous road of phil-
osophical knowledge. 146
From its origins in Husserl, Scheler, A. Pflinder, Adolf Reinach, and Roman In-
garden on, phenomenological philosophy has understood itself as a road of philo-
sophical analysis away from reductionisms of all kinds: of logical laws to psycho-
logical ones, of works of art to subjective experiences of artists or readers, of objec-
tive values to mere products of feeling or imagination. Phenomenology at its best
has found that the data in question resist any such attempt at their reduction to some-
thing else that shows itself clearly distinct from the datum under consideration.
Phenomenological philosophy is also distinct from some kind of traditional men-
tality of quoting just handbooks of ethics to settle moral disputes and questions.
Likewise, it moves away from easy and too early explanations, premature causal, fi-
nalistic or religious accounts, which falsify or simplify the given, distorting it and
losing contact with the clearly given essences of things. Phenomenology had in its
original program a move away from constructions of all sortS.147 It aimed at a pure
letting reality itself speak and at allowing it to unfold its intelligible nature.
Certainly, however, a mere theory, theoretical maxim, or program of 'going back
to things themselves' calls for such a procedure but is not yet thereby accomplishing
this call. The ideal of the phenomenological program may thus contradict its practi-
cal execution by the adherents of phenomenology. And in fact, while we find in the
phenomenological movement masterful expositions that put this ideal into prac-
tice,148 we fmd other so-called phenomenological investigations that violate it radi-
cally. Among them I would reckon even many theories of Husserl himself after
1905. But such failures of 'phenomenologists' actually to remain faithful to the giv-
en and to their own maxims must not be confused with a mistake in the method it-
self, which seeks to do nothing other than to uncover being; a method that truly pur-
sues and serves this goal is no doubt correct.
Of course, a phenomenological interpretation of philosophy is not totally presup-
positionless but has itself certain presuppositions. And yet this does not contradict
its effort or rightful claim to be 'presuppositionless' demanded in Husserl's Logical
Investigations. 149 For the desirable presuppositionlessness as freedom from prejUdice
does not mean that no experiences, insights, or truths are presupposed for the phe-

146 A few realist phenomenologists extended the phenomenological method beyond the sphere of es-
sences, even beyond objectively necessary essences: namely, to a return to the esse as to the ontolog-
ical principle of real entities-a principle distinct from essences. Thus, these thinkers united a phe-
nomenology of essences with an existentialism very much in line with that of Thomas Aquinas. See
Edith Stein, Endliches und Ewiges Sein; see also D. von Hildebrand, What Is Philosophy?, Fritz
Wenisch, Die Philosophie und ihre Methode, and my book Back to Things in Themselves, my
"Essence and Existence," and my Sein und Wesen.
147 This anti-constructionist nature of phenomenology that seeks to discover receptively the true essences
of things has to reject constructionist ethical theories. According to some of these, moral responsibil-
ity itself is the product of a coinstructionist interpretation and can be reduced to a social 'attributing
deeds to persons'. See Bernhard Irrgang, Praktische Ethik aus hermeneutischer Sicht, pp. 162 ff.
148 For example, Adolf Reinach's investigation into the social acts, Die apriorischen Grundlagen des
biirgerlichen Rechts.
149 See Husser!, Logical Investigations, trans!. J. N. Findlay, II, 1, First and Second Investigation.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 291

nomenological method to be applied, but that the nature or truth of these presupposi-
tions, too, can be brought to evidence.
What are these presuppositions of that phenomenological method which we are
employing in ethics? A phenomenological philosophy presupposes an objective ma-
terial (content-full, non-formal) a priori; therefore, it does not rely on behavioral
sciences, on statistics or on empirical observations which are necessary for medicine
but are only confusing and unacceptable as methodical devices for ethics. Phenome-
nology also presupposes something like a 'categorial intuition',lso i.e., insights into
essences and essential states of affairs, which are independent from the subject and
disclose themselves in what they are themselves. Thus, phenomenological philoso-
phy also rests on the receptivity, more precisely on the receptive transcendence of
knowledge: lsl Only if cognition consists ultimately in a discovery of that which is as
it is, the phenomenological program 'Back to Things in Themselves' makes sense.
Thus, the first methodical requirement for a convincing bioethics today is, I suggest,
a properly understood and exercised phenomenological method. A phenomenologi-
cal bioethics presupposes also a theory of knowledge and of truth, but also ofobjec-
tive values, which in the last analysis nobody can deny without presupposing them.
But these presuppositions are not mere prejudices, mere blind or irrational as-
sumptions. No, they reveal themselves to our intellects in their truth. Thus, to speak
here of presuppositions is misleading: the truth of these things are both the condition
for the meaning of the phenomenological return to things themselves as they are also
themselves given in their truth by such a method. In order to dissolve the radical di-
chotomy between reason and faith in a politically acceptable medical ethical system,
we have to return to the central epistemological questions that surround Engelhardt's
position of the relationship between reason and faith.

5.4. Critique o/Engelhardt's Christian 'Fideism' and o/His Divorcing Religion

from Reason-Ambiguities in His Use o/the Term 'Rationalism' and Some
Reflections on the Relations between Reason and Faith in Ethics
As we have seen, Engelhardt argues that we have some knowledge of ethical imper-
atives and moral values which hence are not solely 'canonical' in the sense of being
objective but also in the sense of being binding/or the subject who recognizes them.
Engelhardt even admits, pace Engelhardt, that we must not- be wholly pessimistic
but admit some rational secular ethical knowledge. ls2 Nevertheless, he attacks any
'rationalism', implying, though not quite rigidly, that the only way to have a con-
tent-full ethical knowledge is through religious faith and living as a member of a re-
ligious community. If by 'rationalism' Engelhardt just understands the defense of
the capacity of human reason to know many metaphysical and moral truths by its
own powers, I will proudly confess that I am 'a rationalist'. To believe, however,

150 This term stems from Husser!, Logical Investigations, VI.

151 Cf. Josef Seifert, Erkenntnis objektiver Wahrheit.
152 See H. T. Engelhardt, Jr., "The Foundations of Bioethics and Secular Humanism: Why Is There No
Canonical Moral Content?," p. 280.
292 CHAPTER 5

that such a view of the relationship between reason and faith in ethics is rationalistic
calls for some crucial distinctions. 153
In order to do justice to the truth, and to criticize what I regard as false elements
in this position, I propose to investigate different meanings of 'rationalism' and dif-
ferent kinds of their critique.
Although I do concur with Engelhardt on several bad senses of 'rationalism' and
also on the claim that much of false rationalism has entered into Catholic manuals of
moral theology, I find it necessary to distinguish radically different good and bad
phenomena that are intended by the terms 'rationalism' or 'rationalistic'. In fact, I
find it quite generally unfounded and intellectually dangerous to raise the reproach
of 'rationalism' against anybody and anything without an extremely careful distinc-
tion between entirely different senses of this term. Not wishing to respond simply
with the witty Professor Gombrich when he said in an interview on the reproach of
'rationalism' launched against him that he means by 'rationalism' only that when
you talk about anything you should talk sense and not non-sense, I propose the fol-
lowing distinctions:
(1) A first critique of 'rationalism' rests on the idea that reason cannot derive
ethical foundations and criteria for public ethics or that it cannot even arrive at an
objective knowledge of moral and morally relevant goods binding for the individual
or for communities, especially for states. 154 Correspondingly, 'rationalism' would be
the view that both individuals and communities can recognize moral and morally
relevant values. Rationalism in this sense coincides with the view that a 'canonical'
secular ethics, in the second and third meaning of 'canonical' distinguished above, is
possible.

153 Engelhardt claims very strongly that 'rationalism' has crept into both traditional ethics and Catholic
moral theology. See H. T. Engelhardt, Jr., ''The Foundations of Bioethics and Secular Humanism,"
pp. 280-281. If he just means that the Catholic Church defends the fIrst sense of 'rationalism', he is
entirely right. Catholicism is distinct from many other fIdeistic, antiphilosophical, or philosophically
relativistic versions of Christianity by approving of philosophy-not only in Encyclicals and teach-
ings but even on the level of dogma. Catholicism is a religion for philosophers and philosophical ob-
jectivists, fIrst of all by recognizing that all of the most central Christian dogmas, such as that ofChal-
cedon, are imbued with reason and contain philosophy as an integral part; secondly, by teaching in the
First Vatican Council dogmatically that human reason is capable of knowing the existence of God
with certainty.
Engelhardt, however, sees the rationalism he deplores as a deviation from original Christianity.
But even if one concurs with him in deploring several forms of bad 'rationalism', the strong presence
of reason and philosophy in Christian faith itself, for example in the central Christological dogma of
Chalcedon, is undeniable.
We all unanimously teach ... one and the same Son, our Lord Jesus Christ, perfect
in deity and perfect in humanity . . . in two natures, without being mixed, trans-
muted, divided, or separated. The distinction between the natures is by no means
done away with through the union, but rather the identity of each nature is preserved
and concurs in one person and being.
This most central Christological dogma goes back to the work "Tome" of Pope Saint Leo the
Great and contains the core of the essence of the utter mystery of the Christian faith and simultaneous-
ly a thoroughly philosophical language.
154 See on this The Foundations of Bioethics; see also my critique of this view in my "Is 'Brain Death'
actually Death?" The Monist 76 (1993): 175-202.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 293

Its critique rests upon a negation of objective and intersubjectively shared knowl-
edge of values and seems to restrict knowledge only to value-free knowledge or to
deny the knowledge of objective truth altogether. But how to justify either one of
these claims? Why should the human person, outside of a religious worldview, know
only mathematical laws and logical truths and not also some ethical ones? We cer-
tainly all do possess some natural moral knowledge, and we could not even consent
to our religious faith if we did not grasp in it the light of ethical truth evident already
to our reason to some extent. ISS The fact to be explained below that ethical knowl-
edge has some moral conditions, without fulfillment of which ethical value blind-
ness instead of moral knowledge will be found in an individual, in no way contra-
dicts the objectivity of ethical knowledge and the fact that it rests on an evidence
which is in no way reducible to just being the object of consensus. 156 In fact, consen-
sus has nothing to do with evidence and truth; it can never replace it nor is it impro-
bable that people agree on falsities. Of course, consensus should rest on some
shared and mutually checked evidence, and from the hope that it does so democ-
racies derive their justification. Consensus, therefore, is no condition of objectivity
or of the character of philosophy as a rigorous science; and its lack can be explained
in many ways besides the claim of an absence of objective knowledge and even of
objective rigorous science. ls7 Therefore, it is wrong to suggest that a negative 'ra-
tionalism' lies in the simple insistence on the understanding of a natural law and of
a rationally graspable moral order, which can be perceived by truth-loving reason
prior to any religious faith. ISS The mere recognition of the universal presence of ethi-
cal knowledge is falsely called rationalism in a negative sense. 159
Regarding the claim that there are ethical intuitions into a moral 'natural law',
i.e., into some objective essence and moral character of certain acts, I do not agree

ISS The Catholic Church even dogmatically declared content-full philosophical knowledge independent of
faith to be possible in the Vaticanum I in which the knowledge of God was declared possible for all.
Thus Catholicism, still more than the Orthodox Church, and against the main stream of Protestantism,
insists on the union of faith with reason, rejects all Averroist and Siger of Brabantian concepts of
double truth and considers the marriage of the greatest philosophical discoveries of the Greeks with
Christianity as a great providential event and not as a hellenization of Christianity to be replaced by
some 'sola fides' doctrine or irrationalistic and skeptical fideism. See the Encyclical of John Paul II,
Fides et Ratio.
156 See the important treatise on this by Dietrich von Hildebrand: Sittlichkeit und ethische Werterkennt-
nis.
157 Edmund Husser! held in his Logos-Article "Philosophie als strenge Wissenschaft" that a science (Wis-
senschaft) can only be accepted to exist when all fundamental disagreements among representatives of
a (rigorous) science cease. See my critique of this view in my article by the same name, "Phlinomeno-
logie und Philosophie als strenge Wissenschaft." See also my Back to Things in Themselves and my
"Zur Begriindung ethischer Normen. Einwlinde auf Edgar Morschers Position. Ein Diskussionsbei-
trag," and "Und dennoch: Ethik ist Episteme, nicht blosse Doxa."
ISS This does not exclude the falsity of Aquinas's observation that original sin weakens our mind's pure
understanding ofnaturailaw which remains accessible to all, however.
159 This is evident purely philosophically, at least if one encounters even one single case of evident ethi-
cal knowledge. Such a fideism or, given the peculiar mystical theory of knowledge of Engelhardt by
faith-life only, such a 'religionism' in ethics is also conflicting with the Christian faith itself. Holy
Scripture itself is 'rationalistic' in this first sense, too. Is not Saint Paul a rationalist in virtue of his
claim that the divine law is inscribed in every man's heart and that pagans are therefore inexcusable?
See Romans 2:4.
294 CHAPTERS

that such a position is by its very nature guilty of some false 'rationalism' and that
only skepticism regarding rational ethical knowledge lacks such a rationalistic char-
acter. The sheer recognition of the existence and function of ethical human reason is
no negative 'rationalism'. It means simply the eminently positive rejection of any
historicism, cultural or general relativism and skepticism, which discard the capacity
of human reason to recognize truth, also ethical truth. Socrates, Plato, Aristotle,
Cicero, and many other minds in history prove that there is reason as well as ethical
rational knowledge of values everywhere and at all times. Neither axiological and
ethical nor general skepticism or relativism is justified, as we have already seen in
this chapter. 16o
Now what is H. T. Engelhardt's relation to this first meaning of 'rationalism'?
As already mentioned, he criticizes this position and rejects it as 'rationalistic', de-
fending himself also against Robinson's justified claim that Engelhardt himself pre-
supposes some such canonical rational ethics. 161 Nevertheless, we find some recog-
nition in his work that natural reason, prior to the life of religious faith, knows some
objective ethical truth. Such an assumption is made by Engelhardt, not only strongly
by implication when he reintroduces a whole set of humanistic and libertarian val-
ues, but weakly also by express admission about his ethical 'optimism'.162 To be 'ra-
tionalistic' in this sense is simply to correspond to truth.
At no time, all humanity or any member of the human race was deprived entirely
of ethical knowledge. It simply does not correspond to thousands of facts and expe-
riences with members of the secular society that they do not have clear ethical value
perceptions. Often they have better ones than Christians who should feel ashamed in
the presence of such noble agnostics and atheists. Therefore, I cannot agree with
H. T. Engelhardt, Jr. and others when they claim that "Christians are separated from
others by their epistemology, their metaphysics, their appreciation of history, their
axiology, their sociology of knowledge and value ..."163 Granted that all these ele-
ments contain important distinctions between Christians and non-Christians, they do
not involve per se any 'separation' of Christians from truth-seeking non-Christians. I
rather think that all genuine epistemology, axiology, etc., unites Christians with non-
Christians and that Christians just know many more things than secular reason, and
that they can also know the things known by reason much more deeply. Saint Bona-

160 See Edmund HusserI's Logical Investigations, Prolegomena, in which general and historical relati-
vism are refuted. I argue that Husser later became victim of a 'transcendental relativism' and that this
is contradictory. See likewise Josef Seifert, "Kritik am Relativismus und Immanentismus in E. Hus-
serls Cartesianischen Meditationen. Die Aquivokationen im Ausdruck 'transzendentales Ego' an der
Basis jedes transzendentalen Idealismus," Salzburger Jahrbuch fUr Philosophie XN (1970); the same
author, Back to Things in Themselves. See also Dietrich von Hildebrand, Ethics, ch. 9, as an excellent
critique of ethical relativism.
161 See Wade L. Robinson, "Monopoly with Sick Moral Strangers," in Brendan P. Minogue, Gabriel Pal-
mer-Fernandez, and James E. Reagan (eds.), Reading Engelhardt. Essays on the Thought of H. T.
Engelhardt. Jr., pp. 95-112, especially p. 100, p. 107. See also H. T. Engelhardt, Jr., "The Founda-
tions of Bioethics and Secular Humanism," p. 267; for his rejection of this 'rationalism', see ibid.,
pp. 259-266.
162 See Brendan P. Minogue, Gabriel Palmer-Fernandez, and James E. Reagan (eds.), Reading Engel-
hardt. Essays on the Thought ofH. T. Engelhardt, Jr.
163 H. T. Engelhardt, Jr., "Physician-Assisted Suicide Reconsidered: Dying as a Christian in a Post-Chris-
tian Age," Christian Bioethics, vol. 4, no. 2 (1998), pp. 143-167, p. 148.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 295

venture expresses this marvelously when he says that man knows truth both by the
natural light of reason and by faith. But since reality and truth are one, a person who
has both lights can, ceteris paribus, see more even of the reality accessible to reason
than one who has only one light, that of reason.
(2) A different reason for calling a position or moral stance 'rationalistic' is its
rejection of any pure situationism, i.e., the thesis that not only situations determine
the moral quality of acts but that there are some universal essences of human acts
and actions which make these morally wrong or right always and everywhere, re-
gardless of circumstances. This is the position of most great ethicists in antiquity
and in the middle ages. 164
(3) A good and important thing wrongly disqualified as 'rationalism' lies also in
the making of basic rational moral distinctions found in classical ethics, such as the
distinctions between ordinary and extraordinary means, or the similar though differ-
ent one between proportionate and disproportionate means, the distinction between
different quantitative and qualitative meanings of 'futility', 165 or the identification of
the conditions under which the principle of double effect comes into play. Not more
deserving of the negative qualifier 'rationalistic' is the crucial distinction between
the finis operis, i.e. the constitutive essential end of an action that makes it into the
kind of action it is (self-defense, life-saving, assassination, etc.), and the finis ope-

164 This position will be defended in the next chapter, and is closely related to the famous Catholic doc-
trine recently expounded in many documents that there is an intrinsece malum. Hearing this, one im-
mediately disagrees because one just thinks of Humanae Vitae and other documents and teachings re-
garding specific sexual issues rejected by many. In rejecting these teachings and understanding their
connection with the view that there are intrinsically evil acts, one fails to see the full accordance with
natural human reason of the ethical teaching on an intrinsece malum implying the non-utilitarian di-
mension of morality. Is this not a well-nigh universal moral consensus? If we think of Auschwitz, is it
not a universal ethical intuition that the racist Nazi crimes are morally wrong always and under all cir-
cumstances, whether produced by orders from authorities, by political pressure or by one's own ac-
cord? To call the insistence on a rationally evident intrinsece malum 'rationalistic' implies that only a
situation ethics or a teleological foundation of ethics, which precisely denies the morally wrong char-
acter of some human acts under all circumstances, would overcome this rationalism. But do not at
least the extreme examples of evil acts allow us to see clearly that this position on intrinsically wrong
acts is simply true and also rationally knowable, being in no way 'rationalistic'? Not only in the first,
also in this second sense, Saint Paul is a 'rationalist' when he writes:
revelation of the righteous judgment of God; 6 who will render to every man accord-
ing to his works: 7 to them that by patience in well-doing seek for glory and honor
and incorruption, eternal life: 8 but unto them that are factious, and obey not the
truth, but obey unrighteousness, shall be wrath and indignation, 9 tribulation and an-
guish, upon every soul of man that worketh evil, of the Jew first, and also of the
Greek; 10 but glory and honor and peace to every man that worketh good, to the Jew
first, and also to the Greek: II for there is no respect of persons with God. 12 For as
many as have sinned without law shall also perish without the law: and as many as
have sinned under the law shall be judged by the law; 13 for not the hearers of the
law are just before God, but the doers of the law shall be justified: 14 (for when Gen-
tiles that have not the law do by nature the things of the law, these, not having the
law, are the law unto themselves; 15 in that they show the work of the law written in
their hearts, their conscience bearing witness therewith, and their thoughts one with
another accusing or else excusing them); 16 in the day when God shall judge the
secrets of men, according to my gospel, by Jesus Christ. Romans 2:4.
165 See H. T. Engelhardt, Jr.lGeorge Khushf, "Futile Care for the Critically III Patient," Current Science
(1995): 329-333.
296 CHAPTER 5

rantis, i.e. the further subjective or accidental purpose of an action, for example, the
aim of making money on saving someone's life as opposed to having the value of
this life as motive of the action. Without this distinction the sphere of human actions
cannot be properly understood. These positive senses of rationality must not be de-
bunked as 'rationalism' even if conceptual rational distinctions and principles
neither exhaust the qualitative depth of the moral life nor solve the infinity of situa-
tions, as already Aristotle observed. 166 (Consequently, if one were to attempt such a
reduction of the moral life to what a few principles allow us to perceive, this would
indeed constitute a false 'rationalism'.)
(4) Fourthly, and now we approach negative meanings of 'rationalism', we could
mean by 'rationalism' a reduction of virtues and fundamental moral attitudes to mor-
al actions aimed at realizing states of affairs in the world, and the additional reduc-
tionist conception that the latter obey a certain set of definable moral principles
which would make them good or evil. Such a reductionism of morality to concrete
actions, and the additional reduction of the morality of these external actions to their
conformity to some principle or categorical imperative would be a wrong 'rational-
ism'· indeed. 167 In reality, morality includes, besides actions which realize or omit re-
alization of states of affairs in the world, free inner stances to all kinds of goods and
values as well as superactual attitudes and value responses such as love and humili-
ty, virtues and vices, and even freely sanctioned affective responses, which can in no
way be reduced to human actions aiming at realizing something in the world or even
to purely free inner responses. 168
(5) Rationalism as a significant concept in ethics could also refer to a reduction
of specifically Christian attitudes and virtues to pagan or purely rationally founded
ones, which would overlook the overwhelming new qualities, motivations, and ful-
fillment of the moral life through the specific objects of religious faith and the spe-
cifically Christian life and holiness.
(6) A very different meaning of 'rationalism', especially brought out by H. T.
Engelhardt, Jr., lies in a lack of understanding the specifically connatural moral
knowledge that presupposes virtue and cannot substitute for it, an ethical knowledge
that is not an isolated, merely intellectual affair, but grows from the humble, loving,
holy heart. Rationalism in this sense would be the wrong opinion or general attitude
according to which the neutral attitude of the amoral man would be the best founda-
tion of objective knowledge in ethics, instead of the heart which opens itself to the
Good and which perceives the depth of moral goodness by the mediation ofhumili-
ty, purity of heart and above all love that opens the intellect. 169 More generally
speaking, this rationalism overlooks the manifold influence of moral and immoral
acts and attitudes on ethical knowledge and on moral value blindness. 17o

166 See Aristotle, Nichomachean Ethics VI, 1144b30-1145a6.

167 See against this, for example, Dietrich von Hildebrand, Sittlichkeit und ethische Werterkenntnis.
168 On the significant relation between the affective life and morality see Augustine, The City of God IX,
XN. See also Dietrich von Hildebrand, Ethics, ch. 25.
169 See Max Scheler, Liebe und Erkenntnis, in Max Scheler, Gesammelte Werke Bd. VI: Schriften zur So-
ziologie und Weltanschauungslehre (Bern: Francke, 1963).
170 See Scheler's Essay, "Ordo amoris," in Max Scheler, Gesammelte Werke Bd. X, 3. Aufl. (Bonn:
Bouvier, 1986), pp. 345-376; english translation by David R. Lachterman, "Ordo Amoris," in Max
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 297

There are different other forms of rationalism.

(7) One such different, though not unrelated, rationalism reduces the prudential
knowledge,17I which alone can do justice to the infinite variety of ethically relevant
facts, to a mere practical syllogism from a few abstract principles, as ethical knowl-
edge was often presented by moral theological manuals. Certainly, ethical decision-
making in the face of countless cases and circumstances in intensive care units can-
not simply be deduced from a few general principles, helpful as these are, but must
be grasped by an infInitely differentiated knowledge of concrete 'cases', wherein
lies the root both of the indispensable usefulness of 'casuistry' and the limits of
books on applied ethics which can never exhaust the variety and wealth of concrete
reality which demand an ever renewed Sachkontakt. But all such casuistry depends
on universal ethical principles and also should be seen integrated in the sphere of es-
sentially good and essentially wrong moral attitudes and acts. And to reject radical
situationism has nothing to do with false rationalism but only with authentic ration-
ality.
Thus we reach the conclusion that the admission of rational ethical knowledge,
including that of species of acts that are intrinsically wrong, as such has no implica-
tion of negative rationalism. Moreover, from an ethical standpoint, intrinsically
wrong acts should never be demanded from, or performed by, a physician. Also
from a legal standpoint, intrinsically evil acts should never be demanded by the state
or allowed by the state to be demanded by private institutions from those whose ob-
jective ethical knowledge and/or subjective conscience rejects such actions. For this
reason, policies such as those of the school of midwifery in Zurich, which rejects ac-
ceptance of women who refuse abortion as midwives, ought to be outlawed. More-
over, any force exerted on persons to perform intrinsically morally wrong acts such
as prostitution should be strictly persecuted and prevented by the forces of law and
order in states, and when immoral acts violate natural and positive human rights or
public morality they should likewise be forbidden and punished by the law. How-
ever, the state has no authority to punish intrinsically immoral acts when they do not
violate anyone's rights or the public moral order.

5.5. On the Indispensability ofLooking for the Foundation ofBioethics in Objective

Values
Can we give an objective foundation to such values, however? Are they more than
just matters of convention, of consensus, or of subjective belief? Or are they a
Kantian imperative arising within the subject, which has no cause outside the imma-
nent demands of human reason? Many theories deny the objectivity of human digni-
ty and other morally relevant values, as well as of moral Good and Evil, and thus the
rational foundation of ethics. We have seen this already and criticized ethical relati-
vism.

Scheler, Selected Philosophical Essays (Evanston, 1973); or Dietrich von Hildebrand's Sittlichkeit
und ethische Werterkenntnis.
171 The phronesis of which, for example, Aristotle speaks in Nichomachean Ethics VI, 6.13, 1144 b 17-
1145 a6, and again in NE 10.8 1178 a 16-19; Thomas Aquinas in his Summa Theologica I-II, Q 57, a
4-5; Q 61, a 2; II-II, Q. 47, a. 5; or Dietrich von Hildebrand in his Morality and Situation Ethics.
298 CHAPTERS

We recall again that in order to understand the existence of objective values, we

have to contrast them first with the object of mere subjective likes and dislikes. The
Hippocratic Oath and many other codes of medical ethics warn the doctor against a
desire for money or for other subjective advantages that may seduce him to violate
what we nowadays call the dignity of his profession and of his patient. Thus, they
contrast that which is merely subjectively satisfying with that which possesses in-
trinsic value. They contrast a pleasure in which the doctor only uses patients for his
satisfaction and a respect that takes them seriously because of a dignity, which they
possess in themselves. A recent and very successful play in European theaters on an
earlier political situation in Chile by the Chilean writer Ariel Dorfman, Death and
the Maiden, has the same theme of doctors who were abusing patients and torturing
them for subjective advantages, contrasting this to an attitude towards the patient as
a being endowed with an inherent dignity and as being worthy of respect. The
mentioned statements from the Hippocratic Oath, one of the most splendid docu-
ments of humanity, invite the doctor also to exercise a moral transcendence in which
he shows true concern for the patients in virtue of an intrinsic worthiness of respect
of the good and persons of patients. 172
Only the human and morally good affirmation of the patient propter seipsum is
an ethics of genuine affirmation of persons, of benevolence and of love. Only such
an ethics, which recognizes objective morally relevant goods from which moral calls
issue, can open the way to what ethics properly speaking is, and it alone gives an ul-
timate explanation for the oath of Hippocrates and is capable of grasping the true
value of kind concern for others, distinguishing it from ethical egocentricity and im-
moral abuse of patients, of the unborn, or of the elderly.
Human dignity and other objective values, which deserve affirmation for their
own sake such as truthfulness, are central backbones of bioethics. Also Kant, in spite
of his denial that any characteristic of the object of the moral act can ground moral
imperatives and that these are solely founded in the synthetic a priori formal struc-
tures of pure practical reason, cannot help introducing a foundation of moral impera-
tives in the intrinsic value of the object of moral acts. In fact, he states explicitly that
without things the value of which does not depend on our inclination but is absolute,
no rational foundation of ethics would be possible, as we have already seen several
times. Nonetheless, we wish to repeat a passage from this centrally important quota-
tion in our present context:
But suppose there were something the existence of which had itself absolute worth,
something which, as an end in itself, could be a ground of definite laws. In it and only in
it could lie the ground of a possible categorical imperative, i.e., of a practical law.
Now, I say, man and, in general, every rational being exists as an end in himself
and not merely as a means to be arbitrarily used by this or that will ... All objects of in-
clinations have only a conditional worth, for if the inclinations and the needs founded
on them did not exist, their object would be without worth ... 173

172 On the objectivity of values and their distinction from the merely subjectively satisfying as founda-
tional ethical concepts cf. Dietrich von Hildebrand, Ethics, chs. 1-3.
173 Immanuel Kant, Grundlegung zu einer Metaphysik der Sitten, BA 64, 65:
Gesetzt aber, es g!lbe etwas, dessen Dasein an sich selbst einen absoluten Wert hat,
was als Zweck an sich selbst, ein Grund bestimmter Gesetze sein konnte, so wUrde
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 299

5.6. Can We Derive an Ought From an Is? Another Objection against an Objective
Bioethics in a Pluralistic Society

Many philosophers, particularly in modern times, hold With David Hume ethical rel-
ativism for another reason: namely, that an ought can never be derived from an 'is'.
Some infer from this that 'oughts' can only derive from a will, from positive law or
are nothing but expressions of our emotional reactions to things.
Now if we ask about the meaning of the verdict against deriving an ought from
an 'is', we find at least three different senses of this very verdict itself:
(1) First, one could mean that mere facts as such do not give rise to oughts, even
when these facts are connected with the natural inclinations of things. It is a natural
fact that men tend to grow beards. Does this give rise to an ought not to shave
beards? Certainly not. Does the tendency of people to be envious ground a value of
envy? Even more certainly not. Thus, no values can be derived from mere facts. In
this first sense, therefore, we all have to agree that facts cannot be normative and
that no 'ought' can be derived from an 'is'.
(2) In a second sense, we would mean 'facts' along the lines of Scholastic philos-
ophy of 'secundum naturam'174: not in the sense of any blunt matter of fact and of a
faktische Natur-which admittedly never grounds values-but in the sense of an es-
sential nature, where 'nature' is only the original and objective nature, the 'rational
part' of nature (Wesensnatur), not any mere series of facts. This traditional secun-
dum naturam theory of ethics, if interpreted intelligently, does not really derive
oughts from an 'is' as the first theory does. For it distinguishes precisely two kinds
of facts: mere facts and morally potent facts.
But nevertheless also this ethics has the tendency of deriving an 'ought' from an
'is' in an untenable way. Its explanation that the morally good lies in actions that are
in accordance with the essential nature is insufficient. For it wishes to give its moral
oughts an empirical factual foundation in natures but in so doing, it introduces the
distinction between factual nature and essential nature and thus presupposes an intu-
ition into the essential goodness of some natures or aspects of a nature and the neu-
trality of others. Thus it wants to have it both ways. It really circumvents in its theo-
ry the need for an intuition into values and for the recognition of the new datum of
value, which is grounded not in facts as such, but only in the peculiar nature of cer-
tain facts. But at the same time it admits that no mere factual information about a na-
ture gives us values and that therefore a sidestepping of the need to recognize that
some facts are endowed with value, others not, is impossible. Therefore, this theory
distinguishes value-bearing from neutral facts and leads to the third interpretation of

in ibm, und nur in ibm allein, der Grund eines mtlglichen kategorischen Imperativs,
d.L eines praktischen Gesetzes, Iiegen.
Nun sage ich: der Mensch und Uberhaupt jedes vernUnftige Wesen, existiert als
Zweck an sich selbst, nicht blofJ als Mittel . .. Alle Gegenstiinde der Neigungen
haben nur einen bedingten Wert; denn wenn die Neigungen und darauf gegrUndeten
BedUrfnisse nicht waren, so wfirde ihr Gegenstand ohne Wert sein.
See also Kant, Kritik der praktischen Vernunft, 61,62.
174 Not all Scholastic philosophers held this view, particularly not Duns Scotus. But also in St. Thomas
Aquinas we find another possible interpretation of his ethics which was emphasized particularly by
Cornelio Fabro, in his Riflessioni sulla Liberta.
300 CHAPTER 5

deriving an 'ought' from an 'is' to be discussed below. In other words, the 'secun-
dum naturam'-element as such does not explain value if first the value of the
'natura' has to be distinguished from value-free nature and thus needs an explana-
tion for its value rather than proving it.
The explanation of morality in terms of nature also gives rise to an entirely dif-
ferent confusion, which is not related to the ontological problem of how values de-
rive from being, but to the problem of motivation. Then nature is understood as an
entelechy that aims at its own perfection. And acting in accordance with nature
means then to act so that one reaches self-fulfillment. Therefore, the secundum natu-
ram ethics from Aristotle on often tends to be eudemonistic and immanentistic. That
is to say, it reduces the idea of the good life to acting in such a way that our happi-
ness is fulfilled. Thus, the character of the moral act as esteem of something that de-
serves a value-responding recognition and response for its own sake, and as a proper
response to goods endowed in themselves with value, is overlooked. This second
reason for disagreeing with such an ethics was developed carefully by Tadeusz
Styczei and by others.175
For these two reasons we disagree also with the second manner of attempting to
derive 'oughts' from 'ises'.
(3) A third interpretation of the impossibility of deriving an ought from an 'is' is
quite different. It would hold that no investigation of the real nature of something,
like of the specific content of the rational human nature, could allow us access to the
knowledge of the dignity of the person. Values would never be founded upon the be-
ing of things. Therefore, they would only be projected into things or affixed to them
by a will. This would be Kelsen's opinion regarding rights and any other oUghts.
But then a worm and a man would not be recognizably different in value; the
atrocities committed in a concentration camp against Jews and many others, or the
forcing of men by Serbian soldiers to bite off the genitals of their fellow-prisoners,
would, ethically and axiologically speaking, not be recognizably different from
using worms for fishing or cutting flowers. A law-suit in accordance with principles
of fair trial, which involves the hearing of all parties, of all witnesses, and a judg-
ment which proceeds in accordance with the real nature of committed actions, would
not be any better than a tyrannical confinement to jail of innocent people for purely

175 See on this Tadeusz StyczeIi., "Zur Frage einer unabhlingigen Ethik," in Karol Kardinal Wojtyla, An-
drzej Szostek, Tadeusz Styczei, Der Streit urn den Menschen. Personaler Anspruch des Sittlichen (Ke-
velaer: Butzon und Bercker, 1979), pp. 111-175. See also Dietrich von Hildebrand, Ethics, chs. 3, 17-
19. In medieval philosophy, Duns Scotus insisted-against the Thomists who held that the good is
only so in relationship to appetites-that the 'good' belongs to things in se and ad se and that love and
the affectio iustitiae does justice to their intrinsic goodness. In fact, in such a value-responding char-
acter of the will and of love Scotus sees the condition for the true rationality of the will which could
never be explained by self-centered appetites which would eternally fail to relate appropriately to
goods as they are in themselves. Such adequacy is only possible if love can love the good for its own
sake. Only then, Scotus adds, love can be explained at all; for any authentic love of the other person
affrrms the other for her own sake. Only then, Scotus continues, can God be loved more than the self,
which is impossible if he were only loved as source of our own happiness, in which case self-love
would range supreme. Scotus also points out that the essence of rationality is adequacy: of the intellect
to things as they are in themselves in truth, and of the will to good in itself. For an analysis of this
point and the original texts, see Walter Hoeres, Der Wille als reine Vollkornrnenheit nach Duns Scotus
(Miinchen: 1962). See also on this J. Seifert, Essere e persona, chs. 5,6,9.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 301

political reasons. Obviously this is absurd. We are able to gain a real intuition into
the nature of the respective beings and, based on the understanding of their natures,
into their values. We do not affix these values arbitrarily to things but they stand in a
clear relation to the essence of certain objects. They grow out of their specific na-
ture. I76 This view was also the classical teaching of 'natural law' in ancient and me-
dieval philosophy up to Pufendorf and Kant in modern times. It is part of perennial
philosophy in a broad sense of the term. For example, Cicero was a defender of this
position. He writes about natural law and justice: "ratio summa, insita in natura,
quae iubet ea quae facienda sunt, prohibetque contraria" ([the true law] is supreme
rationality, that lies within nature and commands that which ought to be done and
forbids the contrary).177
We find the values of things, discovering in their nature and real existence the
source and seat of their intrinsic goodness and non-neutrality. And we find an ob-
jective order of such values in that the dignity of man is higher than that of a flower
or ofa worm.

5.7. Does a Publicly Acceptable Bioethics Today Require a Utilitarian Basis? On

the Irreducibility ofMoral Values to Means for the Morally Relevant Values Which
Are the Results of}oJoral Actions

Medical action is so intimately bound up with ethics because all or at least most of
the ends of the medical art are also morally relevant (life, health, alleviation of suf-
fering, etc.), as we have seen above.
We must remind ourselves again of the crucial significance of recognizing the
absolute superiority of moral values over all others when it comes to the basis of
medical ethics. While moral values are borne by the conscious and free acts and
their subjects themselves, the consequences of specifically medical actions all move
on the level of extramoral or morally relevant goods which are not moral goods, as
we have seen in chapter 3. We come here across a very crucial distinction within
ethics, which was introduced very forcefully by some philosophers from Plato on.
Among the most powerful classical statements of this distinction, which is crucial
for bioethics, is Kant's opening statement in the First Section of The Foundations of
a Metaphysics of Morals as to the independence of the moral value with respect to
all consequences brought about through actions and as to the superiority of moral
values with respect to these consequences. We have interpreted this statement in de-
tail in chapter 3 but now add a few lines relevant in our context to the quote.
Nothing in the world-indeed nothing even beyond the world---can possibly be con-
ceived which could be called good without qualification except a good will. Intelli-
gence, wit, judgment, and the other talents of the mind, however they may be named, or
courage, resoluteness, and perseverance as qualities of temperament, are doubtless in
many respects good and desirable. But they can become extremely bad and harmful if
the will, which is to make use of these gifts of nature ... is not good. It is the same for
the gifts of fortune ... The good will is not good because of what it effects or accom-

176 See on this John F. Crosby, "The Idea of Value and the Reform of the Traditional Metaphysics of
Bonum."
177 Cicero, De Legibus I, 18. Cf. also Josef Seifert (Hrsg.), Wie erkennt man Naturrecht?
302 CHAPTERS

plishes or because of its adequacy to achieve some proposed end; it is good only be-
cause of its willing, i.e., it is good of itself. And, regarded for itself, it is to be esteemed
incomparably higher than anything which could be brought about by it in favor of any
inclination or even of the sum total of all inclinations. Even if it should happen that, by
a particularly unfortunate fate or by the niggardly provision of a stepmotheriy nature,
this will should be wholly lacking in power to accomplish its purpose, and even if the
greatest effort should not avail it to achieve anything of its end, and if there remained
only the good will (not as a mere wish but as the sununoning of all the means in our
power), it would sparkle like a jewel in its own right, as something that had its full
worth in itself. Usefulness or fruitlessness can neither diminish nor augment this
worth. 178

The independence of the moral value of human acts from the latter's success
must not be interpreted, as Kant tends to do in other passages although not in this
one, as a kind of divorce between the will from its object. On the contrary, the value
of the will, as Scheler points out, presupposes a genuine interest in the object. Only
if we intend the well-being of our neighbor, this will of ours is morally good, not if
we are interested only in our own will's value.
However, the distinctions intended by Kant between the objects brought about
by the action and the moral value of the action itself, as well as the latter's superior-
ity in value, remain fully valid. Especially the distinction between the object inas-
much as it motivates moral actions and the moral act and its value itself was brought
to clearer evidence only recently by means of the distinction brought up several
times in the preceding chapters between the morally good and the morally rele-
vant. 179
The morally good can only be attributed to persons; it consists in the moral value
itself in the person and presupposes the freedom of its subject, the knowledge of the
respective object and the inherent value of an act as a due response to its object. The
moral good also involves merit or guilt, deserves praise or punishment and embodies
goodness or evilness in the moral sense of the term for which the German language
has the words 'gut'versus 'bOse' as distinct from all other evils (which are called
Obel).
None of this can be said of the morally relevant goods and values. By 'morally
relevant' we understand that which gives rise to moral obligations or to calls. For
example, human life is morally relevant but, as such, not morally good. Nobody is
morally good in virtue of being born-and yet the human life of the newborn baby is
morally relevant because it imposes a duty to respect it, not to harm it, etc.
A closer analysis would show that we can distinguish three meanings of 'moral
relevance': (1) the morally relevant good in contrast to that which is neither morally
relevant nor good (such as producing postage stamps or tennis rackets), (2) that
which is not morally good but imposes moral obligations on us to respect it (such as
the newborn baby's life}-and it was this sense of 'moral relevance' which we had
in mind in the above remarks _180 and (3) that which is characterized not as a type of
values it embodies but in purely ethical functional terms: namely, as that which sim-

178 Kant, Foundations a/the Metaphysics a/Morals, BA 1, 3, text and essays ed. by R. P. Wolff, 11-13.
179 Cf. Dietrich von Hildebrand, Ethics, ch. 19.
180 Even animals possess a certain moral relevance not to torture and abuse them and yet they carmot be
morally good or evil.
 AN OBJECTIVE BIOETHICS-ANSWER TO ENGELHARDT 303

ply is the source of moral obligations or calls. The morally relevant in this third
sense is neither distinct from, nor identical with, moral values. It can lack moral val-
ue but it can also be morally good itself; for example, in education, all moral values
and evils of a child are simultaneously morally relevant for the educator inasmuch as
the task to further them falls to him as a moral duty.181
In medical ethics, we are mostly interested in the morally relevant in the second
sense of the term: i.e., in those goods which are not morally speaking good in
themselves but still impose moral obligations on us, such as the fIrst fIve (immanent)
ends of medicine discussed in chapter 1. But where and how can we fInd such a
good and show that there are morally relevant goods? The most obvious example of
such a morally relevant good of the highest order has always been the person in his
or her dignity.

5.8. Does a Modern Bioethics in a Pluralist Society Require the Abandonment of

'Speciecism', as Singer Postulates? On the Dignity ofthe Human Person as a
Unique Objective Value-the Untenability ofRegarding the Insistence on Human
Dignity as a Mere 'Speciecism'
Peter Singer suggests that a modem bioethics suitable for our pluralistic society re-
quires the abandonment of what he calls 'speciecism'. Such a speciecism could at
best dominate a public ethics in a religiously united society, which believes in some
supernatural dignity of man as distinct from other animals.
Is it true that the concept of an intrinsic sanctity of human life is an untenable
principle for a bioethics in our modem secularized and non-Christian society? Or is
there an intuition independent from religion, which allows us to look also for a foun-
dation of contemporary bioethics in the inviolable dignity of human persons? Is
there some rational basis for claiming in our pluralist society a unique dignity, which
sets apart persons from even the highest developed animals?
We have expounded in detail our answer to this question in chapter 2: The per-
son as a being endowed with reason, with an ability to judge, to distinguish truth
from falsity, to will, to fe~l happy or unhappy, etc., is endowed with a unique value
which we call her dignity. Perhaps even Peter Singer will admit this value of the per-
son. But is such a value found in all members of the species man or do we fall into
what Singer calls 'speciecism' if we hold that?182 Singer speaks of his "proposal that
we reject the sanctity of human life."183 He thinks that the value of human beings can
only lie in their actual capacity to think, to will, etc. He goes as far as to defend the
view that retarded and otherwise handicapped children are less endowed with digni-
ty than pigs or chimpanzees. 184

181 See Dietrich von Hildebrand, Moralia.

182 Peter Singer, "Unsanctifying Human Life."
183 Singer, ibid., p. 59; p. 43; p. 50.
184 See Singer, ibid., p. 50:
I will only point out that if we believe it is the potential of the infant that makes it
wrong to kill it, we seem to be committed to the view that abortion, however soon
after conception it may take place, is as seriously wrong as infanticide.
304 CHAPTERS

Our investigation presented in chapter 2 into a philosophy of man and into hu-
man dignity now proves again indispensable for the foundations of ethics. In the
light of these preceding investigations, the decline of an appropriate philosophy of
the human person and of her dignity shows itself once again as an extremely danger-
ous philosophical disease of medicine. An appropriate philosophy of the human
mind (soul) and of the ftrst source and dimension of human dignity, the ontological
dignity of the human person, revealed to us that human nature and personhood is
something that belongs to human beings at all stages of their development and in
virtue of their invariant essence-and not only when the person is in the actual pos-
session of her mental capacities.
Thus, only the results of a careful philosophical anthropological investigation
could reveal that human dignity belongs to all human beings at all stages and not
only to normal and functioning ones.
Here we see that the investigation into the foundation of medical ethics leads us
always back to a philosophy of man. For the value of the human person cannot be
conceived apart from that which possesses it: the being and essence of the person.
Value is what Ross calls a 'consequential property'.
Consequently, since the being of the human person is not reducible to her actual
being capable of human activities and since therefore the value of man is founded
not only in his actually consciously lived being as person but also in the lasting na-
ture and essential ontic potentiality of each human being to act as a person, and since
human dignity is grounded in the spiritual substantiality rather than on accidental
passing states of the human person, Peter Singer's view and its devastating destruc-
tion of medical ethics, by denying human dignity to an immense number of human
beings, must be sharply rejected.
Thus, the apparently abstract questions of a philosophy of man presented in
chapter 2 prove again of radical importance for medicine and in particular for ethical
problems concerning abortion, contraception, euthanasia, or the elimination of hand-
icapped human beings or patients in the vegetative state.
 CHAPTER 6

ARE THERE ABSOLUTE MORAL OBLIGATIONS

TOWARDS FINITE GOODS?
A CRITIQUE OF 'TELEOLOGICAL ETHICS' AND OF
THE DESTRUCTION OF BIOETHICS THROUGH
CONSEQUENTIALISM
On The Invertebratitis of Medical Ethics and Its Cure

1. INTRODUCTION

1.1. The Denial ofIntrinsically Wrong and Evil Acts as Ethical Invertebratitis

Even if we recognize the crucial significance of moral values and resist any form of
ethical relativism and nihilism, as well as any fideistic 'secular ethical agnosti-
cism' -as we have done in the preceding chapters-there are still many forms of
ethical systems that likewise reject relativism and skepticism but otherwise take
completely opposite stances when it comes to the question which medical ethics
physicians and hospitals should adopt today. In the present chapter, we will deal
critically with a position in medical ethics that, while not denying objective moral
values of human acts, reduces them in some way to the indirect values these actions
possess in virtue of bringing about consequences different from the acts themselves.
This position judges the moral quality of human acts simply by a calculus of conse-
quences and-applying the principle of proportionalism-seeks to weigh these con-
sequences, in order to determine the morally right or wrong (good or evil) character
of human acts. If adopted, this position changes traditional medical ethics radically.
In fact, this position constitutes one of those philosophical diseases of medicine
this book undertakes to diagnose and to cure. This philosophical disability could be
named and understood as a disease unknown to medicine-invertebratitis: a slow
dissolution of the vertebrae that transforms a vertebrate into an invertebrate. One
might also speak of more moderate philosophical diseases of medical ethics such as
ethical springomyelia, poliomyelitis, myalgic encephalomyelitis, or osteomyelitis
that may, in most serious cases, gradually lead to a total corrosion and ensuing break
of moral backbone.
Countless times physicians and nurses are confronted with a crucial question of
all ethics which is at the same time a central question for bioethics, especially for

305
306 CHAPTER 6

medical ethics: does the moral character of human acts depend solely on their conse-
quences and on the particular situation---or are there acts which are morally right or
wrong under all circumstances? In other words, are there unjust and morally wrong
acts, which are always wrong? Are, for example, abortion, euthanasia, human expe-
rimentation on embryos or on children and adults without taking their good into ac-
count (but just for the sake of science) intrinsically wrong? Or should physicians and
nurses just weigh the consequences of concrete actions and may sometimes legiti-
mately perform the described acts, at other times not?' It is clear that this question is
of crucial importance for medical ethics: whole clinics would have to be shut down
depending on whether it is answered in one way, and the same clinics would have to
remain active, if the question were answered in another way. If the answer is that
some actions performed in hospitals are intrinsically morally wrong, no physician
and nurse would ever have a right, let alone a duty, to perform such acts or to advise
patients as to who would assist them in such actions; if it is answered in the opposite
way, there could well exist a duty to perform these very same actions.
In the history of philosophy, we fmd both views expressed in many forms-that
of 'consequentialist'2 and situationist3 ethics, and the so-called 'deontic' or absolute
ethics. But here we are not interested in a history of ideas but in their truth; and we
wish to propose a critique of ethical consequentialism.
According to this rapidly spreading philosophical disease, there are no intrinsi-
cally wrong moral acts-i.e., acts that would be wrong in all situations and under all
circumstances. This position that we want to discuss in the following breaks the spi-
nal column not only of all ethics, but also of the diseased person herself. It makes
fluid what gives substance and stability to the moral life and to the person herself. In
other words, this philosophical disease destroys the moral identity of the person and
makes her spineless.
Socrates expresses very beautifully and forcefully the position that there are in-
trinsically evil and unjust acts:
SOCRATES: And if we find that we should be acting unjustly, then we must not take
into account either of death, or of any other evil that may be the consequence of remain-
ing here, where we are, but only of acting unjustly ...
Ought we never to act unjustly voluntarily? Or may we act unjustly in some ways,
and not in others? Is it the case, as we often agreed in former times, that it is never
either good or honorable to act unjustly? Is not what we used to say most certainly the

, For a discussion of this question see Thomasine Kushner, "Doctor-Patient Relationships in General
Practice-A Different Model," J Med Ethics (Sununer 1981), 9: 128-131, where the author argues
that neither "the teleological (outcome) approach" nor "the clinical model" is an adequate theory to
understand "this relationship," a relation that should, much rather, be interpreted along the lines of a
new and "more appropriate basis for the physician-patient relationship": the ''relational model."
2 This term has been coined by G. Elizabeth M. Anscombe, as the Encyclopaedia Britannica tells us.
3 The classical situation ethics with its mysticism of sin and several other more personalist dimensions
was very different from consequentialism and utilitarianism, but the notion of situation ethics has also
been understood in a purely utilitarian (consequentialist) sense, for example by Joseph Fletcher, Situa-
tion Ethics (London: SCM Press, 1966); see also Joseph Fletcher & John Warwick Montgomery,
Situation Ethics-True or False (Minneapolis: Dimension Books, 1972). See for a critique both of
Fletcher and of the different form of situation ethics Karl Rahner has first named so, Dietrich von
Hildebrand, Morality and Situation Ethics.
 ABSOLUTE MORAL OBLIGATIONS 307

truth, whether the multitude agrees with us nor not? Is not acting unjustly evil and
shameful in every case, whether we incur a heavier or lighter punishment in conse-
quence?
If we ought never to act unjustly at all, ought we to repay injustice with injustice, as
the multitude thinks we may?
CRITO: Clearly not ...
SOCRATES: Then we ought not to repay injustice with injustice or to do harm to
any man, no matter what we might have suffered from him. And in conceding this,
Crito, be careful that you do not concede more than you mean. For I know that only a
few men hold, or ever will hold, this opinion. And so those who hold it and those who
do not have no common ground of argument. 4

In Plato's Republic, at the beginning of book II, the fundamental problem is

brought up whether justice is good and injustice evil in themselves or only in view
of their effects. Glaucon and Adeimantus wish to show that in most ethical discus-
sions the value of justice and the evil of injustice in themselves are completely over-
looked; only their appearances and consequences are considered. Thus, if the magic
ring of Gyges, which renders him invisible to the eyes of the world while he per-
forms all sorts of crimes, allowed him to be taken for just because neither gods nor
men could see his vile actions; if he were praised for his seeming justice and if his
life produced all kinds of good effects, would his murders, his adulteries, and other
crimes remain evil and a cause of reproach? And if, conversely, the justest of all
men would be misjudged by the public, and if all kinds of bad effects would result
from the false appearances of his actions, and if his actions themselves had unin-
tended bad consequences both for himself whom his fellow-men would hate and
crucity, and for society which would be shaken up by his bad example and harmed
by his well-intended but ill-succeeding actions-would he remain just and good, re-
gardless of all the bad consequences of his life and acts? Would his virtue remain a
good to be praised or would it partake in the evil of its bad results? And also in this
work of Plato Socrates gives the same response.
ADEIMANTUS: ... Some extend their rewards even further; the posterity, as they say,
of the faithful and just shall survive to the third and fourth generation. This is the style
in which they praise justice. But about the wicked there is another strain; they ... inflict
upon them the punishments which Glaucon described as the portion of the just who are
reputed to be unjust ... Such is their manner of praising the one and censuring the
other ... no one has ever blamed injustice or praised justice except with a view to the
glories, honors, and benefits which flow from them. No one has ever adequately de-
scribed either in verse or in prose the true· essential nature of them abiding in the soul,
and invisible to any human or divine eye; or shown that of all things of a man's soul
which he has within him, justice is the greatest good and injustice the greatest evil. ...
And therefore, I say, not only prove to us that justice is better than injustice, but show
what they either of them do to the possessor of them, which makes the one to be a good
and the other an evil, whether seen or unseen by gods and men....
SOCRATES: ... I cannot refuse to help while breath and speech remain to me; I
am afraid that there would be an impiety in being present when justice is evil spoken of
and not lifting up a hand in her defence. And therefore I had best give such help as I
can.

4 Plato, Crito, 49 a ff.

308 CHAPTER 6

1.2. Some Bearing of Our Previous Discussion on the Morally Intrinsic Character of
Right and Wrong Actions-Beyond the False Alternative: Kant or Utilitarian
Consequentialism
Kant, who has defended an ethics of moral absolutes, a deontic ethics which holds
that certain acts are under all circumstances wrong, has believed that such an ethics
cannot be derived from the object of human acts because these could not ground ab-
solute moral imperatives, but only from the subject. He has furthermore believed
that such an ethics must be purely formal and cannot have material content. 5 The
reasons why Kant thought this lie in part in his wrong idea that objects of human
acts could only motivate us eudemonistically, i.e. through some pleasure or happi-
ness they provide for us. 6
We have already seen in the preceding chapters, however: On the one hand, an
adequate bioethics cannot be based on duty alone, and even less on purely subjective
forms of the will, but must refer to the relationship of moral acts to their morally rel-
evant objects. It must also have content, which can only come from a content-full
good on the object-side or in the subject. As a matter of fact, not even Kant can
uphold his ethical formalism, but some of the many formulations Kant gives of the
'categorical imperative' recognize the intrinsic goodness of the dignity of the per-
son, who deserves respect, as ground of any categorical imperative-as we have
seen previously.
Notwithstanding such occasional admissions to the contrary, however, Kant en-
tirely overlooked in his general ethical theory the due-relation and calls for an ade-
quate value response issuing from goods endowed with intrinsic value. He also
failed to see clearly that the good in objects can take the radically different forms we
distinguished in the preceding chapters, and that only some of them correspond to
his wrongly generalizing view of the purely hedonistic or c;udemonistic relationship
between object of human acts and motivation. There are also goods that are intrinsi-
cally good and ought to be affIrmed for their own sakes (as Kant himself recognizes
in a striking passage quoted in chapters 2 and 3). In this respect, an adequate medi-
cal ethics cannot be a Kantian formalistic ethics but must be a 'material' (non-for-
mal) value-ethics. 7 Therefore, the notion and the extremely rich, content-full and
manifacetted value and dignity of the person in which the different fundamental hu-
man rights have their root, turn out to be crucial for the foundation of ethics, as we
have seen.
On the other hand, Kant is entirely right when he recognizes a completely new
value and the highest value in the moral act itself in its distinction from its effects. In
his recognition that moral values alone are 'good in an unrestricted sense' we fol-
lowed Kant, even distinguishing many insights contained in this statement. As we

5 See on this Josef Seifert, Was ist undwas motiviert eine sittliche Handlung?
6 See the critique of any eudemonism in Dietrich von Hildebrand, Das Wesen der Liebe, chs. 1,4-7,9.
See also the study and critique of Kant's eudemonism by Robert Miller, Kant's Critique of Eude-
monism (lAP-dissertation 1999).
7 I refer here to the ground-breaking work of Max Scheler, Der Formalismus in der Ethik und die mate-
riale Wertethik (1913). Formalism in Ethics and Non-Formal Ethics of Values, transl. Manfred S.
Frings and Roger L. Funk.
 ABSOLUTE MORAL OBLIGATIONS 309

have seen in chapters 3 and 4, the unique and superior moral value ''which sparkles
like a jewel" is bound to freedom, and possesses the character of good and evil in a
radically new sense compared to any non-moral good.
Kant did see, moreover, that the absoluteness of the moral imperative cannot be
fully accounted for by the finite object of human actions but constitutes a new mo-
ment, which in the absoluteness of submission it demands is not simply the duty to
give finite goods their due value response. The absoluteness of the moral ought goes
beyond what could be explained in terms offmite objects of human moral actions. 8
All of these are not only genuine Kantian insights but also an expression of the
truth about moral values. Only these----of all purely natural values-are related to the
unum necessarium, only they make the person praiseworthy or blameworthy; only
they are linked to the person's transcendent fate and have a unique relationship to
the supreme Good.
Modem bioethics frequently overlooks entirely these Kantian insights-which
were brought out more clearly by later phenomenological ethicists. It discards the
inherent moral value of personal acts qua freely willed acts and is largely a theory of
practical reasonableness or even of utility of actions in terms of their effects. Yet
such a theory, in which the whole dimension of morality is lacking, is no ethics
properly speaking, and here we reach the topic of this chapter: Are there, at the nu-
cleus of human moral life, such absolute values and obligations that any action that
is by its very essence and form directed against these goods is intrinsically evil? Or
can all species of human actions be justified under certain circumstances and in cer-
tain situations?
A new form of the consequentialist ethics developed by Anglo-Saxon thinkers
from Hobbes to G. E. Moore has been largely accepted and was introduced during
the past few decades in Germany by moral theologians and philosophers, and spread
from there to the USA and other countries. Still older roots of this consequentialism
lie in British moral philosophy. The ethical consequentialism the German moral the-
ologians adopted was partly translated by them into the terminology of transcenden-
tal philosophy. The fruit of this transformation process emerged, under the name of
'teleological ethics' or 'purely teleological foundation of ethics', especially among
German moral theologians and from there spread to the United States, to Italy, and
to other countries.
Many regard this new 'revolutionary ethics' that absorbs many elements of older
forms of consequentialism and (ideal) utilitarianism as the dominant view among
moral philosophers and moral theologians today, at least in the German-speaking
and in large parts of the Anglo-Saxon world. Given the fact that we deal here with
an increasingly influential school that revolutionizes the foundations of ethics and
bioethics, and given the far-reaching moral, social, legal, and theQlogical conse-
quences of this theory, which also implies a radically new philosophical anthropol-
ogy, this new ethics deserves the utmost critical attention and examination.
The importance of such an examination derives not only from the immense con-
sequences of such an ethics for medical ethics, and from the gravity of the men-
tioned critical task itself, but also from the fact that any critical study of teleological

8 See on this Seifert, Was ist und was motiviert eine sittliche Handlung?, pp. 44 if.
310 CHAPTER 6

ethics must go beyond mere criticism and return to the moral data and 'things them-
selves', and thus delve anew into the nature and foundations of morality. It is impos-
sible fruitfully to criticize errors in ethics without offering a positive analysis of the
essence and foundations of moral values and disvalues, just as it is impossible to
recognize and cure diseases without any idea of the healthy body. Such an attempt to
elucidate positively the foundation of ethics must be regarded as the main theme of
the ensuing investigations.

2. THE MAIN THESES OF A 'TELEOLOGICAL' FOUNDATION

OF MORAL NORMS

The main theses of this new 'purely teleological ethics' must first be brought to at-
tention:
(l) Intending to refer exclusively to the interhuman (creature-related) sphere of
(external) moral actions, the new 'purely teleological ethics' denies that any action
towards oneself or towards other men (finite goods) should be judged morally ex-
cept in terms of the sum of its (foreseeable) consequences. Thus in medical ethics
only the consequences of a Giiterabwiigung (weighing conflicting goods against
each other in light of the principle of proportionality which becomes the chief prin-
ciple for ethical choices) and no general abstract norms could teach us whether a
given species of acts of physicians, such as euthanasia, assisted suicide, or torture, is
wrong.
As will be seen, this new theory of ethics combines some utilitarian moral phi-
losophy, applied to the ethical theory of external action, with some deontological
and even Kantian ethics which explores a sphere of pure interiority: intentions, fun-
damental options, and other absolute conditions of morality which cannot be derived
from consequences of moral behavior: neither from the results of single actions, as
act utilitarianism would hold, nor from the consequences of one's behavior towards
rules, as 'rule utilitarianism' would have it. 9 We shall reach the conclusion that these
two heterogeneous ethical theories of consequentialism and transcendental ethics
which 'teleological ethics' attempts to fuse into one are incompatible with each
other. This essay will center first and mainly on the consequentialist element in the
theory under discussion which is also its dominant and most influential aspect.

9 The notion of rule utilitarianism as well as the critique of its sufficiency as ethical theory in view of
principles of justice and fairness was developed by John Rawls. See, for example, John Rawls, ''Two
Concepts of Rules," Phil Rev (January 1955), 64: 3-32. See on this also Joseph Margolis, "Ru1e
Utilitarianism," Austl J Phil (August 1965), 43: 220--225. Margolis tries to show in which cases
Rawls's restrictions on utilitarian considerations do not hold and why it is "inherently impossible to
distinguish rule-utilitarianism from act-utilitarianism." For a defense of rule utilitarianism see John C.
Harsanyi, "Rule Utilitarianism, Rights, Obligations and the Theory of Rational Behavior," Theor
Decis (JE 1980), 12: 115-133. The author seeks to work out the difference between 'act' utilitarian-
ism and 'rule' utilitarianism by use of game-theoretical concepts. Act utilitarianism is in his view a
'noncooperative' game. In contrast, for rule utilitarianism, he thinks, moral behavior is a 'cooperative'
game; thereby he seeks to avoid that human rights and obligations be overridden by considerations of
social expediency. In reality, as we will see, this is untenable. Other authors distinguish still further
kinds of utilitarianism, for example Jonathan Harrison in his "Rule Utilitarianism and Cumulative-Ef-
fect Utilitarianism," Can J Phil (SUPP 1979),5: 21-45, where "the author distinguishes between rule
utilitarianism, ideal-rule utilitarianism and cumulative-effect utilitarianism."
 ABSOLUTE MORAL OBLIGATIONS 311

(2) The choice of a concrete action in terms of its consequences ought to be

guided by the principle of the proportionality of the goods and evils, which will be
realized by alternative actions (including their causal results). The action, which in
itself, and/or in its foreseeable consequences, leads to the greatest good or to a lesser
evil, is then to be preferred over any other action.
(3) The value standard which underlies this new ethics is no longer necessarily
the old utilitarian principle-the greatest pleasure for the greatest number-since
non-hedonistic values are admitted by a new 'ideal (value-) utilitarianism'. Some of
the authors defending the teleological position even grant that there are rational in-
tuitions into a hierarchy of contingent goods and values. 10
(4) From the preceding points (especially I or 2) it follows that there are no ac-
tions which have human beings or other finite goods as their object and which would
intrinsically-and therefore always (ut in omnibus)-be morally wrong or morally
right. At the most, interhuman actions could be called right or wrong in the majority
of cases: ut in pluribus.
This very same position derives also from the very different empiricist episte-
mological assumptions, according to which any strictly universal principles and nec-
essary synthetic propositions have to be rejected. If this empiricist premise is true,
universal apodictic moral laws, which could not be falsified by future experience,
will have to be denied.
(5) Of the many reasons advanced in support of this new ethics, the one that con-
stitutes its chief metaphysical-theological argument is that non-absolute, i.e., finite,
goods cannot impose absolute moral obligations. Because it is always possible that
limited goods compete with other limited goods and are mutually exclusive (Kon-
kurrenzialitiit), any limited good ought to be sacrificed for the sake of a higher good
in the case of a conflict between them, in accordance with the principle of Giiter-
abwiigung (weighing conflicting goods against each other in light of the principle of
proportionality which becomes the chief principle for ethical choices). To treat a
limited good as being worthy of unconditional absolute respect is to idolize it.
(6) All those undeniably universal moral imperatives which demand or forbid ac-
tions absolutely and under all circumstances are really non-informative and merely
analytic propositions. Ethical commands like "thou shall not murder the unborn or
the old" or "thou shall not lie to your patients" really mean nothing but: an immoral
way of killing (that is what 'murder' means) is always forbidden but it does not tell
us whether all deliberate killing of the unborn or elderly is such a wrong killing; the
second imperative only says: "to tell untruth to your patients when this is immoral
(i.e., to lie) is always sinful." This is certainly correct, these authors would claim,
but it does not tell us anything about a describable action such as telling the untruth
or taking away one's neighbor's property. The predicate in these analytic impera-
tives only repeats what the concept of the subject already contained by definition:
immoral untrue statements are immoral, etc. 11

10 See Jonathan Harrison, "Rule Utilitarianism and Cumulative-Effect Utilitarianism."

11 See the phenomenological rethinking of the difference between analytic and synthetic a priori in Diet-
rich von Hildebrand, What Is Philosophy?; Fritz Wenisch, "Insight and Objective Necessity-A Dem-
onstration of the Existence of Propositions Which Are Simultaneously Informative and Necessarily
True?"; Josef Seifert, "Was ist Philosophie? Die Antwort der Realistischen Phanomenologie", Zeit-
312 CHAPTER 6

3. IMMANENT CRITIQUE OF 'CONSEQUENTIALIST ETHICS':

ITS CONTENTS AND IMPLICATIONS, CONTRADICTIONS,
AND SILENT ADMISSIONS

The task of an immanent critique of this type of teleological ethics, which has im-
mense consequences on medical ethics, involves, first, the uncovering of its effects
and implications; and, secondly, an analysis of the position discussed to determine
whether it is internally consistent or whether it is fraught with internal contradic-
tions, inconsistencies, and other signs of falsity which are such that they can be rec-
ognized prior to investigating the subject-matter at hand (morality) itself. The basis
for such an immanent critique is mainly the principle of contradiction of which Aris-
totle says in book Ganuna of the Metaphysics that it is the most fundamental and
certain of all principles. It is the fact "that nothing can pertain and simultaneously
not pertain to the same (being) in the same respect" which guarantees the internal
consistency and unity of all being and hence also of all truth: as being cannot contra-
dict itself, so also truth cannot contradict truth. Therefore, inner inconsistency and
contradiction in a theory is a sign of its falsity. This is also the reason why the Pla-
tonic Socrates makes it a major theme of his investigations to determine whether a
given view is free of contradictions since this is a necessary (albeit not a sufficient)
condition of its truth.
The second major part of an immanent critique of a theory takes into account to
some extent the nature of the subject-matter at hand, in this case the nature of moral-
ity, but only to the extent to which a Sachkontakt (lived pre-philosophical contact)
with moral reality is universally presupposed and is also conceded by the opponent.
Here, a certain type of philosophically significant argumentum ad hominem is used
which the opponents of Socrates falsely perceived as mere polemics or linguistic pe-
dantry, as an attempt to confuse the opponent. In contradistinction to other dubious
types of ad hominem arguments, we mean here a perfectly respectable type of ad
hominem argumentation. 12 In reality, such argumenta ad hominem are designed to
show that, therefore, the nature of the thing in question is so evident that its evident
traits are also recognized by the opponent, at least when some clear instances of the
disputed datum are brought up; and that therefore the recognition of the true nature
of the thing in question by the opponent himself leads to an inconsistency with the
false elements in his position.
In demonstrating the first type of inconsistency, an immanent critique uncovers a
formal-logical inconsistency in a theory. In uncovering the second type of contradic-
tion, a material-logical and, specifically, a new kind of inconsistency is demon-
strated which derives from the fact that the evident nature of a thing, in this case, of

schriftfiir philosophische Forschung 49 HI (1995): 92-103; the same author, Erkenntnis objektiver
Wahrheit.
12 See Erik C. W. Krabbe/ Douglas Walton, "It's All Very Well for You to Talk! Situationally Disqual-
ifying 'Ad Hominem' Attacks," Inform Log (Spring 1993), 15 (2): 79-91. The authors identify there
"situationally disqualifying ,ad hominem' attacks" as "an argumentative move in critical dialogue
whereby one participant points out certain features in his adversary's personal situation that are
claimed to make it inappropriate for this adversary to take a particular point of view, to argue in a par-
ticular way, or to launch certain criticisms." They distinguish also other types of 'ad hominem' argu-
mentation.
 ABSOLUTE MORAL OBLIGATIONS 313

morality, is also perceived and admitted by the opponent. (Of course, such a non-
formal logical contradiction, i.e., a contradiction to the silently admitted nature of a
thing, when fully spelled out, gives rise to a formal-logical one as well; one which
arises between the explicit assertions and the material, content-related implications
and admissions found in a theory or author.

3.1. The General and Specific Consequences of Con sequentialist Ethics (Giiter-
abwagungsethik) for Medical Ethics
Prior to actually entering into an immanent critique of teleological ethics, the main
consequences of such an ethics must be pointed out. Only a few of these conse-
quences will be treated in greater detail.
(1) According to the described ethical position there is no general type of human
action (such as killing the innocent, active euthanasia, abortion, assistance to sui-
cide, telling a lie to patients, etc.) which would be morally wrong intrinsically and
always: Any of these acts are permitted when their consequences justify them, nay,
all types of human action (including, for example, a surgeon's accusing his innocent
nurse of his own crime so as to produce her being innocently condemned to death)
can not only become morally permitted but morally good and obligatory when their
consequences call for them. (This follows at least from the principles of this ethics
even if some of the defenders of the teleological position seek to except actions such
as leading others to sin, which Bernhard Schilller, for example, regards as always
and intrinsically evil.)
(2) No individual concrete action could be intrinsically morally wrong or right:
Not only is there no longer any general type of action which would be intrinsically
right (good) or wrong (evil) but no concrete individual act in any concrete situation
can ever be intrinsically wrong in such a way that the consequences could not-if
they change-justify it. Even an abortion carried out in order not to become over-
weight-an example of a concrete action which some adherents of consequential-
istlteleological ethics quote as an instance of an action which they regard as always
being wrong---could become good through the consequences of, in this example,
avoiding a gain in weight by means of abortion. For instance, preventing a husband
who is adamantly opposed to living with his wife if she loses her slim figure from
leaving the family, or from committing an action which is worse than the death of a
child, could justify an abortion committed in order to avoiding a gain in weight. As
soon as one ceases to regard any particular action and consequence in abstraction,
and begins to consider it in its causal context, consequentialist teleological ethics
can no longer admit that such a concrete action possesses any intrinsic moral predi-
cate which it cannot or could not lose through future consequences that have no es-
sential and intrinsic relation to the action itself.
The reason why the teleological theory cannot but ultimately dissolve any intrin-
sic moral character of concrete external actions is found in the fact that external ac-
tions are always integrated into wider and possibly changing causal and motiva-
tional-historical relationships with other events. Thus they must, from a consequen-
tialist point of view, never be considered 'abstractly', i.e., in separation from the en-
tirety of their future consequences. Therefore, no action would be complete in itself,
314 CHAPTER 6

a unity to be judged according to its inner rightness or wrongness in relation to its

immediate object, end, and foreseen consequences. Rather, according to consequen-
tialism, an action will continue to receive changing moral characteristics throughout
the entire future. Therefore, no individual action can have any fixed ethical character
that would be determined by its essence and not by its future effects.
Hence, ethical 'teleologism' denies 'intrinsically wrong (or right) actions' in two
senses. Neither any general type of action nor any concrete action in individual cir-
cumstances can, according to this position, ever be right or wrong in itself, i.e., re-
gardless of its consequences.
(3) Not even intrinsically good (right) acts in a third (weakest) sense can be de-
fended by a purely teleological ethics but only the end of history can reveal the mor-
al character of acts: Franz Scholz (with others) would perhaps admit that no action
can be intrinsically right or wrong in any of the first two senses but reply that this
position does not lead to a destruction of morality because it recognizes a third sense
in which actions can be 'intrinsically right' or 'wrong'. The adequate response to the
entirety of good at stake (Scholz applies here Augustine's conception of the ordo
amoris, the order of right love) bears a moral value that cannot be altered by the ac-
tual consequences of a deed when it is performed in good conscience and after delib-
eration in the face of all foreseen consequences. If an act of abortion (which as type
of act would not be wrong and would not be wrong regardless of its concrete and
changing consequences) would be performed concretely in this 'conscientious
weighing of good versus bad effects', the act would be intrinsically good. The mere-
ly factual (but unforeseeable) consequences cannot turn it morally evil, even when
they turn out to be very bad.
This attempt, however, to make a transition from consequentialist extrinsecism
(as William May calls it) to the 'interior moral value' of an action which was chosen
on the basis of Guterabwiigung (the weighing of good versus bad effects), seems to
be untenable from the purely teleological point of view because the claim that there
is an intrinsic value in realizing the ordo amoris, which would be independent of ac-
tual consequences, really contradicts the basic thesis of this theory of ethics. This
fundamental thesis of the new ethical teleologism is well expressed by Franz
Bockle: " ... concrete actions in the inter-human sphere must be judged solely in
view of their consequences [emphasis mine], i.e., teleologically.»!3
If, however, actions in the inter-human sphere were right or wrong regardless of
their factual consequences, they would precisely be judged in light of an inner right-
ness or wrongness which is quite independent of consequences (even if the intention
and effort to realize the immediate object and further consequences of actions is of
course very important and even co-decisive for the moral value of an action). For, as
we have seen, the causal effects and historical consequences of any human action
are never completed as long as history extends into the future. And if the value or
disvalue of a given action such as assistance to suicide depended solely and essen-
tially on the consequences, the moral character of an action would then solely de-

13 Bockle adds: "This means that in the sphere of moral actions (virtutes morales) there can be none
which are always morally right or wrong, regardless of what their consequences may be" (Franz
Bockle, "Werteinsicht und Normbegriindung," in Concilium, 12. Jg 1976/12, p. 615).
 ABSOLUTE MORAL OBLIGATIONS 315

pend on the future or the end of history. An ethics that adopts this viewpoint is thus
wholly unable to attribute convincingly any fixed intrinsic moral character to any
human action. G. E. Moore draws out convincingly the ethical agnosticism and mor-
al nihilism that follow from a pure consequentialism of the sort he himself defends:
But before proceeding I propose, first, to deal with the third kind of ethical question-
the question: What ought we to do? It introduces into Ethics ... an entirely new ques-
tion-the question what things are related as causes to that which is good in itself ...
All moral laws, I wish to show, are merely statements that certain kinds of actions will
have good effects. The very opposite of this view has been generally prevalent in
Ethics. 'The right' and 'the useful' have been supposed to be at least capable of con-
flicting with one another, and, at all events, to be essentially distinct ... In order to
show that any action is a duty, it is necessary to know both what are the other condi-
tions, which will, conjointly with it, determine its effects... and to know all the events
which will be affected by our action throughout an infinite future. We must have all this
causal knowledge, and further we must know accurately the degree of value both of the
action itself and of all these effects; and must be able to determine how, in conjunction
with the other things in the Universe, they will affect its value as an organic whole. And
not only this: we must also possess all this knowledge with regard to the effects of every
possible alternative; and must then be able to see by comparison that the total value due
to the existence of the action in question will be greater than that which would be pro-
duced by any of these alternatives. But it is obvious that our causal knowledge is far too
incomplete for us ever to assure ourselves of this result. Accordingly it follows that we
never have any reason to suppose that an action is our duty. 14

These agnostic and ethically nihilistic consequences do indeed follow from the
view that, to put it as Bockle did, "concrete actions in the interhuman sphere must be
judged solely in view of their consequences, i.e., teleologically." To relate this view
to our subject and to show its relevance for medical ethics, no physician or nurse
would ever know whether any of their actions of healing or killing their patients
would be morally right or wrong because they could not weigh the entirety of good
and bad consequences of this action. There is no way to evade the radical ethical ag-
nosticism which follows from this position; above all, there is no way back to the in-
teriority of moral good and evil as depending on the intention, object, and motiva-
tion, on the personalistic structure of the moral act itself. The extrinsecism, and the
ethical agnosticism consequent thereupon, are complete and radical.
Some authors introduce, in order to demonstrate the fact that Moore exaggerates
the human ignorance about the future, the distinction between act utilitarianism and
rule utilitarianism. While indeed we cannot foresee the total causal effects of indi-
vidual deeds, we can well foresee the consequences of general 'rules'. Insofar then
as also individual actions are conceived as expressing general rules, or as strength-
ening or diminishing the rule-consciousness in society or in an individual, the fore-
seen 'rule-related' effects of human actions provide a viable criterion for the latter's
moral character. Thus a physician-while being unable to foresee the consequences
of individual lies to patients about their health---could foresee the consequences it
would have for patients at large ifthey were lied to.
In reply to this objection, it has to be conceded that it is far easier to grasp the
future effects of general norms, laws, moral maxims, and so forth on society and on

14 G. E. Moore, Principia Ethica, pp. 146--149.

316 CHAPTER 6

the individual than to foresee natural causal effects of an individual action. Yet, tele-
ological ethics precisely deals primarily with the causal effects of individual deeds
that this position wishes to justify in particular situations. For it does not deny the
generally good effect of certain types of action or rules but only the universal truth
that in all cases (ut in omnibus) a rule applies and hence an action of a certain type
or a given individual action which violates the rule would be wrong (have wrong ef-
fects). In regard to the entirety of effects of such individual actions, however, which
teleological ethics wishes to exempt from the general rule, our ignorance is indeed
radical, as Moore pointed out. Moreover, while we ourselves will use, in a later ar-
gument against teleological ethics, the foreseeability of effects which are intelligibly
proceeding from theories such as teleological ethics, and while we grant that our
foreknowledge of future effects attains here 'practical certainty', this certainty does
not apply to the mere facticity of natural effects, or to results conditioned by free-
dom, but only to the 'logical' connection between the content of a theory or proposal
and its direct legal, social, or moral consequences. Moreover, a strictly teleological
viewpoint still leads to the impossibility of upholding the criterion of effects, even in
the case of the intelligible effects of 'rules'. For the 'dialectics of history' makes it
quite possible that, for example, the standpoint of teleological ethics will provoke a
profound ethical renewal that will have tremendously good consequences. Thus,
even in the most predictable of cases, the foreseeable 'intelligible' consequences of
a 'rule' are only those which follow from the rule's inner logic, not those which
involve freedom and which may go radically against the logic of the direct and intel-
ligible consequences, as history teaches. A strict and universal consequentialism,
however, would also have to take into account these entirely unpredictable historical
reactions and consequences of theories and general maxims. Hence, also from the
standpoint of rule utilitarianism, each moral agent will have to be either omniscient
and know all future consequences of his and other actions or he will act without any
reason as long as he remains a 'teleologist'.15
If really the sum-total of the values found in the consequences themselves were
to provide the criterion for the goodness of an act, the most radical extrinsecism
would follow: only the end of history could reveal the moral character of human acts
such as giving deadly injections to patients, even against their present will (if they
have previously signed a 'living will' or a 'living will by proxy' to the opposite), as
this is reported happening in some hospitals today; and the moral value of such acts
would be completely determined from without, without any relationship to the per-
sonal act qua personal. I6 G. E. Moore realized and accepted this consequence and,
for this reason, was a much more coherent philosophical thinker than those modern
consequentialists who seek to avoid acknowledging of this consequence (which, of
course, is so devastating for ethics that even G. E. Moore tries to get around it in
some fashion).17

15 For an interesting analysis of the effects of rule utilitarianism on problems of euthanasia and medical
ethics see Gregory W. Trianosky, "Rule-Utilitarianism and the Slippery Slope," J Phil (August 1978),
75: 414-424.
16 See on this my paper, "Ontic and Moral Goods and Evils. On the Use and Abuse ofhnportant Ethical
Distinctions. "
17 G. E. Moore, Principia Ethica, ch. 5, pp. 167, 146-147.
 ABSOLUTE MORAL OBLIGATIONS 317

Yet, as shall be shown, the thesis that the moral character of an action depends
solely on the latter's causal effects contradicts precisely the datum of good and evil.
As Kierkegaard put it in a similar context, namely his critique of Hegel's consequen-
tialist 'ethics of world-historical personalities': " ... the best king and the worst ty-
rant can cause the same catastrophe . . . the well intentioned and the evil deed can
bring about the same consequence ... "18
(4) Radical ignorance about our obligations: A further conclusion to be drawn
from the consequentialist position would be that we are radically ignorant as to what
concretely is our duty. This, as Moore clearly sees, could be neither certain nor
probable if the goodness of our actions depended on the entirety of their future con-
sequences. Also, if only the consequences were decisive for the moral value of our
action, the difference between foreseeable and unforeseeable consequences would
dissolve because we do foresee that, in principle, an infInite number of conse-
quences may result from most actions (for example, from having or from aborting a
child), while we are totally ignorant of the content of these simultaneously foresee-
able (in principle) and unforeseeable (concretely) consequences. It would also be to-
tally unknown to us whether the good effects of our abortion will ultimately out-
weigh the bad ones (which would be the case, for example, if we aborted a future
Hitler). Hence we could never know, as Moore puts it, whether any action is our
duty. 19
If, however, foreseeable consequences (as distinct from the object and state of
affairs directly intended in the action) are only one among other factors to account
for the moral character of an action, or, rather, if the decisive factor that determines
the moral quality of an action never consists in the consequences as such but in the
justice and adequacy of an agent's response to directly intended objects and conse-
quences of his action, then the need to consider all foreseeable consequences does
not lead to any of the absurd implications of purely teleological or consequentialist
ethics. For then, the primary justifIcation of the act does not lie in its consequences
but in its essential directedness to its immediate object, and even the conscious rela-
tion to the consequences of our acts then influences the moral character of an action
only by the adequacy of the conscious response to the foreseeable consequences, not
by the purely objective causal bond and usefulness of the action as such.
(5) and (6) The difference between morally good and extramorally good acts, as
well as the distinction between obligatory, good but non-obligatory, and merely
permitted acts is denied by 'universal-teleological' ethics: The difference between
morally good acts and extramorally good acts (for instance, helping the poor versus
building a bank to make more money), as well as the difference between morally

18 Soeren Kierkegaard, Concluding Unscientific Postscript, trans!. by David F. Swenson, completed,

with an introduction and notes by Walter Lowrie (Princeton: Princeton University Press, 1994), I,
"Becoming Subjective."
19 See Moore, op. cit., p. 146: "To ask what kind of actions we ought to perform, or what kind of
conduct is right is to ask what effects such action and conduct will produce." Ibid., p. 149:
... it is obvious that our causal knowledge is far too incomplete for us to ever assure
ourselves of this result. Accordingly it follows that we never have any reason to sup-
pose that an action is our duty. We can never be sure that any action will produce the
greatest value possible.
318 CHAPTER 6

permitted and obligatory actions will be dissolved in consequence of this theory.

The latter consequence comes clearly to the fore in Bernhard Schillier who denies
the difference between commandments and (evangelical) counsels for this reason. 20
Such a position logically follows from consequentialism because among the future
consequences, all of which determine the moral quality of an act, there will always
be morally relevant and obligatory goods. In fact, morally non-relevant goods can no
longer be distinguished from morally relevant goods because each good must be
considered, according to this theory, in its causal link to all future events. Thus, all
things become obligatory and too much gets demanded from the moral subject, as
Spaemann has pointed out in his critique of 'universalteleologische Ethik'.21 For
medical ethics this would mean that each and every heroic commitment of medical
staff would become obligatory, a consequence of the position that is logically con-
tradictory to the other mentioned consequence that nothing is known to be obliga-
tory in view of our ignorance of the future.
(7) A radical division between an ethics of external actions (praxeology) and the
ethics of 'fundamental options', inner acts and attitudes, is being introduced: Fur-
thermore, only actions which have effects extrinsic to the act itself are covered by
this theory, and these actions are explained by their consequences only but interior
acts; and virtues like love or humility which, as such, do not have external conse-
quences of which some would be good, others bad, are admittedly not considered by
this teleological ethics which redefines ethics as praxeology (theory of external ac-
tion) only.22 The morality of inner attitudes has to be studied, according to most of
these authors, by another 'transcendental discipline', as, for example, A. Auer pro-
poses. Hence, a division is introduced between ethics (understood as praxeology)
that would study solely external actions (including their consequences) and a 'tran-
scendental ethics' that studies the morality of the fundamental options and inner
attitudes of the person.
(8) The specifically personal character of the moral action becomes indistin-
guishable from the impersonal nature of mere means: It becomes very difficult or
even impossible for this ethics to distinguish the specifically personal quality of
morality from the mere instrumental value, which any impersonal thing that pro-

20 See Bernhard Schuller, Gesetz und Freiheit Eine moraltheologische Untersuchung (Dusseldorf,
1966), pp. 61 ff.
21 See R. Spaemann, "Uber die Unmaglichkeit einer rein teleologischen Begriindung der Ethik."
22 See Franz Backle, Fundamentalmoral (Miinchen, 1977), p. 311, where absolute obligations concern-
ing actions are explained as being only analytic propositions. Ibid., p. 306-307 he argues that
man is unconditionally obliged by the absolute ground of morality, but as a contin-
gent being in a contingent world he can realize the bonum with its absolute demands
solely in the bona which-as contingent goods or values are precisely 'relative
values' .... In order not to absolutize contingent things, any categorial decision
must ultimately rest upon some preference in which we decide according to good
and value-priorities.
Similarly A. Auer, "Absolutheit und Bedingtheit ethischer Normen," in J. Brantschen and P. Sel-
vatico (eds.), Unterwegs zur Einheit (FreiburglWien, 1980), p. 350. Compare on this question note 5
above. See also B. Lotz's critique of this view in "Philosophische Bemerkungen zum Finden und Gel-
ten sittlicher Normen," in K. Demmer and Bernhard Schuller (eds.), Christlich glauben und handeln.
Fragen einer fimdamentalen Moraltheologie in der Diskussion (DUsseldorf, 1977), pp. 243 ff., 258-
260.
 ABSOLUTE MORAL OBLIGATIONS 319

duces the same effect likewise possesses. The value as means or cause of good con-
sequences replaces .the specific moral value. If the consequences alone are decisive
for the moral value of an act, why are not animal or natural causes morally good if
they bring about life or happiness of persons? (This was already Shaftesbury's ob-
jection to Hobbes in his penetrating and devastating critique of the latter's conse-
quentialist and egocentric ethics). Why is it then not morally good if a nurse who in-
tends to murder an old person in her care in order to inherit her fortune actually mis-
takes a life-saving medicine for a poison and saves him? The moral value of an ac-
tion could only be that of a means towards an end or the indirect value of a cause in
reference to its effect, and thus the distinction between morally good causes and
non-moral, or even morally evil, causes of the same good effects becomes ultimately
inexplicable from this view-point.
(9) Ethical extinction and/or extolling of the subject? Furthermore, there is, in
purely consequentialist-teleological ethics, a mixture of ethically extinguishing and
of extolling the personal subject. For, on the one hand, as was just pointed out, the
agent of moral actions is no longer really important because all that counts are the
effects of his actions, not the actions themselves qua personal acts and the conscious
intentions. It is not any more the unique personal value of a free decision of a physi-
cian that makes his act morally good but the consequences for his patients' health
which are, however, as Kierkegaard shows in his brilliant refutation of Hegel's
ethics of the world-historical personalities, completely removed from the essence of
the moral act. For the best action can have the worst consequences and the worst act
the best ones; the actus nocens can be innocens as far as the effects are concerned,
and vice versa. According to ethical consequentialism, a person's conviction and
free decision are not really sufficient to give rise to a moral act but specialists and
futurologists should best map out the programs according to which she should act.
Yet, thereby, a decisive dimension of the autonomy of the moral subject is lost in
that the moral decision is completely taken away from the individual: a consequence
of denying his 'competence' to decide. 23 Physicians and nurses could no longer de-
cide whether they should save or kill their patients; they would have to call upon
specialists on futurology.
On the other hand, the subject's personal and wholly autonomous decision would
rule supreme. The moral agent is 'extolled' because the ignorance of even the futur-
ologists about the future is so thorough that it is ultimately completely left up to the
subject to decide whether he subjectively feels that the consequences of one act are
better than those of another one. Since the entire sum of consequences and their pos-
itive or negative character is unforeseeable by means of any objective method, while
it is clearly foreknown that an indefinite number of future consequences can result
from any human action, the subject ultimately reigns supreme and sovereignly de-
cides in complete arbitrariness which act to perform and of which action to declare
that it is subjectively intended as having the best consequences. The subject has to
decide on his own which action is to have the best consequences because no objec-
tive standard is available. This would have enormous effects on medical ethics: ev-
ery doctor and nurse would be absolutely autonomous in whatever decision regard-

23 R. Spaemann, "Uber die Unmoglichkeit einer rein teleologischen Begriindung der Ethik," p. 80.
320 CHAPTER 6

ing medical action they take. If they were honestly convinced that to kill all patients
in their ward were the best course of action to take, their acts would eo ipso be
morally right.
(10) Teleological ethics leads necessarily to the thesis that the good end justifies
(also the morally evil) means: Finally, although this new 'teleological' utilitarian-
ism, unlike classical Machiavellianism, seeks to keep moral good and evil as such
out of the radius of a 'calculation of effects', this view has the consequence that
moral evils themselves actually must be recognized as falling within the sphere of
contingent goods and evils and thus must become subject to the calculus of effects.
Hence the good end once again justifies the (morally) evil means. For even if mor-
ally good or evil acts are directed not against men but against God (as, for example,
blasphemy), and if all moral acts have, at least implicitly, the Absolute Good as their
ultimate object, they nevertheless are finite goods and evils themselves. And thus, if
a morally evil act leads to good consequences such as the preservation of the life of
many morally good persons whose goodness is a good that far outweighs the minor
evil of my immoral lie, then I should not hesitate in committing this immoral act.
This idea of 'sinning for a good purpose' is actually suggested by Charles Curran. 24
In this case, physicians and nurses could commit even what they regard as morally
evil acts in order to avoid worse (moral) evils. A gynecologist in Switzerland, chief
of a clinic, told me that he is doing this: in order to avoid that his assistant doctors
perform many abortions, he performs some abortions though he believes that to do
so is immoral: thus, he is ready to commit a lesser moral evil himself so that a
greater one committed by his assistants be avoided. This is completely in line with
the teleological ethical reasoning.
It is possible, in principle, for an adherent of teleological ethics to deny this con-
sequence by arguing that it is not possible for a morally evil action to be used for a
good purpose because to use it for a good purpose makes it good. For, according to
this position, an action undertaken for the sake of a good purpose is, by this very
same token, also good. The transcendent critique of this position (under heading 4.)
will make it clear, however, that a full-blown Machiavellianism that justifies mor-
ally evil means for good ends follows necessarily from consequentialist teleological
ethics. For many moral actions aim directly at the moral quality of the other person's
acts.

24 See C. Curran, "Utilitarianism and Contemporary Moral Theology. Situating the Debates," in Read-
ings in Moral Theology, no. 1, ed. C. E. Curran and R. A. McCormick (New York, 1979), pp. 341 iI.,
especially 359-360:
... in the imperfect world in which we Jive ... one must (sometimes) accept the
limitations of the sinful situation. This explains the theological concept of compro-
mise because of which an act which in ordinary circumstances would be wrong for
this person in the sinful situation is not wrong. (360)
See also J. Fuchs, Essere del Signore (Rome, 1981), pp. 192 iI., where a similar position is ex-
pressed.
 ABSOLUTE MORAL OBLIGATIONS 321

3.2. Immanent Critique Properly Speaking ofthe Position of 'Teleological Ethics'

(1) Teleological ethics ends up not explaining at all what it is designed to explain:
what concretely are our moral obligations? There are other related contradictions in
teleological ethics: The entire teleological position sets out to explain better than
previous 'legalistic' deontological ethical systems what concretely is our duty. Now,
it is an obvious requirement for any good theory that it actually explains the very
thing to be explained by it, and that it does not explain it away. But we have seen
that (as, e.g., G. E. Moore admits) a purely consequentialist-teleological ethics can-
not provide any clue as to what concretely our duty is. Thus, it fails to fulfill the task
it was designed to solve, and it denies the datum that it set out to clarify. In addition,
the theory wishes also to explain what constitutes the morally right (good) or wrong
(evil) character of an act. But it fails to accomplish this task as well. For if each and
every action can (as the first three consequences of teleological ethics expounded
above illustrate) become good or evil through consequences of which one is utterly
ignorant, then the difference between right and wrong actions rather than being ex-
plained is being explained away. The contradiction between explaining away any
such difference and yet assuming it, is especially evident when it is found that the
teleologists themselves presuppose the existence of duties and of the difference be-
tween right and wrong not only in their own starting point and in frequent general
ethical assertions about actions but also in the moral objections to their opponents
such as that these are proud, arrogant, that they oppress human beings by moral ab-
solutes, wish to possess God, idolize finite goods, etc. (Such moral accusations are
brought forward, for example, by Josef Fuchs, without any attempt to justify them
by reference to consequences. 25) By themselves presupposing moral qualities which
can be perceived without recourse to consequences, however, the adherents of ethi-
cal teleologism bear witness to the fact that their theory that does not account for
such intrinsically good (right) and evil (wrong) actions cannot be a correct ethics be-
cause it cannot explain the data of morality, not even those which lie at the founda-
tion of their own ethics and moral judgments.
(2) The disastrous practical consequences of teleological ethics forbid to spread
this theory, and to defend it for the sake of its truth regardless of all consequences
contradicts its content. An inescapable contradiction which shows the falsity of the
theory is the following: If the criterion proposed by ethical teleologism for judging
right and wrong acts were applied to this theory itself, the moral imperative would
undoubtedly follow that no one ought to hold it and, in any case, that no one would
be morally permitted to spread it. For if this theory has the consequences described
and justifies any general type of human action and any (even the most monstrous)
individual action as long as the agent believes that the consequences of his act will
be better than those of its omission; and if, moreover, any knowledge of our duty is
impossible because of our ignorance of the future; and if, therefore, ultimately every
subject is unbounded and the supreme authority in his ethical choices; then the adop-
tion of ethical teleologism will lead to disastrous consequences which even the pro-
ponent of this theory can hardly avoid admitting. Take as example the ethics in a

25 See J. Fuchs, Essere del Signore, pp. 179-180.

322 CHAPTER 6

hospital. According to teleological ethics, a physician or nurse could sometimes kill

a patient who requests this, other times not, they could experiment with children or
dismember healthy embryos, and so do anything they please, insisting that according
to their judgment these acts were to have the best overall consequences. Nobody else
could refute their claims. But to adopt such a position would produce the greatest
chaos and worst consequences for hospital and patients. The teleological ethicist
who recognizes the foreseeability of future consequences even of individual acts
must certainly admit the disastrous consequences that follow from his theory, not in
a merely factual manner of historical and natural causality but in a highly intelligible
logical manner as expounded above. Thus, these bad consequences, to be' further
explained in the following, must not be denied by the teleological ethicist. What are
these consequences of ethical consequentialism especially for medical ethics?
In the first place, physicians and nurses, as all other men or women, would tend
to regard any crime as permitted and would easily persuade themselves that-given
our ignorance of the future-it is a safe bet for them to perform any act to which
they feel an inclination because nothing forbids the hope that its consequences in an
infinite future might turn out to be better than those of its alternatives. Moreover, the
punitive legal system and criminal law, for example condemning medical crimes
against humanity such as human experimentation for racial reasons or torture for the
sake of experimenting with methods of palliative medicine, would totally collapse
on the assumptions of the teleologists. 26 For the question of guilt could never be de-
cided on the basis of determining that somebody freely and consciously transgressed
a law (be it positive or natural law, such as that forbidding murder), but could only
be decided in terms of the entirety of foreseeable future consequences. And since,
ultimately, nobody could know these with any certainty, any sentence passed on a
nurse who murdered her patients, for example, would have to be based on the purely
subjective opinion of the judge about the value of this action in view of its unknown
consequences; and the same crime would have to be punished or rewarded in a
wholly changeable way depending on whether or not the 'criminal nurse' intended
(and thus in her entirely subjective opinion produces) preponderantly good conse-
quences, or on whether or not she realized according to the judge's entirely subjec-
tive judgment, effects the value of which outweighs the evil of the death of her vic-
tims, in which case she would be acquitted. Another nurse could be condemned as
criminal because she refused heroically to murder her patients, against pressures of
her boss, because it was found by the judge that she intended or actually produced
by her action preponderantly evil consequences. But from this, chaos in society and
in the legal system would result.
Moreover, the greatest psychological damage would be done: conscientious
people especially would fall into perpetual 'teleological scrupulosity',27 eternally un-
certain as to what is the right or the wrong for them to do-and this they could never
know, not even with probability. Furthermore, which friend could rely on his friend

26 See A. Laun" "Teleologische Nonnenbegriindung in der moraltheologischen Diskussion. Ein kriti-

scher Bericht," in Theologisch-praktische QuartalschriJt, 126 Jg. H 2 (1978), pp. 167 ff.
27 Ludger Hillscher, a doctoral candidate at the International Academy of Philosophy, has proposed this
critique in oral discussions.
 ABSOLUTE MORAL OBLIGATIONS 323

that he would not one good day cut his throat or rob him or commit adultery, in light
of some alleged good consequence? But such uncertainty would psychologically un-
dermine any possibility of human friendship and trust which are fundamental to any
communion and which are inseparable from the conviction that there are certain
things that the other would never do.
The ethical consequences of the consequentialist view would be even worse, not
only because of the described implications of this theory but also because the abso-
lute (intrinsic) goodness of the fundamental option (or 'formal attitudes' and 'cate-
gorial value stances') granted by teleologists (for example, by Auer) is radically
shaken under the impact of this ethical position. Even if this were not a necessary
logical consequence of the theory, there would result from it, as a psychological
consequence, the feeling that 'everything is permitted'. If one takes into account in-
terior psychological consequences (which each conscious act has), it follows logical-
ly from the basic assumptions ofteleological ethics that also no interior act and atti-
tude, such as violent hatred of physicians for their patients and staff, can be abso-
lutely right or wrong as long as its individual psychological or social effects are not
studied.
Only two alternatives seem to exist for the 'consequentialist' at this point: either
he applies his consequentialist criteria for determining good acts to his own teleo-
logical theory; and then he ought to abstain absolutely from defending or publishing
it; he would have to hide it in view of its disastrous consequences which are so intel-
ligibly linked with the essence of the theory that they can be clearly foreseen. Or he
adopts an absolute ideal of truthfulness for the sake of which he must defend teleo-
logism in the name of truth and regardless of all its disastrous consequences. But
then the defender of teleological ethics refutes his theory by his very action of abid-
ing by the principles of truthfulness also when the consequences of saying the truth
are bad, nay horrible. Thus, this contradiction (that the teleological consequentialist
has to give up defending the theory if he obeys it or must contradict it by an absolute
non-consequentialist standard of honesty ifhe chooses to spread it) demonstrates the
necessary falsity of the theory.
(3) The contradiction between the radical Machiavellianism which logically fol-
lows from the basic assumptions of teleological ethics and its verbal rejection: An-
other immanent criticism of the 'new teleological consequentialism' refers to the
previously discussed thesis implied by this theory, that finite (non-absolute) goods
do not impose absolute obligations to respect them. From this it follows that also all
human moral values can be sacrificed or that immoral deeds with good private or
world-historical consequences have more positive weight on the scale of proportion-
ality of effects than morally good acts without similar success. Then a Socrates or
Thomas More acted wrongly because they refused to look at the success and effects
of actions they regarded as intrinsically wrong. But then the new teleologism turns
into a sheer Machiavellianism and teaches with The Prince that the good end justi-
fies the evil means. Precisely this necessary consequence, however, is rejected by
most proponents of the new version of 'purely teleological ethics', from whence it
follows that their position is inconsistent also on this count.
(4) Contradiction between extinction and extolling of the ethical subject: A furth-
er contradiction regards the previously mentioned tension between extinction and
324 CHAPTER 6

absolutization of the moral subject. Insofar as only the consequences, and conse-
quences which at best are predictable by a futurologist, are responsible for the moral
value of an action, the personal subject's decision and knowledge count for nothing
in this theory and the subject's motivation goes unnoticed. The subject or a nurse or
physician is degraded to a mere means to bring about good effects. On the other
hand, according to this view, a person's subjective autonomous decision which
creates the value of future consequences (which cannot be known in any objective
manner) and opinion turns out to be everything that counts in the evaluation of the
moral quality of an action, because nobody can know objectively what the future
consequences of a given act might be. In this way, whatever the physician or nurse
decide to be the morally right thing to do and therefore their duty is thereby morally
right and their duty. But this pair of contradictorily opposite consequences that must
be drawn from the teleological foundation of ethics shows another one of the incon-
sistencies of this position.
Related to this contradiction between simultaneously extinguishing the subject
(by taking away his competence to know his duty) and extolling the agent (by as-
cribing to his entirely subjective opinion the power to determine which action is to
have preponderantly positive consequences) is another different contradiction. I
mean the contradiction between declaring every action to be obligatory (by dissolv-
ing the distinction between what is morally obligatory and what is only permitted)
and thereby extinguishing the sphere of optional actions which are decisive for the
dignity of the moral subject (another type of extinguishing the subject's role); and
declaring that no action is one's duty because, as has been shown, any knowledge of
one's obligations is dissolved. This extols the ethical subject, giving him a pseudo-
divine value- and obligation-positing power. Thus everything, for example every
gratuitously worked extra hour of a nurse, every heroic sacrifice of his free time and
pay of a physician, becomes obligatory (rigorism: Oberforderung des Subjekts), and
this implies the extinction of legitimate free option between the good and the better.
And simultaneously nothing is obligatory (everything is permitted); and this results
in too little of an ethical demand, in fact in the abandoning of ethical demands, in
granting to the subject the role to decide in radically unbounded autonomy what he
opts as his 'duty'. Thus, a hospital nurse can do nothing good that would not be her
duty, and yet she could do everything she pleases as long as she thinks or arbitrarily
decrees that the effects of her deadly injections, cruel killings of babies in partial
birth abortions, etc., will have overall better consequences than all alternative ac-
tions. This implies simultaneously what Robert Spaemann has called an ethical 'Un-
terforderung'.28
(5) Radical and untenable separation between consequentialist praxeology of ex-
ternal actions and transcendental ethics of fundamental option: Finally, another
grave problem is linked to the fact that the teleological approach explicitly does not
explain the morality of inner acts and attitudes but only that of external actions, as
its adherents themselves admit. But then the moral goodness of internal acts and re-

28 See R. Spaemann, "Uber die Unmtlglichkeit einer rein teleologischen BegrUndung der Ethik," pp. 70-
8!.
 ABSOLUTE MORAL OBLIGATIONS 325

sponses (fundamental option, categorial valuations, etc.) must be governed by a radi-

cally different ethical principle from the one that refers to external actions.
Franz Scholz might object to this point by arguing that the ordo amoris is the
common basis for all morality; the due response to finite goods precisely motivates
Giiterabwagung as the only response adequate to contingent goods; the interior
'transcendental' acts or the fundamental option are to be explained by the same prin-
ciple of ordo amoris, without, however, any consequences being involved here. Yet
we reply: if the adequacy to the object is the real ground for the moral goodness of
human acts and actions, then it will be true about external actions, too, that their
goodness does not depend on the consequences alone, in fact, that it does not depend
on the consequences as such at all but on the adequacy of the act to the dignity and
value of the object which it seeks to realize. And herewith we reach a principle of
goodness of an act that radically breaks with the ethical foundation of pure conse-
quentialistic teleologism and replaces it with a principle of dueness or rightness.
Such an excellent critic of the new version of teleological foundation of norms as
T. Styczen thinks that it is not utility, consequence, etc., which are improper cate-
gories to explain moral actions. He rather believes that all depends on the particular
interpretation of usefulness and utility. He speaks therefore of a 'personalistic teleo-
logism' which lays emphasis on the fact that the moral action aims at the promotion
of the good of the person. But then it is not consequences as such but, instead, the
personal conscious aiming at positive effects, as a part of the conscious response to
the persona affirmabilis propter seipsam, which is the ground of the moral goodness
of the action which has the other person and his or her welfare as its object. In this
profoundly personalistic vision of the moral act no external consequence but the
essential perfection of the moral act itself and of the person in it are the criterion, no
negotiable consequences in the sense of the new teleological foundation of norms.
Thus, even the term 'consequence' and 'teleology' become different here.
With the last point of our immanent critique, however, we reach already the
point of transition to the far more important 'transcendent critique' which does not
look for the internal inconsistencies of teleological ethics but for the 'moral data
themselves', the elucidation of which is the principal aim of ethics.

4. TRANSCENDENT CRITIQUE OF A 'PURELY TELEOLOGICAL' ETHICS

The task of a transcendent critique of a position consists in the return to the 'thing it-
self which is dealt with, in order to examine the given position as to whether it re-
lates adequately to the Sache selbst (thing itself).

4.1. Positive Insights Contained in Purely Teleological Ethics

4.1.1. Serious Difficulties for an Ethics ofMoral Absolutes, Which Seem to Speak
for Purely Teleological Ethics
In the more extensive German text of the present critique, I have attempted to render
the case for consequentialism as strong as possible, to present even stronger argu-
ments in favor of this position than those usually put forward by its defenders. For a
326 CHAPTER 6

philosophical critique should always seek the strongest case of the criticized posi-
tion. The many powerful arguments which speak for teleological ethics culminate in
the consideration that an absolutist deontological ethics seems to lead to a total ethi-
cal impersonalism in that one or many human lives, nay the good of whole mankind,
will have to be sacrificed for the sake of allegedly absolute moral imperatives such
as that we should not lie, not engage in promiscuous acts, etc. Such imperatives for-
bid evils that are very small in comparison with the destruction of humanity and thus
should not present themselves as absolute. Yet, the horrible holocaust of all happi-
ness and of the very existence of humanity on the altar of ethical abstractionism and
impersonalistic norms seems to be readily accepted by the ethical absolutist who im-
molates man in the name of exceptionless and absolute moral imperatives which
claim to respect the person but in fact forget the person qua person.
In answer to this question and to a host of related difficulties many important
points can and should be made. Yet this is not the proper place to develop the entire
chain of reasons and arguments for absolute moral norms in the face of these objec-
tions. One central reply to these difficulties, however, lies in emphasizing the abso-
lutely unique position of moral values and disvalues. If indeed there are intrinsically
morally right and wrong actions, and if moral values and disvalues lie on a wholly
different order, higher than any extramoral goods and evils, then a man (and also hu-
manity at large, which is only quantitatively superior to the single man) should in-
deed sacrifice life and happiness rather than perform a morally evil act. The absolute
primacy of moral goodness over other forms of goodness, nay, the incommensura-
bility between moral goods and evils and extramoral ones, discussed in chapter 2,
must be recognized in order to see this point. But once this absolute primacy of mor-
al goodness over extramoral and morally relevant goods which do not involve the
unique depth of moral values and the terrible disharmony of moral evil (which is
presented in Shakespeare's Macbeth or by the mysterious guest of Zoszima in Dos-
toyevsky's Brothers Karamazov) is understood, there is no doubt that man should
give his own life up, rather than slaughter an innocent or unjustly condemn a man to
death. Then it is clear that a physician and nurse should much rather forego saving a
life of a mother or of other patients or of the whole world than commit the moral
evil inseparable from the act of abortion or of extracting vital organs from the living
and killing them.
Thus, the really decisive question in regard to the problem of 'deontic' versus
'teleological' ethics can be formulated thus: are there intrinsically morally wrong or
right actions or not? If not, consequentialist teleologism is justified. The ensuing
critical considerations (2.) will attempt to show, however, that there are indeed abso-
lute and inviolable moral obligations and that these are grounded primarily in the
dignity of the object-person and are inseparable from the dignity of the subject-
person of moral action.

4.1.2. Is There a Legitimate 'Personalistic Teleologism' Which Is Opposed to

'Teleological' Consequentialism?
One might also ask whether the refutation of purely teleological consequentialism
suffices to refute any form of teleologism and whether the latter is not true. Is not a
purely deontological ethics in the Kantian sense radically untenable precisely be-
 ABSOLUTE MORAL OBLIGATIONS 327

cause it overlooks the material and essential relation of moral acts to the object to be
realized as well as to the subject of moral actions and thus to man's utility?
In answer to this question let us underline that any external action essentially
aims at the realization of some good outside of the act itself. As Max Scheler bril-
liantly put it, whosoever cares for the good of the neighbor without really intending
this good as such (but acts perhaps only in order to fulfill his moral duty), is not real-
ly good and fails to act in a morally good manner. Hence the moral agent needs to
intend consciously and freely the good which is its object, aim at its realization, and
therefore also seek the success of the action, in the sense that he can never remain
indifferent vis-a-vis to the question of whether its goal will actually be realized or
not. If only this conscious aiming at the realization of a good were meant by 'conse-
quentialism', any good ethics should be consequentialist because no ethics ought to
forget the essential relation of a morally good external action to the intended realiza-
tion of the good in question.
Moreover, both the moral value of the action itself in its unique value-excellence
as well as the value and dignity and happiness of the acting (subject-)person is af-
firmed, at least implicitly, in the reflexive structure of the morally good action. This
may well be implied by Plato when he refers to the good (strengthening of being) of
him who acts justly and calls justice the greatest good for man. Moral goodness is so
intimately bound to the objective structure of the acting person, it is so much what
Plato calls the 'proper good' of the soul, that every attempt to offend the order of
morality or to find a higher good which could justify immoral behavior must appear
as a killing in the name of vivification. A purely personalistic teleologism asserts
that in moral goodness itself and in the dignity of the person who acts (as well as in
that of the object) there lies a value which is realized by morally good acts only, and
which would necessarily be violated by any immoral act and by any thesis that de-
nies the exceptionless validity of certain moral obligations. A personalistic teleolog-
ism and emphasis on utility in this sense is defended by Tadeusz Styczen and other
Polish critics of purely teleological ethics.
I agree fully with the thesis that we do not deal with abstract moral obligations as
such but with moral values and with morally relevant persons and goods whose
dignity absolutely requires a certain response.
I think, however, that the terms 'usefulness' and 'consequence' of actions are be-
ing used by Styczen in a radically different sense from the one which 'teleologist
ethics', as described here, intends. In Styczen, these terms no longer refer to external
consequences and effects as such but to the intrinsic structure and moral value of
acts and to the conscious and free dialogue and adequacy between an action and its
object-person who deserves a certain response absolutely and whose being is af-
firmed for her own sake and whose good the moral subject intends to realize.

4.2. Critique ofthe Central Thesis that No Finite Good Could Ground Absolute
Imperatives in the Moral Sense of the Term

The central argument of the new version of consequentialism in ethics that we inves-
tigate is (according to Bernhard SchUller, Franz Bockle, Josef Fuchs et al.) that finite
non-absolute goods can never ground absolute moral obligations. This thesis has at
328 CHAPTER 6

first sight a certain plausibility: how could a non-absolute good be the object and
ground of absolute moral obligations? This seems to be a contradiction in terms. But
let us investigate the issue at hand more closely and critically.

4.2.1. Absolutely Required Inner Responses to Non-Absolute Goods

First we turn to the question whether the thesis that non-absolute goods, such as the
value of the person of the patient, cannot address absolute moral imperatives to us,
i.e. imperatives which bind us ut in omnibus, applies to the morality of virtues as
general moral attitudes and to the sphere of interior stances we take towards con-
crete beings and values. We notice without difficulty that with respect to these
spheres of morality the thesis is clearly false. For the adequate inner attitudes to-
wards finite beings and especially towards other human persons: e.g., love, respect,
justice, etc., are required always and absolutely. This fact is also admitted by the ad-
herents of the purely teleological ethics in that they assert a 'transcendental sphere
of morality' that would not be dependent on consequences. And the moral goodness
of an action is declared to be based fundamentally on the presence or absence of the
right 'fundamental option', a thesis which flatly contradicts another assertion which
many regard as the teleological thesis: that (external) actions depend in their morali-
ty solely on their consequences. Yet, prescinding from the question of such a contra-
diction for the moment, and concentrating on the 'fundamental option' as a 'tran-
scendental sphere' behind the domain of external action, we must recognize the fol-
lowing. Ethics would then only encompass praxeology as the theory of external ac-
tions which would have to be judged according to their consequences, whereas a
separate discipline, a transcendental theory of morals, would analyze those funda-
mental moral options and attitudes which are good regardless of the question of their
consequences. Whatever we may think of this distinction, and of the tenability of di-
vorcing the sphere of external action from that of interior attitudes, the very mention
of fundamental moral options proves that the proponents of the new consequentialist
ethics presuppose that attitudes which have the neighbor (a finite good) as object can
bear absolute moral value and that there are unconditional obligations with reference
to finite goods. Even in the case in which actions are allowed which destroy goods,
the right inner attitudes (for example, love and respect of the enemy or of a criminal
person whom, at least in the case of self-defense, it may be allowed to kill, instead
of wild rage and hatred for him) are required. Such fundamental attitudes as respect,
justice, patience, loving affirmation, etc., towards each person and each patient are
certainly required from physicians and nurses absolutely and always; but they have
as their object finite goods (human persons).
Such interior attitudes are not only morally good in themselves and do not only
constitute the heart of morality, but from this 'heart' proceed countless good exter-
nal actions. Similarly, all external evil actions proceed from an evil heart, from a de-
ficiency or an evilness of the fundamental and general attitudes of a person.
Obligations, however, which demand absolutely and unconditionally that we
take the right fundamental inner attitudes towards finite beings and persons, such as
the respect and concern a physician or nurse owe to a patient, whatever his age or
gender, refute the theory of consequentialist teleologism in ethics in that they prove
 ABSOLUTE MORAL OBLIGATIONS 329

that non-absolute goods in the metaphysical sense can indeed become the object of
absolute duties in the ethical sense of the term.

4.2.2. A Radical Equivocation of 'Absolute' at the Root ofthe ChiefArgument of

Teleological Ethics
In addition, at the root of this main argument for the alleged impossibility that finite
goods can be the objects of absolute obligations, there is a radical equivocation in
the term 'absolute'. A study of these radically different meanings of 'absolute' will
demonstrate the bearing of such a distinction for a critique of teleological ethics.
There is indeed a first sense of absolute in which no finite good can be absolute: No
finite good (for example, no patient) is the absolute, i.e., the infinite good (id quo
maius nihil cogitari possit).
There is secondly a moral sense of 'absoluteness' which directly corresponds to
the first metaphysical one: the sense in which the absolute good (God) calls for a
surrender which is so total that to give it to any creature would indeed be an idoliza-
tion of it. Think, for example, of the act of adoration which, when turned to a crea-
ture, such as a fellow-physician or patient, would be blasphemy: the hymn of St.
Thomas Aquinas, Adoro te, is most beautiful when God is its object, but would ex-
press an evil act as soon as man were taken as its object. Similarly, the infinite good
(God) alone must be loved 'above everything else'. As soon as such acts that are
owed to God, i.e. acts whose proper object can only be the absolute good, turn to-
wards finite goods, finite (relative) goods are absolutized, even if they are such high
goods as health, human life, or patients. If indeed such an idolization of finite goods
were to occur in an ethics which recognizes absolute moral obligations towards fi-
nite goods, this ethics would be vulnerable to the objection launched against it by
purely teleological ethics, namely, that it idolizes finite goods.
No trace of such an idolization of the world can be found, however, in deontic
ethics that recognizes absolute moral demands imposed upon us by finite goods. For
a third sense of 'absoluteness' has nothing to do with such an absolutization of the
relative. We have in mind here a 'purely ethical' sense of absolute. An absolute obli-
gation in this sense only says that an act is absolutely due to a good, that this good,
once the general conditions of its becoming actually morally relevant are met (that a
person encounters it, is in possession of her reason and freedom, etc.), uncondition-
ally calls for such a response or respect, and that, as long as the obligation exists, it
can never be suspended by a reference to consequences. 29 Examples of such absolute
obligations would refer to the immorality of taking actively an innocent human life
or the forbiddenness of committing or assisting suicide.
An absolute obligation in this sense can just as well refer to the infinite good as
to finite goods. We absolutely ought to love both God and man; we absolutely ought
to abstain from intentionally killing an innocent man or from violating other obliga-
tions toward finite goods. On the other hand, not even all responses to the absolute
being are prescribed in this third ethical sense of 'absolute'. The so-called evangeli-
cal counsels, for example, express an invitation to a special total donation to God
that is not a commandment, i.e., not an absolute moral demand, albeit the object and

29 See J. Fuchs, Essere del Signore, pp. 179-180.

330 CHAPTER 6

motivating ground of this form of life is the absolute good. On the other hand, cer-
tainly, the discussed attitudes (such as respect, love) that have fInite goods as object
are absolutely called for in the (third) moral sense of this term. Many external ac-
tions are likewise 'absolutely called for'. Denying this would result in an untenable
moral dualism, as we shall see.
A fourth sense of absoluteness refers to the objective existence of norms and
moral obligations, both norms regarding the absolute being and obligations which
have fInite goods as their object. Both kinds of norms and obligations can in this
sense be absolute.
A further sense of 'absoluteness' that is important for the ethical discussion sur-
rounding the consequentialist teleological position refers to the necessary universal-
ity of eternal truths. The empiristically inspired denial of the absolute generality of
necessary ethical facts and norms constitutes a major methodological-epistemolog-
ical reason why many consequentialist ethicists argue that moral norms can at best
apply to most cases (ut in pluribus), but never to all individual instances of a certain
type of action (ut in omnibus). Thus, if the existence of absolute in the sense of apo-
dictically certain (synthetic apriori) truths about moral reality can be established, a
major advance in the refutation of consequentialist teleologism is made. 3D
A sixth sense of 'absolute' which is important for our discussion refers to obliga-
tions which are not only objective but which, in addition, cannot ever be suspended
or suppressed by higher ones. While, to stay with S. Kierkegaard's example in Fear
and Trembling, Abraham's higher religious obligation to obey God, to be an instru-
ment of God's will who is Lord over life and death, and to sacrifIce everything to
him, might have made the killing of the innocent permitted, there are other obliga-
tions which are absolute in the sense that they can never be suspended. (Some of the
absolute obligations in this sense, such as the obligations forbidding injustice and to
abstain from condemning someone innocent to death, could not even be broken by
God, while others depend also on the nature of the subject of the moral act, for ex-
ample man, and would not necessarily have to be 'fulfIlled' by an absolute subject
of moral perfection.) Absolute duties in this sense are the opposite of prima facie
duties in Ross's sense that can precisely be suppressed by higher duties. Such abso-
lute duties in the sphere of medical action include never to kill intentionally an inno-
cent human being, regardless of race and sex, whether born or unborn, young or old;
never to lie to a patient, never to use human persons as mere objects of experimenta-
tion without concern for their good or in harming them, etc. It is clear that the conse-
quentialist teleologism in ethics denies 'absolute duties' of this sort in relation to any
fInite good and claims that all moral obligations towards fInite goods are prima facie
duties.
One single case of an 'absolute obligation' in the specifIcally ethical (third)
sense towards a fInite good, or one single instance of the type of 'absolute' obliga-
tions which cannot be suppressed by higher ones, would suffice to disprove purely
teleological ethics. While the purely theoretical denial of 'absolute obligations' in
these senses is possible, no culture in the world fails to recognize such 'absolute' ob-

3D SeeAletheia. An International Journal o/Philosophy, vols. I (1977) and II (1981), for further discus-
sion and for literature on such an objective apriori knowledge.
 ABSOLUTE MORAL OBLIGATIONS 331

ligations. Chapter 15 of Cervantes' Don Quixote brings this out very beautifully
when Sancho Pansa observes that even a gang of wretched thieves and robbers can-
not live without some principles of justice that are respected by them as absolute.
Seventh, and finally, there is an 'existential absoluteness' of the moral sphere
which forbids to regard it ever as a means towards other ends or as 'negotiable' for
higher goods, even moral goods. In other words, the ''thou shalt (not)" of the moral
imperative is such that even if I could bring about greater moral good in others as
consequence of my immoral deed, I would never be permitted to commit it. There
lies a certain 'self-containedness' and absoluteness in the moral sphere which for-
bids me to look 'outside of it' and to 'trade' it in for some other good. The moral
evil is something 'absolutely wrong' that I should never do and the morally obliga-
tory act something that is absolutely good in the sense that I absolutely ought to do
it. Therefore, the moral subject cannot have himself represented by other moral
agents who will act better than he himself would act, if only he commits an immoral
action. The moral subject must not leave the position his duty demands him to fill
out, even if the moral effect of his violation of a moral duty were to lead to a greater
moral good than the one which comes from doing his duty.
The importance of these distinctions for our critical task is obvious because now
it is clear that, and in which sense, there are absolute duties towards non-absolute
goods and that it is, above all, in no wayan argument against such absolute obliga-
tions to point at the non-absolute nature (in the metaphysical sense 1) of the goods to
which they refer.

4.3. Are There Intrinsically Good or Evil Acts?

According to consequentialist teleologism, the morally good act itself or rather the
act in its relation to its object as such would never bear any moral value independent
of its consequences. 31 This thesis, however, is evidently false. When an act(ion) does
justice to its object and to the theme of the situation, when the 'inner word' of an act
forms an organic unity with the value of its object, when a person gives to a good
the adequate value-response, such an act possesses value always and intrinsically,
whether the consequences of the well-intended action are fatal and destroy the entire
world or have most salutary effects. And this its specifically personal and moral
value does not accrue to an action from the outside or from its consequences-how-
ever important the will to realize these consequences is for the constitution of the
moral value of the act. Evidently, the moral value of an act is borne by an act pre-
cisely in virtue of its personal agent's attitudes and adequate relation to the given ob-
ject or the will to realize it. The obvious moral facts that morally good actions, such
as the will to save a patient's life, can have adverse effects, if objectively the means
used to save a life destroys it, and vice versa prove this point. Without recognizing
this, the personal character of morality is lost sight of. This essential dependency of
morality on the person and on her motivation and inner dispositions is wholly inex-
plicable in terms of consequentialist teleologism. The radical thesis that no act what-

31 See note 1 and the corresponding quotation from Franz Bockle's Fundamentalmoral, in the body of
the text ofthis chapter.
332 CHAPTER 6

soever directed at a finite good is intrinsically morally good (right) or evil (wrong)
would have to apply not only to external actions but to all interior attitudes as well.
Precisely when it refers to the inner moral life and heart of the person, however, the
theory shows itself to be radically false.
On closer reflection, it becomes clear that at least the inner acts (responses) are
'intrinsically good' (or evil) in the third to the seventh senses distinguished above,
and specifically in the following (partly additional) senses:
(a) Their moral value does not depend on their external effects but on their es-
sential structure and adequacy to their object.
(b) The inner acts and attitudes are always prescribed: superactually as well as
whenever a morally relevant good (like human life) becomes thematic in a concrete
situation. This could not be said correctly about all types of external actions. In other
words, while some external actions can be suspended and appear as undesirable, the
right inner acts and attitudes are always demanded.
(c) Absolute obligations are not dependent on the will of any positive lawgiver.
Also in a sense that corresponds to this fact, many moral acts are 'intrinsically' (ab-
solutely) good or evil. They do not depend in their moral character on any positive
lawgiver but are good or evil by their very nature, as the Platonic Socrates in the
Eutyphro saw.
From all of this it follows that purely teleological ethics (consequentialism) is at
least not correct for the morality of interior acts and attitudes including those which
definitely have as their object finite (non-absolute) goods. These acts, although they
have non-absolute goods as objects, are nevertheless not only absolutely (i.e., with-
out possible exception) prescribed but also intrinsically good or evil in various
senses of this term that were just distinguished.

4.4. On the Possible More Moderate (Third) Thesis of Con sequentialist

Teleologism: Only External Actions Which Are Directed towards Finite Goods Are
Not Intrinsically Good or Evil
A further possible version of a teleological foundation of ethical norms would be far
less radical: instead of denying that any act whatsoever which is directed at a finite
good would be intrinsically good or evil, this third thesis would only claim that ex-
ternal actions directed towards finite goods in such a way that they intend conse-
quences in the (physical) world outside of the action itself, could never be intrinsi-
cally good or evil. In other words, this view would hold that from the so-called
'transcendental' inner attitudes described earlier nothing follows directly for the
sphere of external actions that aim at the realization of states of affairs outside of
themselves. Certainly, the adherents of this view would admit that one must always
preserve a deep sense of reverence for the dignity of each human person or for the
value of human sexuality. But from these intrinsically good general (,transcenden-
tal' or also 'categorial') attitudes it would not follow that actions such as abortion or
torturing patients in medically sophisticated ways would be wrong always and in-
trinsically. Similarly, in our attitudes, we ought always to respect the dignity and the
rights of other persons so that it is never justified to hate another person or to be in-
different as to whether she is punished justly or unjustly. Nevertheless, according to
 ABSOLUTE MORAL DBLIGATIONS 333

the teleological ethics to commit active euthanasia or to condemn actually the inno-
cent to death (the external action of killing an innocent man) may be permitted when
the consequences of not condemning him would include, for example, racial unrest
and many more deaths than would occur without condemning him unjustly. This so-
called 'Caiaphas principle' would only refer to the external action, not the interior
attitude that would require that, while we condemn the innocently accused man, we
do so only 'with a bleeding heart'. Similarly, while hatred of a man is always wrong,
it may be permitted to punish a person who has committed a hideous crime with the
death-penalty. Hence not the external action of 'not killing' but only the interior atti-
tude ofloving concern is absolutely required.
The teleological thesis, thus interpreted, could be formulated in the following
way: Absolute imperatives that have finite goods as their objects refer exclusively to
interior attitudes and allow for any external action towards finite goods (as long as
its consequences justify it). This version of teleological ethics, too, can be criticized,
and in various manner:

4.4.1. The Third Possible Thesis of Consequentialist Teleologism Denies the Unity
ofMan
First, this thesis denies the unity between the inner man and his external actions. In a
well-known book32, Ginters presents an analysis of Ausdruckshandlung (expressive
action) that seems to recognize this fact of the unity between internal attitudes and
those external actions that express these inner attitudes and thus must be judged in
light of a criterion other than their consequences (success). But, as Spaemann has
shown in various articles critical of 'universal teleological' ethics, Ginters seeks then
to reduce the value of Ausdruckshandlung to the principle of purely teleological eth-
ics according to which the proportionality between good and bad effects of one's ac-
tions is the only criterion for determining good actions and discerning them from
evil ones. At any rate, also the thesis that, while inner acts are intrinsically good or
evil, external actions are right and wrong solely in view of their consequences, com-
pletely breaks up the deep unity of the person, notably the unity between her inner
life (being) and her external Tat (action). It overlooks the central thesis of Karol
Wojtyla's book The Acting Person, that the person's being manifests itself primarily
in her free action so that between the being of the person and her actions we find an
inseparable and necessary bond. The organic unity that unites the absolutely re-
quired inner attitudes with the sphere of external interpersonal actions is denied if
one thinks that the intrinsic goodness of interior acts could exist without any intrin-
sic goodness or evilness of external actions. It is impossible to have respect for a
person superactually and always, and then, nonetheless, be justified in uttering cal-
umnies and lies about her, or beating her up, or commit partial birth abortion,H to

32 R. Ginters, Die Ausdruckshandlung. Eine Untersuchung ihrer sittlichen Bedeutsamkeit (1976). Gin-
ters maintains that the Wirkungshandlung (effect-directed action) participates in the moral quality and
"obligatory character of the inner position (response)." See also R. Spaemann, "Uber die UnmlSglich-
keit einer rein teleologischen Begriindung der Ethik," pp. 87-88.
33 The horrible form of abortion/infanticide (legally permitted in the US through President Clinton's
Veto against the large Congressional vote against permitting it), in which the crane of the partially
334 CHAPTER 6

use just a few striking examples. Likewise, it is impossible that a doctor respects the
dignity and the mystery of human sexuality, but then rapes his woman patient. This
act is by its nature evil even when its effect may be that, for example by a tyrannical
order and whim of ruler, hundreds of lives are saved. Here, the interior attitudes and
the external actions are absolutely incompatible with each other. Hence, the new
version of ethical consequentialism and 'teleologism' under consideration leads at
this point to a total divorce between the inner man and his outer action-a divorce
which contradicts the essence of the person and which 'depersonalizes' as it were
external human actions.
Consequentialist ethics denies the unity of man also in another respect. It creates
an intolerable dualism between body and soul, separating the interior life of man
from his bodily and embodied actions. The ambiguous term 'dualism'34 means here
not the distinction between soul and body which to hold is perfectly justified by the
data, but a divorce between the mental attitudes and the bodily sphere of human ex-
istence. Man's lived body is precisely-in the phenomenon of expression, in our
feeling of the body from 'within', and in many other ways-organically united with
the human spirit. Hence, an attitude of kindness and truthfulness towards the other is
absolutely incompatible with telling him actual lies, torturing him, humiliating him,
etc. (We speak: here of an intelligible 'logic of expression' between inner attitudes
and outward bodily behavior and do not preclude, of course, that some objective
necessity such as a life-saving operation may justify the inflicting of pain on another
man by a merciful doctor. Again, the principle of double-effect justifies actions of
self-defense by which the aggressor is hurt or killed. Also such actions do not con-
tradict the essence of an interior attitude of love or kindness. These cases, however,
are essentially different from those in which the entire meaning, intention, and na-
ture of the external bodily action radically contradicts the required inner attitudes.
This precisely applies to the examples we used, where it is morally and even psy-
chologically impossible that a person with purity of heart rapes a woman or per-
forms pornographic external acts or produces indecent materials, or that a merciful
and loving man tortures the innocent in order to obtain important information.) Any
view, therefore, which declares the ethical quality of bodily actions to be relative to
their consequences only, instead of recognizing their essential relationship to inner
attitudes, contradicts the unity of body and soul both in the subject-person and in the
object-person. For there are mean forms of speaking and bodily relating to another
person, forms of external actions that violate essentially and necessarily the dignity
both of the subject-person and of the object-person of moral actions. To this group
of actions belong such deeds as unfaithfulness, sexual perversions, torture, and so
on.
Finally, purely teleological ethics contradicts also the unity of the moral princi-
ple which underlies, on the one hand, morally good but fruitless and, on the other
hand, successful moral actions. For, as Kant put it, it is clear that also an action that
fails to be successful but was undertaken with full commitment and the activation of

born baby, brought before into a breach-position, is crushed before the head emerges from the womb
in the birth process.
34 See J. Seifert, Das Leib-Seele-Problem, pp. 126 ff.
 ABSOLUTE MORAL OBLIGATIONS 335

all our strength retains its full moral value and "sparkles like a jewel." It is clear that
the success of an action as such cannot add anything to its moral value. But if the ef-
fects (consequences) were the sole standard for judging moral qualities of actions,
this fact would become totally inexplicable. The moral goodness of the ineffective
good action would have to be explained by some purely internal 'rightness' of the
agent's response to a morally relevant object and to other factors (the circumstances,
and so forth), while only the successful action would be explicable in terms of its
consequences. But how can one and the same type of heroic action, whose success is
quite uncertain at the beginning, be made dependent on two entirely different ethical
principles and foundations? Given the essential sameness of the moral quality of
successful and unsuccessful actions, such a dualism in the ethical foundation of ex-
ternal actions is untenable.

4.4.2. Teleological Ethics Must Admit at Least One Important Exception to Its
Principles: Moral Values. An Internal Contradiction and the Denial ofMoral Facts
Consider a second critique of the divorce between the ethics of external actions
(praxeology) that would have to be judged by their consequences only, and the eth-
ics of inner attitudes and virtues. This critique is both an immanent critique that will
uncover an internal contradiction in most teleological positions and a transcendent
critique that demonstrates that any position that would deny this important 'excep-
tion' of countless external actions from the 'teleological-consequentialist' principle
would flatly contradict the moral facts.
Purely teleological ethicists themselves usually assert that moral evils themselves
(as opposed to morally relevant non-moral evils) must never be included in the cal-
culus of the good and bad consequences to be weighed against each other when de-
ciding on which course of action to take. The reason for such an absolute interdict
of, for example, actively cooperating with sin, is seen by some of these authors, for
example by Bernhard SchUller, in a teleological factor (namely the unconditional
character of moral values and disvalues). In his article, "Direct KillinglIndirect Kill-
ing," for example, Bernhard Schuller writes:
It would seem that one could not do anything if the negative consequence consisted: in a
sin, even if the sin is another's. Sin is an absolute nonvalue... Therefore, it must be
avoided unconditionally. It is unthinkable that one could justifY condoning what is mor-
ally evil ... It should be clear, then, that leading another into sin, as this is understood
by moral theology, must be considered morally evil by its very nature. For it takes this
term to mean an act which has the sin of another as its foreseen and intended conse-
quence ... It may be conjectured that a permissive will and an indirect act are required
as ethically meaningful categories only for moral evil (pp. 141-142).

On the other hand, the thinkers who defend the purely teleological theory hold
that (a) no non-absolute (finite, created) good can impose absolute obligations, and
(b) that there are no "ways of acting which must be judged ethically right or wrong,
independent of their consequences," that "a legalistic misconception of ethical
336 CHAPTER 6

nonns underlies deontological nonns/ 5 and that (c) no interhwnan action is absolute-
ly (in itself) right or wrong.
There exists a non-formal logical contradiction between these two claims ([a] to
[c] on the one hand, and the claim that sin must absolutely not be actively cooper-
ated with, on the other), at least one of which is clearly untenable because countless
interhwnan actions have precisely morally good or evil qualities in the other person
(and in ourselves) as object. What is meant here specifically are countless actions in
the field of education (moral education), sermons, moral exhortations and psycho-
logical-moral counseling, journalism, advertisement, movies and art, the engaging
in, or opposing of, the business of prostitution and pornography, and so forth. It is
clear that these actions are interhwnan (directed towards other hwnan beings) but-
even in the opinion of defenders of ethical teleologism-absolutely good or evil be-
cause they intend directly moral qualities in other persons. Also in the opinion of te-
leological ethicists who grant (and mistakenly regard it even as tautology) that moral
evils must never be willed actively, such actions, which clearly are interhuman,
would have to be regarded as intrinsically morally good or morally evil. In addition,
the unconditional character of moral values and disvalues does not derive from their
being the absolute good (because they are finite goods and by no means divine) nor
from the impossibility that they could give rise to a competition with other higher
goods (because my morally wrong act might save the life of another person who re-
alizes much higher moral values).
This argwnent against purely teleological ethics forces the adherent of that view
to make a choice between two alternatives both of which are fatal for his position.
Either he has to accept the fact that interhwnan actions aiming at the moral qualities
of another person involve a complete refutation of the theory that non-absolute finite
goods cannot impose absolute obligations on us and he has to accept that inter-
hwnan actions can be intrinsically right or wrong. Or the 'purely teleological ethics',
in order to escape this flagrant contradiction with its foundational principle, must
openly make the cynical transition from an allegedly moral and noble consequential-
ism, which rejects all sinful acts absolutely, to a pure Machiavellianism. Since Bern-
hard SchUller rejects the latter consequence, he should adopt the first one which, for
the sake of avoiding what he calls 'rule-worship', he attempts to circwnvent by
falling into what can be called a 'morality-worship', namely a declaring finite moral
values absolute and beyond any possible competition, as if they were divine, and as
if it were not also true that very frequently we fmd ourselves faced with a choice be-
tween actions which will precisely influence positively or negatively our own or
someone else's moral life. While Bernhard SchUller-followed therein also by some
articles of Josef Fuchs-rejects the second (Machiavellian) solution to the men-
tioned alternative and tries at the same time unsuccessfully to avoid any fundamental
revision of the consequentialist principle, Charles Curran and Josef Fuchs seem to
go at times all the way to adopt a pure and more radical Machiavellianism which

35 Bernhard SchUller, "Various Types of Grounding of Ethical Nonns," in Readings in Moral Theology,
No.1. Moral Norms and Catholic Tradition, eds. Charles E. Curran and Richard A. McConnick S.l.,
pp. 184-198;pp. 184-186.
 ABSOLUTE MORAL OBLIGATIONS 337

holds that the good end justifies all evil (also morally evil) means. 36 This view would
ultimately also imply a moral justification for the actions of the devil and for the se-
duction to sin, if these were undertaken in view of their magnificent consequence:
redemption.
Should the proponents of the new purely teleological ethics protest and say that
of course they would never embrace such an immoralist Machiavellianism and dia-
bolical attitude, then they would have to abandon their own fundamental theory
about the foundation of the ethics of external actions. Then they have to admit that
there exist many external actions which are morally right or wrong intrinsically and
absolutely, and which cannot be justified even if their effect outweighs in goodness
their evilness.

4.4.3. The Abuse o/the Distinctions 'Moral-Premoral' and 'On tic versus Moral'
Goods and Evils
A third critique of the thesis that external actions must never be judged morally ex-
cept in terms of their consequences is the following. This ethics makes a highly mis-
leading use of various distinctions (for the most part fully justified and valuable in
themselves) between premoral and moral goods in order to deny that any created
good could impose absolute obligations upon us. The notions 'premoral goods' and
'moral goods' and the distinction between them can have good legitimate meanings
but can likewise merge into one ambiguous notion many different concepts and then
be used for sophistical purposes. The distinction between the correct use and the
abuse of the terms moraVpremoral good shall prove helpful in the clarification of the
issues at hand.
(1) Incorrect use of the correct distinction moral-premoral, when moral goods
and evils themselves are called 'premoral': A first sense of premoral goods refers to
what Hildebrand37 called 'morally relevant goods' in the sense of those goods which

36 See Bernhard Schuller, "Direct KillinglIndirect Killing," especially pp. 141 ff. For a certain lack of
clarity and of committing himself to the teleological position more explicitly stated by Franz Bockle
and others, see also Bernhard Schuller, "Various Types of Grounding of Ethical Norms." See note 8
on C. Curran's and Franz Bockle's position. 1. Fuchs seems to take---in contradistinction to some pas-
sages in Essere del Signore and against W. Korff's and A. Auer's views that a lesser moral (!) evil can
be justified in order to avoid a greater one---a position similar to that of Bernhard Schuller. See
J. Fuchs, "'Intrinsece Malum': Uberiegungen zu einem umstrittenen Begriff, " in W. Kerber (ed.),
Sittliche Normen. Zum Problem ihrer allgemeinen und unwandelbaren Geltung (Dusseldorf, 1982),
pp. 74-91, especially pp. 75,90 (Nr. 2), 91.
Among the critics of this view one should also mention-besides those already mentioned-Ra-
mon Garcia de Haro and Fernando Inciarte. See the latter's exchange with Bernhard Schuller, in Theo-
logische Revue (MUnster) Nr. 2, 78. Jg. (1982). The title of Inciarte's paper is "Thenomie, Autonomie
und das Problem der Politischen Macht," Theologische Revue (MUnster) Nr. 2, 78. Jg. (1982): 89-
102.
37 See D. von Hildebrand, Ethik, pp. 267 ff. The same author, Moralia, pp. 445 ff., where three meanings
of 'morally relevant' (sittlich bedeutsam) are distinguished: a merely functional meaning of this term
which refers to all those goods and values which can ground moral imperatives and are objects of
moral acts (whether they are themselves moral values and goods or not); a second meaning of this
term distinguishes the morally relevant but not moral goods and values from the moral sphere itself
(for example, the human life as morally relevant albeit not moral good); a third sense of 'morally rel-
evant goods' intends those goods which do not issue moral imperatives (for example, certain aesthetic
338 CHAPTER 6

are not themselves moral goods but which impose moral obligations. In regard to
such morally relevant goods it is quite true that Konkurrenzialitiit (competitive,
mutually exclusive character) is possible and that it may be demanded that one of
these morally relevant goods be sacrificed or be left to perish in order to save an-
other more important morally relevant good which needs to be saved. For example,
it might be necessary to allow the death of some men because any action on our part
to save them would make it impossible for us to save other human persons and
would thus perhaps mean the death of persons more directly entrusted to our care.
Yet, moral values and disvalues differ radically from morally relevant goods and
evils that are not themselves good or evil in the moral sense. And this difference re-
gards especially the fact that the 'competitive' nature of morally relevant goods does
not at all apply to the moral sphere itself, as if we were allowed to realize one moral
evil in order to avoid others or in order to save some morally relevant goods. In the
first place, moral values and disvalues have, as we have seen, a peculiar kind of (ex-
istential) absoluteness which is radically different from the absoluteness of God but
which nevertheless forbids realizing moral disvalues for the sake of any other higher
goods (even when this is actually possible, as in the case in which a sin saves the life
of a morally much better man than we are or in the case in which sin would be com-
mitted in view of redemption). In the second place, we need to remember that those
morally relevant goods that are not themselves moral goods (also moral goods and
evils are morally relevant goods and some of our preceding reflections referred to
them) do not possess the same 'absoluteness' by which morality itself is character-
ized. Hence the 'competitive mutual exclusiveness' that in the case of some morally
relevant goods justifies their destruction does not justify the violation of morality
itself. For this reason, too, it is absolutely wrong to regard moral goods and evils-
as long as one prescinds from their consequences-as merely 'premorally good or
evil', because such a position precisely implies the confusion between the specifi-
cally moral (and specifically, the morally obligatory) sphere and the domain of ex-
tramoral morally relevant goods within which the calculation of the higher of mu-
tually exclusive goods can have some rightful place.
Moreover, as Carlo Caffarra rightly points out, morally 'relevant' goods partici-
pate in the absoluteness of the moral sphere itself when they become morally rele-
vant, i.e., when they concretely address a moral imperative to us. This moral rele-
vance of a good arises only in its encounter with a person who is specifically related
to it. For example, the cry for help of a needy person is not in itself morally relevant;
it becomes so for someone who passes by and hears it. Morally relevant goods such
as the need of a human being cease to assume this absolute character when they ap-
pear outside of the context of a moral action, or rather when their moral relevance is
potential and does not address somebody. When Socrates is commanded to take the
life of an innocent man by murder, the value of this life unfolds its moral relevance
and Socrates is absolutely forbidden to take it even in order to save his own and oth-
er lives; because to kill in this case is immoral and the dignity of the one innocent
man partakes in the absoluteness and superiority of moral values over all extramoral

values and goods) in contradistinction to those which ground moral obligations and which are then
called morally relevant precisely for this reason.
 ABSOLUTE MORAL OBLIGATIONS 339

values. Hence it is here not a question of many lives against one but what is at issue
is the incomparable and 'absolute' primacy of the obligation to avoid moral evil ver-
sus the coming into existence of extramoral evils. Of course, one needs to under-
stand, in addition, that moral good and evil (moral relevance) is not restricted to the
totality of good and evil effects of human actions to be weighed against each other
(as Josef Fuchs argued against Caffarra), but that certain modes of behaving towards
created goods are intrinsically morally good or evil because their object-goods are
morally relevant directly and in reference to specific actions.
The weighing of good versus bad effects of human actions as basis of moral de-
cisions would, however, be a proper consideration when the moral theme does not
exclude certain actions and when we have merely to select the higher value, as when
we can save one life in one part of town by quick medical action and two hundred in
another part of the same town. When we consider this fact it becomes clear that
Grisez, Boyle, and May offer a questionable argument against ethical consequen-
tialism. 38 They maintain that there is an absolute incommensurability of the elemen-
tary goods in such a way that it is impossible to compare them in terms ofhierarchi-
cal superiority. In reality, however, 'quantitative' as well as 'qualitative' hierarchical
gradation within the so-called elementary goods must be recognized and is also pre-
supposed for any meaningful application of the principle of 'double effect'. If it is a
mere question of the goods on the object-side, of course a quantitative hierarchy of
goods applies in that it is better to save two hundred human lives than just one
(which does not exclude that special obligations towards the one person may bind
me to save her life rather than the two hundred). Similarly, when it is a question of
permitting that either our life, or our honor, or our moral integrity, or our physical
integrity be violated, qualitative hierarchical points of view play the decisive role,
even if it is true that many different points of view (rank of value, indispensability,
and the like) come into play here so that one clear 'ranking' of these goods (life,
freedom, honor, moral integrity, health, etc.), as if these goods were 'higher' or
'lower' simply speaking and under all relevant points of view, is impossible. Never-
theless, it is clear that life ranks higher than health, or that moral integrity is a higher
good in itself than life, and so forth.
This hierarchical gradation of the 'elementary goods' is not only to be admitted
in the context of any meaningful application of the principle of double-effect but al-
so for the insistence on the absolute priority of the moral point of view over extra-
moral considerations without which primacy the consequentialist position cannot be
refuted at all. The decisive point that the moral drama and moral obligations are
more absolute than the 'premoral' sphere of morally relevant goods and that these
goods, when their dormant moral relevance becomes actual, partake in the absolute-
ness of morality itself, as Caffarra puts it well, could also not be seen without recog-
nizing a hierarchy of goods and a 'negative hierarchy of evils' .39

38 See, for instance, G. Grisez and J. M. Boyle, Jr., Life and Death with Liberty and Justice: A Contribu-
tion to the Euthanasia Debate (Notre Dame, Ind., and London 1979); G. Grisez, Abortion: The Myths,
the Realities, and the Arguments (New York and Cleveland 1970).
39 See C. Caffarra, "Die Unmoral der Empfiingnisverhiitung," in Theologisches, Nr. 133, Mai (1981):
4078-4088.
340 CHAPTER 6

In order for consequentialism to be refuted it is of crucial importance to under-

stand precisely this point, which is contained in the famous Socratic thesis in Plato's
Gorgias that "it is a greater evil for man to commit injustice than to suffer it." This
truth cannot be grasped without understanding the fact that the moral evil of an ac-
tion is precisely different from the non-moral but morally relevant good of health or
life on the object-side and outweighs the latter by far. There is, for example, a great
difference between allowing/not preventing that a false sentence be written by an-
other (where the evil of a false statement is given as such), and myself writing or
asserting it (where it is morally relevant and issues an obligation to me which to vio-
late brings about a grave moral evil). Thomas More, to take a concrete example,
died for the difference between these two cases. He would not have been obliged to
die in order for the false statement not to be made by Henry VIII, but he was obliged
not to agree to make, under oath, the false statement (about the ecclesiastic suprem-
acy of Henry VIII) himself. Morally relevant goods and evils (from which moral
calls issue but which are not themselves goods and evils in the moral sense, such as
life) and moral goods and evils are radically different from each other. The physi-
cian is not obliged to sacrifice his life for the life of a dying patient, but he is obliged
rather to die than to commit the immoral acts of euthanasia or abortion, or others.
Moral evils have a peculiar form of 'absoluteness' through which they reject the ab-
solute good and offend God, whereas extramoral evils (which can become relevant
for morality) do not. The reason for moral relevance does not lie exclusively in the
image-of-God-character of the human person or in the fact that a good or evil is re-
lated to the person (because not all personal values are morally relevant and also ani-
mals possess a certain moral relevance).
Thus, we conclude that a serious ethical confusion is being introduced as soon as
moral goods and evils themselves are called 'premoral' as long as they are regarded
independently of their consequences. This is an illegitimate usage of the term 'pre-
moral' goods because it is entirely based on the consequentialist-utilitarian error.
This sense of the discussed pair of distinctions must not be confused with the sense
in which morally relevant (not moral) goods are called 'premoral' because some
(potentially) morally relevant goods really are not actually morally relevant objects
of human action when they are not seen in reference to consequences. This applies,
for example, very clearly to the case in which the moral relevance of a certain true
statement depends on the effects it will have on society, on the reactions the person
to whom it is made will have, etc. In another sense, it applies also to the moral rele-
vance of a human life in danger, whose actual moral relevance and originating of
moral obligations may be suspended if the action of saving it prevents me from sav-
ing hundred other lives on the other side of a sinking ship.
(2) An incorrect use of the distinction when it is denied that premoral goods can
impose absolute moral obligations: A second confusion results as soon as those
morally relevant goods and evils which are not moral goods and evils are interpreted
in such a way that no moral response due to them could ever be absolutely required.
Then it is forgotten that also these morally relevant goods, insofar as they demand a
certain moral response, partake in the absoluteness of the moral sphere. Hence also
non-moral morally relevant finite goods can issue absolute moral imperatives. {I am
 ABSOLU1E MORAL OBLIGATIONS 341

thinking here especially albeit not exclusively of the sixth sense of 'absolute' distin-
guished above.)
(3) Incorrect use of the distinction between moral and premoral goods when all
moral obligations are called 'prima facie' obligations: The actions corresponding to
prima facie obligations could likewise be called 'premoral goods'. Such prima facie
obligations as pacta sunt servanda do not as such and necessarily make each and ev-
ery action immoral which fails to keep a pact. Only when a prima facie obligation is
not suppressed by a higher one, is a moral obligation actually present. Therefore,
one could say that fulfilling the terms of a contract is not intrinsically and neces-
sarily morally good; for example, it is morally evil when a surgeon keeps a pact to
perform an immoral operation. Hence, actions which obey the principle pacta sunt
servanda are good only in a 'premoral sense', which means here that they are nor-
mally morally good but can under circumstances (as when the contract itself is in-
trinsically immoral) become morally bad.
As long as it is clear that one speaks here of 'premoral' in an entirely different
sense, it is legitimate to say that obedience to prima facie duties is good only pre-
morally and that the real moral value of fulfilling a prima facie obligation depends
on the presence of additional factors which make the observation of these principles
in the actual situation specifically morally good.
But an abuse of the term 'premoral' results from a generalization of this case of
prima facie obligations, i.e., from regarding all obligations as prima facie obliga-
tions only, denying the difference between non-absolute prima facie duties, i.e., ob-
ligations which can be suppressed by higher conflicting ones, and absolute (i.e.,
non-suppressible) duties. From a universal application of the last distinction between
'premoral' versus 'moral' it would follow that no action is intrinsically morally right
or wrong.
The denial of intrinsically good or evil (right or wrong) acts rests largely on this
entirely different sense of the moral-premoral distinction, which by definition elimi-
nates any acts or actions that could be morally forbidden universally, i.e., under all
circumstances. We have already found, however, that non-absolute, finite goods im-
pose ethically speaking absolute obligations, both in reference to inner responses
and stances and in regard to some external actions. Thus, the universal claim that no
type of action as such is intrinsically morally right or wrong is false.
(4) Morally right/wrong versus morally good/evil acts: Finally, another totally
different sense of premoral versus moral goods and evils simply designates the dis-
tinction between morally wrong (false) and right actions, on the one hand, and mor-
ally good and evil ones, on the other. As was recognized by most ethicists of the
past, the objective nature of an action (the materia) is not sufficient to account for
moral goodness or evilness. Rather, knowledge (consciousness) and actual posses-
sion of freedom are presupposed for the coming into existence of moral properties
including the morally right or morally wrong character of actions that does not exist
for animals deprived of reason and freedom. Nevertheless, a decisive distinction ex-
ists between the objectively morally wrong or right nature of human acts and the
actual morally good or evil character of human acts. For if a person innocently does
not understand that an act of euthanasia is morally wrong, it would remain wrong
but not be morally sinful. In the discussion surrounding purely teleological ethics
342 CHAPTER 6

this distinction is frequently confused with the preceding ones, and the obvious fact
of the validity of this distinction (which was always made in the tradition in that it
was recognized that moral responsibility and knowledge are required to make an ob-
jectively morally wrong act immoral or sinful) must not be invoked to justify the
above-mentioned illegitimate usages of the 'moral-premoral' distinction.
(5) Ontic versus moral goods and evils: In teleological consequentialism we also
find another fundamental abuse: that of the important distinction between moral and
ontic goods and evils. All extramoral ontic goods are distinct from moral ones and
must be perceived in their clear difference from them, although there are many ontic
goods, such as human life, which make moral claims upon us. Human actions are di-
rected towards such goods as the life that we attempt to save. Moral values, as
Scheler puts it, appear "on the back of the moral action" because the action focuses
primarily on the realization of the ontic goods that are its object. The extra-moral
ontic goods in relation to which the moral act unfolds as value response or in other
modes do not make the absolute claim upon us which moral goods themselves
would make. It is true, for example, that circumstances and other calls may force us
to abandon the life of a human being that, under these circumstances, we are no lon-
ger obliged to save. It is true that these goods are not imposing the same 'absolute
duty' upon us which morality itself contains.
But the question is precisely: what is the relationship of these ontic goods, which
Kant classifies as objects of inclination and as natural goods, to moral goods?
We have to exclude three fundamental misunderstandings that lead to ethical er-
rors and attempt to recognize, positively, important ethical truths concerning the re-
lation between the moral act and ontic goods that are its object:
(1) The first misunderstanding we need to exclude is that these ontic goods-be-
cause of their finitude and because of the absoluteness of the moral act-have noth-
ing whatsoever to do with the origin of moral oughtness. This is the fundamental
mistake of Kantian ethics which, recognizing the discrepancy between ontic goods
and moral goods, believes that the source of the absoluteness of the moral ought
must lie not in the object of the act but in the subject, in the pure form of the cate-
gorical imperative. Kant believes that the object of the moral act can never justify
the moral ought, which must be explained a priori by the subject. While we do not
wish to deny that the subject, and the personal subject's encounter with objects, is
crucial for the arising of moral oughtness, which never lies in the object or ontic
good alone, the moral imperative still originates intelligibly in the nature and value
of objects and in the imperative issuing from them. Thus, for example, the ontic
good of the dignity and freedom of persons addresses its call for proper recognition
to the free agent. The raison d'etre of the moral act is, in a certain sense, to give the
due response to certain ontic (morally relevant) goods that deserve recognition and
affirmation by the agent from a moral point of view. This is expressed in what Karol
Wojtyla, Tadeusz Styczen, and Andrzej Szostek regard as the foundational moral
norm: "persona est affirmanda propter seipsam. "40
Thus, there is an important relationship between moral and ontic goods, a rela-
tionship which Kantian ethics does not recognize, partly because Kant has a concep-

40 See K. Wojtyla, A. Szostek, T. Styczen, Der Streit urn den Menschen, pp. 31 ff., 94 ff., 144 ff. 10.
 ABSOLUTE MORAL OBLIGATIONS 343

tion of the relation between a priori necessities and experience which forbids him to
recognize that ontic goods could be understood in their essence in themselves and
that absolutely necessary moments such as the moral imperative could be grounded
in the essence of the object of the moral act although it is an object of experience.
Yet, if one recognizes and brings to evidence that in and through the object of expe-
rience also essentially necessary facts disclose themselves to us, Kant's reason for
denying that the intelligible essence of objects of experience can be the origin of
moral imperatives and that we can recognize moral imperatives related to the objects
of moral acts is refuted.
(2) We have to exclude two possible misinterpretations of the nature of the rela-
tionship between moral acts and their objects.
A. First, the misunderstanding must be avoided as if the moral act had only the
function of a means through which the respective ontic goods would be brought
about as consequences. This interpretation of the relation between moral act and on-
tic good, which is its object, forgets that many moral acts (such as purely interior
stances a person takes towards others, as love or envy) are bearers of moral qualities
without having any function of realizing goods that are extrinsic to the act. Clearly,
at least their relationship with their object must be entirely different from a means-
end or a cause-consequent-relationship. All goods endowed with intrinsic value and
preciousness make a call upon persons who are able to understand them that they
ought to acknowledge them in freedom or by a rational affective response. All
value-bearing goods demand to be affIrmed by persons in accordance with their
value-merit, with what is due to them. The due-relationship, which is fulfIlled in the
adequate value-response, demands not only to be respected for the sake of man and
his fulfIllment but also and primarily for the sake of giving the good, which calls for
an adequate response, its due. This response mayor may not increase the happiness
of the object-person to whom it is directed, as in the case of the worship of God,
which does not increase his Blessedness. Nor does man have to give the due re-
sponse primarily for his own sake, in order to become happier. He ought to give his
response primarily for the sake of the good itself, for the sake of its intrinsic pre-
ciousness and worth: because it is right and just and good-only secondarily be-
cause it also fulfIlls his own objective good. Hildebrand has profoundly investigated
these dimensions of the person's response to goods and values and has made these
investigations fruitful for ethics. This due-relation itself and its fulftllment in the
adequate response are not reducible to the ontic good that is the object of our re-
sponse. This due-relation and the value that lies in its fulftllment are something radi-
cally new with respect to a given ontic good itself. Especially persons, and the uni-
que dignity which they possess, call for such an affirmation and respect which is due
to them. This was recognized by Kant in one of his formulations of the 'categorical
imperative' which is not 'formal' but has distinct reference to the object of the moral
acts, namely persons, forbidding that these be ever treated as means only and not si-
multaneously as ends in themselves. Kant gives the profound reason that persons
possess an inherent 'absolute' value (worth), an absoluten Wert, which is not rela-
tive to inclinations or other dispositions of the subject but resides in the objective na-
ture of persons. All of this presupposes the relation between goods and persons. It is
344 CHAPTER 6

an arch-datum that can only be understood intuitively but is as evident as the first
principles of logic or mathematics.
As we have seen, above and beyond the presence of a good endowed with an in-
trinsic preciousness, 'moral relevance' is required in order for our stance to that
good to be bearer of moral goodness or evilness.
Against this background, the errors of an ethics become manifest which con-
centrates only on counting and weighing the consequences of actions in the sphere
of ontic goods (which stand on the object-side). For clearly, the due response or the
violation of it may express themselves as well in purely interior virtues or vices, in
attitudes and stances of persons, as in external actions. Both interior stances, which
do not even have external consequences, and actions in the world, however, must be
judged not solely in accordance with their consequences but with reference to their
inherent adequacy or inadequacy to their object. If a man kills another one or tor-
tures and humiliates him, his act is evil not simply because it results in death, which
can likewise be the case with a legitimate and well-intentioned operation, but be-
cause this action manifests a response to the person which stands in violation of her
morally relevant dignity and worth. This does not exclude any teleological directed-
ness to consequences of acts. Of course, the right response involves where possible
the attempt to realize, protect, or save the morally relevant good by means of
external action. Moreover, the moral imperative and the moral relevance of the good
also require that we do also what is objectively good/or the object-person of our act,
that we do what is useful for him. Yet-and this is the decisive point-our act is
good or evil not simply for the reason of its consequences but because it realizes the
right and just response to that good. And even the act that aims at external results is
to be judged morally not by its actual success but by the internal being and personal
structure of 'justness'.
B. The most obvious immediate ethical consequence of the described different
conceptions of the relationship between moral act and ontic good relates to the rec-
ognition or negation of intrinsically permitted, intrinsically wrong or right (obliga-
tory) actions. If only the consequences of actions count, consequentialism and teleo-
logical ethics are correct. Then the moral character of a person's action results only
from her weighing the consequences of her actions. If this is so, the destruction of
morally relevant 'ontic' goods for the sake of preserving other and higher ones is al-
ways permitted. There are, then, no longer intrinsic and essential relationships be-
tween moral actions and their objects. Under these assumptions, a revolutionary
concept of the relation between moral and ontic goods follows.
If the principle of 'due response' to morally relevant goods is introduced, the
morality of internal acts as of external actions flows primarily from the same source.
The moral character of a human act is due, namely, to the inner justice, rightness,
and goodness of the free response of a person to that ontic good which, in its moral
relevance, is the direct object of the action and intention of the agent. 41
We have seen, however, that with the person's encounter with ontic goods their
moral relevance becomes actualized and they partake in the absoluteness of the mor-
al sphere itself. As soon as they address their call to persons to give the due response

41 See Josef Seifert, Was ist und was motiviert eine sittliche Handlung?
 ABSOLUfE MORAL OBLIGATIONS 345

to them, the moral drama unfolds. And then the respective ontic good is not to be
considered alone, in isolation, as it were, from the ethical subject. Rather, in the in-
trinsic connection of ontic goods, with the moral obligation or call and with the mor-
al response, the same seriousness and unconditional respect which moral value
themselves command is communicated also to ontic goods inasmuch as they stand in
the moral situation. The sanctity of human life which, when this life is destroyed as
side-effect of a morally legitimate action, does not appear actualized in its morally
obligatory character, appears in the drama of justice or of murder in its whole depth
and demands with moral sovereignty and absoluteness the morally adequate re-
sponse. In fact, the new and absolute moment of moral calls and obligations enters
into the objective situation and imbues the ontic goods with moral weight and se-
riousness, as long as they remain in this moral context. For example, as long as the
human fetus is not just dying or living by natural causes but the object of being
killed or not killed in abortion, it is connected with the whole weight of the moral
question-as opposed to the situation in which its death is caused by natural causes
or also by the removal of a cancerous uterus. Thus, when the potential moral rele-
vance of life is actualized in a concrete encounter between ontic good and moral act,
the principle holds: to violate the morally relevant ontic good and the obligatory
moral response to it is intrinsically wrong because it includes a violation of morality
itself. The moral in this sense is in the world, not transmundane. It has to do with the
concrete Gestalt of actions towards inner-worldly goods. To violate them is to
wrong the moral order and to offend the absolute good; to act rightly towards them
is to act rightly in itself and, at least implicitly, towards the absolute Good, towards
God.
It becomes manifest that it does man no good, as Socrates puts it, to flee death
(an ontic evil) if the quicker (moral) evil of injustice takes possession of the soul,
and that it serves man nothing even if he gains the whole world but suffers damage
in his soul.

4.5. Critique ofthe Depersonalization ofMorality Implied in the Allegedly

Personalistic Ethical Teleologism
The champions and followers of the new utilitarianism of 'purely teleological ethics'
pride themselves with getting away from an ethical legalism and with rediscovering
the autonomy and dignity of the person. Their position seems to recognize the con-
creteness of a person's situation and of her problems. Seemingly, it gives full weight
to each individual's moral decisions and frees man from being enslaved by some
universal standards whose generality of 'always' or 'never' allegedly forgets the
concrete moral subject and the infinite complexity of situations which permits only
an ut in pluribus (in the majority of cases), if morality is to avoid the reproach of be-
ing a depersonalizing legalism and 'rule-worship'.
However, we discovered upon closer examination that precisely the thesis that
the consequences of actions alone provide the clue for their moral character implies
a total depersonalization of morality, already for the reason that the very same good
consequences that allegedly justify a concrete action could in many cases also be
brought about by impersonal causes. Consequentialism (we prescind here from the
346 CHAPTER 6

doctrine of 'fundamental options' as principle of goodness which, as we tried to

show above, contradicts the consequentialist foundation of ethics) forgets one of the
most obvious facts of ethical experience, namely, that the subject's stance, knowl-
edge, and intention are decisive for the constitution of moral qualities. A rigorous
consequentialist position results in a total overlooking of the factor of motivation
and Gesinnung which distinguish an action of a Pharisee from that of a saint, also
when both actions have exactly identical consequences. Kierkegaard in his critique
of Hegel's world-historical ethics, Kant in his critique of utilitarianism, and Plato in
Republic II (in his interpretation of the story of the ring ofGyges and in his compari-
son of the best life with the worst consequences and of the worst one with the best
consequences) bring out forcefully the untenability of ethical consequentialism
which makes the moral value of an act dependent on effects which are external to its
essence and its personal relationship to its object and end.
When we consider the interior motivation of external actions, it also becomes
evident how utterly untenable is any separation between inner acts and outer actions
because the deepest source of value of an external moral action lies precisely in the
inner free stance of the agent which is based on the knowledge of morally relevant
goods. Phariseism or ressentiment can totally vitiate any external action regardless
of its excellent consequences. Thus, its moral goodness or rightness cannot be
grounded in its relation to its effects.
Another aspect of the depersonalization of morality through consequentialist te-
leologism consists in this position's overlooking many important moments in the ob-
jective but personalistic structure of the human action itself. Thomas Aquinas has
clearly made the decisive distinction between finis operis (objective essential 'end'
of an action itself) and finis operantis (subjective motive and intention). Both of
these moments concern the conscious and free structure of the human action and in-
volve the immense difference between merely foreseen and indirect 'consequences'
and purposes of an action, on the one hand, and intended and direct consequences,
on the other. Hence both of these decisive elements of moral actions are lost sight of
as soon as the essential role of the person's intention, inner stance, and motivation is
overlooked as formative for the moral value of the (external) human action and as
totally irreducible to that action's causal function of producing consequences. The
same applies to the crucial distinction between object (in the broader sense of, for
example, the persona affirmanda propter seipsam which plays such a crucial role in
the personalistic ethics of Karol Cardinal Wojtyla and of Tadeusz StyczeiJ.42) and the

42 The various critical contributions of Tadeusz Styczei on the subject of a purely teleological ethics are
not yet published in any language besides Polish. The fundamental ethical position of T. Styczei,
however, in which the "person is to be affinned because of herself (because of his or her dignity)"
plays a central role, and also the ethical position of Styczeil's philosophical teacher (Karol Wojtyla-
Pope John Paul II), is outlined excellently in T. Styczeil's article, "Zur Frage einer unabhangigen
Ethik."
Many other authors, for example Grisez in some articles, have emphasized the personalistic nature
of morality and have rightly pointed out how especially "Christian morality is a morality of the heart"
and that the loving attitude of the heart is far more important than the consequences of our actions. For
from here proceed all the motivations and intentions which account for the specifically moral and
personal character of human actions, also external actions.
 ABSOLUTE MORAL OBLIGATIONS 347

Sachverhalt which is the direct object of the external action as such, the fact to be
realized by the agent. Only the latter (the state of affairs directly realized by the
agent) can at all be recognized by teleological-consequentialist ethics because the
object of an action in the broader sense (for example, the person herself in regard to
whom I act) is not a consequence of my action, has no further consequences initiated
by my action itself, yet should be affirmed in and through any external action in or-
der for this action to have any moral value. Any action that aims at a human or di-
vine person, for example, is morally good or evil primarily because it expresses a
loving affirmation or hateful negation of the person. This loving affirmation of the
person as such is in no way identical with that side of the action that realizes states
of affairs outside the human act itself. Yet, only the states of affairs directly realized
by human actions have consequences. Thus, consequentialist and teleological ethics
take into account only an extremely limited part of the entire object of the external
moral action. Consequentialism thus distorts the nature of moral action by cutting
out the primary object(-person) at which the action is directed. This is a particularly
great flaw in a theory of medical ethics for here the moral relevance of the person of
the patient to be affIrmed by physician and nurse infInitely exceeds the small
fraction of her reality which medical art can improve or change. Moreover, even that
part of the object (Sachverhalt) which consequentialist ethics does admit is reduced
to the same level as those mere effects of an action that are not the intended finis of
the act. To overlook such central distinctions or to be unable to account for them im-
plies another aspect of the depersonalization of morality that objectively is implied
by 'purely teleological ethics', however much this may be opposed to the intentions
of its proponents.
The specifIcally personal dimension of morality, nay the person herself, is not
only overlooked but also actively negated in this ethics. Instead of a new personal-
istic ethics it is an anti-personalistic ethics. For if the person and her actions become
a mere means with respect to consequences, he or she is degraded as person. Such a
consequentialism goes directly against the personalistic principle enunciated by
Kant (and in Love and Responsibility and elsewhere by Karol Wojtyla) that "a per-
son must never be treated solely as a means but always simultaneously as an end in
herself." Any reduction of the moral value of an action (as well as of object-persons
of human actions) to mere functions with respect to results is thus the moral attack
on the person-in the name of ethical personalism. This anti-personalism of ethical
consequentialism emerges especially when one considers the essential truth about
the person formulated by the Platonic Socrates in the Republic, the Gorgias, and
elsewhere, that moral goodness is the good for the person, the 'proper good of the
soul'. If, then, the person is reduced in what is the perfection of man and of any per-
son qua person to the function of acts for consequences, we are confronted with a
program of radical anti-personalism and, as Tadeusz Styczen has shown, of-anony-
mous-anti-theism. 43

In reference to the personalistic anthropological foundation of ethics in the Polish school see also
the book by R. Buttiglione, II pensiero di Karol Wojtyla (Milano, 1982), especially pp. 121 iI.
43 See Tadeusz Styczei's contribution to the volume, Mariano Crespo (ed.), Menschenwiirde: Meta-
physik und Ethik (Heidelberg: Universitatsverlag C. Winter, 1998).
348 CHAPTER 6

Thus we fmd, as ultimate consequence of this position, a radical instrumentaliza-

tion of morality. In spite of all subjective intentions to achieve a new personalism,
and the talk of a new personalism in purely teleological ethics, we must speak both
of a forgetfulness of the ethical subject (person) and of the specific moral dimension
of morality, and of an active attack on the person. To overlook and to degrade both
the person as moral agent and the specifically moral dimension of moral acts con-
stitutes perhaps the most fundamental defect of the new consequentialist teleologism
in ethics. (The emphasis on a transcendental dimension of morality in the 'funda-
mental option' cannot remedy this serious flaw not only because it is inconsistent
with the utilitarian-consequentialist part of this position but also because it banishes
the personal motivation and decision into a sphere completely outside that of inner-
worldly human actions which are to be explained ethically.) In the calculus of ef-
fects to which this position leads, the primary end of the world that lies in moral
goodness (and in the glorification of God which solely can be realized through mor-
al values) is forgotten. The specifically moral qualities as such are usually not in-
cluded in the Giiterabwiigung (calculus of goods and evils in view of their propor-
tionality). This exclusion of moral values themselves from the relativity of finite
goods contradicts the thesis that no finite (created) good can command uncondi-
tional respect. Moreover, it is usually not primarily because of a respect for the abso-
luteness of the moral sphere that moral values are not included in the Giiterabwii-
gung but rather because almost exclusively morally relevant goods are considered
by this new ethics. The free love of the good in accordance with its true value, the
heart of morality, cannot even come into sight when the inner invisible intention (the
measure of love, for example), which counts ultimately in the determination of an
action's moral value, is overlooked and only the consequences are stressed.
The focal point of the spiritual universe, the knowing, free, and conscious assent
to the good, must, however, never be forgotten but rediscovered and discovered ever
more deeply, if a new ethics and not the destruction of ethics is to be achieved. It is
the concern for this most central value of any person, human or divine, moral good-
ness, which motivated this critique and has, in its pure positive significance, prece-
dence over any critique. All effects and consequences of moral actions put together
cannot amount to the value and sublimity of the smallest moral act or love which
surpasses all non-moral goods in value and belongs to an entirely new and higher
order.
 EPILOGUE

First, I distinguished and analyzed three parts of the general nature of medicine:
(1) medicine as science (the type of scientific knowledge medical practice requires
and is based on); (2) medicine as practical and technical art, as best exemplified in
surgery; and (3) medicine (the medical professions) as entailing knowledge of, and
moral commitment to, the end of medicine, of which Aristotle recognized so insight-
fully that it is constitutive of the essence of medicine. (The present work sought to
overcome the all too narrow concept and definition of the end of medicine in terms
of health alone, showing that that there are at least five immanent and two transcen-
dent goods medicine ought to serve as its proper ends.)
Whereas the first two parts of medicine are based on empirical experience and
practice, on experiment and observation, the third constitutive part of medicine is
properly speaking philosophical and ethical but not for this reason less essential for
medicine.
In fact, the main purpose of the present work consisted in showing that this phi-
losophical and ethical dimension is as inseparable from, and as essential for, medi-
cine as scientific knowledge and practical art, which are universally recognized in-
gredients of a sound medical professionalism. More concretely, I tried to show that
from the seven goods medicine ought to serve moral calls and obligations proceed,
which physicians, nurses, and other health-professionals need to heed and assign a
central place to in their professional lives and activity.
Many of the ethical dimensions of medicine connected with the fundamental
goods it ought to serve have been mentioned or treated in passing in this volume, but
to study their concrete content and manifold forms will be the task of volume II of
the present work, which will develop the concrete applications of the ethical founda-
tions to different medical ethical problems, and the concrete forms in which the
seven goods ought to bind medical practice.
The most fundamental and basic philosophical disease of medicine has to do
with a general and wide-spread dwindling of the awareness of the central role of
those goods which constitute the raison d'etre of medicine and with no longer notic-
ing the fact that any turning away from the service to these goods-human life, the
specifically personal health of human beings, their rational conscious existence, their
wellness, pleasure, and the soothing of their pains and sufferings, the restoring of the
integral form of the human body-threatens the theory and practice of medicine and
throws the medical profession into a deep state of a world-wide crisis-which is a
crisis on different levels: (1) a crisis of understanding the values and goods ofmedi-
cine, including the two transcendent goods medicine ought to serve; (2) a crisis of
medical ethics and of concrete unwavering commitment to these goods as the Hip-
pocratic Oath expressed it; (3) a crisis which results from the fact that this crisis is
hardly noticed (chapter I).
Underlying all those goods that medicine ought to assist through its manifold ac-
tions is one central value that we call the dignity of the person. Without respect for it
medicine loses its entire life-support and suffers from a sort of philosophical con-

349
350 EPILOGUE

swnption (the last state of tuberculosis that ends in death by suffocation). Without
understanding hwnan dignity in all its important aspects and dimensions, medical
activity will be ill with an acute and multiple philosophical disease.
We witnessed in the last century unbelievable horrors and abuses of medicine
that were precisely due to ideologies and philosophies which attacked human dignity
or operated from understanding only an extremely small fraction of its entire exten-
sion and of its various sources. In order to understand hwnan dignity correctly, four
quite distinct sources and dimensions of personal dignity had to be comprehended
and clearly distinguished. Overlooking anyone of them or reducing hwnan dignity
just to one or another of them, e.g., to the dignity of the awakened thinking life of
the person, or to the man-given aspects of bestowed dignity, which result from so-
cial or familial acceptance of born or unborn hwnan beings, obscures the founda-
tional ontological dignity which belongs inalienably to healthy and sick, to con-
scious and unconscious, to old and young, to born and unborn hwnan persons and is
in no way the result of hwnan acts, social acceptance, or legal verdicts. Whole ethi-
cal systems of medicine, such as that of Peter Singer, are founded on an utterly in-
complete understanding of the sources ofhwnan dignity, and on a grievous failure to
comprehend properly the authentic anthropological roots of personal dignity.
To understand that level of hwnan dignity, however, which is grounded in the
very being and nature of the hwnan person and whose correct comprehension is in-
dispensable for medical ethics, requires an understanding of the fact that the hwnan
being is not just body, not merely a biological organism, not a brute, not even just
the lived, experienced, and specifically human body, but includes a rational hwnan
soul irreducible to brain activity and to brain functions. Without an appropriate
grasp of human nature there cannot be any proper understanding of hwnan dignity.
Therefore, the full rediscovery ofhwnan dignity as a true 'ethical universal' ofmed-
icine has to rest on a rediscovery of the spiritual nature of the hwnan person, a hu-
man nature that is irreducible to any ever so complicated machine.
Consequently, an adequate ethics cannot exist without a proper philosophical an-
thropology. Both are necessary parts of the cure of medicine from its philosophical
leprosy that corrupts it from within and leads to the loss of one of its limbs after the
other, transforming the healthy and fragrant body of medical practice into a smelly
and festering torso that lost its natural beauty and becomes unable to stand on its
feet.
Insisting on the ontological dignity of the hwnan person, as we did, we had
nonetheless also to avoid anyone-sided and exclusive emphasis on the inalienable
ontological hwnan dignity alone, a one-sidedness that would overlook the different
dimensions of 'bestowed dignity' and above all the profound ordination of the per-
son to possess also an acquired dignity that is in fact the most important dignity of
the person and of the medical professionals and that cannot be understood without
understanding hwnan freedom and moral values (chapter 2).
The consideration of the crucial dimension of acquired and moral dignity, which
to realize the person is destined but which is in no way inalienably hers but a great
conquest (Gabriel Marcel), led us to discover another aspect of the philosophical
disease of medicine and simultaneously a potent cure for it. Whereas we had first
identified the philosophical diseases of medicine that had to do with the forgetful-
 EPILOGUE 351

ness of the goods medicine should assist (Le., the immanent goods of medicine: hu-
man life, human health, rational consciousness, liberation from pain and suffering,
and repairing as far as possible physical deformities), the second great philosophical
disease of medicine we identified is in a sense opposite to the first: it originates in an
exclusive interest in those extramoral and premoral goods that medicine should bring
about but which, while extremely relevant for ethics, still are not themselves moral
goods and bearers of moral values.
In contemporary medical praxis and thinking we often find this grave illness of a
forgetfulness of the nature of the moral values themselves, which to realize is the
primary task of any human person and which therefore also medical professionals
ought to realize more resolutely than all other extramoral goods that play such an
overriding role in their dealings with their patients. A general forgetfulness of the
superiority of moral values over all extramoral, albeit morally relevant, values there-
fore constitutes another disease and epidemic that threatens to infect and to shrivel
medical theory and practice. For this reason, we had to propose the only possible
cure from this philosophical disease of medicine: a rediscovery of the nature and
central role of moral values and of their superiority over all extramoral goods med-
icine ought to be concerned with (chapter 3).
Not solely in order to understand moral values, but also to do justice to the dra-
matic moral choice facing health professionals today, a dramatic choice insistence
on which this book pits against the Aristotelian thesis that the physician does not
have to deliberate about the end of medicine and does not need to choose it freely
because he allegedly aims at it by necessity, we had to include a chapter on the na-
ture and scope of free choice. Only in its light it could become clear that the physi-
cian today stands at a cross-road and has to opt freely and in a fundamental moral
optionfor serving those goods that medicine ought to serve and not to allow himself
or herself to pursue other goals and advantages extrinsic to, and often standing in
sharp conflict with, the true ends and goods of medicine (chapter 4).
Precisely the discovery of the foundational role of the seven goods medicine
ought to serve and of the superior position moral values themselves ought to hold in
the physician's and nurse's practice, another chapter was needed which diagnosed
the most life-threatening philosophical disease that faces medicine today: a total
skepticism and agnosticism regarding values and an ethical relativism that divorces
medicine, at least secular medicine, from morals, throwing it into total chaos and
loss of orientation with regards to its goals. To combat these philosophical diseases,
this ethical plague of skepticism and relativism that endangers all ethics and the phi-
losophical AIDS of a fideist restriction of ethical contents to private communities
that attacks the philosophical immune-system at least of secular society, we also had
to include among the essays on the foundations of medical ethics a critique of ethical
skepticism and relativism, and of the type of content-less and purely procedural pub-
lic medical ethics T. H. Engelhardt, Jr. proposes for the secular world in his influen-
tial book Bioethics. In other words, we also had to free medical ethics from the type
of religious provinciality that would renounce any idea of a universal and global
ethics and restrict content-full medical ethics just to the morals of small or large reli-
gious communities that would be closed from the global human community and, as
352 EPILOGUE

"moral strangers in a public universe," banished from any formative role of public
ethics and medical law.
We found this position both inconsistent and untenable: Human dignity as well
as the basic contents of ethics and fundamental human rights are open to be known
at least in some measure by the natural human reason of any physician and nurse,
whether religious or not, whether adhering to the agnostic world-view of the noble
doctor in Camus's The Plague, or whether deeply religious such as Moses Maimo-
nides, Avicenna, Paracelsus, or Albert Schweitzer. The morally relevant goods and
ends of medicine and the moral values themselves are not only metaphysically
speaking objective, which Engelhardt does not deny, they are also open to the hu-
man intellect and constitute true universals and global foundations for medical ethics
(chapter 5).
There are many other philosophical diseases of medicine and of medical ethics.
Of these we picked just one in the last chapter of the present book: the consequen-
tialist and utilitarian theory of morality that does not deny all objective moral and
morally relevant values but reduces the moral qualities of human actions to the func-
tion of human acts for bringing about the series of consequences and effects they
have in the life of patients and in the world. We identified different parts and ele-
ments of this philosophical disease of medicine, which figuratively speaking
destroys the spinal column of medical ethics and of personal life, by justifYing every
action as long as it is a means towards some good end that is judged superior to the
value of alternative ways of acting.
This widespread ethical view not only fails to do justice to the existence of those
intrinsically morally wrong acts which to reject belongs to the core of human moral
life, but it also negates, as Shaftesbury observed against Hobbes, the essentially
personal nature of moral acts and the personal moral identity of the physician, nurse,
or other health workers, reducing them to some form of health-service-machines that
ideally should carry out the dictates of computers that calculate chains of probabili-
ties of positive future consequences of human actions.
This consequentialist ethical view that denies that any human action, even the
most gruesome one, is intrinsically morally wrong, if put into practice, would trans-
form all health professionals into moral invertebrates and would justifY any sort of
medical action, as long as it would appear to serve good ends or to produce ultimate-
ly better results than its alternatives.
We identified the cure from this philosophical disease as a becoming aware of
the essentially personal and entirely new kinds of values that we call moral values,
and of the utter impossibility of reducing an ethics of external human actions to a
mere weighing and assessing of consequences of human acts. The consequentialist
ethical position sadly overlooks the whole personal character of moral acts and spe-
cifically the fact that there is an intrinsic appropriateness or inappropriateness,
goodness or evilness in the relation of volitional or affective responses to such high
goods as human dignity and human life. There is an objective dueness to the objects
of human acts or a deep axiological discrepancy of human acts in relation to their
objects, which no consideration of external consequences of human actions can sub-
stitute for. Whatever these external consequences are, the inner harmony or dishar-
mony of human acts in relation to their objects remains the same.
 EPILOGUE 353

This dimension of medical ethics as an ethics of moral absolutes, of absolutely

forbidden or demanded moral acts, is deeply engrained in the Hippocratic Oath. We
found therefore the recognition that there are intrinsically wrong acts and the rejec-
tion of a consequentialist and purely teleological ethics to hold an indispensable key
to a new discovery of the true foundations of bioethics. These foundations of bio-
ethics resist any depersonalizing functionalization of morality that banishes moral
acts to a mere slavish role and service with respect to consequences.
The cure from the philosophical disease of medicine which we identified as 'in-
vertebratitis' (unknown to medical theory and praxis) lies in seeing in the center of
the moral life of the person acts that are intrinsically right or wrong and that demand
absolutely to be performed or to be rejected. This cure alone is able to restore the
moral vertebral column of the person. It alone can likewise preserve the integration
and unity between the different spheres of the moral life of the person: specifically
between the fundamental moral option and virtues and those external actions that are
expressive of, and inseparable from, the inner life of the person. There is only one
ethics. Therefore one must not invent a separation between a transcendental moral
theory only applicable to the fundamental human option or other inner acts and atti-
tudes and a praxeology as an ethics of external human action severed from the tran-
scendental ethics and subject to entirely different principles. No, all spheres of the
moral life of the person obey the same principle of giving to all goods the response
due to them (chapter 6).
A big task lies still ahead of us: to develop, on the firm foundations of medical
ethics, the manifold applications of these principles to concrete cases and to intro-
duce and investigate carefully some new general principles needed in the spheres of
ethical applications, rules, such as the correctly understood principle of double effect
and others, that have been touched upon only briefly in the present volume. In a
word: at the end of this book on the foundations of bioethics we have to start to
work on a second book- Philosophically Healthy Medicine. Philosophy and Ethics
of Medicine, volume II: Applications.
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Wreen, Michael J. ''Nihilism, Relativism, and Engelhardt." Theor Med 19 (I) (January 1998): 73-88.
Xenophanes. In Dieis-Kranz, cit.
Zarkovich, Erica: see Ross E. G. Upshur and Erica Zarkovich.
Ziemske, Burkhardt (Hrsg.). Staatsphilosophie und Rechtspolitik. Festschriftfor Martin Kriele zum 65.
Geburtstag. Miinchen: Verlag C. H. Beck, 1997.
 INDEX OF PERSONAL NAMES

Adeimantus 307 Buttiglione, Rocco xxiv, 1,27, 50, 56, 135,

Aeschliman, Michael D. 253 244,246,347
Alluntis, Felix 174 Byrne, Paul A. 123
Amundsen, Darrell W. xxxii, xxxv Caffarra, Carlo 338, 339
Anderson, R. 9 Cajthaml, Martin xxxvi, 17, 135, 239, 243
Anscombe, G. E. M. 50, 306 Callicles 218,252
Anselm of Canterbury 75, 150, 160, 172, 174, Calvin, Jean 18,76,222
176,177, 194, 195, 196 Cameron, Nigel M. de S. xxxi
Antiseri, Dario 200,218,255 Campbell, Courtney S. 239
Aristipp 218, 263 Carnap, Rudolf 12,255
Aristotle xix, 14-16,20,29,32-34,40-43,48, Cameades 201
49,52,72,101,107,108,112,115,116, Cassin, Rene 80
118,122,130,153,157,158,163,176,177, Castellano, Danilo 246
183-185,187,190,199,215,216,222,242, Cervantes, Miguel de 285,331
243,247-249,259,268,269,273,277,288, Chabrajska, Dorota 287
294,296,297,300,312,349,351 Chaitin, Gregory 1. 3
Asklepios 49 Cherry, Mark 1. 58
Athenaeus 53 Chisholm, Roderick M. 108,144,156
Au, Derrick K. S. 7 Cicero 50, 134, 153, 160,201,204,222,249,
Auer, A. 318, 323, 337 258,259,287,294,301
Augustine 106,153,161,175,192,197,198, Clinton, William 1. 333
199,201,204,209,222,225,243,247,248, Cohen, Richard 53
250,268,277,296,314 Conrad-Martius, Hedwig 9, 112
Ave-Lallement, Eberhard 112 Cratylus 106, 247
Averroes 212,293 Crespo, Mariano xxviii, 139,248,347
Ayer, A. J. 151,255 Crosby, John F. xxi, 17,50, 104, 134, 142,
Balthasar, Hans Urs von 197 167,189,239,301
Barger, John xxxiv, 151,253,255 Culver, Charles M. 83
Beethoven, Ludwig van Ill, 172 Curran, Charles E. 50,320,336, 337
Bergson, Henri 113,209 Deecke, LUder 203
Bernard, Claude xxii, xxiii, 4, 6, 10, 11,25 Demmer, K. 318
BertalanfiY, Ludwig von 9 Descartes, Rene 197,214
B lash, Ira 108 Desmond, William 190, 234
Blau, Helen 108 Diels, Hermann 174, 180
Biickenforde, Ernst-Wolfgang 120 Dilthey, Wilhelm 266
Biickle, Franz 50,314,315,318,327,331, Dolinta, Marin 133
337 Donohue-White, Patricia xxiii, 40, 52, 56, 57,
Boethius 66,100,101,107,113 140
Bonaventure 49,276,295 Dostoyevsky, Fyodor 74, 79, 98, 171,220,
Boozer, J. S. 152 259,326
Boyle, Joseph M. Jr. 339 Draper, Hal 91
Brantschen,l. 318 Duncan, Montrose 11
Brentano, Franz 212 Duns Scotus, John xvii, 172-174, 193-195,
Breuer, Clemens 168 212,216,299,300
Breuer, Hubertus 204 DUrig, GUnter 120
Brysch, Eugen 211 Dutari, Julio Teran 196
Buchholz, Arnold 246 Dutra, Luiz Henrique 11
Busa, Roberto SJ. 163 Eber, George, Fr. xxxii, xxxiii
Eccles, Sir John C. 9, 105,204,207-210

375
376 INDEX OF PERSONAL NAMES

Ehrlich, M. 38 Harsanyi, John C. 310

Einstein, Albert 13 Harvey, John W. 179
Eleganti, Marian 127 Havel, Vaclav 124
Engelhardt, H. T. xx, xxi, xxv, xxix, xxxii- Hegel, G. W. F. xxviii, 266, 346
xxxv,58,123,237,239-242,245,246,252, Heidegger, Martin 289
254,259,264-271,274-283,285-288, Heller, B. 139
291-296,351,352 Hengstenberg, Hans-Eduard 197
Engels, Friedrich 6,91,246 Henry VITI, King of England 340
Epictetus 72, 125, 130, 150 Heraclitus 96, 97
Epicurus 201 Herdegen, Matthias 120
Fabio, Udo von 120 Hering, Jean 192
Fabro, Cornelio 216,223,299 Herre, Heinrich 139
Fedoryka-Cuddeback, Kateryna xxiii, xxxv, Herz, Marcus 78
39,40,52,56,57,140 Hildebrand, Dietrich von xviii, xx, xxiv,
Feyerabend, Paul 14,15 xxxiv, xxxvi, 3, 5,12,17,18,21,32,49,
Fichte, Johann Gottlieb 153,211,213 50,69,76,83,90,96, 103, 113, 114, 127,
Findlay, J. N. 110,290 129,135,146,148,151,152,154,156,161,
Finnis, John 50, 134, 170,255,261 162,168,169,173,177,179,180,182,190,
Fleming, Alexander 27 191,198,211,214,216,218,219,221,226,
Fleming, John Irving 77,79,94,95,258,284 230-235,239,243,244,246,249,252,254,
Fletcher, Joseph 50, 306 259,263-265,271,276,277,288-290,293,
Frankl, Viktor E. 61,64,91 294,296-298,300,302,303,306,308,311,
Freeman, Anthony 203 337
Friedrich, Hans 261 Hildebrand-Jourdain, Alice von xxiv, 19,277
Frings, Manfred S. xx, 250, 308 Hippocrates xxi, xxxi, 26, 41, 42, 49, 50, 70,
Frornharz, Peter 108 79,80,84-87,95,298
Fuchs,Josef 50,320,321,327,329,336,337, Hitler, Adolf 77,245,317
339 Hobbes, Thomas 309,319,352
Funk, Roger 1. 308 Hoeres, Walter 244, 300
Gadarner, Hans-Georg 7,244 Holmes, Gregory 1. 123
Gadenne, Volker 7 Hillscher, Ludger 197,248,322
Galenus, Claudius 24, 29, 53, 54 Horckheimer, Max 75
Gandhi, Mahatma 97 Horstmann, Rolf-Peter 261
Garcia de Haro, Ramon 337 Hume, David xxxiv, 10, 11, 13, 14, 19,23,
Gert, Bernard 83 105,151,299
Ginters, R. 333 Husser!, Edmund xxxvi, 5, 35, 36, 96, 110,
Girgenti, Giuseppe 102 139,188,194,212,244,248-250,276,
Glaucon 307 289-291,293,294
Glldel, Kurt 268 Hutschala, D. 38
Goethe, Johann Wolfgang von xxx, 92 lnciarte, Fernando 337
Gomez, Esther 133 lngarden, Roman 20, 192, 290
Gorgias 60,84, 161, 164, 168, 170,218,243, bTgang, Bernhard 244,290
252,277,340,347 Jakowljewitsch, D. 22
Gould, Elizabeth 108 Jaspers, K. 214
Grabenwoger, M. 38 Jonas, Hans 210
Grass, Rudolf 7 Kalinowski, Georges 218
Gregor the Great 184 Kant, Immanuel xxxiv, 3, 5,12,16,31,33,67,
Gregory of Nyssa 112 75, 101-103, 114, 127, 151-153, 155, 156,
Grisez, Germain 50, 170, 339, 346 160-162,167,172,173,176,178,180-185,
Guerra LOpez, Rodrigo 263,264 193,199,200,201,208,209,213,214,216,
Gutsmann, D. 249 221,222,229,237,242,244,246,249,254,
Guttmann, Giselher 38 257,261,281,282,288,297-299,301,302,
Habermas, Jllrgen 118, 262 308-310,326,334,342,343,346,347
Haecke1, Ernst 77 Kaplun, A. 9
Hamlet 258 Kerber, W. 337
Hare, Richard Mervyn 50 Khushf, George 295
Haring, Bernhard xxiv, 19,50, 168 Kierkegaard, Soeren 201,202,317,319,330,
Harrison, Jonathan 310,311 346
 INDEX OF PERSONAL NAMES 377

Kolakowski, Leszek 287,288 Moore, G. E. 18,134,154,239,262,270,309,

Kolbe, Maximilian 155,156,229 315-317,321
Korczak,Janusz 229 More, Sir Thomas 323, 340
Korff, W. 337 Moreno, Jonathan 239
Kornhuber, Hans 203, 209 Moreno, Luis Fernandez 13
Kotarbinski, Tadeusz 287 Morscher, Edgar 255, 262, 293
Krabbe, Erik C. W. 312 Mother Theresa 79,97,229,245
Kranz, Walter 174,180 Munson, Ronald G. 2
Kraus, O. 212 Nanji, Azim A. xxxi
Kriele, Martin 239,240 Nederbragt, H. 7
Kuehn, K. 139 Nenon, Thomas 276
Kuhn, Thomas S. 10 Neumann, Herbert A. 211
KUng, Hans 285 Newman, Cardinal John Henry 127,178, 191,
Kuschel, Karl-Josef 285 199,230,235
Kushner, Thomasine 306 Nida-Rtlmelin, Julian xxxiii, 8, SO, 58, 81,
Lachterman, David R. 251,296 260-262
Lammer, J. 38 Nietzsche, Friedrich 20,21,226,231
Laun,llndreas 50,81,235,239,322 Noack,H.9
Lavados Montes, Manuel 56 Noble, Bernard 251
Leibniz, G. W. 77,105,202 Noce, Augusto del 246
Lejeune, Jerome 10 Olmsted, E. Harris 11
Lenin, Wladimir I. 91 Olmsted, James 11
Leser, N. 246 Orr, Robert D. 42, 87
Lewis, C. S. 244, 253 Otto, Rudolf 152, 179
Libet, Benjamin 203-207,209 Palmer-Fernandez, Gabriel xxi, 254, 294
Lippoldt, K. 139 Pang, Norman 42, 87
Loeffier, M. 7, 139 Paracelsus, Theophrastus Bombastus von
Lotz, B. 318 Hohenheim 6, 11,28,29,37,70,81,143,
Lowrie, Walter 317 238,352
Lukas, Elisabeth 64 Parfit, Derek 66
Luther 76 Pascal, Blaise 15,17,66--68,121,122,126,
Machiavelli, Niccoli> 320,323,336,337 233,256
Mackie, John L. xxxiv, 134, 151,254,261 Pasolini, Pier Paolo xxx
Maher, Michael 108 Paton, H. J. 15 1
Maimonides, Moses 77, 78,95,352 Payen, G., SJ. 42
Maiherbe, J. F. 11 Pellegrino, Edmund D. 42, 87
Mandahl, Otto W. xxxii, xxxv PfWnde~Alexander 14,15,19,22,139,248,
Maranon, Gregorio 61 268,290
Marcel, Gabriel 87, 128, 132,211,234,350 Piegsa, Joachim 168
Margolis, Joseph 310 Plato xxxi, xxxiv, 20, 22, 39, 49, 57, 60, 70,
Marx, Karl 6,91,246 72,76,77,84,85, 106, 126, 130, 156, 159,
Maunz, Theodor 120 161,164-166,168,170,171,176,177,
May, WilliamE. 50,78,314 179-181,199,200,209,218,222,242,243,
McCormick, Richard A. 320, 336 247,252,277,289,294,301,307,327,340,
McKenna, Stephen 198 346
McKeon, R. 112 Plitzner, K. 246
McLuhan, Marshall 27 Plotinus 171, 175
Mead, Margaret 87 Polos 218,252
Melanchthon 76 P6ltawska, Wanda xxviii
Melley, Christopher 26 Pope John Paul II 263, 346
Mengele, Josef xxviii Pope Saint Leo the Great 292
Merecki, Jaroslaw 188 Popper, Sir Karl 2,8-17,19,20,22-24,105,
Mertens, Karla 161 135,204,207-210,246
Miller, Robert 308 Premoli De Marchi, Paola xix, 49, 113, 127,
Minogue, Brendan P. xxi, 254, 294 191
Minos 161 Protagoras 243
Montgomery, John Warwick 80,306 Prusiner, Stanley B. 2
Przywara, Erich 196
378 INDEX OF PERSONAL NAMES

Pufendorf, Samuel von 301 Siger of Brabant 293

Purola, T. 9 Singer, Peter 49,51,77,81,85,116,122,123,
Rahner, Karl 50,231,306 141,142,218,239,259,303,304,350
Rajek, A. 38 Smith, J. A. 112
Rawls, John 310 Smith, Russell E. xxxii
Reagan, James E. xxi, 254, 294 Socrates 49,50,70,72,73,75, 126, 144, 156,
Reale, Giovanni 10,57,77,188,200,218, 159,164,165,174,177,181,182,194,209,
243,250,255,264 213,215,216,218-221,227,230,237,258,
Reinach, Adolf xxxvi, 3, 5,18,96,102, 103, 273,277,294,306,307,312,323,332,338,
139,182,191,206,249,268,289,290 340,345,347
Rhadamanthys 161 Soizhenitsyn, Aleksandr 244, 288, 289
Rhonheimer, Martin 50 Sommavilla, Guido 197
Ricoeur, Paul 118 Sophocles 134
Robinson, D. N. 105 Spaemann, Robert 37,50,51,140, 177,318,
Robinson, Wade L. 9, 294 319,324,333
Rosmini, Antonio 243 St. Catherine of Genoa 171
Ross, Sir David 7,19, 134,304,330 Starhemberg, H. 249
Roth, Joseph xxx Stegmtl1ler, Wolfgang 23,24
Russell, Bertrand 12, 16 Stein, Edith 131, 173, 290
Saint Clement of Alexandria 268, 272, 273 Steinberg, Rudolf 92
Saint Francis de Sales 235 Stem, Robert 77
Saint Justin the Martyr 268, 272, 273 Stevenson, Charles L. xxxiv, 151,255
Saint Paul 268,277,293,295 Struck, Karin xxx
Saint-Exupery, Antoine de 130 Styczen, Tadeusz 188,191,218,222,264,
Salamun, K. 22 287,300,327,342,346,347
Sartre, Jean-Paul 201,210,213,214,231 Suarez, Francisco 212
Scheler, Max xx, 2, 40,103, 134, 146, 161, Sutherland, Keith 203
177-179,188,191,216,227,239,250,251, Sweeney, Leo, S.J. 172-175
254,256,259,264,281,282,296,308,327 Swenson, David F. 317
Schlick, Moritz 9,252 Szostek, Andrzej 50, 222, 300, 342
Scholz, Franz 50,314,325 Taboada, Paulina xxiii, xxv, 9, 40, 52, 56, 57,
SchUller, Bernhard 50,313,318,327,335- 140
337 Tallmon, James M. 265
Schuschnigg, H. 249 Tarski, Alfred 13
Schwarz, Balduin xviii, xxiv, xxviii, xxxiii, Theresa of Avila 229
90,144,234,243,255,265,277 Thomas Aquinas 10,24,40,51,61,75,107,
Schwarz, Stephen 50, 67 114,116,118,131,147-149,158,163,173,
Schweidler, Walter 211 175,184,185,187,189,193,212,215,216,
Seifert, Josef xviii, xxi, xxiii-xxv, xxviii, 240,290,297,299,329,346
xxxiii, xxxvi, 3, 6,10, 11, 14, 16, 18,24, Thurnher, S. 38
27,29,40,45,52,66,68,69,74,75,77,90, Trianosky, Gregory W. 316
96,102, 103, 105, 106, 108, 109, 112, 124- Turgenev, Ivan 61
126,135,140-144,146,148,168,171,172, Upshur, Ross E. G. 7
175,177,182,188,191,193,196-198,200, Veatch, Robert M. 77,95
201,203,204,207,208,210-212,224,234, Ventimiglia, Giovanni 173
237,239,240,244,246,248,249,252,255, Waldstein, Wolfgang 239, 240, 285
262,263,265,276-278,285,289,291,294, Walton, Douglas 312
300,301,308,311,334,344 Wegener, Daniel 204
Selvatico, P. 318 Wenisch, Ernst 246
Seneca 75 Wenisch, Fritz xviii, xxxvi, 3,12,23,191,
Sepp,Rainer 276 255,290,311
Sextus 96 White, John R. 144
Sgreccia, Elio xxiii, 4, 39 Whitehead, Alfred North 16
Shaftesbury, Anthony Ashley Cooper, 3rd Earl Wickler, Wolfgang 18
of 319,352 Wigner, Eugene Paul 210
Shakespeare, William 62,64,71, 102, 181, Wildes, Kevin W. 265
326 Wittgenstein, Ludwig 11 0
Shewmon,D.Alan xxv, 67, 123,278
 INDEX OF PERSONAL NAMES 379

Wojtyla, Karol xxiii, 113, 139, 146-148, 158,

167,188,190,197,202,207,214,217,218,
222,239,246,256,263,264,300,318,333,
342,346,347
Wolff, R. P. 302
Wolner, E. 38
Wolter, Allan B. 174, 193, 194
Worrall, John 7
Wreen, Michael J. 241
Xenophanes 174,179,194
Zarkovich, Erica 7
Zdybicka, Zofia J. 189, 190
Ziemske, Burkhardt 239, 240
 SUBJECT INDEX
AJ])S 59,241,257,351
a priori xxxiv, 1,3-5, 12, 17, 18,21,
32,122,191,203,210,282,291,
298, 311, 342, 343
abortion xx, xxii, xxvii, xxx, 41, 42,
46-49,56,60,71,77,82-84,86,
87,115,118,119,122,130,135,
178,223,225,259,279,280,282,
284-297,303,304,306,313,314,
317,320,324,326,332,333,340,
345
abortifacient xxxi, 46, 80
absolute 6,15,17,18,24,39,49,51,
73-75,85,101,103,104,107-
109, 113, 114, 119, 122, 123, 132,
133, 135, 136, 138, 150, 152, 154,
155,159,163-166,171,175,176,
178,182,192-196,199,200,210,
211,222,229-231,248,249,251,
259,261,262,264,267,271,282,
286,288,289,298,301,305,306,
308-311,318,323,326-332,335,
336-343,345
obligation 119,318,323,329,
330,331,335-337,341
truth 138,182,249,267
accident 21,25,36,68, 101, 105,
107, 110, 141, 142, 163,210
accidental 19-21,25,27, 142,
163,251,253,296,304
acqurre 27,28,70,77,91,97,126-
128,131-134,211,228,233,242,
245,350
acquired dignity 127, 128, 133,
350
actuality 66, 122, 196
actualize 65, 90,212,235
acms 147,148,319
hominis 147
humanus 147, 148
381
adequacy 62,300,302,317,325,
327,332,344
adequate xxvii, 29, 56, 57, 97, 99,
135, 154, 155, 159, 184, 185,
188,220,225,226,234,235,
242,243,249,261,263,264,
306,308,314,325,328,331,
343,345,350
adequation 249
agent 39, 73, 76, 82, 153, 169, 190,
191,199,200,202,203,316,317,
319,321,324,327,331,335,342,
344,346-348
agnostic 75, 137,231,294,315,352
agnosticism xxi, xxxiii, 93, 195,
241,305,315,351
agreement xix, xxxii, 78, 118,240,
243,258,272,278-280,286
disagreement xxv, 98, 259, 276,
282,284,293
analysis xxi, xxxii, xxxiv, 3, 18,36,
37,45,52, 70, 100, 113, 148, 160,
168, 178, 179, 184, 187, 196,201,
206,238,243,252,256,272,288,
290,291,300,302,310,312,316,
333
analytic propositions 311, 318
anthropological xix, xx, xxii, xxvii,
xxix, 8, 80, 99, 114, 143, 144, 185,
189,244,304,347,350
anthropology xxi, 81, 85, 100,
139,143,146,148,210,309,
350
antibiotics xix, 25, 48
antinomy 16, 102, 103,200
atheism 21,98,125,201,231,273
atheistic 77, 176,230,259
attitude xxxiv, 27, 28, 60, 63, 71, 77,
111,148,168,172,178,181,184,
188,218,224-233,235,236,251,
382 SUBJECT INDEX
253,286,296,298,318,323,324,
328,330-335,337,344,346,353
fundamental moral 168, 181, 188,
226-232,236,296
moral 226-232,297,328
autonomous 36, 101, 178,210,214,
319,324
autonomy 66,99,178,190,205,
213,234,260,275,319,324,
345
axiology 294
axiological 58, 100, 122, 133, 155,
194,214,218,242,244,286,
294,352
begging (the question) 268-271
bestow xxii, xxv, 4, 128-134, 137,
149, 161, 164, 168, 181,211,218,
350
bestowed dignity 129-131,134,
350
bioethical xxiii, xxix, xxxvi, 39, 49,
58,141,142,239,243,271,280
bioethics xviii, xx-xxiii, xxv,
xxvii-xxix, xxxi, xxxiv, xxxv, 4,
40,58,67,80,95,98,100,142,
143,185,187,192,238,239,
241,243,246,264-268,271,
278,279,289,291,298,301,
303,305,308,309,353
biological xvii, xix, 12, 54, 76, 85,
104, 105, 112, 116, 117, 124, 139,
141,203,350
biology 4, 10,22,87, 116
blindness xxxiv, 49, 140,232,243,
271,272,276,277,293
moral value 276, 277, 296
body xix, xx, 5,6, 9, 11,22,24,27,
30,31,34,35,38,53-55,57,63,
65,68-70,78,91,103,104,108-
113,115-117,145,204,208,209,
225,232,248,253,256,310,331,
334,349,350
brain xix, xx, xxii, xxiv, 6, 8, 9, 38,
46,58,63,65, 101, 105-111, 113,
141,142,203,204,206-210,350
events 10, 105-107, 110, 111,
114, 141,203,208
calculation, calculate 91, 119,320,
338,352
canonical 245,264,265,267,280-
283,291,292,294
casuistry 83, 265, 297
categorical 152, 155, 156, 180, 195,
221,254,282,296,298,308,342,
343
imperative 152, 155, 156, 180,
221,254,282,296,298,308,
342,343
category 13,55,56,69,81, 101,
110,139-144,155,173,193,
194,216,219,220,221,223,
238,249,251,252,288,289,
325,335
causality 20, 199-202,208,209,322
principle of 200-202
cause xviii, xix, 3, 6, 9, 10, 12,31,
34,36,39,56,57,60,63-65,80,
82, 106, 109-111, 153, 155, 161,
169, 176, 181, 190, 191, 199-202,
206,208-210,214,215,224,230,
231,236,275,277,297,307,315,
317,319,343,345
efficient 109,200,201
final 34
certainty 13, 16, 17,20-22,23,24,
76,205,277,292,316,322
certitude 196, 199
chemical 28-30,38,106,201
chemistry 5,24,253
chess 3,4,149,154,160,206
choice xix, xxi, 37, 40, 44, 72, 124,
183-185,187,188,202,206,213,
215,219,223,225,236,238,258,
275,311,336,351
Christ 79,94, 165, 174, 179,230,
273,292,295
Christian xx-xxii, xxv, xxxii-
xxxvi, 50, 72, 76, 77, 79, 81,
95-97, 127, 130, 131, 136, 137,
169,171,174,179,189-191,
 SUBJECT INDEX
230,234,235,240,241,266,
272,273,278,280,285,286,
291-294,296,303,346
chromosome 10, 116
coherence xxxiii, 260, 262
communism 91, 135,246,288
communist 42,57, 77, 91, 288
compromise 320
uncompromising 85, 138
condition xviii-xx, xxxii, xxxiv, 3,
7-9, 11, 14, 18, 19,48,52,55,57,
61,64-66,70,86,93,97,106,
109-111, 115, 123, 132, 133, 144,
153-155,157,160,161,164,166,
169,170,173,175,191,193,195-
199,203,211,213,215,222,223,
226,227,242,246,248,255,260,
262,266,276,279,291,293,295,
300,310,312,315,329
conscience xxx, xxxii, 67, 82, 83, 86,
124,149,158,159,164,171,211,
221,229,243,282,295,297,314
moral 82, 146, 158, 159, 178,222,
230
conscious xx, xxxii, 51, 61-67,102,
105-111,113,115,121-125,132,
140, 141, 156, 157, 168, 171, 188-
190,197,202-210,212,230-234,
248,253,277,289,301,317,319,
323,325,327,346,348-350
consciousness xx, xxvii, xxx, 24,
39,61,64-68,99,102,105,
107-110,113,115,118,122-
124, 126, 133, 141, 142, 156-
158,168,178,197,205-207,
212,225,231,232,253,256,
266,268,315,341,351
moral 229
consensus xx, xxxii, xxxiii, 52, 77,
79,94,95,97,99, 118, 120, 121,
136,140,242-244,257,258,261,
267,272,278,279,283-288,293,
295,297
theory of truth 279
consequence xix-xxi, xxxii, 10, 12,
383
16,23,24,26,30,32,38,48,50,
61,73,82,83,92-95,98,104,
111,117,119,121,122,128,140-
142, 144, 145, 147, 150, 158, 161,
165,169,171,176,177,182,191,
194,201,208-210,223,224,238,
240-242,244,246,247,257,283,
285,301,305-307,309-325,327-
329,331-338,340,343-348,352,
353
consequent 27,55,236,315
consequentialism xxi, xxxi, 305,
306,309,310,314-316,318,
319,322,323,325-327,332,
334,336,339,340,342,344,
346,347
consequentialist 50, 176, 177,226,
242,262,306,309,310,312-
314,316,317,319-321,323,
324,326-328,330,331,335,
336,339,340,346,348,352,
353
consistency, consistent xxxiii, 13,
247,260,286,312
content xxi, xxiv, xxxii, xxxv, 4, 19,
41,42,49,53,64,65,70,94,95,
98,106,111,140,154,156,159,
191,193,195,196,226,227,230,
232,233,237,238,240-243,245,
254,258,261,264-271,274,275,
278,279,281,283,285,286,291,
293,300,308,313,316,317,321,
349,351
content-full xxi, xxxii, xxxv, 98,
140,237,238,240-243,245,
254,258,261,264-271,274,
275,278,279,281,283,291,
293,308,351
ethics xxxii, xxxv, 265, 268,
271,274
contingent 3, 5, 6, 16, 17,22, 53, 73,
75,76,109,141,192,200,202,
211,237,253,311,318,320,325
contraception xxii, xxxi, 75, 76, 304
contradict 17,18,23,43,112,136,
384
175,200,201,202,207,210,217,
252,270,276,283,290,312,323,
334,335
contradiction 13, 17,23,47,49,
66,103,194,200-203,231,
247,248,251,252,261,272,
312,321,323,324,328,335,
336
cooperation 76,82,131,133,138,
196,235
crime xxx, 44, 103,245,259, 313,
322,333
criminal xviii, xxx, 22, 39, 53, 69,
81,86,87,128,160,238,241,
271,322,328
criterion xxix, 12,20,23, 82, 134,
140, 145, 159, 184, 193,218,236,
260,288,292,315,316,321,323,
325,333
critical xviii, xix, xxi, xxv, xxxiii, 6,
53,93,120,135,173,184,210,
309,312,326,331,333,346
rationalism 135
cure xviii, xix, 4, 6, 8,25,27,29-31,
4~57,6~79,81,82,85, 122,
138, 159,213,22~242,305,31~
350-353
death xviii, xix, xxiii, xxiv, xxvii,
xxix, xxx, 4-6, 16,20,36,39,42,
44-46,48,51,58,60,62,65,66,
72-76,78-80,85,92,95-97,115,
117, 123, 124, 126, 130, 140, 155,
159, 164, 165, 170, 182, 192,224,
236,241,246,261,267,272,306,
313,322,326,330,333,338,344,
345,350
brain xix, xx, xxii, xxiv, 58
definition- xix, xxiii, xxix, 7, 12,25,
53,54,56,60, 100, 114, 174, 191,
222,288,311,341,349
define, definable 54, 122, 195,
261,267,296
demonstrate 145,203,239,268-271,
288,315,329
SUBJECT INDEX
indemonstrable 208, 268-270,
272,288
deontological 261,310,321,326,
336
determinism, determinist 190, 204,
208,231
diagnose xviii, 305, 351
dignity xix, xx, xxii, xxiii, 17, 28,
34,35,43,45,47,49-51,63,66-
69,73-76,80,83,84,86,87,89-
100, 103, 104, 110, 113-115, 118-
138, 143, 146, 148, 152, 166, 167,
188,189,191,211,212,216-218,
221,222,225,232,235-237,254,
263,271,275,276,282,286,287,
297,298,300,301,303,304,308,
324-327,332,334,338,342-346,
349,350,352
disease-see also 'philosophical'
xviii, xix, xxxiii, 3, 6-8, 11, 19,25,
29,31,34,35,37,44,45,47,48,
54,56,63,68,78,79,85,93,110,
135, 138, 140, 159, 162, 164, 185,
213,214,217,224,241,242,257,
260,304-306,310,349-353
dogmatic 12,247
doubt xxxiv, 23, 26, 28, 72, 76, 79,
116,118,148,149,172,182,198-
200,207,241,247-251,257,265,
284,287,290,326
Down Syndrome 10
drama xix, 4, 153, 188, 191,213,
215,216,219-222,225,236,238,
345
dramatic xxi, 57, 66, 185, 187,
213,219,223,225,239,351
moral xix, 187,339,345
duty xxiii, 26, 57, 78, 79, 85, 86, 92,
118,121,126,129,159,160,172,
216,229,252,302,303,306,308,
309,315,317,321,324,327,329-
331,341,342
eclipse xxxiii, 138,279,284
of reason xxxiii, 284
embryo xx, xxix, 45, 60, 75, 98,
 SUBJECT INDEX
116-118,123, 124, 130, 136, 140,
189,259,306,322
embryonic 117, 119, 123
empirical 1-14,16,17,19-23,25,
26,28,29,31,34,35,45,53,91,
110,116,203-205,207-211,237,
291,299,349
empiricism xxxiv, 8, 12,21,22
encephalomyelitis, myalgic 305
enlightenment xxvii, 240, 245, 265,
279
epiphenomenon 101, 105-107, 111,
114,141,142,203,210
epistemological xviii, xxxiii-xxxvi,
7,8, 11, 12, 14, 15,20,22,37,99,
103, 139, 143, 144, 175, 187,205,
213,240,247,261,268,281,287,
291,311,330
epistemology xviii, xxi, 7, 14,
103, 143, 152, 182, 188, 191,
262,281,286,294
epoche 131,188,247
ethical xviii-xxiii, xxv, xxvii- xxix,
xxxi-xxxv, 1,5, 7, 8, 17, 18,20,
32,33,36,39,40,44,49,50,65,
66,69,73,74,79,80-85,87,89,
92-95,97,98,100,104,115,119,
122, 127, 137, 139, 143-145, 147-
149,151-155, 157-159, 161, 179,
182,192,201,213,216,222,229,
238-245,251-260,262,263,265-
267,269-271,275-283,285,287-
299,302,304-311,313-316,
319-321,323-326,329,330,332,
334-336,339,340,342,344-353
ethical universal 241,350
medical ethical universal 95,
96, 114, 138
ethics xvii-xxi, xxiii, xxv, xxviii-
xxxv, 2,4, 7,19,21,33,36,39,
42,43,49-51,58,60,73,76,
81,83,89-91,93-96,98-100,
114,118,122,130,135,138-
140, 143-149, 151, 152, 164,
176,178,182,185,187,188,
385
191, 192, 196,201,213,221,
226,228,233,237-244,253-
256,258,260-263,265-271,
274,275,278-280,282,283,
285,286,289-301,303-306,
308-321,323-330,333-337,
342-344,346-348,350-353
applied ethics 297
euthanasia xx, xxii, xxvii, xxxi, 41,
42,45,46,48,49,74-77,87,115,
119,135,136,176,178,192,225,
279,280,282,284,285,304,306,
310,313,316,333,340,341
evidence xxxiv, 7, 8,14,17,18,21,
41,46,48,51,55,79,89,97-99,
103, 106, 111, 115, 118, 166, 172,
179,187,197-199,203,205,207,
242,250,251,254,256-259,263,
268-271,273,277,278,287-289,
291,293,302,343
evident xx, 17, 23, 24, 32, 33, 45,
61,72,84,97,101,105,107,
108,111,112,130,132,153,
168,194,197,198,200,203,
205,208,210,215,218,220,
222,229,231,235,240,247-
252,255,257,258,264,269-
272,276-278,282,285,287,
288,293,295,312,321,344,
346
exception 3, 16,39,46, 102,210,
332,335
exceptionless 15,326,327
experience xviii-xx, 2, 3, 5-8, 10,
12,13,15,17,19-21,25-31,36,
42,54,59,61-66,77,90,91,95-
100, 104-110, 112, 118, 123, 125,
136, 137, 140, 161, 171, 173, 189,
191,192,197,204,208,209,211,
212,218,225,232-235,238,244,
253,254,256,265,266,268,274,
275,281,282,285,290,294,311,
343,346,349
custom of 11
experiment xxvii, xxviii, 8, 10, 15,
386 SUBJECT INDEX
20,21,26,29,44,81,108,125,
203-205,207,209,210,276,322,
349
experimental xvii, xviii, 2, 4--6,
10,20-22,31,77,203-205
science 2,4,5,10,20,22
experimentation xxvii, 8, 75, 125,
255,330
human xxii, xxvii, 26, 60, 306,
322
false xxxii, 4, 6, 18,26,29,36,39,
49,63,76,135,167,188,190,
201,226,231,244,249,250,262,
268,277,284,285,292,294,296,
297,307,312,328,331,340,341
falsification 10, 13-19,23,24,26
falsity, falsify 12, 40, 190, 244,
249-251,258,278,288,290,
293,303,312,321,323
fetus 47,345
fideism xxxiv, xxxv, 276, 281, 282,
286,293
fideist, fideistic xxxii, xxxv, 241,
292,305,351
finis 40,51, 148, 184,295,346,347
operantis 296, 346
operis 51,295,346
finite 73,74,76,128,174-176,187,
188, 191, 193, 194, 198, 199,201,
202,222,305,309,310,311,320,
321,323,325,327-330,332,333,
335,336,340,341,348
goods 74,76,305,309-311,320,
321,325,328-330,332,333,
336,340,341,348
foundation xviii-xxiii, xxvii, xxviii,
xxxii, xxxiii, xxxv, xxxvi, 4-7, 19,
20,36,37,49-51,53,57,83,85,
87,99,114,119,120,123,125,
127, 132, 135-138, 144, 146, 155,
188, 189, 192, 195, 196,201,205,
209,213,226,228,238-242,248,
260-262,266,269,270,272,273,
277-280,282-284,289,292,295,
296-298,299,303,304,308-310,
321,324,325,332,335,337,346,
347,349,351-353
free xxi, xxiv, 17, 35, 44, 48, 49, 64,
67,73,92,102,103,106-108,
111, 123, 124, 127, 131, 133, 138,
146-148, 150, 153, 155, 157, 160,
166,167, 172, 182, 185, 187-194,
196-214,217,222-226,228,229,
232-236,238,253,257,261,274,
281,293,296,300,301,312,319,
324,327,333,342,344,346,348,
351
acts-see also under 'choice' 17,
48, 102, 107, 111, 127, 147,
148, 153, 157, 160, 166, 167,
187, 189-191, 196, 199-204,
206,207,211-214,224,225,
232,233,235,253,301
freedom xxi, xxx, 17, 18,40,51,
56,64,66-68,74,82,83,91,
99,102-104,106,107,115,
116,122-125,128,131,138,
144, 146, 148, 150, 153, 155,
157,160,166,168,170,175,
182, 185, 187-193, 195-205,
207-217,220-225,232-235,
238,246,254,260,264,271,
275,282,284-286,290,302,
309,316,329,339,341-343,
350
function, functionalistic xx 6, 54, 67,
97, 101, 111, 133, 140, 141, 158,
178,187,203,294,343,346,347,
352
fungus 3
futurology, futurologist 319,324
general xviii, xix, xxi, xxix, xxxii,
xxxiv, xxxv, 4, 5, 9-17, 19,20,23,
24,31,37,42,43,54,58,62,75,
77,87,93,97,99, 106, 107, 118,
125, 129, 135-137, 139, 142, 143,
148, 152, 154, 158, 159, 174, 180,
181,185,192,201,205,210,221,
225-228,230,232,233,235-239,
241-244,246,251,253,255,257,
 SUBJECT INDEX
265-268,279,281,283,286,294,
296-298,308,310,313-315,321,
328,329,332,349,351,353
~ob~ 27,137,237,285,351,352
ethics 351
God xxxi, 43, 61, 63, 71-81, 85, 98,
100, 101, 113, 123, 125, 126, 129-
132,137,150,153,160,169-171,
174-179,191-196,199,201,202,
217,221,222,224-226,230-232,
236,238,246,249,259,264,273-
275,280,283,292,293,295,296,
300,320,321,329,330,338,340,
343,345,348
good will xxxv, 98, 136, 138, 151,
156,167,172,176,181,182,184,
185,202,222,239,257,281,301
goodness 74, 143, 151-153, 162-
164,167-172,174-176,179,181-
185,193,195,202,211,218,219,
222,223,228,231,232,243-245,
258,263,299-302,308,316,317,
320,323,325-327,333,337,344,
346,352
moral 83, 112, 127, 134, 143, 145,
150-153,156,157,163-165,
167-172,174,176-178,180-
185,192,193,211,222,227,
228,231,242,245,296,324-
328,335,341,344,346-348
unrestricted 152, 162, 165, 176
gynecology, gynecologist xxx, 46,
76,83,166,320
happiness 32, 40, 42, 43, 54, 62, 64,
65, 144, 160, 161, 169-172, 176,
177,182,185,215,218,219,221,
223,261,263,300,308,319,326,
327,343
happy 62,64,160,161,218,225,
248,303
health xviii, xix, xxi-xxiii, xxvii,
xxix, xxxii, 4-7, 21, 25, 26, 28-31,
33-37,39-46,48,50,52-59,64,
65,68-71,73,77,78,82-87,89,
91-93,95,97,99, 114, 124, 128,
387
137,138,140,143-146,148-151,
159, 162, 164, 166, 168, 176, 181,
182,184,188,213,214,225,229,
236,237,241,246,257,267,275,
301,315,319,329,339,340,349,
351,352
human 5,24,28,29,35,39,52-
55,57,65,89, 139, 140, 144,
162,164,238,351
professional xviii, 6, 73, 93, 95,
124,138,151,213,351,352
worker xxi, 92, 99, 128, 188,352
healthy xx, 10, 11,42,44,53,54,
141, 142, 149, 150, 162,218,
310,322,350
hedonism, hedonistic 218, 311, 318
hermeneutical, hermeneutics xxxiv,
7,244
Hippocratic xxi, xxxi, 26, 41, 42, 49,
50,70,84-87,128,147,236,298,
349,353
HIV 241
hospital xxxii, 71, 82, 95, 124, 125,
128,129,157,322,324
hypothesis, hypothetical 8, 10, 12,
13, 155
idol 30
idolize, idolization 29,311,321,
329
immanent 54,55, 70, 84, 126, 141,
143,150,162,208,297,303,312,
313,323,325,335,349,351
immanentism 178
immune system 241
imperative 57,149,151,154,155,
228,297,308,309,311,321,331,
338,342-344
categorical 152, 155, 156, 180,
221,254,282,296,298,308,
342,343
hypothetical 155
inclination 12,53, 152,216,223,
298,299,302,322,342,343
indubitable 21,22, 103, 106, 197,
198,248,250
388
truth 248
induction 11-14,19,20,22,24
inductive 7,9-12,14-16,19-24,31
infallible 20
inference 12,14,19,21,24,262,
268,270
infertility 45,47
infinite 72, 76, 78, 127, 128, 162,
169,174,175,191,193-195,197,
199,202,230,268,269,271,277,
297,315,317,322,329,345
good 72,329
injustice 74,119,159,165,166,170,
182,213,215,220,246,252,253,
256,258,259,307,330,340,345
insight 3, 13,37, 72, 73, 75, 77, 148,
153,159,163,164,166-168,170,
174, 176, 178, 179, 184, 189, 196,
197,223,228,229,248,251,252,
255,256,258,268
philosophical 129, 179,205,207,
208,236,258
rational xxxiv, 3, 18, 196
integrity xix, xxii, xxix, xxxi, 50,
68-70,74,89,150,164,271,339
intellect xxxv, 49,55,67, 103, 125,
128, 137, 154, 166, 167, 173, 187,
190, 191, 198, 199,215,232,235,
241,256,288,296,300,352
intellectual xxii, 27, 33, 37, 48,
55,61,66,77,97,105,111,
127,158,170,176,179,180,
184,221,222,243,245,253-
257,262,268,269,274,288,
296
intrinsic 6,32,33,35,61,67,69,
74-76,85,90,92,94,103,114,
120,150,152,169,190,216-223,
225,228,236,254,258,261,263,
264,278,282,298,300,301,303,
308,313-315,323,327,333,343,
344,345,352
intrinsically evil 51, 119,295,
297,306,309,313
intrinsically good xxviii, 216, 220,
SUBJECT INDEX
308,314,321,332,333,341
value 33,35,61,69, 76, 90, 94,
120,152,169,190,216-220,
225,228,236,254,261,264,
282,298,308,314,343
invertebratitis 305, 353
investigation 2,4,6,8,26,31,35,
44,51,58,71,96,139,142,143,
146-148,176,182,185,188,192,
204,237,238,256,289-300,304,
310,312,343
investigate 3,8,44,50,52,53,87,
130,145,147,172,267,292,
327,353
ionic 9
Jewish xx, xxx, xxxi, xxxiii, xxxv,
44,50,72,75,77,79,81,95-97,
130,137,169,230,234,235,258
justice 28,29,51,87,113,120,129,
146, 150, 161, 162, 168, 170, 172,
174-177,180,181,183,184,195,
196,208,209,211,216,217,219,
220,222,225,228,232,236,245,
246,252,254,257,263,267,272,
275,277,285,292,297,300,301,
307,310,317,327,328,331,344,
345,351,352
justification xxi, xxxiii, 11-13, 15,
16,20,32,34,161,195,200,235,
246,259,261,268,272,286,293,
317,337
rational xxxiii, 11, 12,281
Kantian 3, 12, 103, 185,201,244,
281,297,308-310,326,342
kill xxii, xxvii, xxx, xxxi 18,22,44,
46,49,52,58,66,67,72-75,77,
80, 83, 94, 114, 115, 118, 122,
126,149,155,164,217,219,246,
259,284,303,311,313,315,319,
320,322,326-330,333,338
knowledge xvii, xviii, xxiii, xxv,
xxix, xxxii-xxxvi, 2-11, 13-37,
39,41,44,49,61,65,67,70,75,
76,78,80,82,83,86,87,89-93,
96-99, 102, 104, 106, 107, 111,
 SUBJECT INDEX
112,122-124,127-132,135,137-
139, 144, 145, 153, 154, 156-159,
162, 169, 170, 173-175, 182, 190,
191,195,197-199,205,209,212,
213,215,218,221,229,235,238-
245,248-250,253-258,261,264-
278,281-288,290-294,296,297,
300,302,315,317,321,324,330,
341,346,349
law xxix, xxxi, 3, 5, 8, 15-18,20,
21,24,34,36,39,41,46,47,49,
51,60,86,97,99,119-121,130,
132,152,157,159,160,201,209,
210,221,229,239,240,243,248,
265,269,278-280,282-285,290,
293,295,297,298,300,311,315,
322,352
necessary 14, 103,201
positive 86,97,99, 119, 120,299,
332
state xxxi, 136
legal xxvii, xxix, xxxv, 46, 60, 77,
86,94,119,157,241,243,284,
286,297,309,316,322,350
order 119,241
system 284,322
legalization xxx, xxxi
leprosy 68,229,257,350
liaison 9
libertarian xxxiii, 240, 275, 279, 283,
286,294
lie xvii, xix, xxvii-xxix, xxxiv, 2,3,
7, 11, 17,32-34,48,55,56,61,
63,65-67,71,76,77,84,86,91,
100, 111, 112, 115, 122, 124, 128,
132, 135, 138, 141, 147, 148, 150-
153,168,180,185,202,205,208,
209,211,213,219,220,222,228,
230,233,235,258,269,282,283,
293,295-299,301,303,308,309,
311,313,315,317,320,321,326,
327,330,331,333,334,340,342,
343,346,348,353
life xviii-xxi, xxiv, xxv, xxvii, xxix,
xxxi, xxxiv, xxxv, 4, 5, 9, 22, 29,
389
33,34,36,39-41,43-52,54-59,
61-67,69,71-87,89-92,94,96,
97,102,103,105,108,109,111-
113,117-119,122-125,127,128,
130, 136-140, 143, 144, 146, 147,
149,150,153-155,157-159,162,
164,166,168,170-172,174,175,
178,.179,181,182,185,187,190,
192,195,197,204,208,212,215,
220,221,223-226,229,230,232,
233,235-237,240,242,243,253,
254,259,264-266,272-274,276,
278-281,283,286,293-296,300-
302,306,307,309,319,320,326,
330,331,333,334,336,338-340,
342,345,346,349-353
human xviii, xx, xxii, xxiii, xxvii,
xxix, xxx, 5,6,24,28,33-35,
43,45-52,54,57,58,64-67,
73-77,79,81,85,86,89-91,
94, 115, 117, 122, 125, 133,
137, 139, 140, 143-145, 151,
152, 154, 162, 164, 166, 182,
192,216,218,219,223,229,
232,237,238,258,302,303,
329,332,337,340,342,345,
349,351,352
logic xxxiii, 4, 12,22,25, 53, 116,
260,262,316,334,344
logical 5, 11-15, 18, 19,23,24,
99,107,116,134,155,190,
193,194,212,248,251,255,
256,268-270,272,290,293,
312,316,322,323,336
love xxxiv, 43, 47, 56, 61, 71-73,
78,80,96,97, 104, 112, 113, 123,
125, 131, 150, 154, 156, 168, 169,
171,175,177,180,181,183,184,
191,195,196,217,219,221,222,
224,225,228,230-236,238,251,
254,258,260,263,264,272,273,
282,296,298,300,314,318,328,
329,334,343,348
being loved 130,134
Mad Cow Disease 3
390 SUBJECT INDEX
magician 1,38
man,nuulldnd 78,85,87,96,97,
138,159,243,259,266,276,326
material 19, 104-113,201,203,210,
237,238,261,281,291,308,312,
327
immaterial 106-111, 134,208,
255
mathematical 3, 17, 208, 256, 293
mathematics 3,5,21,37,245,
255,344
matter xxxii, 5, 15,25-27,49,54,
60,64,65,75,76,78,91,96-98,
105-109, 112, 113, 116, 144, 149,
154,165,191,197,208-210,216,
235,238,246,248,251,257,258,
267,271,280,283,285,287,299,
307,308
medical ethics xviii-xxi, xxvii-
xxxiii, xxxv, xxxvi, 18, 20, 40, 44,
50,51,58-60,65,71,76,77,80,
81,83-85,87,89,90,93-96,98-
100,114,122, 135, 138-140, 143-
150, 152, 157, 159, 160, 164-166,
176-178, 185, 187-189, 192, 196,
213,228,233,237-239,242,265,
270,298,301,303-306,308-310,
312,315,316,318,319,322,347,
349,350,351-353
medicine
end of 52,58, 128,349,351
evidence-based 7
seven goals of xxii, 83, 146
seven goods of xix, 5, 79, 89, 92,
146,149,236,349,351
man 1,6,29,31,32,39,84,85,87
medieval xxvii, 2, 67, 96, 147, 173,
184,212,240,265,300,301
mental xix, 10,28,29,35,42,46,
49,52,54-56,63,65,79,92,97,
105,110-112,145,189,204,251,
272,304,334
health 28, 29, 35, 52, 54-56
metaphysics 32,58,64,66,81, 100,
102,130,171-173,175,188,192,
194-196,200,259,294
metaphysical xxvii, xxxiii, xxxiv,
9,32,72-77,85,100,104,130,
154-156,161,176,178,181,
187, 189, 191, 192, 195, 196,
198,200-203,212,213,231,
242,245,247,280,281,291,
311,329,331
method xviii, xxix, xxxiv, xxxvi, 2-
6,8,10,11,22,26,27,29-31,37,
38,46,52,85,95,145,146,188,
205,246,254-257,268,289-291,
319,322
millisecond 205-207
modular 9, 204, 207
moral xix-xxi, xxviii, xxix, xxxi-
xxxvi, 1,4,7,17-19,33,39-41,
44,48-51,55,56,64-66,70-76,
82-84,89,90,92,94-98,104,
112,114,118,119,126-128,131,
133,134,136-138,143-172,174-
185, 187, 188, 191-193, 196-199,
211,217,219-233,236-238,240-
243,245,246,251-272,274-276,
279-282,284-293,295-303,305,
306,308-321,323-353
extra-moral 342
goodness 83,112,127,134,143,
145, 150-153, 156, 157, 163-
165,167-172,174,176-178,
180-185, 192, 193,211,222,
227,228,231,242,245,296,
324-328,335,341,344,346-
348
morality xxi, xxxiv, 4, 47,50,67,
82,83,87,126,145,147,151-
154, 157, 158, 160, 166, 170,
177,178,181,182,185,187,
196,222,227,228,230,239,
240,242,245,246,266,267,
270,276,278-281,283- 285,
288,295-297,300,309,310,
312-314,318,321,324,325,
327,328,331,332,336,338-
340,342,344-348,352,353
 SUBJECT INDEX
morally relevant xxi, xxii, 44, 71,
74,83,96,97,114,127,143-
146,149-159, 164, 166, 177,
182,184,221,222,224-230,
232,236-238,242,255,259,
271,275,281,292,297,298,
301-303,308,318,326,327,
329,332,335,337-340,342,
344-346,348,351,352
values xxi, 33, 55, 64, 83, 97, 127,
133, 134, 143, 145, 146, 149-
157, 159, 160, 162, 164-172,
175-185,187,191,196,198,
199,221,222,225,227,228,
230,231,237,238,242,245,
246,251-253,255-259,261,
263-266,269,270,277,280-
282,291,301,303,305,308-
310,323,326,327,335-338,
348,350,351,352
motivation 79, 111, 144-146, 177,
178,213,215,219,300,308,315,
324,331,346,348
motive 44, 72, 90, 124, 144, 150,
160,162,177,201,228,261,
296,346
murder xxx, 20, 48,81, 124, 167,
258,283,284,288,311,319,322,
338,345
Muslim xx, 50, 79, 96, 130, 137
Nazi, Nazism xxvii, xxx, 26, 39, 42,
44,57,77,84,86,135,155,241,
246,252,267,275,279,295
necessity 12, 17,23,40,42,43, 73,
84,109,187,201,211,215,220,
223,225,236,268,269,274,311,
334,351
essential 3,4,6, 13,37, 142, 166,
212,214,343
neurology, neurological 123, 203
nihilism xxxiv, 53, 241, 242, 245,
246,257,268,305,315
nurse xvii-xix, 21, 40, 66, 71, 73,
78,82-84,95,102,132,137,143,
145, 146, 149, 157, 159, 163, 172,
391
181,182,185,188,214,216-219,
223,224,228,232,233,236,238,
305,313,315,319,320,322,324,
326,328,347,349,351,352
object xxxii, 4-7, 13, 17,21-23,32,
44,58,59,61-65,69-73,75,76,
82,85,89,95-97,99,102,106,
109-111, 118-120, 134, 136, 140,
142, 143, 148, 152-154, 157, 160,
164-166,169,171,173,178-180,
184, 185, 187, 190, 193, 196, 197,
202,209,210,212-218,223-227,
229-235,250-256,263,267,269,
270,285,286,289,293,296,298,
301,302,308,309,311,314,315,
317,320,325-337,339,340,342-
347,352
objective xviii, xix, xxi, xxii,
xxxii, xxxiii, xxxv, xxxvi, 6, 20,
48,56,66,69,71,76,81-83,
85,87,89,90,93,98-100,106,
108,114,118,120,130,134,
135, 140, 142, 145, 149, 152,
154,155,158,159,169-173,
177,178,185,196,210,211,
216,218-223,225,227-229,
231,239,240,241-252,254-
268,272,276-278,280,281,
283,286-294,296-299,301,
305,317,319,324,327,330,
334,341,343,345,346,352
good for the person 169-171,
219,223,228
objectivism xxxiii, xxxiv, 145,
241,246,261,262,281
truth xxxiii, 135, 243, 245-248,
250-252,265,266,278,280,
281,283,293
value xxxiii, xxxvi, 69, 99, 114,
149,152,177,196,216,218,
221,241,245,254,257,260,
262-264,286,287,290,291,
298
obligation xxviii, xxxi, 18, 19,44,
71-74,76,83,89,97,114,120,
392 SUBJECT INDEX
127, 144, 148, 154-158, 164, 190,
214,217,221,226-229,238,255,
276,302,303,305,309-311,317,
321,324,326-330,332,338-341,
345,349
ontic 66, 100, 140, 141,304,342-
345
goods 342-344
ontology xx, 99, 107, 121, 139-143,
146,173,192,200,255,286
medical 139, 143, 192
ontological xx, xxxiii, 7, 8, 20, 22,
51,61,62,66,67,100,104,
105,107,113-115,118,119,
121-125, 127, 128, 130-133,
135, 139, 140, 142-144, 167,
189,192-194,196,210,241,
248,255,280,290,300,304,
350
status 140, 141
option 224,226,231,232,318,324,
325,328,351,353
fundamental 168,231,232,310,
318,323-325,328,346,348
osteomyelitis 305
ought xviii, xx, xxi, xxix, xxx, 18,
19,36,41,43,45,46,49,50,57-
59,69-71,73,81,83,85-87,89,
90,92,98,113-115,118,119,
121, 124, 126, 129, 133, 138, 140,
144, 145, 149, 150, 154, 155, 157-
159,165,176-178,180,185,198,
217,221,222,228,230,234,236,
238,250,267,275,285,297,299-
301,307-309,311,315,317,321,
323,327,329,331,332,342,343,
349,351
pain xix, xxiii, 37, 44, 45, 58--60,
62--66,74,78,79,96,110,124,
125, 143, 150, 154, 159, 161, 168,
182,208,236,257,334,351
painful 59, 85
palliative medicine 59,322
paradigm 8, 10
paradox, paradoxical 18,51,84,123
patient xviii, xx, xxii, xxix, xxxii, 4,
7,20,22,26,30,31,34,36,38,
40-44,46,48,57--60,64--67,69-
71,74,77-79,81-86,89-91,95,
98, 100, 102, 123-125, 128, 129,
132, 133, 137, 140, 143, 146, 149,
152, 157, 159, 164, 166, 168, 182,
184,189,214-218,222-225,228,
232,233,235,236,260,277,298,
304,306,311,313,315,316,319,
320,322,323,326,328-332,334,
340,347,351,352
perfection 43, 54, 55, 56, 76, 118,
127,131,144,160,172-176,181,
184,191,193-196,215,222,224,
225,232,236,254,300,325,330,
347
pure 172-176,192-196,232
person xvii-xx, xxv, xxxv, 1,4, 5,
17, 19,23,24,29,33,35,37,39,
40,43,46,47,51,52,54,57-59,
61,62,64-75,80-83,89-93,96-
105, 107-110, 112-133, 135, 137,
139-144, 146-148, 150-153, 155-
158, 161-172, 176, 181, 182, 184,
185,187-192,195-205,207,208,
211-213,216-230,232-237,242,
245,247,248,257,259-264,270,
271,276-278,282,283,287,292,
293,295,300,302-304,306,308,
309,318-320,324-329,331-334,
336,338-341,343-351,353
personal xvii, xx, xxii, xxv, xxix,
xxxv, 1,7,18,32,33,39,40,
50,51,58,61,65--68,73,74,
82,86,91,99,100,103-105,
107-109,113-115,117,121-
123, 125, 126, 130, 132, 135,
138, 140, 143, 145-148, 150,
153, 157, 159, 161, 192, 196,
197,205,216,223,230,233,
239,253,254,280,286,309,
312,316,318,319,324,325,
331,340,342,344,346-352
personalistic xix, 39, 73, 75, 91,
 SUBJECT INDEX
196,221,239,254,315,325,
327,346,347
petitio principii 268
Pharisee, pharisaism 151, 164, 165,
177,227,346
phenomenology 96,100,179,208,
227,256,289,290
realist 96, 276
phenomenological 95, 100, 105,
131,188,204,230,237,242,
268,289-291,309,311
phenomenon xx, 5,28,30, 87, 102,
106,109,110,131,140,144,158,
159,200,204,208,220,240,256,
270,272,292,334
philosopher xxiii-xxv, 1,35,39, 72,
77,80,84,85, 108, 112, 129, 148,
150,167,174,204,214,248,273,
289,290
philosophical xviii-xxi, xxiii, xxv,
xxvii-xxix, xxxi-xxxvi, 1,4,5,
8,10,17,25,28,29,31-33,35,
37,39,40,45,49,50,52-54,56,
57,60,61,72,75-77,80-85,93,
96-100,105,112,115,116,125,
126, 129, 130, 132, 135, 137-
139, 143-146, 148, 150, 159,
168,175,178,185,187,192,
201,203,205,207-209,213,
235-239,241-243,245,248,
251,256,258,260,264,265,
267-269,271,272,275,278,
281,282,290,292,293,304-
306,309,312,316,326,346,
349,350-353
diseases xviii, xix, xxvii, 82,
145,159,239,305,350-352
philosophy xvii-xx, xxii-xxv,
xxviii, xxix, xxxii-xxxvi, 1-3,5,
13,23,29,32,34,37,39,40,43,
44, 48- 50, 52, 53, 56-58, 64,
67,71,77,80,81,84,87,89,96,
97,101,102,105,114,130-132,
137, 139, 140, 143, 145, 146,
148,159,179,184,185,188,
393
194,200,201,209,226,230,
234,235,237,238,240,241,
243,245,247,250,251,255,
256,268-270,273,274,285,
286,289-293,299-301,304,
306,309,310
of religion 130,131,179
physical xix, xxxii, 9, 29, 33, 46, 52,
54-56,59,63-65,68,85,92,106,
110,111,189,201,203-205,208,
210,223,236,253,332,339,351
physician xvii-xix, xxi, xxvii, xxx-
xxxii, 1,2,4,6, 11,20-22,25-29,
31,32,34-46,48-53,57,59-66,
69-71,73,74,76-87,89-92,94,
95,97-100,102,114,124,128,
129, 132, 137, 143, 145-152, 157,
159, 163, 164, 168, 169, 172, 176,
181-185,188,213-217,219,223,
224,228,232,233,236,238,243,
269,274,297,305,306,310,315,
319,320,322-324,326,328,329,
340,347,349,351,352
physics 2-4, 10, 17,22,34,35,209,
210,253
plague xviii, 41, 43, 239, 241, 351
pleasure xix, 58-60, 64, 65, 96, 114,
154,216-220,222,233,257,263,
298,308,311,349
pleasurable 114,245,263
pluralism, pluralist 249,267,276,
279,280,286,287,303
poliomyelitis 305
politics 48,53,86,241
political xxvii, xxx, xxxiii, 5, 49,
57,87,89,91,94,97,124,125,
137,138,160,183,240,243,
246,255,279,283,288,295,
298,301
positivism, positivist 4, 8, 21, 86,
254
possible world 3, 108, 188, 189,202
postmodem, xxvii, 11,240,245,275,
278,280,283,286
potency 115, 122, 123
394 SUBJECT INDEX
potentiality 67, 123, 189,304
potential 34,38,67, 115, 122,
136,156,175,191,192,205,
206,209,226,261,303,338,
340,345
practical xvii-xix, xxviii, 2, 8, 20,
24,32-40,50,54,80,81,90-92,
102, 135, 137, 138, 148, 149, 152,
184,220,290,297,298,309,316,
321,349
practice xxvii, xxx, 2, 7, 25, 27, 28,
30,34,41,44,46,53,86,87,93,
94,97,137,138,140,185,289,
290,349,351,352
medical xxvii, xxix, 2, 4, 7, 25,
31,47,66,76,77,92,136,140,
241,349,350
pragmatism, pragmatist xxi, 14, 103
premoral 337,339-341,351
prevention, preventive 8,26, 35,59
prima facie 19,330,341
obligations 19,341
principle xxxii, xxxiii, xxxvi, 5, 7,
12,14,18,22-25,27,36,40,41,
50,60,67,69,71,83,85,87,93,
95-97,104,105,108,109,112,
115,118-120,122,123,126,131,
132, 136, 149, 154, 158, 159, 162,
173,176-178,183,188-190,196,
199-202,209,210,212-214,218,
221,222,227,228,230,239-243,
247,248,254,256,258,260,265,
268-271,275,277,281,282,285,
286,288-290,295-297,300,303,
305,310-313,317,320,323,325,
331,333-336,339,341,344-347,
353
logical 14, 256, 290
moral 242, 266, 296, 334
of contradiction 18,24,247,248,
256,277,312
ontological 290
priority 48,59, 122, 123, 133, 197,
318,339
private xxvii, xxxii, xxxv, 96, 125,
238,241,244,246,265-267,278-
281,283-286,297,323,351
privatization 266, 267
probability 11, 13, 16,20,22-24,
273,322
probable 20, 23, 24, 235, 317
profession xvii, xxvii, xxx, xxxi, 1,
45,50,57,65,78-80,83-87,97,
138,145,159,172,236,273,298,
349
professional xix, xxix, xxx, 41, 42,
44,48,59,69,71,73,84-87,
89,147,148,223,236,349
progress, progressive xviii, 25-31,
38,47,48,70,92,135,159,288
probability 11, 13, 16,20,22-24,
273,322
proportion 54, 160
proportionalism 305
proportionality 310,311,323,
333,348
proposition 12-18,23, 74, 76, 122,
134,152,212,244,248-251,255,
268,269,270
psychiatry 3-5,29,57,63
psychology xx, 3, 12,63,87,210
psychological xxxiv, 11, 12,54,
61,125,207,248,290,322,
323,336
psychotherapy 4, 64
public xxvii, xxviii, xxx-xxxii, xxxv,
4,7,56,85,125,137,240,241,
243,246,264-266,272,275,278-
281,283,285,286,292,297,303,
307,351
punishment 51,146,160-162,165,
170,171,222,228,230,231,302,
307
punish xxx, 161, 162,297,333
raison d'etre 34,87, 128, 191,342,
349
rational xxi, xxvii, xxxii-xxxvi, 3,
11-14,18,25,54,61,62,64-68,
75,76,96,99-101,103,104,106-
110, 113-116, 118, 122, 123, 125,
 SUBJECT INDEX
130-132, 135, 137, 138, 140, 142,
152, 156, 15~ 160, 163, 172, 175,
179,196,210,212,214,221,223,
232,238-241,243,245,249,255,
256,258,262,264,266-269,271-
274,277,279-288,291,294,295,
297-300,303,311,343,349-351
justification xxxiii, 11, 12,281
rationalism 240,282,291-297
critical 135
rationality 106, 157,235,249,
272,296,297,300,301
readiness potential (RP) 203-207
real 3,5,8,9,16,19,21,28,31,37,
61-63,65,66,70,81,85,97,102,
103, 105, 113, 115, 121, 129, 130-
132, 136, 144, 145, 168, 171, 178,
187-189, 191-193, 195, 196, 198,
200,201,209,219,224-226,235,
245,251,259-261,284,285,289-
301,325,341
realism 3, 11,90,96, 100, 102,
103,289,290
reality xx, xxi, xxxiii, xxxv, 1,3,
5,8,9,16,19-21,27-29,31,
37,52,61-63,65,66,70,81,
85,96-98,102,103,105,110,
111, 113, 115, 121, 125, 127,
129-132, 134, 136, 144, 145,
151,153,168,171,172,175,
178,181,183,187-189,191-
193,195,196,198,200,201,
203,205,208,209,211,214,
219,223-226,232,235,238,
245,251,259-261,264,268,
274,277,283-285,287,289,
290,295-297,300,301,310,
312,325,330,339,341,347
realize 7,25,33,35,61,69, 71,
73,84,97,130,148-151,154,
155,162,166,171,180,188,
191,222,224,227,233,234,
237,296,314,318,325,327,
331,338,344,350,351
reduction xxxii-xxxiv, 13,66, 113,
395
130,136,139,260,290,296,347
reductionism, reductionist xx, 9,
28,54,156,296
relativity 2,93,241,243,244,247,
263,288,348
relativism xx, xxi, xxxiii, xxxiv, 7,
23,49,56,86,87,93,135,138,
145,151,239,241-247,249-
252,255,257,260,263,265-
267,271,276,280,286,287,
294,297,299,305,351
relativist xxxiii, 247, 249, 252
religion xxviii, xxx, xxxi, xxxiv,
xxxvi, 32, 64, 67, 68, 71, 72, 77,
79,81,83,86,94-99,125,129,
130, 132, 133, 136-138, 160, 161,
170,178-180,230,238,240,242,
265,275,278,285,292,303
religious xx, xxvii, xxxi-xxxv, 1,
31,33,49,61,63-66,72,76,
77,79-81,91,93-97,104,112,
123, 125, 127, 129-133, 135,
137, 138, 15~ 154, 167, 171,
175,178-180,222,230,236,
238,240-243,246,257-259,
265,266,272,275,279-283,
285,286,290,291,293,294,
296,330,351,352
reproduction xxix
reproductive 45- 47,50,56, 130
medicine 45, 46, 130
responsibility xxiii, xxxii, 20, 46, 64,
92,157,158,222,230,233
moral 17,104,157,236,290,342
revelation 295
Divine Revelation 49, 137,238
right xvii, xxvii, xxix, xxx, 15,22,
42,43,51,55,56,60,65,67,68,
70,72-76,81-83,85,89,92,94,
97, 103, 115, 118, 119, 121, 124-
126, 128, 129, 132, 135, 136, 144,
145, 147, 149, 154, 166, 183, 184,
192,209,215,221,223,232,257,
260,261,272-274,277,280,284,
289,292,295,297,300,302,305,
396 SUBJECT INDEX
306,308,311,313-315,317,320-
324,326,328,332,333,335-337,
341,343,344,353
and wrong 92,144,284,321,326,
333
human xix, xxvii, xxviii, xxx,
xxxiv, 51, 73, 75, 82, 89, 90, 94,
95,97-99,114,118-121,123-
125, 128, 132, 135, 136, 138,
178,225,243,246,258,263,
271,276,278,279,282,284,
285,297,308,310,352
to life 119, 121, 124
science xvii, xix, xxiv, xxix, 1,2,4,
5-8,10-13,15,16,20-36,40,44,
53,56,78,80,84,91,92,105,
135,143,145,208,209,237,238,
245,254,255,258,269,273,291,
293,306,349
natural xvii, xviii, 2, 4, 19,22,29,
34,35,209,238,274
rigorous xxxvi, 145,256,293
scientific xxiv, 1,2,4,6-8, 10--13,
23-31,33,35,36,38,39,42,
80,85,91,92, 112, 123, 141,
142,145,149,159,203,205,
208,209,272,276,349
scientist xvii, 2, 6, 10, 25, 26, 36,
44,80,85, 105, 112,207,210,
269
self-creation 210,211
-determination 106, 146, 153, 190,
198,202,211,275
-governance 146, 153, 190
-possession 153, 190
sexual 18,42,47,53,58,59,71,74,
75,119,216,217,255,271,279,
283,284,295,334
sexuality 75, 232, 332, 334
sick 26,40,41,43,53,55,58,59,
63,78,350
sickness xxvii, 5,25,36, 39, 45,
56,78,97,164,189,220
skeptic xxxiii, 201, 226, 247-249,
252,281
skeptical xxxiii, 10, 19,24,247,
251,287,293
skepticism xxi, xxxii, xxxiv, xxxv,
7,12,20,23,87,135,239-242,
245-252,260,265,276,278-
281,287,294,305,351
society xxi, xxvii, xxx, xxxi, xxxvi,
23,53,57-59,85,92,95,96,122,
123,128,129,135-138,188,238,
240,242,243,260,264,266,267,
272,275-281,283-289,294,303,
307,315,322,340,351
sophism, sophist 81, 85
soul xx, 9,49, 57, 70, 71, 77, 78,83,
101, 103, 105, 107-118, 126, 135,
141,161,168-171,200,203,218,
222,226,234,236,246,248,259,
295,304,307,327,334,345,347,
350
species 8, 14, 16, 19-22,51,54, 73,
85,111,139,141,142,147,174,
196,243,259,297,303,309,310
speciecism 85, 142,303
specific xxi, xxii, xxxi, 9, 16,20,21,
30,48,53,55,58,64,68,69,76,
83,84, 106, 107, 125, 129, 141,
146,147,154,194,203,229,239,
241,244,254,255,295,296,300,
301,319,339,348
spiritual xxxii, xxxiv, 57, 61, 63, 65,
67,69,72,79,99,103-105,107-
113,117,125,132,135,142,147,
148,169,170,179,189,203,211,
233,235,253,304,348,350
spirituality 79, 107, 109
springomyelia 305
standard xxx, 56, 72, 82, 252, 260,
311,319,323,335
state xxx, xxxi, xxxiv, xxxvi, 3, 9,
11, 13, 15, 17, 18,22-24,32,34,
38,43,46,49,53,54,56,61,62,
64,66,67,70,79,92,94,107,
109, 110, 111, 114, 119, 120, 122-
124, 131, 133, 136, 139, 151, 156,
160, 173, 182, 187, 188, 191, 198,
 SUBJECT INDEX
200,202,209,212,214,222,224,
225,231,232,235,240,243,244,
247,249-252,258,259,268,272,
275,279,280,283,284,286,291,
292,296-298,304,317,332,347,
349,350
subject xxiv, 2, 3, 5,12,17,25,27,
40,53,58,64,81,82,91,100-
109,111,113-115,121-124,126,
128, 129, 132, 133, 135, 139, 144,
147,150,153,155,157,158,164,
166, 167, 174, 175, 177, 188, 189,
194,196,200,202,203,205,208,
210-214,216,217,229,244,245,
251,255,268,272-274,277,282,
291,297,301,302,308,311,312,
315,318-321,323,324,326,327,
330,331,334,342,343,345,346,
348,353
subjective xxxiii, 3, 5, 21, 53, 56,
63,64,82,85,87,8~ 114, 118,
126, 135, 140, 142, 145, 146,
151,152,158,166,171,173,
192,212,218,219,223,225,
245,246,249,250,252,260-
263,266,280,290,296-298,
308,322,324,346,348
subjectively satisfying 152, 153,
216-219,221,227,245,263,
298
subjectivism xxxiv, 3, 53, 56, 93,
103,151,241,260
subjectivist xxxiii, xxxiv, 3, 56,
140,193,260,262
substance 16,41,67, 78, 86, 100-
105,107-109,114,115,122,128,
131,139,163,165,178,193,210,
266,306
substantial 66,67, 107, 109, 112,
115,121,122,124,135,140,
142,163, 189,203,251
suicide xxvii, xxxiv, 45, 48, 50, 72-
76,260,313,314,329
assisted xxii, xxxi, 71, 178,284,
310
397
supererogatory 155, 156
supervenient 101, 105, 107, 111,
114, 141, 142
supervenience 210
surgery 4,27,37,38,45,68,69,
150,349
symptom xxx, 6, 8,27,37,65
syndrome 10,242
synthetic 12,18,191,298,311,330
propositions 12, 18, 311
teleology 325
teleological xxxi, 177,226,295,
305,306,309-314,316-318,
320-330,332-337,341,342,
344-348,353
ethics xxxi, 177,305,309,310,
312-314,316,318,320,321,
323,325-330,332-334,336,
337,341,344-348,353
theology xxxi, 32, 50, 76, 228, 233,
292,335
theological xxxi, 77, 81,116,178,
235,297,309,320
theory xviii, xxi, xxxiii, 3-14, 16,
17,29-31,34,36,37,53,54,66,
87,93, 102, 103, 116, 118, 141-
143,174,204,209,216,242,254,
260,261,265,267,272,277-279,
286,287,290,291,293,299,306,
308-310,312-314,316,318,321,
323,324,328,332,335-337,347,
349,351-353
theoretical xvii, xix, xx, xxii,
xxvii, xxxii, 8,24,26, 27, 30-
37,39,40,50,54,81,83,84,
86,90-93, 135, 137, 152, 191,
235,242,278,290,310,330
things themselves 6, 18,97, 100,
173,175,184,188,264,287,289-
291,310
thought xxvii, xxviii, xxx, 3, 5, 9, 28,
37,43,49,51,52,59,62,66,67,
75,78,84,90,9~ 101, 102, 116,
121-124,126,137,158,171,200,
205,212,213,216,226,227,230,
398 SUBJECT INDEX
231,240,242,258,266,276,289,
295,308
torture xxii, 39, 48, 59, 60, 74, 81,
92,114,125,154,183,217,219,
225,246,279,283,284,302,310,
322,334,344
torturing 74, 114,259,284,298,
332,334
totalitarian, totalitarianism 53, 114,
279,286
transcend 43, 126, 130, 173, 194,
264
transcendence 106,123,124,291,
298
transcendent 43,63,69-71, 76,
83, 84, 128, 143, 150, 170, 177,
178,190,277,309,320,325,
335,349
transcendental 173, 174, 193-
195,200,208,212,226,231,
244,294,309,310,318,324,
325,328,332,348,353
trisomy 10
truth xxviii, xxxii, xxxiv, xxxv, 3, 4,
9,12-19,22,23,32,33,36,45,
48,49,56,62,70,72,78,80,82,
83,85,87,90,92,93,96-98,101,
106, 113, 118, 120, 123, 124, 126-
128, 130, 134, 137, 138, 144, 145,
152-154, 156, 157, 159, 161, 164-
166, 170, 171, 173, 180, 182, 184,
189,191,193,195,197,203,208,
211-214,217,221,222,225-228,
230-232,235,236,241,243- 252,
254,258,261,263-267,270,272-
274,276-288,290-295,300,303,
306,307,309,312,316,321,323,
330,340,342,347
truthfulness 70, 172, 236, 282,
298,323,334
universal xxvii-xxix, 11-19,21-24,
42,51,52,54,79,81,83,93,95-
100, 128, 130-132, 135-138, 149,
158,170,188,191,193-195,212,
221,226,229,232,237,238,248,
249,251,257,266,267,270,275,
279-281,285,293,295,297,311,
316,317,333,341,345,351
universality xxxv, 15, 17,22,93,
180,229,330
utilitarian 50,295, 306, 310, 311,
348,352
utilitarianism 176,306,309-311,
315,316,320,345,346
value xviii-xxii, xxviii, xxxi, xxxiii,
xxxiv, 7, 12, 13, 16,20,21,23,
32-35,40,44-47,51,52,55-58,
61-69,71,72,76,77,79,81,84,
85,87,89-98,100,113,114,118,
120-122, 124-127, 129, 130, 133-
138, 140, 142-146, 148-160, 162,
164-173,176-185,187,196,198,
211-214,216-219,221,222,225-
228,230,232,233,235-239,241,
243-246,251,252,254-267,271,
273-282,284-288,292-294,296-
305,307-309,311,314-319,322-
328,331-333,335-340,342,343,
346-349,351,352
kinds of 155,352
moral xxi, 33, 55, 64, 83, 97, 127,
133, 134, 143, 145, 146, 149-
157,159, 160, 162, 164-172,
175-185, 187, 191, 196, 198,
199,221,222,225,227,228,
230,231,237,238,242,245,
246,251-253,255-259,261,
263-266,269,270,276,277,
280-282,291,296,301-303,
305,308-310,314,316,317,
319,323,324,326-328,331,
332,335-338,341,345-348,
350-352
verification 10,12,17,23,26,208
vice 144, 156, 165, 168,225,232,
234,236,296,319,331,344
virtue xxxii, 7, 34, 60, 73, 79, 80, 85,
90,94, 100, 105, 114, 119, 127,
133, 137, 141, 144, 154, 156, 158,
162-165,168,171,172,176,178-
 SUBJECT INDEX 399

185,193,194,217,222,225-227,
230-232,234,236,240,254,259,
267,270,276,293,296,298,302,
304,305,307,318,328,331,335,
344,353
virus xix, 3, 6,44,48,241
World Health Organization (WHO)
53,54
~ongness 74,75,177,236,314
zoology 4, 8, 253
 Philosophy and Medicine

1. H. Tristram Engelhardt, Jr. and S.p. Spieker (eds.): Evaluation and Explanation
in the Biomedical Sciences. 1975 ISBN 90-277-0553-4
2. S.P. Spicker and H. Tristram Engelhardt, Jr. (eds.): Philosophical Dimensions of
the Neuro-Medical Sciences. 1976 ISBN 90-277-0672-7
3. S.P. Spicker and H. Tristram Engelhardt, Jr. (eds.): Philosophical Medical Ethics.
Its Nature and Significance. 1977 ISBN 90-277-0772-3
4. H. Tristram Engelhardt, Jr. and S.P. Spicker (eds.): Mental Health. Philosophical
Perspectives. 1978 ISBN 90-277-0828-2
5. B.A. Brody and H. Tristram Engelhardt, Jr. (eds.): Mental Illness. Law and Public
Policy. 1980 ISBN 90-277-1057-0
6. H. Tristram Engelhardt, Jr., S.P. Spicker and B. Towers (eds.): Clinical Judgment.
A Critical Appraisal. 1979 ISBN 90-277-0952-1
7. S.P. Spicker (ed.): Organism, Medicine, and Metaphysics. Essays in Honor of
Hans Jonas on His 75th Birthday. 1978 ISBN 90-277-0823-1
8. E.E. Shelp (ed.): Justice and Health Care. 1981
ISBN 90-277-1207-7; Pb 90-277-1251-4
9. S.P. Spieker, J.M. Healey, Jr. and H. Tristram Engelhardt, Jr. (eds.): The Law-
Medicine Relation. A Philosophical Exploration. 1981 ISBN 90-277-1217-4
10. w.B. Bondeson, H. Tristram Engelhardt, Jr., S.P. Spicker and J.M. White, Jr.
(eds.): New Knowledge in the Biomedical Sciences. Some Moral Implications of
Its Acquisition, Possession, and Use. 1982 ISBN 90-277-1319-7
11. E.E. Shelp (ed.): Beneficence and Health Care. 1982 ISBN 90-277-1377-4
12. G.J. Agich (ed.): Responsibility in Health Care. 1982 ISBN 90-277-1417-7
13. W.B. Bondeson, H. Tristram Engelhardt, Jr., S.P. Spicker and D.H. Wmship:
Abortion and the Status of the Fetus. 2nd printing, 1984 ISBN 90-277-1493-2
14. E.E. Shelp (ed.): The Clinical Encounter. The Moral Fabric of the Patient-
Physician Relationship. 1983 ISBN 90-277-1593-9
15. L. Kopelman and J.e. Moskop (eds.): Ethics and Mental Retardation. 1984
ISBN 90-277-1630-7
16. L. Nordenfelt and B.I.B. Lindahl (eds.): Health, Disease, and Causal Explana-
tions in Medicine. 1984 ISBN 90-277-1660-9
17. E.E. Shelp (ed.): Virtue and Medicine. Explorations in the Character of Medicine.
1985 ISBN 90-277-1808-3
18. P. Carrick: Medical Ethics in Antiquity. Philosophical Perspectives on Abortion
and Euthanasia. 1985 ISBN 90-277-1825-3; Pb 90-277-1915-2
19. J.C. Moskop and L. Kopelman (eds.): Ethics and Critical Care Medicine. 1985
ISBN 90-277-1820-2
20. E.E. Shelp (ed.): Theology and Bioethics. Exploring the Foundations and
Frontiers. 1985 ISBN 90-277-1857-1
 Philosophy and Medicine
21. G.J. Agich and C.E. Begley (eds.): The Price of Health. 1986
ISBN 90-277-2285-4
22. E.E. Shelp (ed.): Sexuality and Medicine. Vol. I: Conceptual Roots. 1987
ISBN 90-277-2290-0; Pb 90-277-2386-9
23. E.E. Shelp (ed.): Sexuality and Medicine. Vol. II: Ethical Viewpoints in Transition.
1987 ISBN 1-55608-013-1; Pb 1-55608-016-6
24. Re. McMillan, H. Tristram Engelhardt, Jr., and S.F. Spicker (eds.): Euthanasia
and the Newborn. Conflicts Regarding Saving Lives. 1987
ISBN 90-277-2299-4; Pb 1-55608-039-5
25. S.F. Spicker, S.R Ingman and I.R Lawson (eds.): Ethical Dimensions ofGeriatric
Care. Value Conflicts for the 21th Century. 1987 ISBN 1-55608-027-1
26. L. Nordenfelt: On the Nature of Health. An Action-Theoretic Approach. 2nd,
rev. ed. 1995 SBN 0-7923-3369-1; Pb 0-7923-3470-1
27. S.F. Spicker, W.B. Bondeson and H. Tristram Engelhardt, Jr. (eds.): The Contra-
ceptive Ethos. Reproductive Rights and Responsibilities. 1987
ISBN 1-55608-035-2
28. S.F. Spicker, I. Alon, A. de Vries and H. Tristram Engelhardt, Jr. (eds.): The Use
of Human Beings in Research. With Special Reference to Clinical Trials. 1988
ISBN 1-55608-043-3
29. N.M.P. King, L.R Churchill and A.w. Cross (eds.): The Physician as Captain of
the Ship. A Critical Reappraisal. 1988 ISBN 1-55608-044-1
30. H.-M. Sass and RD. Massey (eds.): Health Care Systems. Moral Conflicts in
European and American Public Policy. 1988 ISBN 1-55608-045-X
31. RM. Zaner (ed.): Death: Beyond Whole-Brain Criteria. 1988
ISBN 1-55608-053-0
32. B.A. Brody (ed.): Moral Theory and Moral Judgments in Medical Ethics. 1988
ISBN 1-55608-060-3
33. L.M. Kopelman and J.e. Moskop (eds.): Children and Health Care. Moral and
Social Issues. 1989 ISBN 1-55608-078-6
34. E.D. Pellegrino, J.P. Langan and J. Collins Harvey (eds.): Catholic Perspectives
on Medical Morals. Foundational Issues. 1989 ISBN 1-55608-083-2
35. B.A. Brody (ed.): Suicide and Euthanasia. Historical and Contemporary Themes.
1989 ISBN 0-7923-0106-4
36. H.A.M.J. ten Have, G.K. Kimsma and S.F. Spicker (eds.): The Growth ofMedical
Knowledge. 1990 ISBN 0-7923-0736-4
37. I. Lowy (ed.): The Polish School of Philosophy of Medicine. From Tytus
Chalubinski (1820-1889) to Ludwik Fleck (1896-1961). 1990
ISBN 0-7923-0958-8
38. T.J. Bole III and W.B. Bondeson: Rights to Health Care. 1991
ISBN 0-7923-1137-X
 Philosophy and Medicine
39. M.A.G. Cutter and E.E. Shelp (eds.): Competency. A Study of Informal Compe-
tency Detenninations in Primary Care. 1991 ISBN 0-7923-1304-6
40. J.L. Peset and D. Gracia (eds.): The Ethics of Diagnosis. 1992
ISBN 0-7923-1544-8
41. K.W. Wildes, S.J., F. Abel, S.J. and J.C. Harvey (eds.): Birth, Suffering, and
Death. Catholic Perspectives at the Edges of Life. 1992 [CSiB-l]
ISBN 0-7923-1547-2; Pb 0-7923-2545-1
42. S.K. Toombs: The Meaning of Illness. A Phenomenological Account of the
Different Perspectives of Physician and Patient. 1992
ISBN 0-7923-1570-7; Pb 0-7923-2443-9
43. D. Leder (ed.): The Body in Medical Thought and Practice. 1992
ISBN 0-7923-1657-6
44. C. Delkeskamp-Hayes and M.A.G. Cutter (eds.): Science, Technology, and the
Art of Medicine. European-American Dialogues. 1993 ISBN 0-7923-1869-2
45. R. Baker, D. Porter and R. Porter (eds.): The Codification of Medical Morality.
Historical and Philosophical Studies of the Formalization of
Western Medical Morality in the 18th and 19th Centuries, Volume One: Medical
Ethics and Etiquette in the 18th Century. 1993 ISBN 0-7923-1921-4
46. K. Bayertz (ed.): The Concept of Moral Consensus. The Case of Technological
Interventions in Human Reproduction. 1994 ISBN 0-7923-2615-6
47. L. Nordenfelt (ed.): Concepts and Measurement of Quality ofLife in Health Care.
1994 [ESiP-l] ISBN 0-7923-2824-8
48. R. Baker and M.A. Strosberg (eds.) with the assistance of J. Bynum: Legislating
Medical Ethics. A Study of the New York State Do-Not-Resuscitate Law. 1995
ISBN 0-7923-2995-3
49. R. Baker (ed.): The Codification ofMedical Morality. Historical and Philosophical
Studies of the Formalization of Western Morality in the 18th and 19th Centuries,
Volume Two: Anglo-American Medical Ethics and Medical Jurisprudence in the
19th Century. 1995 ISBN 0-7923-3528-7; Pb 0-7923-3529-5
50. R.A. Carson and C.R. Bums (eds.): Philosophy of Medicine and Bioethics.
A Twenty-Year Retrospective and Critical Appraisal. 1997 ISBN 0-7923-3545-7
51. K.W. Wildes, S.J. (ed.): Critical Choices and Critical Care. Catholic Perspectives
on Allocating Resources in Intensive Care Medicine. 1995 [CSiB-2]
ISBN 0-7923-3382-9
52. K. Bayertz (ed.): Sanctity of Life and Human Dignity. 1996
ISBN 0-7923-3739-5
53. Kevin Wm. Wildes, S.J. (ed.): Infertility: A Crossroad of Faith, Medicine, and
Technology. 1996 ISBN 0-7923-4061-2
54. Kazumasa Hoshino (ed.): Japanese and Western Bioethics. Studies in Moral
Diversity. 1996 ISBN 0-7923-4112-0
 Philosophy and Medicine
55. E. Agius and S. Busuttil (eds.): Germ-Line Intervention and our Responsibilities
to Future Generations. 1998 ISBN 0-7923-4828-1
56. L.B. McCullough: John Gregory and the Invention ofProfessional Medical Ethics
and the Professional Medical Ethics and the Profession of Medicine. 1998
ISBN 0-7923-4917-2
57. L.B. McCullough: John Gregory's Writing on Medical Ethics and Philosophy of
Medicine. 1998 [CiME-l] ISBN 0-7923-5000-6
58. H.A.M.J. ten Have and H.-M. Sass (eds.): Consensus Formation in Healthcare
Ethics. 1998 [ESiP-2] ISBN 0-7923-4944-X
59. H.A.M.J. ten Have and J.V.M. Welie (eds.): Ownership of the Human Body.
Philosophical Considerations on the Use of the Human Body and its Parts in
Healthcare. 1998 [ESiP-3] ISBN 0-7923-5150-9
60. M.J. Cherry (ed.): Persons and Their Bodies. Rights, Responsibilities, Relation-
ships. 1999 ISBN 0-7923-5701-9
61. R. Fan (ed.): Confucian Bioethics. 1999 [APSiB-l] ISBN 0-7923-5853-8
62. L.M. Kopelman (ed.): Building Bioethics. Conversations with Clouser and Friends
on Medical Ethics. 1999 ISBN 0-7923-5853-8
63. W.E. Stempsey: Disease and Diagnosis. 2000 PB ISBN 0-7923-6322-1
64. H.T. Engelhardt (ed.): The Philosophy of Medicine. Framing the Field. 2000
ISBN 0-7923-6223-3
65. S. Wear, J.J. Bono, G. Logue and A. McEvoy (eds.): Ethical Issues in Health
Care on the Frontiers of the Twenty-First Century. 2000 ISBN 0-7923-6277-2
66. M. Potts, P.A. Byrne and R.G. Nilges (eds.): Beyond Brain Death. The Case
Against Brain Based Criteria for Human Death. 2000 ISBN 0-7923-6578-X
67. L.M. Kopelman and K.A. De Ville (eds.): Physician-Assisted Suicide. What are
the Issues? 2001 ISBN 0-7923-7142-9
68. S.K. Toombs (ed.): Handbook of Phenomenology and Medicine. 2001
ISBN 1-4020-0151-7; Pb 1-4020-0200-9
69. R. ter Meulen, W. Arts and R. Muffels (eds.): Solidarity in Health and Social
Care in Europe. 2001 ISBN 1-4020-0164-9
70. A. Nordgren: Responsible Genetics. The Moral Responsibility of Geneticists for
the Consequences of Human Genetics Research. 200 1 ISBN 1-4020-0201-7
71. J. Tao Lai Po-wah (ed.): Cross-Cultural Perspectives on the (Im)Possibility of
Global Bioethics. 2002 ISBN 1-4020-0498-2
72. P. Taboada, K. Fedoryka Cuddeback and P. Donohue-White (eds.): Person, Soci-
ety and Value. Towards a Personalist Concept of Health. 2002
ISBN 1-4020-0503-2
73. J. Li: Can Death Be a Harm to the Person Who Dies? 2002
ISBN 1-4020-0505-9
 Philosophy and Medicine
74. H.T. Engelhardt, Jr. and L.M. Rasmussen (eds.): Bioethics and Moral Content:
National Traditions ofHealth Care Morality. Papers dedicated in tribute to Kazu-
masa Hoshino. 2002 ISBN 1-4020-6828-2
75. L.S. Parker and R.A. Ankeny (eds.): Mutating Concepts, Evolving Disciplines:
Genetics, Medicine, and Society. 2002 ISBN 1-4020-1040-0
76. W.B. Bondeson and J.W. Jones (eds.): The Ethics ofManaged Care: Professional
Integrity and Patient Rights. 2002 ISBN 1-4020-1045-1
77. K.L. Vaux, S. Vaux and M. Sternberg (eds.): Covenants of Life. Contemporary
Medical Ethics in Light of the Thought of Paul Ramsey. 2002
ISBN 1-4020-1053-2
78. G. Khushf (ed.): Handbook of Bioethics: Taking Stock of the Fieldfrom a Philo-
sophical Perspective. 2003 ISBN 1-4020-1870-3; Pb:
1-4020-1893-2
79. A. Smith ntis (ed.): Institutional Integrity in Health Care. 2003
ISBN 1-4020-1782-0
80. R.Z. Qiu (ed.): Bioethics: Asian Perspectives A Questfor Moral Diversity. 2003
ISBN 1-4020-1795-2
81. M.A.G. Cutter: Reframing Disease Contextually. 2003 ISBN 1-4020-1796-0
82. J. Seifert: The Philosophical Diseases of Medicine and Their Cure. Philosophy
and Ethics of Medicine, Vol. 1: Foundations. 2004 ISBN 1-4020-2870-9

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