George A. Blair

Copyright © 1996

NOTE: The first five chapters of this book are identical with Human Conduct, and so the contents link to the chapters of that book.


This is a scientific and objective approach to ethics. First, it establishes that everyone in fact believes that morals are objective, and that all moral codes derive from "Do not deliberately act as if you weren't what you really are."

First, the general implications of this are developed, discussing why people feel necessitated to obey this command, and secondly its implications for the choice one makes rather than the act itself one performs: how morality depends on one's knowledge of one's reality, and is modified by constraints on one's freedom.

Then, the book explores the various aspects of health-care delivery: the relation between the practicioner and the patient, the profession and business of health care, the patient's life, the patient's physical integrity, and then issues dealing with other types of providers: nurses, psychologists, and researchers.



Part One: General Principles
Chapter 1: The Moral Command
1.1. A science of ethics?
1.1.1. A self-contradictory moral position
1.2. The two basic observable facts
1.3. The question to investigate
1.4. Observed characteristics of the fact
1.4.1. How to use the observed data
1.5. Association from early training
1.6. Social pressure
1.6.1. Examples of "immoral=inhuman"
Chapter 2: The Real Issue
2.1. The true moral norm
2.1.1. A note on "natural-law" ethics
2.1.2. The moral command
2.2. The real issue
2.2.1. The problem
2.2.2. The reason people are afraid of immorality
Chapter 3: The Consequences
3.1. Can this theory be scientific?
3.2. Evidence dealing with life after death
3.3. Nature of the life after death
3.3.1. Relation of this theory to others
3.3.2. Happiness and enjoyment
3.3.3. No forgiveness
3.3.4. The afterlife and God Theological note on salvation
3.4. The meaning of life
3.4.1. God as the "real" goal of life?
Chapter 4: Freedom and Responsibility
4.1. The choice as free
4.1.1. Characteristics of free choice
4.2. The general moral rule
4.3. Morality and emotions
4.3.1. Morality and emotional problems
4.3.2. Habits: virtues and vices
4.4. Responsibility
4.4.1. Responsibility and guilt
Chapter 5: Moraliity and Knowledge
5,1, Morality and knowledge: conscience
5.1.1. Clear and unclear conscience
5.1.2. Clearing an unclear conscience
5.2. Act and situation
5.2.1. The motive
5.2.2. The means
5.2.3. Side effects
5.2.4. The Principle of the double Effect
Part Two: Applications to the Field of Health Care
Chapter 6: Provider and Patient
6.1. Applying ethics
6.1.1. Informing the ignorant
6.2. Health
6.2.1. The health-care provider
6.3. The provider's own humanity
6.3.1. Lying Lying by implication: the placebo Public-health propaganda
6.4. Relations to others: rights
6.4.1. The right to privacy
6.4.2. Concealing information
Chapter 7: The Profession and Business of Health Care
7.1. Health care as a profession
7.1.1. Expertise Malpractice
7.1.2. Referrals
7.2. Health care as a business
7.2.1. The value of the service
7.2.2. Values and necessities
7.3. Pricing health care
7.3.1. Government and insurance
7.4. Control over the service
7.4.1. Experimental treatment
7.4.2. Mutual respect
7.5. Quackery
Chapter 8: The Patient's Life
8.1. The physician
8.2. What human life is
8.2.1. Abortion
8.2.2. Fetal tissue experimentation
8.2.3. "Test-tube babies"
8.2.4. Monsters and mutants
8.3. Death and dying
8.3.1. When death occurs
8.3.2. Respect for the corpse
8.3.3. Suicide
8.3.4. Postponing death The "living will"
Chapter 9: The Patient's Physical Integrity
9.1. The Principle of Totality
9.1.1. Mutilation Removing diseased organs Removing healthy organs Organ transplants Fetal transplants Sterilization "Sex changes"
9.1.2. Non-mutilations Cosmetic plastic surgery
9.2. Suppression of functions
9.2.1. Irrelevant use of parts
9.2.2. Recreational drugs
9.2.3. Multi-dimensional functions Sexual inconsistencies
Chapter 10: Other Providers
10.1. The nurse
10.1.1. Immoral and unjust commands
10.1.2. Morally correct commands
10.1.3. Responsibility of the assistant
10.1.4. Cooperation in evil
10.2. The psychologist
10.2.1. The mind Mental unhealth and immorality Implications for treatment
10.2.2. Methods of treatment
10.3. The researcher


Just a word or two before we begin. If you're looking for a book on "values clarification" in the ethical field, I'm afraid you'll have to look elsewhere. If you want a book on the history of ethical theory, this is not your book. If you want "discussions" on the issues which lay out both sides of controversial topics, and leave it up to you to make up your mind, then don't bother reading this. This book lays out what the facts are in the moral aspect of the health-care field.

"What nonsense!" you say. "Who are you to say that you "know what the facts are" and can presume to tell other people what they should do!" There are no "facts" in ethics, anyway—if there is such a thing as a "fact" that can be absolutely known at all."

Oh yes? Is that a fact? Is it a fact that there are no facts in ethics? How do you know? And who are you to presume to tell me that there aren't? And what do you mean by "presume"? That it's somehow wrong of me to dare to say that my position is correct and that anyone who disagrees with it is wrong?

But how can you say that? Aren't you trying to tell me that my position is wrong? Isn't it wrong of you to dare to say that, based on your own principles? How do you know that it's an absolute fact that no one can know absolute facts? (You seem to know this one.)

The moral disease I discuss at the beginning of the book is a symptom of the intellectual disease that is infecting our whole culture: that no one "really knows" the actual facts, and that everyone "has a right to his own opinion"—meaning that you're "dissing" someone, somehow, if, instead of saying, "I disagree with you," you say, "Nope. Things aren't that way. You're mistaken."

That attitude kills learning. All it means is that we "share" our opinions, and if you happen to like mine, you'll adopt it. But if it doesn't grab you, then you'll stand on your "right" to your own opinion, and denounce me as a sinner for claiming that I'm objectively right and you're objectively wrong.

But that position is sustainable only if it is objectively true that no position is objectively true—in which case, that position (that no position is objectively true) isn't true. So it's not a wise position, it's a stupid one, not because I disagree with it, but because it disagrees with itself. And it's not a tolerant position, because it refuses to tolerate anyone who knows what he's talking about; it's not open-minded, but closed-minded, because it insists, "I've got a right to my opinion, so don't bother me with facts!"

Besides, you yourself know at least one fact that can't be doubted by anyone: There is something, meaning that there's not just absolutely nothing at all. Try to deny it. There's the denial, and that's something, and you know it. Doubt it. There's the doubt, and that's something, and you know it. Disagree with it. There's the disagreement. No matter what you do, you know with absolute certainty this fact, and you also know that it's certain for anyone, because no matter who denies it, there's the denial, which is something.

So we can know facts; we can find evidence that shows that one position is correct and its opposite is incorrect. Hold onto that. There are no "facts for" someone. You may or may not know what the fact is, but a fact is a fact is a fact.

So don't tell me I can't come up with the facts in ethics. Challenge me to do it. The rest of the book is an attempt to meet the challenge. Sometimes I may not succeed; but don't kill the attempt before I even start by declaring without any evidence that it can't be done.

[For more on this see Modes of the Finite, Part One, Section 1, Chapter 1 and following.]

Feast of St. Alphonsus Liguouri,
August 1, 1996





1.1. A science of ethics?

In this book, we are going to attempt to treat ethics scientifically. It was thought for centuries that there was no problem in this; but nowadays, if a person tries it, he is laughed at as some kind of anachronism.

Why is this?

Partly, it is because the progress in physics has led people to think that you can't do science unless you measure things; but actually, the measurement is not what makes physics scientific, but the testability of the theories by experiment.

But you can't test ethical theories, can you? It turns out that you can; and this is what we will be trying to do in this book.

A second difficulty people have with a scientific approach to ethics is where you can find objective data. People have such different notions of goodness and badness, rightness and wrongness, that there seems to be no hope of coming up with anything that everyone would agree on; and if you can't do that, you can't even start, scientifically; you have no data to base your conclusions on.

We are going to get round this difficulty by starting from the fact that people think certain things about ethical matters. Whether what they think is right or wrong is irrelevant as our starting-point; right or wrong, they think a certain way, and you can observe this just by asking people. It may seem that this isn't a very promising place to begin; but we will see that it can lead us quite a distance if we are careful.

The third difficulty people have is an outgrowth of the other two. Since it is assumed that you can't treat moral matters objectively, then people conclude that morals are a question either of emotions or religion or both--usually both.

But this can't be all there is to morals. Respecting people's rights is one of the major moral issues; and if this is a matter of "emotions" or "religion," then how are people's rights to be guaranteed? That is, if some Muslim felt that I, as a Christian, should be killed for blasphemy, do my rights yield to his religion? Shouldn't he be stopped from killing me

1.1.1 A self-contradictory ethical position

This indicates one of the  reasons for trying to find out whether there is any objectivity to morals. If there is no objective morality, then there are no such things as rights. If morals are a "deeply emotional issue," then why should I respect anyone else's rights unless I "feel deeply" about respecting them?

Most people's reaction to this would be, "Well, you had better 'feel deeply' about respecting our rights, because we're going to see that you respect them, whether you like it or not." This seems to indicate that people do think that there is something objective about morality; and so it is worth a try to see if the subject can be treated scientifically.

In fact, the notion that morals are not objective leads to a self-contradiction. People who hold that there are no objective moral standards reason in this way:

"There are no objective moral standards that apply to everyone. Therefore, no one has any right to try to impose his moral standards on anyone else."

Why does this contradict itself? It seems so obviously true. Ask yourself this: what does "No one has any right to impose..." mean? It doesn't mean that no one has the strength to do it; it means that it's wrong to try to do it, and should be stopped.

But "It's wrong for anyone to try to impose his moral standards on anyone else" is a moral standard that everyone is supposed to adhere to. So if there are no moral standards that apply to everyone, it follows logically that there is one moral standard that applies to everyone: let people alone. But that's impossible, if there are no moral standards.

So it can't be true that there are no objective moral standards, because if there aren't, there are. The view that there are no objective moral standards is objectively stupid.

So if someone tells you, "This is a moral issue; you have no right to impose your moral standards on me," you can retort, "Who are you to impose your standard of non-interference on me?" A person who consistently held that there were no moral standards would have to let others interfere with him whenever the other people felt morally justified in doing so. And there's no one--least of all the "moral relativists"--willing to admit this.

CAUTION: Note that the fact that it is self-contradictory to say that we can never interfere with others' morals does not mean that we can interfere whenever we please. (We will have to discover later when interference is moral and when it isn't.) It only means the following:

CONCLUSION: No one in practice believes that there are no objective moral standards. Everyone, whether he realizes it or not, believes that there are some things that everyone must do or avoid.

1.2. The two basic observable facts

Let us, then, make a try at developing a scientific study of ethics. There are, as it happens, all kinds of ways of approaching the subject, which is to philosophy what engineering is to science. That is, ethics deals with human behavior, but not with a description of what human behavior is, but with how human beings should behave.

DEFINITION: Behavior is the actions human beings perform, especially those actions which follow from human choices (and therefore which the humans are held "responsible" for).

DEFINITION: Conduct is human behavior in relation to some standard for judging whether that behavior is "good" or "bad."

Ethics, then, is about human conduct.

Some of the many questions connected with ethics are whether human "conduct" has any real meaning, in the sense of whether there is any standard by which human behavior can be judged. If there is a standard for human behavior, what is it? Is the standard, if any, one which applies to any human being, or does it only apply to the one who has it, or to the culture in which he exists?

What we know so far is that people think there is at least some objective standard for judging right and wrong conduct, because even those who profess to think there isn't one consider interference wrong. Clearly, that standard can't be the "objectively correct" one, because it contradicts itself.

But then (a) is this belief that there are objective standards a delusion (and there really aren't any), and (b) if there are, what are the "right" standards, and how are we going to recognize them when we see them? These are questions that we will have to try to answer.

But there is more. Supposing there are standards for human conduct, but a person (even knowingly) doesn't follow them, what then?

One answer is that society will punish him. But suppose he can get away with it; suppose he has such power that society can't touch him? Take Hitler. Few today would think that what he did to the Jews was anything but horribly wrong. But no one in his society did anything to him for it; it was for those who conquered the society to "bring him to justice"--except that he killed himself first. Or take Stalin. No one "brought him to justice;" he died in bed with honor, though he had killed, tortured, and enslaved thousands if not millions of his own people.

So society doesn't always punish people. Does this mean that, if you can get away with it, it may be (in theory) "bad" to do what you are doing, but in practice it's good? That is, if Stalin got pleasure out of killing and torturing people, if he got rich and powerful doing it, and if he won fear and respect from his people because of it--and if these were what he wanted--shouldn't he do these things? Why shouldn't he?

But people don't in fact think that the fact that you're better off for being immoral makes it good to be immoral, or means that you "ought" in any sense do to what is immoral.

That is, people put moral "badness" in a different category from artistic badness, logical badness, and other forms of badness. If you sing off key, and you want to hire an auditorium to give a concert, then no one says you "shouldn't" do it, as long as no one is forced to attend (which would make it a moral issue). If you want to reason illogically, so what? But if you want to murder people, that's another story.

BASIC ETHICAL FACT: People are reluctant to do what they think is morally wrong; they tend to be afraid to do it, even if it is to their advantage.

When people do something they think is wrong, there is the experience of guilt afterwards, which--as a psychological experience, now--is more than just, "Oh, I did something people don't approve of." We often do things others don't approve of and experience no guilt, because we think they have no business disapproving of what we have done; then we feel anger or contempt, not guilt.

The experience of guilt involves (a) the knowledge that we have violated the moral standard that we think is the "right" one, and (b) the fear that because we did, something bad is going to happen to us. The experience of guilt is the expectation of punishment.

And this implies that the "reluctance" we have to do something we consider morally wrong is actually a kind of fear that if we do it, then something bad will happen to us.

1.3. The question to investigate

As I mentioned, there are all sorts of questions to investigate in an examination of ethics; but if you are going to get anywhere, you have to be careful which one you choose.

Most people have tried to investigate ethics by tackling the question of the ethical standard; but there have been any number of theories generated from these investigations, none of which lead to any testable predictions; and the result has been that ethics (as a study) seems to remain in the realm of speculation, without our being able to decide in favor of one theory over another, as long as each one is internally consistent.

But you can't leave things like this, if there is in fact something bad that happens if you do what is "really" wrong. If Hitler can find an ethical theory to justify what he did to the Jews, does that make it okay? Just because the theory is internally consistent?

So that line of investigation doesn't look productive of the results we need. Hence, we will try to investigate the following question:

Question to be examined: Why do people tend to be afraid of doing what they think is morally wrong?

This is an interesting question particularly in view of the fact that we know that there are people who do what is wrong and get away with it. And each of us has had the experience (probably in some minor matter) of doing something we thought was wrong and yet being better off for it: lying, for instance, to save ourselves from embarrassment.

We felt guilty afterwards for a while, but the person we lied to never found out; and on the whole we were the gainers. But this doesn't teach us that we should lie when in similar circumstances. We still feel that we "lucked out" that time, but you can't count on it. So the fear is still there, even against our own experience. Why is that?

Refinement of the question: Where did this fear associated with immoral conduct come from?

That is, what we will be investigating is not precisely where people get their moral standards, but how the idea of "immoral conduct" got associated with "something bad will happen if you do it."

Did people get the idea because their parents told them this, and they got "brainwashed" into believing it? Did they get the idea because society disapproves strongly of certain acts, and this makes people around you afraid of doing them, and the fear just communicates itself to you? Did they get it because some God told them he would punish them if they did these things?

These are the main explanations of the origin of this fear attached to immoral conduct that we are going to investigate. All three of them have quite respectable authorities in favor of them: the first is essentially the theory of the psychologist Sigmund Freud, the second of the sociologist William Graham Sumner; and the fourth any number of religious philosophers such as Thomas Aquinas.


You are already inclined to believe one of these views. Be aware of this bias you have, and keep your mind open to the evidence. No one of the views above is a "fact." They are all theories developed to explain a fact.

The theories are only good if in fact they do explain the facts they are trying to explain. If they don't, then it doesn't matter whether you would like to "believe" them or not; they are false, and they aren't facts. We are not trying to develop a theory of morality that you can be "comfortable" with; we are trying to find out the facts, if any, and if we can.

1.4. Observed characteristics of the fact

If we are going to be investigating these various explanations of why we feel afraid to do what we think is wrong, then we had better first find out all we can about what this fear attached to our notion of immoral conduct is. Just as Galileo discovered important things about falling bodies by measuring how fast they fall (leading to Newton's theory of gravity as their explanation), so if we are to be scientific about ethics, we have to observe our data carefully.

There are six characteristics that we can point to about this fear associated with immoral conduct:

1 It is universal: Everyone tends to think immoral conduct must be avoided; everyone experiences guilt when doing something he thinks is morally wrong.

Even the so-called "pathological" person is not really guilt-free. These people tend not to feel guilt at what normal people feel guilt about (such as murdering people); but they have strange standards that they feel guilty violating. So we can say that everyone associates immoral conduct with some kind of fear.

NOTE: All this characteristic says is that the fear itself is "universal." What people are afraid of is not (see characteristic 4)

2 It is serious: People think that immoral conduct must be avoided even if you "gain the whole world" by being immoral. That is, people don't think that Stalin should have done what he did, even if he got power, wealth, and honor for it.

3 It tends to be associated with a divine source: That is, people tend to think that some sort of invisible being will punish them for being bad. Certainly there are enough people who have held this through history and who hold it today that we can say that this is a general characteristic of the fear, if not a universal one.

This is not to say that there actually is a god who enforces morality. What we are saying here is that enormous numbers of people think there is; and they at least claim that it is their fear of God that makes them avoid being immoral.

The above three characteristics deal with the fact of the fear itself. The following three deal with what it attaches itself to.

4 The definition of "immoral conduct" varies greatly from culture to culture, and is relatively the same within a culture.

Depending on how simple or complex the culture is, you find less or more variation on what "immoral conduct" means. In simple (the so-called "primitive") cultures there seems to be complete agreement on what is morally "good" and "bad"; in very sophisticated, complex cultures like ours, there is great disagreement--but not as much as there is between cultures.

So the fact that a fear attaches itself to some behavior is (as a fact) universal in all cultures; what it attaches to is not universal.

5 Each person or culture thinks that his or its standards are the "right" ones.

This is an interesting fact. If you think something is wrong for you, you automatically think that it's wrong ("really") for anyone. You may excuse other people ("because they don't know any better"), but you don't really think that if something is really wrong for you, then it's really right for anyone else in the same circumstances.

Even, as we saw, those who hold that there are no "real" standards think that therefore it is wrong to interfere with anyone else's following his conscience. This is the only thing that such people think is morally wrong--but what is interesting is that they think that this is "really" wrong for everyone.

6 The standard is basically negative. That is, we all recognize some acts to be morally good; but we don't have the same kind of "necessity" connected with them that we feel with respect to the things we consider "bad."

That is, when we recognize that it is morally good to give to the United Appeal, we also recognize that this is something that we don't have to do; it is a generous act. We only think we have to do those things whose omission is the practical equivalent of actually doing something bad. For instance, we think we have to eat enough to stay alive and not harm our health; beyond that, eating the "proper" food is not obligatory. We have to help others only to the extent that refusing our help is the same as doing them harm; beyond that, the act is good, but not obligatory. And so on.

[See also Modes of the Finite, 5.1.2]

1.4.1 How to use the observed data

These characteristics of the fear attached to what people think is morally wrong will give us something to use as a preliminary test of possible explanations of the origin of that fear.

To use some simple examples to show how this testing works, let us consider the following possible explanations:

Hypothesis 1: The fear comes from the fear of punishment attached to violations of laws.

If it did, we know where the laws come from (the legislature) and where the punishment comes from (courts and police). But if this is where the fear of being immoral came from, then why would people think that God would punish us?

Thus, this hypothesis fails to explain the facts. Our fear of being immoral cannot come from our fear of the punishment involved in breaking the law.

That is, our fear of doing what is illegal is different from our fear of doing what is immoral. And this is confirmed by the fact that people sometimes think that the laws can be unjust and immoral, and that they cannot morally obey these laws (as "conscientious objectors" think, for instance, about the draft laws).

Hypothesis 2: The fear comes from our respect for our parents, who taught us to obey them.

If it did, then those whose parents have died would no longer be afraid to be immoral, since the parents would not be around to enforce their wishes, nor would they perceive any "disrespect" to them. Thus, the fear would not be universal. Their wishes might carry over as something that "it is good" to do; but the fear of violating their wishes would no longer be serious. Further, if we obeyed morality out of respect for our parents, how did a divine source get attached to the fear?

Thus, this hypothesis fails to explain the facts. Our fear of being immoral is not a fear of being punished by our parents.

Parents, then, may be largely responsible for what our standards are, but do not seem to be the origin of the particular fear of violating the standards.

1.5. Association from early training: "the unconscious"

There is a version, however, of the "parental" hypothesis which deserves serious consideration. This explanation of the fear of being immoral goes this way:

Hypothesis: The fear we have of doing what is immoral comes from our early training, in which we were punished for "bad" acts. The expectation of punishment remains associated psychologically with these acts, even after we reach adulthood.

To expand on this hypothesis, what it says is that when we were very young and were punished for doing something, the punishment (especially as coming from our parents, who we thought loved us) was very frightening. The severer this punishment was, and/or the more often it was repeated, the more ingrained was the association, "If I do this thing, something terrible is going to happen to me." Thus, we would tend to avoid the act.

The hypothesis says that this emotion attached to the act carries over into adulthood, even after we know that our parents will no longer punish us. It still feels as if they will.

And since there is this feeling "If I do this, Daddy will spank me" with the knowledge that in fact Daddy won't because he can't, then the feeling acts as if there were an invisible, all-powerful "Father" who will "spank" us (i.e. "send us to hell") if we are bad.

Thus, the "obligation" we feel not to be immoral is really of the nature of a neurotic compulsion, and in extreme cases, people actually hear voices commanding them to do things, and when they do something wrong, their guilt becomes so great that their unconscious minds make them "accident prone" until something bad happens that can satisfy this emotional craving for punishment.

Test of the hypothesis against the data

Does this hypothesis explain why:

1. everyone would have a fear attached to immoral conduct? Yes, because everyone has been punished when very young.

2. people would think morality a serious matter? Yes, because they would not know what the punishment was to be, and it would seem to come from an invisible Being, and would have a "fear of hell" attached to it.

3. people would associate the fear with a divine source? Yes, because the emotion would create the feeling of an invisible "punisher" (whether there actually was one or not).

4. the definition of "immoral" would vary as it is observed to? Yes, because parents in a given culture would tend to punish their children for basically the same things, and in different cultures for different things.

5. people would think their standards were the "right" ones? Yes, because people would "just know" what God (the "punisher" of the fourth point) was commanding them, and would know that the command was serious.

6. the standard is negative? Yes, because pain is what tends to carry over as an association leading to a neurotic compulsion.

Thus, the theory passes the initial investigation. You would expect the facts about the fear to be what they were observed to be if this were in fact its origin.

Predictions from the theory

There are, however, some things that would also have to be true if this is where we got our fear of being immoral:

Prediction 1: No culture could change its moral standards within a short time.

This was actually a prediction of Freud; he used it to account for why the definition of "immoral" remained constant (as it had, in his time) for generation after generation. Unfortunately, in our own age, we are confronted with the following:

Fact: Our culture has experienced several drastic and sudden shifts in moral standards.

The "sexual revolution," for instance, occurred within the space of ten or fifteen years, and things practically everyone thought of as immoral and forbidden are now regarded by many people as simply a "different lifestyle," with no moral overtones.

But this kind of shift is impossible if morality is the result of an association with punishment arising from the way you were brought up. These people were brought up to think that extramarital sex, divorce, contraception, and so on were evil and deserved hell. If this theory were true, this "fear of hell" would still be attached to those acts in these people's minds--and it clearly isn't. You can't get rid of a neurotic compulsion by reasoning about it.

This is evidence against the theory

Prediction 2: We would feel as most seriously immoral those acts we were most severely and/or most often punished for when young.

This prediction follows from the nature of the association of fear with an act; the fear is stronger the worse the punishment or the more often it is repeated. And, of course, the acts we would be more afraid of would be the acts we would think were morally worse.

Fact: Children are most often (and most severely) punished for violations of manners rather than morals: for what annoys their parents and makes them angry.

That is, in fact very few children get punished for killing people. Most often, we get punished for slamming the door, leaving food on the plate, tracking dirt into the kitchen, shouting when Daddy has a headache, and so on. Based on the frequency of things like this, you would expect people to find such things morally quite serious.

But no one does. Why? This theory has no explanation.

Further, there are things that people were not punished for at all when they were young that they later regard as seriously wrong. I remember reading (some years ago now, because it would now be regarded as "quaint") an article in a psychological journal seriously puzzled about why boys who had not been taught about sex had this "strange feeling of guilt" when they masturbated and had an orgasm. (The answer is fairly simple, except on this hypothesis. A boy untaught about sex gets aroused in thinking about girls--so he knows that this has something to do with women--and then when the physical and emotional explosion comes from orgasm, he is understandably worried that he has trifled with something terribly important.)

This is evidence against the theory

Prediction 3: We would not be able to distinguish feeling guilty from knowing that we have done something wrong.

The whole point of this theory is that "knowing you have done wrong" is feeling guilty about doing something. It would be impossible to do something that you know is the right thing and feel that you have "sinned."

Fact: We do experience situations where we know clearly that it is morally all right to do what we feel guilty about.

For instance, people who have been brought up to be sexually modest are very apt to feel guilty on their wedding night when they undress in front of their naked partner--precisely because they are doing now what they have been trained from early childhood not to do.

But at the same time, they know that this is not only perfectly morally all right, but that it would be wrong not to do it, because now for the first time, they are in a situation where these acts are virtuous, not vicious.

So we have two different kinds of guilt-experiences: the guilt of doing what we were trained not to do, and the guilt we have at doing what we think is morally wrong. Very often they coincide (in a person who was trained to be moral), but they sometimes are contrary to each other; and in that case, we regard the feelings as trivial and the knowledge as the guide. (Indeed, in these cases, the guilt feeling adds an extra zest to the act.)

This is very strong evidence against the theory

Taking these three predictions into account, then, we can say the following:

CONCLUSION: Our fear of doing what is morally wrong cannot be due to a carry-over from our early training. Moral guilt has nothing to do with the way you feel.

NOTE WELL: This is not to say that the contents of our moral code might not be largely due to what we were taught by our parents; it is just that the fear connected with disobeying it does not come from punishment by them.

[See also Modes of the Finite 5.1.3]

1.6. Social pressure

We now have some additional facts about the fear of being immoral:

7. A culture's moral standards can change even within a single lifetime.

8. Cultures can distinguish manners from morals.

Let us now consider a different explanation of why we are afraid to do what we think is morally wrong:

Hypothesis: The fear attached to immoral conduct comes from the fact that the people around you regard the act as bad and not to be done, and are themselves afraid to do it.

This is the "social pressure" theory of morality. It doesn't deal with what there's a law against (though there may be laws against the acts), but with the unwritten "law" contained in the fact that people regard certain acts with horror. It also doesn't speculate about why people think these acts are horrible. What it says is the mere fact that people are afraid of these acts communicates itself to you and makes you also fear to do them without knowing why--and you in turn become another one of the people communicating the fear to still others.

That is, there are two kinds of "expectations" people have about your behavior. The first deals with what is "done" and "not done" in the culture, so that people can be comfortable with others. Thus, people expect others not to pour coffee into the saucer and blow on it before drinking. They tend to despise and shun those who violate these expectations. These are manners, or what William Graham Sumner sometimes called "folkways."

But there are other expectations where, when you try to do something, the reaction, instead of contempt at your ignorance or impoliteness, is, "Oh my God, don't do that!" If you ask why, they say, "Oh, no! That's a horrible thing to do!" And they act afraid.

Most of the time, the people you ask don't know why they think the act is horrible, still less what will happen to you if you do it. The reason they think it's horrible is not necessarily their early training or personal experience, but the fact that people they know think it's horrible. There are certain attitudes that get into the society somehow, and people adopt them; but once they are adopted, they tend to perpetuate themselves, because we tend to accept what other people believe.

Thus, for example, in our society we take it as "obviously true" that all men are created equal, that slavery is wrong, that discrimination is to be avoided, and so on. In other cultures, such as India, it is taken to be "obviously true" that there are natural classes of people, and that discrimination is the proper way to behave. Reasons can be given in both cases (the Hindu laughs at us and our "equality," when it is so clear that people have vastly different abilities); and the real reason why we hold these "truths" is often the simple fact that everyone else around us accepts them without question.

What the hypothesis says, then, is that the fact that the people accept without question that certain conduct is horrible (as opposed to "not done") is the source of our fear of doing what we think is morally wrong. The fact that no one knows what is going to happen creates the illusion that there is some invisible source of this "law," and that this super-being will enforce it.

Test of the hypothesis against the data

Does this hypothesis explain why:

1. Everyone would have a fear attached to immoral conduct? Yes, because everyone lives in a society, and so is subject to at least some form of social pressure.

2. People would think morality a serious matter? Yes, because they would not know what the punishment actually was, and everyone around them acts as if the act is horrible and is afraid of its being done.

3. People would associate the fear with a divine source? Yes, because people are not aware of the fear's being just the fact that everyone is afraid, and it would seem to come from some invisible "super-being" who will of course presumably punish its violation (whether or not there actually is such a being).

4. The definition of "immoral" will vary as it is observed to? Yes, because different cultures would have different social pressures and so different fears. Within a culture, subcultures would have their own special fears; and so as the society becomes complex, individuals belonging to different sets of subcultures would have different moral standards insofar as they reconciled the different social pressures acting on them.

5. People would think their own standards were the "right" ones? Yes, because they would have in fact got the standards from observing what "everyone" (i.e. everyone around them) "knows" is immoral.

6. The standard is negative? Yes, because again the whole issue is a question of fear, which is the basic negative emotion.

7. A culture's standards could change in a relatively short time? Yes.

But this needs some explaining. According to Sumner, if the life-conditions change, then certain acts which used to be harmful become beneficial to the people. In the beginning, those who do these things are regarded as immoral and evil; but as they prosper, more and more people follow them, and then the standards "catch up" to the practice, and what was before regarded as "bad" now becomes looked on as "good."

For example, once The Pill was invented, sexual intercourse could be engaged in in an apparently "natural" way (What is more natural than taking a pill?) without having children connected with the act. But if there are no children to support, why have the commitment of marriage connected with sex? Hence, people began having sex outside of marriage, and the sexual standards gradually began to dissociate sex and marriage.

Note here that I am not arguing that this reasoning is "correct" (in fact, it is fallacious); what I am saying is that it seemed so to many people, and in fact things happened this way, and so in our society much that used to be considered immoral about sex is now considered morally acceptable. If this theory is true, this is, of course, all there is to the matter. It used to be really immoral to have sex outside of marriage (because "everyone" thought it was), and now it's really all right (because people think it is all right). If the theory stands up, this statement can be taken as factual and valid.

8. Can we distinguish manners from morals? Yes, because the social pressure connected with manners, no matter how severe it is, is not conduct that the society is afraid of, while the moral code of the society deals with what it regards as a threat to its existence, for whatever reason.

Thus, the theory fits all the facts we have so far observed, including the data that the Associationist Theory cannot explain.

Predictions from the theory

But there are also some things that must be facts if this theory is really where we get our fear of being immoral.

Prediction 1: The standards of the society can never be "wrong," nor be thought to be wrong at the time.

The standards may later be recognized (after a change) as having been wrong; but they cannot be thought in that society to be now wrong, because the standards are precisely what the moral obligation is in that society at this time; they are precisely what defines "morality" for the society and are the only definition of it.

Fact: Sometimes people in the society think its standards are wrong.

This is inconvenient, but it is certainly a fact. There are, for instance, quite large numbers of people in our society who think that the "sexual revolution" is wrong, however practical it might be; there are many many others who think that abortion is wrong, even if there are many who think that it is right.

This might be due, however, to subcultures that are out of step with the feeling of the larger society. Hence,

This fact does not prove anything one way or the other.

Prediction 2: The culture cannot change its standards on the basis of their present "wrongness."

This is a variation on the preceding prediction. If the whole culture changed its standard because it (as a whole) recognized that the present one was somehow "evil," then it would be judging its own standard by some "higher standard," and on this theory there can be none. Standards can change, on this theory, if the change follows a change in lifestyle; but they can't change for the reason that the standard is somehow recognized as wrong or evil.

Fact: Sometimes cultures do change their standards for moral reasons and not for practical ones.

For instance, the civil rights movement came about, not because it became practical for Blacks to be treated as well as Whites, but because the community as a whole recognized that it was treating Blacks as if they weren't really human--and human beings must not be treated as if they are not what they are.

This same sort of thing was really what got rid of slavery in this country (Sumner's bad history to the contrary notwithstanding). It was certainly impractical to free the slaves, in whom so much wealth was invested. The Southerners recognized that it would ruin them economically--which it did. But the fiction that Blacks were "really" no different from animals (and so could be owned) became impossible to sustain, especially as more masters had children by their Black slaves. But once they were recognized as human beings, they were automatically recognized as something that could not be owned or treated like animals, however "practical" this might be.

Hence, changes in moral codes do not always follow changes in life conditions; sometimes they lead them.

This is evidence against the theory.

Prediction 3: Reformers would be regarded as immoral people.

The reason for this prediction is that the society's standards on this theory are the only real definition of "moral" and "immoral"; and hence any "reformer's" disagreement with the standards would automatically be a mistake or evil. Appeal to a "higher source" for morality is absurd on this theory; there is nothing that can be appealed to "over" what the people happen to think is right and wrong at any given moment.

Fact: Societies distinguish between reformers and evil people; they listen to the first, and condemn the others.

Martin Luther King, for instance, who preached that the treatment of Blacks was inhuman, was regarded as a troublemaker, but not as an evil person. He was not thought of as we today think of drug pushers, who don't see anything wrong with promoting the use of cocaine or heroin.

And the reason King was regarded as good is that he presented evidence to the society that it wasn't treating Blacks the way it claimed to be treating Blacks: that segregated eating facilities meant that Blacks had bad food and few opportunities to get it; that segregated schools were "separate" but far from "equal"; that segregated toilet facilities meant that Blacks had to walk often for blocks before they could relieve themselves, and so on. The drug pusher, on the other hand, cannot present any real evidence that taking drugs is good for the person who takes them--which is what he claims. Quite the contrary.

Reformers, then, seem to present facts to the society which show that it is being inconsistent in doing what it considers "good": that its actions are fundamentally (even if unwittingly) dishonest. And when the evidence is convincing, the society listens to the reformer, and changes its standards--usually reluctantly, but it changes, once it is convinced.

But this could not happen if the society was in fact the one that defined "right" and "wrong." It implies that there is a standard against which society itself and its standards are to be judged--and the society recognizes this.

This is evidence against the theory.

Prediction 4: The standards of any culture would simply be the set of acts the people regard with horror, and would not be a rational conclusion from a basic standard.

This is clear from the nature of what social pressure is. Why the people fear doing something is not what creates social pressure (and therefore the fear in the individuals); it is simply the fact that they do fear this act. This is another of Sumner's predictions.

Fact: The moral standard of any society, and in fact any moral standard of any person is always some version of this proposition: You must never deliberately do what is inhuman.

If this is so (and in the next section I will give some examples showing that it is), then this means that people and societies consider themselves subject to the "command" to act consistently with what they really are, irrespective of what others think they really are.

This "command" (if it is one) is the same in every society; and hence, it doesn't come from society, because the society itself is subject to it.

[See also Modes of the Finite, 5.1.3]

1.6.1. Examples of "immoral=inhuman"

Before we get into the implications of what this means, let us try to see if in fact a society's view of what is immoral coincides with its notion of what acts are inhuman (or are inconsistent with the reality of the person acting).

Cannibals eat people, and don't see anything wrong with it, don't they? No, not really. Anthropologists were surprised to find that when these tribes referred to those of other tribes as "dogs" or "pigs," they meant this literally: that those of other tribes were animals, not people. Cannibals only eat (a) already dead bodies, or (b) members of other tribes (which aren't "people").

The slave traders also justified their trade on the grounds that Black people weren't people but animals; they were thought (by the scientists, mind you) that Blacks were the result of the rape of women by orang-outans. Those who advocate abortion today consider that "science" shows that fetuses aren't human beings, but are "blobs of tissue." Eskimos, who had the custom of giving their wives to visitors for the night, also had the view that women weren't "really" human beings.

Orientals used to hold that suicide was moral to "save face," which meant to avoid bringing disgrace on the family or group to which the individual belonged. But these same Orientals considered that the individual life was the "animal" life, and the "human" aspect of a person's life consisted in his belonging to the family or group (which is where he differs from animals). Thus, the physical life could be sacrificed in order to preserve the "human" aspect. The same went for what was behind dueling in the West. A person's "good name" (or his relation of "honor" to others) was where he differed from the beasts; and therefore, to protect his "honor" (his human dignity, or essence as human), he had to put his physical life at risk on the "field of honor" (i.e. under certain rigid conditions).

Karl Marx considered that the respect in which humans were different from beasts lay in the fact that humans use tools to transform nature (whereas beasts adapt themselves to nature). Hence, when one human uses another as a tool (when one hires another to work for him), then the first is dehumanizing the other, because the other's essence as human now belongs to someone else, and this is slavery. Therefore, Capitalism, which as a system involves the capitalists' not doing any work (and so not acting humanly) and hiring others to work (and so enslaving them) is an essentially inhuman system and must be destroyed. And from this comes Communism's "command" to work for the "classless" society, where no one will "own" anyone else's work.

Many contemporary thinkers hold that there is no such thing as "human nature"; humans are free to do what they want with themselves. And this is why in our society, interference with another's choice is for practical purposes the only "really bad" thing; because if we are in fact free to make of ourselves anything we want, then nothing is inconsistent with our reality except interfering with a person's doing this.

I am not here trying to judge the objective correctness of any of these views; I will do some of this later on. The point here is simply to show that the moral code of any society or any individual always depends on what that person thinks it really means to be "human": acts that are consistent with his definition of "true humanity" are (to him) all right; and acts inconsistent with this definition are morally wrong.

But this means the following:

CONCLUSION: Society's standards do not in fact determine the moral code for any person, nor does fear of social disapproval constitute the particular fear that is the fear connected with doing what is immoral.

Note, however, that society's standards may have a strong influence on the contents of a person's moral code, simply because if everyone else around you thinks that a given act is perfectly human, you will be inclined to accept that without question.

But society's standards do not determine the person's moral code, because this code depends on the person's own view of what is in fact inhuman behavior, whatever the people around might think. Individuals may adopt others' views without question; but they can also think things through for themselves.

Nor does social disapproval constitute the fear connected with being immoral, because we sometimes have to brave social disapproval in order to avoid being immoral (when our view of "human" differs from society's). People who tried to free slaves faced a lot of hatred and fear from those who owned slaves; people today who are against abortion face the same thing. Conscientious objectors face hatred from those who consider that they are shirking their obligation to their country; and so on.

So if we consider that we must avoid immorality, then the grounds for this cannot be (a) early training, or (b) society's disapproval. We think that, somehow, in the long run, it is not worth it to do what is inhuman.

And why is that?

This is what we must investigate in the next chapter.

Summary of Chapter 1

Ethics can be treated scientifically if we can find some data and test ethical theories against the data. The data will deal with the way people think about ethical issues.

There must be something objective to ethics, because the position that there are no objective moral standards contradicts itself, in that this position will not allow for interference with a person's actions; but not allowing interference is an objective standard (which allows interference with those who are interfering).So everyone in practice believes that there is some kind of objective moral standard (even if they don't agree on what it is).

The basic ethical fact that starts our investigation is that people are afraid to do what they think is immoral, even if they gain by it.

The question to be examined is the origin of this fear of doing what a person thinks is immoral.

The observed characteristics of the fear are that it is universal, serious, associated with a god, attaches to different definitions of "immoral" depending on cultures, attaches to what a person thinks is the "objectively right" definition, and is basically negative.

These characteristics are used to test theories explaining the origin of the fear; it must explain all aspects of it.

The fear cannot come from legal punishments, because then we would not think a God will punish us; nor can it come from respect for parents, because then it would not be universal, serious, or be attached to a divine source.

The "early training" or "unconscious" theory: The fear might seem to come from early training and the habitual association of punished acts with the expectation of punishment, because this fear can carry into adulthood without our remembering the actual punishment. It might seem to come from these because this explanation would account for why the fear is universal, serious, and all the other observed facts about the fear.

But it cannot actually be the origin of the fear we have of being immoral, because then no culture could change its standards in a short time, and they do; we would feel as seriously immoral things that in fact we think are trivial; we would not be able to distinguish feeling guilty from knowing we have been immoral, and we do make this distinction.

The "social pressure" theory: The fear might also seem to come from social pressure, which is the fact that if people around you are afraid of doing something, the fear communicates itself to you. This would seem plausible because this explanation also accounts for all of the observable facts about the fear as actually experienced, plus the two that it would allow for (some) change in moral standards and the ability to distinguish manners from morals.

But it cannot actually be the origin of the fear we have of being immoral, because then the culture could never change its standards on the basis of perceived "wrongness" of the standards, and it sometimes does; because reformers would always be regarded as evil people, when in fact they aren't; and because the standards of a culture would be haphazard, when in fact they follow from the culture's definition of an "inhuman" act.

Exercises and questions for discussion

1. If it's self-contradictory to say that you can't ever interfere with someone else's morals, when do you think it is legitimate to interfere, and when isn't it?

2. If the fear of doing wrong doesn't come from the laws, how do you account for so many people changing their moral views on abortion once the Supreme Court permitted it?

3. How do you suppose that people who hold that morality comes from God account for the different and often opposite views on what is moral in different cultures?

4. Perhaps we give ourselves the moral obligation, the way people give themselves New Years Resolutions. Test this hypothesis.

5. Suppose somebody violates the moral obligation (whatever it really is) without realizing it. Should he be punished?

6. But doesn't morality simply consist in "Don't do any harm to anyone else?" If you want to harm yourself, so what? Hint: How could you motivate anyone not to harm others?



2.1. The true moral norm

Even though our investigation in the preceding chapter was focused on the origin of the fear of being immoral, we discovered along the way that everyone is really afraid of doing what is (as far as he knows) inhuman; and so we stumbled upon what seems to be the basis of the moral norm that everyone holds.

One of the reasons why this had to be "discovered" and was not explicitly known by everyone is that from time immemorial, the study of ethics has focused on the question "What is it to be good?" When we investigate goodness later, we will see that, because of human freedom, there is really no objective answer to this question. Different people consider different things to be "fulfilling"; different people have different ideals.

But when you are talking about what is "bad," you aren't relating the act in question to some ideal, you're relating it to the actual person who is now doing the act; and the kind of person he is is objectively (to some extent) discoverable; and so it is possible to find out objectively whether his act contradicts his reality or not.

This simply illustrates the fact that progress in a scientific investigation very often depends more on asking the proper question. Unanswerable questions generate apparently "profound" answers that are nothing more than speculation.

But let us take advantage of our discovery.

DEFINITION: A norm is a standard against which something can be judged.

The norm for judging moral badness is the concrete humanity of the person performing the action.

When I say concrete humanity what I mean is the actual reality of the person with all of its aspects and relationships. Some of these aspects (such as the fact that the person is alive) may be obvious, some may not be obvious (such as the fact that the person is part of an international community). Some may be part of the person's reality as determined genetically (such as life or sex), some may be due to choices in the past (such as being a doctor or having made a promise). But insofar as these are real characteristics of the person, then they form the norm for judging whether his acts are or are not consistent with his reality.

DEFINITION: An act is morally wrong if it in fact contradicts any aspect of the person who is acting.

NOTE: The act is morally wrong if it contradicts either (a) the "genetically given" human limitations we have, or (b) modifications of our humanity we have made through promises and so on.

For example a person who marries (and promises to be faithful to his partner) has changed his reality from a single person to a married person; and he now can perform acts (sexual intercourse with his wife) which used to be wrong, and cannot any longer perform acts (like dating women) which used to be morally legitimate.

DEFINITION: An act is morally right if it is consistent with all aspects of the person who is acting.

The act may be perfectly consistent many aspects of the person, but if it contradicts any aspect, then it is inconsistent with the nature of the agent. For instance, the statement you make when telling a lie is perfectly consistent with the nature of your vocal cords as sound-makers; but the lie is telling as a fact something that you think is not a fact; and this is inconsistent with the act of factual communication. So it doesn't matter if the lie "fulfills" any other aspect of you; it contradicts you as a communicator of facts.

Now of course, it is probable that a given person won't know all of the aspects of his reality, and even if he knows them he may not be aware of how these aspects can be contradicted by his actions. We will investigate the implications of this later.

But the fact that you don't know that some act is inconsistent with your reality doesn't make it consistent. And if you perform that act, what you have done is objectively wrong, even though you didn't realize it.

For instance, it was not right for the Whites in the South to own Black slaves. Some of them thought that Blacks were not really human beings, and so could be owned; but that idea of theirs didn't change the facts. Blacks, as human, cannot really be owned; and it is objectively wrong to act as if they could be.

Many people who have abortions today do not realize that they are dismembering their own children; but that in fact is what they are doing. The question is not one of "opinion" or "consensus." Even if everyone agreed that fetuses weren't human beings, this agreement wouldn't change the facts, any more than the earth was flat when the consensus was that it was flat. Fetuses are either human beings or they aren't; this is a factual question, not a matter of opinion. It turns out (as we will see much later) that the evidence indicates that they are; and so women who have abortions are pulling their children apart limb from limb, whether they realize it or not.


Moral rightness and wrongness are not a matter of personal opinion, still less of personal choice. They are simply what the facts actually are, whether anyone knows them or not. They depend on whether the act in question is in fact consistent with the reality of the agent or not.

Does this mean that every woman who has had an abortion is a murderess?

No, not if you define "murder" as a "deliberate attempt to kill someone," because most of these women didn't know that they were killing a human being (let us assume). Murder implies that a person deliberately chooses to kill someone, knowing what he is doing. Abortion is always homicide (killing a human being), and as such is always morally wrong; but it's not murder unless the person knows what she is doing. That is, it's always the kind of act you may not deliberately choose to do; but whether you choose to do it or not depends (among other things) on whether you know what kind of act it is.

So we must now make a distinction:

DEFINITION: A choice is immoral if a person chooses to do what he has reason to believe is morally wrong.

DEFINITION: A choice is moral if a person chooses to do what he knows is morally right.


From now on in this book acts are to be referred to as morally right or wrong and choices as moral or immoral. There are no "immoral" acts or "morally wrong" choices.

Moral rightness and wrongness, as we saw, depend on the actual relation of the act to the actual reality of the agent. They are completely objective facts about an act, and have nothing to do with whether anyone knows these facts or not. When I assert later in this book that certain acts are right and others are wrong, what I am saying is that, based on the evidence I have, this is the objective status of the act (just as when a scientist says that the sun is 93 million miles away from the earth, he is stating what he thinks the fact is, based on the evidence he has). I can be mistaken, of course, but that does not alter what the fact is, any more than the actual distance from the earth to the sun is changed if it should be discovered that the astronomers made an error in measuring it.

Morality and immorality, since they deal with the choice the person makes, depend on the person's knowledge of the moral rightness or wrongness of his acts. Morality and immorality are not exactly subjective, since they depend on knowledge of what the facts are; but since you may not know what the facts are, you can do something morally wrong, but be mistaken rather than immoral. That is, each person's morality or immorality with respect to a given act is analogous to the scientist's knowledge of the distance from the earth to the sun. It is based on the evidence you have about the actual moral status (the rightness or wrongness) of the act.

We will have to spell this out in considerable detail later; but for now, let us concentrate upon the fact that we have found the objective component in moral matters: the reality of the agent, and its relation to his acts.

As long as we have made these two distinctions, let us make another:

DEFINITION: An act is regarded as morally bad if it falls short of our expectations of what it "ought" to be, morally speaking. A person is considered morally bad if he does not do what we think he "ought" to do, morally speaking.

DEFINITION: An act is regarded as morally good if it is the kind of act we think a person "ought" to do as a human being; a person is considered morally good if he does what we think a human being "ought" to do.

What's the difference between morally good and bad and right and wrong and moral and immoral? Morally good and bad depend on our subjective standards that we for whatever reason set up for evaluating moral conduct. If the act (or the person) matches the standard, then it or he is "good"; if not, then bad.

Goodness and badness always depend on subjectively created standards and though the act in question "objectively" matches or does not match the standard, the standard itself is made up by the person using it, and is not objective.

Very often goodness and badness are confused with rightness and wrongness. Rightness and wrongness simply deal with the objective fact that the act in question is or is not consistent with the person acting; there is no evaluation connected with them--no implication that we "ought" not to be doing morally wrong acts.

Moral and immoral deal with the fact that we deliberately chose to do what was right or wrong, and again in themselves don't imply the evaluation that we "ought" not to choose what is wrong.

Only goodness and badness have this "ought" connected with them, because only goodness and badness assume that the "correct" situation is the one that doesn't exist and expects the facts to "live up to" this "correct" state of affairs. But obviously, this standard of what the "correct" situation ought to be can't be discovered from the facts "out there," because they precisely don't live up to the standard. Ideals have to be made up; they can't be found.

If the distinctions above are not made clear and held consistently, all sorts of confusion can occur in speaking about ethical matters. A person saying that something is morally wrong, for instance, might be taken to imply that (according to his subjective standards) this act ought not to be done--when in fact all he is saying is that the act in question is objectively inconsistent with the agent.

Now what the preceding chapter was saying in the facts we started investigating is that people think that what is morally wrong is morally bad. That is, as soon as you show something that a given act is "inhuman" (contradicts being human somehow or other), the person automatically thinks that it ought not to be done (is morally bad). We expect people (at a minimum) to act consistently with themselves, whether they "live up to their fullest potential" or not.

But this does not alter the fact that moral rightness and wrongness do not mean the same thing as moral goodness and badness--nor the same thing as morality and immorality.

2.1.1. A note on "natural law" ethics

What I have been presenting here is a version of what is called "natural-law ethics." The reason why it is called this can be seen from the following definition:

DEFINITION: The nature of a being is its reality as related to (or revealed in) its actions.

Thus, it is "the nature" of hydrogen to have a certain spectrum when excited and to combine with oxygen to form water; it is "the nature" of a dog to hate cats; it is "human nature" to wonder about life, and so on. Obviously, then, for a human being to do something inhuman is for his act to violate his nature.

There are three difficulties with this, however. In the first place, "nature" is used in the sense of what is not "artificial." It is "natural" to be naked, and "artificial" to wear clothes; it is "natural" to talk, and "artificial" to communicate (as I am doing) by typing into a computer and having it print out things.

This sense of "natural" is not the sense that is ethically relevant. It is consistent with a human being as human to cover himself and protect himself against the elements (and against sexual temptations--yes, they can happen if everyone you see is naked); and because of the latter reason, it might be morally wrong not to cover oneself. It is consistent with communication to do it by means of a machine, as long as one is not telling lies. "Nature" in that sense refers to "the condition we were born in," not what is consistent with our reality as thinking animals.

Secondly, there is a sense of "nature" that means "what is normal," in the sense of what people usually do. In this sense, it is "natural" to lie to save yourself from embarrassment, because most people tend to do this. But this does not make it consistent to lie, because the lie communicates as a fact something known not to be a fact. Hence, what most people do may or may not reveal the "nature" in the moral sense, because people often violate their natures.

Thirdly--and this is where my theory differs from traditional natural-law ethics--there is the sense of "nature" as a tendency toward certain acts as its fulfillment.

Traditional natural-law ethics takes "nature" in this positive sense and tries to derive the moral obligation from it. But this confuses what is (morally) "good" with what is morally "bad" and runs into the difficulty connected with freedom that we mentioned above. Thus, for instance, since we have a tendency by nature to know things, it is assumed that the "good" is knowing more and more. But where do you go from there? Does this mean that it's bad for a person who can study philosophy to decide not to and spend his time becoming, say, a professional athlete?

As traditional natural-law ethics worked itself out in practice, it wound up with commands that in fact boiled down to what we said above: "Never fulfill any aspect of your nature if the fulfillment involves violating any other aspect"--which, of course, is actually negative, not positive. So the results of natural-law ethics were actually prohibitions; but it tried to derive these from the positive tendencies of the nature; and you can't logically do this.

So we are not really "natural-law ethicians" here in the traditional sense. But from what we discovered at the end of the last chapter and just above, we can say this:

Every moral theory is actually a negative "natural-law" theory.

As I tried to show, every view of what is forbidden (or what is morally bad) rests on the person's notion of actions that contradict his view of the way we are built: his view of the limits, if you will, of our nature. This is simply an empirically testable proposition. Ethical theories are all over the place when it comes to talking about what is "good"; but every single ethical theory derives what it considers "bad" from the theoretician's view of what human reality (a.k.a. human "nature") is. Even those views that say that there is no such thing as human "nature" say that it is "bad" to interfere with others (because it assumes that there is a "nature" when--according to these people--there isn't one; which, of course, is a violation of the way things are: the "non-nature" of the person. "Non-nature" here is, of course, our sense of "nature.")

The thing to take away from this discussion, then, is that, in saying that the moral norm is human reality or human nature, we are not really "imposing" a view on other ethical positions. When we are at this general level (i.e. until you begin spelling out what the nature actually is and how actions can violate it), then differences among ethical theories are only terminological. All ethical theories agree that it's morally wrong to act as if you weren't what you really are.

2.1.2. The moral command

That, then, is the moral norm. We started out this book with the fact that people think that there is some kind of command attached to violating the moral norm (at least as they understand it) because they are in some sense afraid of what will happen to them if they act immorally (i.e. if they choose to violate what they think is the moral norm).

This is not quite the same as saying that what is wrong is bad; it is even more than that. It seems to imply that what is morally wrong "ought" not to be done in a stronger sense than singing off key is "bad singing": it seems to mean that if you do what is morally wrong you will (or should) suffer for it. That is, it implies that you will be better off for doing what is right than for doing what is wrong--and so in that sense it is not just "bad" to do what is wrong, but "you had better not" do what is wrong.


We have not yet found out whether there actually is a moral command, still less whether a person is "really" excused if he doesn't know what it is. This is still on the level of what people think with relation to morality.

But if there really is a moral command, then, as I mentioned in the discussion on social pressure, it would seem to be this:

MORAL COMMAND (first formulation): You must never be willing to act in an inhuman way.

In most people's minds, you are held excused from violating the command if you are sincerely mistaken or ignorant of what it is. The idea is that if you don't know there's anything wrong with the act, you're not willing to do wrong when you do it. If you knew it was wrong, then you wouldn't do it (or if you did, of course, you'd be willing to do wrong). Those women, for instance, who have abortions and have no idea that they are murdering their children are not held morally guilty of murdering their children.

We will shortly resume our investigation of how people come to think in this way; and it will turn out, once we have got through it, that in a sense there is a moral "command," and that people who violate it without suspecting that they are doing so are not actually guilty. But again, do not prejudge the issue; wait for the evidence.

To put this another way, the moral obligation works in this fashion in conjunction with the norm of moral badness:

MORAL COMMAND (second formulation): You must never deliberately try to fulfill any aspect of yourself at the expense of contradicting any other aspect.

This simply spells out what we said above, that the norm is the set of real characteristics we have, none of which may be violated.

But it is possible to reformulate the moral command in still another way, if we take into account the following:

Choices which are immoral are always choices which are fundamentally dishonest. That is, they are a deliberate pretense that things aren't the way you know they are. When you act immorally (as opposed to mistakenly doing something that is morally wrong), then you know what you are doing: you know that the act is inconsistent with you as an agent; and yet you do it anyway, as if it were consistent.

The thief acts as if taking something could really make it his to do what he wants with; the murderer acts as if he had the right to decide when someone else was to stop living; the adulterer acts as if he weren't married to the person he is married to; the woman who has an abortion acts as if her child were a mere lump of tissue or "part of her body"; and so on. Insofar as these people know what the facts are, they are not being honest with what the facts are; they are pretending that things are the way they want them to be, not as (they know) they really are.

MORAL COMMAND (third formulation): You must never act in a way that is fundamentally dishonest.

Acting in this way is, of course, hypocrisy; and so what the moral command in this formulation says is "Don't be a hypocrite." Don't pretend (by your actions) that you are something that you aren't.

But then why not, if you get what you want from being a hypocrite? And this brings up again the issue of whether there really is a command connected with morality.

[See also Modes of the Finite, 5.1.2]

2.2. The real issue

We have finally cleared out enough of the underbrush so that we can see the real issue that is involved in morality:

Is honesty really the best policy? Are you really better off if you act consistently with the way you and the things around you are, or are you better off if you pretend that things are the way you want them to be?

There it is.

When all is said and done, there is the moral issue. What society thinks, what your parents think, is irrelevant. The question is whether it makes sense for you to act honestly or not.

Another way of putting this is, "Is it always bad to do what is wrong?" This uses a slightly different sense of "good and bad":

DEFINITION: Something is good if it leads to a goal you want to achieve. It is bad if it hinders you from achieving the goal.

The point is that you set up these goals yourself, and if you aren't particularly interested in being consistent with yourself in all respects, but you really want to be a millionaire, then it would certainly seem that stealing in order to be a millionaire (if you can get away with it) would be good for you.

DEFINITION: Values are means toward freely-chosen goals.

DEFINITION: Disvalues are what lead one away from a goal he has chosen.

Values, then, aren't what's "good" without qualification (that would be the goal itself), but what's "good" in the sense of what's "good-for" the particular goal they lead to. In the case above, for instance, stealing would be a value for you because it would get you where you want to go. Values, then, are not the same as what is morally right and wrong, because they depend on the subjectively created picture we make of ourselves as "the person I intend to be," and this "ideal self" that we set up to achieve may or may not have any basis in reality.

So the moral issue now becomes "Is it in fact the case that being immoral (choosing what is wrong) is always a disvalue, no matter what your goals are?" If it isn't, then why shouldn't you choose what is wrong?


Morality is not really a question of values but of whether what we choose is in fact consistent with what we are or not.

It is one of the main errors of our age to confuse morality with values. Values deal with the kind of person you want to be. Morality deals with the basic humanity you are given and build on by values. Morality says that your values and goals do not allow you to contradict your basic humanity to achieve them.

[See also Modes of the Finite, 5.1.4]

2.2.1. The problem

But when you think about it, it would seem that it is obviously better to do what is morally right; because, after all, that only means acting realistically. How could there be any percentage in pretending that things aren't the way they really are, especially if you act as if they weren't?

This seems to be reinforced by the following:

Whenever we make a choice to do something, this sets up a goal that we intend to achieve.

What do I mean by this? A choice to do something means that you consider your action and the situation resulting from it. You choose between various alternatives in view of the results you foresee from the various actions open to you.

When you pick one of these alternatives out, that result now becomes the "reason" for the choice of this action; it is the "goal" of the action, its "end" or "purpose."

Thus, human choices by their very nature have purposes: new states of affairs that the actions chosen are to bring about. The purpose is what determines which choice you make. Even if you choose to postpone choosing, this choice has as its purpose to give you more time to make up your mind. Every choice has a purpose you intend to achieve by that choice.

An immoral choice, by its very nature, has a goal that in some respect cannot be achieved.

Why is this? Because the choice can't be immoral unless you see that you are violating some aspect of your reality to achieve your goal. So you want to fulfill yourself; but this kind of fulfillment involves the violation of yourself in some other respect. Hence, immoral (or dishonest) behavior is always, in some respect, self-defeating or frustrating.

DEFINITION: Frustration is having as a goal something that cannot be achieved.

Immoral conduct is therefore by its very nature self-frustrating.

From this it would seem to follow that honesty is the best policy. If you act dishonestly, this doesn't mean that you "make a mistake"; it means (since you are pretending that things aren't the way they really are) that you have a goal that you can't really reach as you intend to reach it. So you are deliberately trying to frustrate yourself.

And how can you be better off by frustrating yourself?

Thus, the thief wants to own what he has taken (because he wants to use it as if it is his, knowing that it isn't--and so has to be careful that no one finds out that it isn't really his). The murderer wants to be able to kill other people but doesn't want other people to be able to kill him if they can get away with it. The adulterer doesn't want to be married to the person he's married to--or doesn't want to have promised what he promised when he married her. The woman who has an abortion wants not to be a mother (at least of this child); but she is his mother now; it's too late not to be; even if she kills him, she's his mother. And so on.


If it were only that simple. True, every immoral choice is in some respect self-defeating. But the alternative can be far more frustrating.

Take the woman who (even knowingly) has an abortion. What is the alternative? Having the baby. But this can mean disgrace, losing her job, sickness, years of anguish, being beaten up daily by her husband who wants her to have the abortion, and on and on. To say, "She can always give him up for adoption" is wildly simplistic in some cases. Sometimes the alternative is not bad; but sometimes it's really horrible.

On the other hand, if she has the abortion, no one will yell at her; her husband will praise her even; she keeps her job, and so on. Sure, she's killed her child; but once it's done, he's not around to torture her. If she doesn't, he and her husband and everyone else will be there.

Is it worth it now to be honest?

Take the adulterer. Sure, he's being dishonest with the promise he made; but after all, he really loves this woman and he doesn't have any affection for his wife any more. If she doesn't find out, who's to say he's worse off?

The thief. If he steals the television set, it isn't his, but it will still work if he turns it on. If he doesn't steal it, he can't watch television. Is he worse off not being able to watch television or watching it on a set that isn't really his?

The murderer. The fact is that the person who was a burden to his life isn't around any more; and in fact other people aren't more likely to kill him than they were before he committed the murder (unless they find out, of course).

So it's not all that obvious now that a person is necessarily worse off for doing what is morally wrong. Maybe some of you think that, on the whole, in each of these cases, the effects of morally wrong actions are worse than the right ones; but you can see that there's room for disagreement. It isn't absolutely clear-cut.

Now suppose this: You and your family have been captured and told to kill another person or you and your family will be tortured to death.

It is clearly inconsistent to kill another person. But if you don't, then you won't be around to enjoy the thrill of being consistent. How can you be better off in these circumstances for doing what is morally right?

After all, the end doesn't justify the means. That's what morality is all about. The goal you want to achieve doesn't make it okay to act inconsistently to get there.

So if you can save yourself from twenty-five years in prison by lying, it's still inconsistent to lie; it's still morally wrong. Is it worth it?

Fact: There are ways of being frustrated that do not involve choosing the frustration. We can be frustrated by circumstances over which we have no control.

Fact: It can happen (and often does) that the frustration involved in an immoral choice is less (sometimes much less) than the frustration involved in not making the immoral choice.

CONCLUSION: It would therefore seem that it is often to a person's advantage to make an immoral choice.

And of course everyone with his eyes open really recognizes this. Why else would so many people do what is wrong? They aren't stupid; far from it. It's the calculating people, the "men of the world," the "practical" people who are the ones who do what is morally wrong.

And they seem to do very well, thank you. I mentioned Stalin at the beginning of this book. Why should he do what is moral, if in doing it he would have to give up riches, prestige, power, and even the love of the fools he was oppressing?

But you don't have to look that far. Look at the people around you. Nice guys finish last. Honest people struggle through life; it's the smart people (who know when to be dishonest, and how to be dishonest and appear honest) who get ahead. Isn't it? Be realistic now.

2.2.2. The reason people are afraid of immorality

Then why don't people act intelligently? Why don't they look to their advantage, and weigh the probable benefits against the frustrations, and act morally when it is to their advantage, and immorally when it isn't?

Some do. But even they are afraid.

That was what we started with, remember. People are afraid to act immorally. Why? If they can get away with it.

HYPOTHESIS: People are afraid to act immorally because they are afraid that life might not end with death, and after they die they might be worse off for being immoral.

The hypothesis was expressed by the character Cephalus at the beginning of Plato's Republic (which, by the way, is about honesty):

"You see, Socrates, when you get near the time when you know the end is coming, fears and worries you never had before haunt you. The stories you used to laugh at about the Land of the Dead, and how bad people get their punishment there, torture your soul now with the thought that they might be true.

"Maybe it's weakness from age, or maybe it's because you're nearer now and can see better; but whatever it is, you get full of doubts and anxiety, and start trying to figure out if you have ever been dishonest to anyone. And if you find a lot of dishonesty in the records of your life, you begin waking up terrified in the middle of the night all the time like a child, and your life becomes just waiting for disaster."

(His position, interestingly enough, is that being wealthy is handy for being honest, because having all that you want removes a strong temptation to lie and cheat.)

But to return to the hypothesis itself, what it says is that people have two types of experience that tends to give them this notion of a life after death where things are made "fair."

First of all, people are aware of being treated unjustly by others or by "fate." That is, they try to achieve some perfectly legitimate goal, and find themselves thwarted either by the morally wrong behavior of others, or by circumstances of their lives that are no fault of any person. At the same time, they see apparently (even obviously) immoral people getting ahead by doing what is morally wrong.

This leads them to reason that, though their lives seem to be in their control because of their choices, their lives really are out of their control and are in the control of "luck." But you can't give up trying to control your life, because you can't avoid making choices (even to choose not to choose is a choice). So we seem to be in a situation where we have to pretend that we have control over our lives, but we actually don't.

Having to make choices, then, makes no sense unless life continues after this one, where what happens to you depends on your choice and not on "luck" or "fate."

In the second place, people see immoral people getting ahead by doing what is wrong and self-contradictory. The best way to circumvent "luck" is to see what the effects of your act are likely to be, and to trade off small deliberate frustrations for larger ones that are imposed by circumstances.

But this means that there is a fundamental inconsistency in human actions: the way to avoid frustrating yourself (a lot) is to deliberately try to frustrate yourself (a little). The intelligent way to behave is to behave inconsistently with the way things are--which is unintelligent. The realistic way to behave is to be unrealistic and pretend that things are as you want them to be, not as you know they really are. The advantageous way to behave is to do what is disadvantageous. The human (because reasonable) way to behave is to do what is inhuman. Being "really" honest means recognizing the situation for what it is (which involves this trade-off) and acting dishonestly.

But this is absurd. Therefore, people conclude that human conduct can't make any sense unless life continues after death in such a way that behaving honestly is rewarded and behaving dishonestly is punished somehow.

These are such natural ways of reasoning, and they reveal that life's ending with death makes life (as Albert Camus, who held this said) absurd and self-contradictory. The result is bound to be that anyone who considers that things can't really be nonsense at least suspects that some sort of reasoning like this might be valid.

And, of course, if it is valid, then we have what Shakespeare has Hamlet say:

To die--to sleep.

No more: and by a 'sleep' to say we end

the heartache, and the thousand natural shocks

that flesh is heir to. 'Tis a consummation

devoutly to be wished. To die; to sleep--

to sleep, perchance to dream. Ay, there's the rub;

for in that sleep of death what dreams may come

when we have shuffled off this mortal coil

must give us pause.

Let us for the moment not consider whether this reasoning is valid or not, but examine whether a reasoning process such as this could be where in fact the fear of being immoral actually originates in people's minds all over the world. We in saw in the previous chapter that it can't come from parental training or society's views. Could it then be the result of the kind of thinking involved in this hypothesis?

Test of the hypothesis against the data

In short, does this hypothesis explain why:

1. everyone would have a fear attached to immoral conduct? Yes, because everyone has been thwarted to some extent by "fate" from achieving his goals, and everyone has realized the inconsistency in getting ahead by violating your nature.

It is also the case that human beings cannot accept contradictions as facts. This is the fundamental law of all thought: contradictions don't actually occur. Hence, if life is contradictory unless it continues after death, reasonable people would say, "well, then, it must continue."

2. people would think morality a serious matter? Yes, because if things are made "fair" after death, then no advantage here and now will make you better off for being immoral.

3. people would associate the fear with a divine source? Yes, because if there is a life after death where your choices are to have their proper effects, then people would reason that there must be some Being "running" the place, a Being who could know our secret thoughts and reward or punish us accordingly: who could know when we made a mistake or when we deliberately chose to violate our natures.

4. the definition of "immoral" would vary as it is observed to? Yes, because the definition depends on what a person thinks "inhuman" means; and we get this idea from our parents and those around us.

5. people would think their standards were the "right" ones? Yes, because people who think they have found out the facts about self-contradictory behavior would automatically recognize that this behavior is really part of what is forbidden.

Of course, insofar as they were not sure of the facts, they would tend to let others make up their own minds on the subject. And this is just the behavior we observe.

6. the standard is negative? Yes, if the deals with the limits of our nature and self-contradictory behavior, and leaves us alone as far as what we do within those limits is concerned.

7. a culture could change its standards in a short time? Yes, if it discovers new facts about what it means to act in an inhuman way.

The culture's standards could change if conditions changed making people think that the new conditions allow some act that was inconsistent under the former conditions, or forbid some act that was consistent formerly. This happens in the individual case, for instance, when a person marries. The new conditions permit acts (sexual intercourse) that were before inconsistent, and now forbid acts (dating) that before were consistent. This sort of thing can happen in society also.

But the standards can also change if the culture discovers a fact that makes it understand that it had mistakenly thought of an act as consistent when in fact it was self-contradictory--even with no change of life-conditions.

8. we can distinguish manners from morals? Yes, because manners are the acts that people expect for the sake of social harmony and being able to predict other's actions, while morals are not really the acts that society is afraid of so much as they are essentially the acts that the people think are self-contradictory. That is, contrary to the social-pressure theory, the fear is not what constitutes the "wrongness" of the act, but is a consequence of the recognition that it is wrong, coupled with the reasoning that forms the basis of this hypothesis.

9. the culture can recognize that its moral code is wrong? Yes, because the uncovering of new facts can reveal that the culture's view of "inhuman" is incomplete or mistaken.

10. the culture can accept reformers as good? Yes, because the reformer can convince the culture that he has the objective facts of the matter.

CONCLUSION: This theory explains all of the originally observed data about the fear people have of being immoral, and also explains all the facts that the other two theories could not explain.

Therefore, it is most reasonable to say that the fear actually comes from the notion that it might actually be true that there is a life after death in which morality is rewarded and immorality is punished.

The other two theories took account of the fact that we seem to fear a hell after death, but tried to explain this away as a kind of superstition, either arising from the emotions based on early training or the peculiarities of collective experience. We saw that both of these explanations don't work.

What we have discovered here is that the fear is probably not the result of superstition, but of a plausible reasoning process, in which life doesn't seem to make sense on any other supposition but that of its continuation beyond death.

This means that our scientific investigation into the grounds for the experience of fear of being immoral has revealed that it is the result of a view of what the facts are on the part of the people. That is, we have uncovered a pre-scientific reasoning process that could actually be valid.

The next step in our investigation into ethics, therefore, should be to consider this reasoning process itself. Is it actually valid? Is there really a continuation of life beyond death, such that those who make immoral choices face a disadvantage that would outweigh any advantage in this life from such a choice, and such that those who make moral choices could somehow fulfill them?

NEW HYPOTHESIS: There is in fact a life after death which (a) makes it always disadvantageous to make an immoral choice, and (b) fulfills moral choices.

But how could we test such a hypothesis? Where would be our data?

Basically, the data come from the results of an investigation of living bodies, particularly focusing on human life. To go into detail in such an investigation is beyond the scope of a book such as this. Those interested in this sort of thing can find it in my book Living Bodies.

But since a philosophical investigation of human beings as living does not necessarily draw out the implications for ethics of the conclusions it comes to, I am going to summarize the findings in the next chapter, show how they corroborate the rough-and-ready reasoning that gives people the fear of being immoral, and draw out some refinements dealing with what we can know of what this afterlife must be like, based on the data that allow us to conclude that there is on.

In the next chapter, I also want to relate these conclusions to what is taught in Christianity, for two reasons: First, to distinguish Christianity from philosophy, and especially ethics; it has often been misinterpreted as a kind of "extrapolation" from ethics, when in fact it is utterly different from an ethical theory. Secondly, to point up that Christianity, if a fact (and I am not going to try to prove that it is a fact), allows for a "reestablishing" of a life that has been deliberately messed up. Our conclusion from the observable data will be that life can make sense on the level of science and reason, but only if we never make an immoral choice. Once we do so, there is no natural way to restore the damage that has been done and start over.

Since I believe that Christianity is a fact, I would not like to leave the impression that the prospects for anyone who has been immoral (and that's all of us, isn't it?) is eternally dismal. There is hope for sinners. But since this is a book of philosophy, not Theology, I am just going to sketch what that hope is, and leave it to the Theologians to go into detail about its nature.

Let me say this, however, before getting into the next chapter:


The fact that we are going to be talking about a life after death does not mean that we are entering the realm of religion. The hypothesis is that it is scientifically possible to establish that there is a life after death and to say something of its nature.

It is pure prejudice that you are talking "religion" as soon as you mention God or a life after death. Religion assumes that there is a God who has told us something, and bases itself on what God has allegedly said. Science bases itself on the observable data we have before us, and may conclude that there must be a God or a life after death.

For the scientist, whether there is a God, what His nature is, whether there is a life after death, are all theories which attempt to account for certain sets of observable data; and these theories are only as good as (a) the factuality of the data they are supposed to be accounting for, (b) how well they account for them, and (c) whether there is an alternative theory that can account for the data as well without using a God or a life after death as the explanation. Scientific theories concluding to such things also are subject to revision if new evidence comes to light, or if flaws are discovered in the reasoning process. Religion is not subject to these restrictions.


To the extent that a culture relegates belief in a life after death to silly superstition with no basis in fact, or believes in a life after death in which there is no punishment for wrongdoing, to that extent one can predict a moral decline in the culture.

Why is this? Simply because nothing in this life provides a motivating force anywhere near strong enough to make it unreasonable in many cases to avoid immorality. People will admire the right thing, but when it comes to the crunch, do the wrong thing, because it becomes silly to do the right thing and suffer for it.

And have we not seen this in our own culture? Why has cheating become so prevalent? Because people see that they can cheat and get away with it, and if they don't cheat, others who do get the better of them. If you tell them, "But if you cheat, you'll go to hell," they simply smile at you. "How quaint," they think. Even believers in God nowadays think, "God loves me too much to send me to hell for a little mistake," not realizing that it was the gentle Jesus who introduced the concept of hell into the Judaeo-Christian consciousness.

Summary of Chapter 2

The norm for judging the moral badness of an act is the concrete humanity of the person acting. This concrete humanity is the person's actual reality, containing all of the real characteristics the person has at the time he acts, whether these characteristics are innate or acquired.

An act is morally wrong if it contradicts any aspect of the person, whether the act fulfills any other aspect or not, and whether the aspect contradicted is known or not. Moral rightness and wrongness do not depend on knowledge or choice, but on the reality of the person acting.

Acts are morally right or wrong insofar as they agree with the reality of the person acting. Choices are moral or immoral insofar as they depend on the person's knowledge of the facts about whether his acts are right or wrong.

Acts or persons are considered morally good or bad insofar as they agree with our subjectively created ideals of the way we think an act or person "ought" to be. Something is also "good" if it leads to a goal we want, and "bad" if it hinders us from achieving it. Values are means toward achieving one's goal, which is the subjectively created ideal of oneself that one intends shall exist. Moral rightness and wrongness and morality and immorality are not questions of moral values or goodness or badness.

Human nature is human reality as related to its acts; therefore morally wrong behavior is a violation of human nature. But "natural" in this context does not mean "what is not artificial," nor does it mean "what is not usual." Further, traditional natural-law ethics tries to derive the moral command from the positive tendencies of the nature, and since these lead to free goals, this cannot actually be done.

But in the negative sense, every moral theory is a "natural law" theory because moral badness always involves a violation of what the theoretician thinks human reality (nature) is.

The moral command has at least three basic formulations: (1) You must never be willing to act in an inhuman way; (2) You must never deliberately try to fulfill any aspect of yourself at the expense of contradicting any other aspect; (3) You must never act in a way that is fundamentally dishonest. That is, you must not be a hypocrite.

The real issue in ethics is whether honesty is the best policy, meaning whether it is to your advantage to act consistently with the way things are.

Since choices set up goals, then immoral choices by their nature set up goals that are in part unrealizable, because in some respect they are self-contradictory. Therefore, immoral choices always involve frustration (having as a goal something that cannot be achieved).

But the fact is that there are ways of being frustrated that do not involve choosing the frustration; and it can occur that the frustration involved in an immoral choice is less than the frustration involved in not making such a choice. In these cases, it is to a person's advantage to be immoral.

But the reason people are afraid to be immoral is that they suspect that life might not end with death, and if it continues, the afterlife might be such as to make it disadvantageous to be immoral.

The reasoning behind this is twofold: (a) we see that our choices are supposed to be what controls our life; but in practice, our lives are really controlled more by circumstances than choice; and (b) the trade-off of a deliberately chosen frustration (immoral conduct) to avoid greater frustration means that the realistic thing to do is act unrealistically, the honest thing to do is act dishonestly, which is absurd.

This fits the data about the fear as actually experienced, including all of the facts that the other two theories could not explain. Therefore, it probably explains why people are afraid to be immoral.

The question then is whether this reasoning is valid, and the hypothesis to be investigated in the rest of the book is that it is: life goes on after death in such a way that immoral choices receive an effect worse than any advantage in being moral, and moral choices are fulfilled.

Exercises and questions for discussion

1. What about the view that holds that what is moral is "the greatest good (i.e. the greatest amount of satisfaction) for the greatest number?" (This is called "utilitarianism.") Can this theory make it consistent to avoid immorality?

2. Does it make sense to study ethics if you can't be immoral unless you know that an act is wrong? Wouldn't it be better not to find out?

3. Suppose somebody does something which is in fact wrong without realizing it, and then later finds out that it was wrong. What is the moral status of that person?

4. If you must never fulfill yourself at the expense of some other aspect of yourself, and if frustration means having a goal that can't be achieved, then the moral obligation says you mustn't frustrate any aspect of yourself. But doesn't this mean that it's morally commanded to do all kinds of things that have been regarded as morally wrong (like having sex whenever it's frustrating not to)?

5. If being morally good simply means acting consistently with what you really are, isn't it possible to be morally good without all this business of a life after death and some kind of heaven and hell?



3.1. Can this theory be scientific?

Scientists are apt to laugh at a theory that tries to establish as factual that there is a life after death, especially a life that could serve as some sort of a heaven and a hell; and so we had better consider whether they have any grounds for this, or if it is pure bias on their part.

The reason why this would occur is that the current dogma of science is that science deals only with what is (a) observable and (b) measurable, and that what science does not deal with is not "objectively factual." Obviously, the life after death is not observable (at least until you get there, in which case it's too late), and it's certainly not measurable. Therefore, according to current scientific thinking, it is not worth serious consideration as "factual."

This dogma of science, however, actually contradicts what science is doing. It is absurd to say that it is not scientifically established that there is such a thing as an "unconscious mind," which is responsible for some phases of our (observable) behavior. But the unconscious drives and so on are neither observable (or they wouldn't be unconscious) nor measurable. It is absurd to say that it is not scientifically established that dinosaurs once roamed the earth; but all that has been observed are the bones; no one has ever observed an actual animal like a dinosaur, let alone measured one. Furthermore, measurement of the dinosaurs' bones is really not relevant; these bones are so obviously unlike those of any known animal that, even without measurement, they establish the fact that animals different from any present kind once existed. Measurement can come in when attempts are made to describe what those animals must have been like.

But the point is that, though the data science starts from is always observable, the conclusions science reaches do not always deal with what is observable--even observable in principle, as Heisenberg's "uncertainty" principle in physics establishes.

Scientific conclusions, when dealing with what is not observable, are based on the fact that if this unobservable entity or property does not exist, the original data are contradicted.

Thus, the scientist says that there has to be something unconscious that accounts for certain uncontrolled behaviors, or these behaviors contradict themselves. There have to have been dinosaurs, or these bones couldn't exist; and the dinosaurs have to have had certain characteristics (such as being carnivorous or herbivorous) or their teeth would have been different, and so on.

But then it follows that if it can be established that human life contradicts itself unless life goes on after death, it is a scientifically valid conclusion that life in fact goes on after death.

Thus, the scientific attitude toward life after death (that it is just a superstition) is scientifically groundless, given evidence that our life on earth (which is observable) is a contradiction unless life goes on after death.

This is not to say that we have in fact presented such evidence by the reasoning given in the preceding chapter. But it is at least scientifically suggestive; and so scientists should be sitting up and taking notice, not simply dismissing it.

3.2. Evidence dealing with life after death

As I said at the end of the last chapter, however, a detailed discussion of the evidence dealing with this question is beyond the scope of this book, and belongs in the area of Philosophy of Human Nature (sometimes called "Philosophical Psychology," "Philosophical Anthropology" or "Philosophy of Man."). Let me here merely make a summary of the evidence.

A. Human consciousness, as aware of itself (and so containing itself within itself) is an act that "does itself" twice without being more than one single act. Such an act cannot be a form of energy, because energy, having a quantity, is limited to being only a certain amount of activity, and therefore cannot double itself. An act that is not energy is called a "spiritual act."

But if consciousness is spiritual and not energy, then it does not depend on the body and its energy, and can be active without a body. Therefore, human consciousness can continue existing beyond death.

Furthermore, consciousness, as a spiritual act, cannot deteriorate or in fact change in any way, except as the spiritual "dimension" of a body which is organized in a basically spiritual way (as the human body is). Hence, after death, there can be no further dying or going out of existence.

This indicates that there can be a conscious life after death, and that this life is an eternal life.

But it is at least conceivable that, since the spiritual "dimension" of the human being is a dimension of a bodily being, this might go out of existence at death even though it could survive on its own.

B. Nevertheless, a study of life and living bodies shows that all the acts of the body as living tend toward continued existence of the being or (as in reproduction) of the form of life. A study of these bodies confirms also that as you go up the scale of living things, there is less and less dependence on the quantitative dimension of the being's reality.

Thus, if human consciousness ceased with death, this ceasing would be directly contrary to the thrust of all acts of life; it would contradict the act as a living act. Therefore, it would be self-contradictory for conscious life to cease with death.

This indicates that human conscious does in fact continue after death.

C. Human life, unlike all lower forms of life, has no genetically determined "mature state." The only thing that the genes determine is a range of possible "states of life." The person himself must pick from this range (by choosing) the state of life that is "his." Thus, it is human choice which specifies which life a human being is going to live, and not something built into the human from the beginning.

But if choice determines the life, it is contradictory for the choice not to be able to achieve its goals; because then the determiner of life cannot determine life.

But if life ends with death, then (a) those goals not achieved before death are necessarily unfulfilled; and (b) those achieved before death must be given up, which contradicts the fact that once a person achieves success in any area of life, he immediately has the goal of staying that way.

This indicates that life must continue after death in such a way that choices can be fulfilled, or the essence of the human as self-determining is contradicted.

This is actually the structural foundation of the first of the arguments that formed the hypothesis in the preceding chapter; it is corroborated by all the evidence that we have to try to control our lives, and in the last analysis it is "luck" and circumstances that have the real control--unless life goes on after death.

Since the goals are conceived in consciousness, it is at least possible that a conscious life after death could be such that the goals could be achieved.

D. Finally, there is the moral argument, which formed the second prong of the rough-and-ready argument stated in the preceding chapter.

If life ends with death, then deliberate seeking of frustration is often more fulfilling than trying to avoid deliberate frustration and being frustrated by circumstances.

Since most people are the oppressed rather than the oppressors, what this means is that most people will have no chance to live any meaningful kind of human life, because they will be prevented from doing so by the greed and malice of those who have power over their lives. This makes it a mockery to try to live consistently with human nature.

But if consciousness survives death, and if immoral choices mean setting up as goals "goals" that are known to be impossible (because self-contradictory), then this might imply that the frustration in immorality (striving for an impossible goal) continues eternally; while the temporary frustration in this life (because not deliberately chosen) would cease, since it is not contained in the conscious act.

This would make sense of morality, and be consistent with the other evidence.

CONCLUSION: Conscious life must continue after death, and is such as to make it possible to fulfill choices and be to one's advantage to be moral.

[See also A HREF="../modes/modes3/m3d3.htm#3.4.3"> Modes, 3.4.3]

3.3. Nature of the life after death

Is there more, based on evidence that we have available to us here, that we can say about what this life after death must be like? It turns out that there is.

First of all, since our consciousness now depends on our brain to select which act we are to be conscious of (it is a kind of spiritual "dimension" of the nerve-energy in the brain), then on the assumption that consciousness continues after death, it continues without a brain to select among the various acts of consciousness we could be having.

Therefore, consciousness after death must consist of every act of consciousness we have ever had during our life as a body, including all our choices with their consciously-set goals--all "rolled up" into one single, extremely complex act of consciousness.

Essentially, what our brain allows us to do now is to forget or put out of consciousness things that we don't happen to find useful to think about at the moment. But this means that consciousness without a brain would have to be an all-or-nothing thing: either no consciousness at all, or no possibility of being unconscious of anything. Since we have concluded that consciousness survives death, the second alternative must be true.

FIRST MORAL IMPLICATION: All of the immoral choices made during life will be eternally present to the person, along with the knowledge that their goals are impossible to obtain; and hence, the frustration implied in immoral choices will be eternal.

Thus, the moral command is the most serious obligation we have, if this is true. Any frustration we would have as a result of being moral would be something that happens in our physical life, not our consciousness, and would be temporary, ceasing with death.

But any frustration deliberately sought (by an immoral choice) is ipso facto an eternal frustration if every act of consciousness is part of our eternal consciousness.

Since even a small frustration which never ends is greater on balance than the most horrible frustration which ends, it follows that it is always to a person's objective advantage to make only moral choices. Honesty is the best policy, after all--not in this life, but taking this life and the eternal one after it into account.

NOTE that it is according to the person's own standards that he will be frustrated, because he himself set the goals that he wants but knows he must try for without being able to achieve.

So even though standards are subjective, the punishment of not being able to achieve your goals makes it always to your disadvantage to be immoral.

Hence, we need not assume that there is an angry god who is going to slap us around for doing what he doesn't like. (Which is fortunate, since it can be proved that that kind of a god doesn't exist.) All this theory states is that if you want to choose your own frustration, then, since your consciousness doesn't stop, you choose eternal frustration.

SECOND MORAL IMPLICATION: Moral choices made during this life will find their fulfillment somehow after death.

The reason for this is that if it doesn't occur, then the totally moral person (one who made only moral choices during life) would not have fulfilled all his goals before he died (as we saw in Argument C above). But if consciousness goes on after death, the consciousness of having unfulfilled goals would also go on after death; and since no change is possible once death occurs, this consciousness of having unfulfilled goals would be eternal. But that means that the moral person would be frustrated eternally also. The essential state of the moral person and the immoral person would be the same.

Actually, this would put the moral person in a worse position than the immoral one, because the immoral person chose his frustration because--in this life at least--on balance he was better off, while the moral person made his moral choices in spite of disadvantages in this life--in the hope that he would be better off after death.

Hence, if moral goals are not fulfilled after death, then it is objectively advantageous for a human being to act inhumanly, or to seek his own disadvantage, and so on, and moral and rational activity is contradicted, as we saw in Argument D above.

It also follows that it is impossible to achieve goals (whether moral or immoral), and so Argument C is also contradicted.

Hence, if a moral person cannot achieve his goals after death, this knocks the props out from the best evidence that there is a life after death in the first place; not to mention that human life as such makes no sense.

CONCLUSION: after you die, you will eternally be and be conscious of yourself as, everything you have chosen to be; no more than that, but no less either--unless you have chosen to be something impossible, in which case you will be eternally frustrated in that aspect of yourself.

Note that this second clause, the eternal frustration, means also that you will eternally be what you have chosen to be, because, knowing that the goal was impossible, you chose to have it as a goal anyhow; and therefore what you chose to be was frustrated.

And this makes sense out of life. What more could we ask than to be just what we ask to be? You can be whatever you want (so long as it is in principle possible for you); and you will eternally be just this: you will not be forced to be any greater, and you will not be compelled to be any less.

3.3.1. Relation of this theory to others

This is not a book whose purpose is to go through the history of philosophy and give and critique all views of ethics; it is supposed to be building a view based on the best objective evidence available.

Still, I should mention where my view stands in relation to the major theories of ethics. We have already seen that I think that the emotivist theory of ethics is false: that is, that what is morally right is a matter of your "deep-set feelings" about things. The problem with this view is twofold: (a) we can feel fine about doing something we know is inconsistent with ourselves (and vice versa); and (b) in the last analysis, it doesn't matter how you feel about something; what's wrong is still wrong--so it can be tremendously to your advantage to get your satisfaction by stepping all over other people's rights.

Secondly, deontological theories of ethics stress that there is a command to avoid what is wrong; but the most famous of them (Immanuel Kant's) doesn't tie this "categorical obligation" to any reward or punishment. But then in practice all this means is that if you choose what is wrong, you're being immoral. Big deal. If that's all that happens to you, and what you gain by it is fame and fortune, why bother?

Thirdly, consequentialist theories define what is right and wrong in terms of the results. For instance, Utilitarianism says that what is "good" (i.e. morally right) is what "brings about the greatest happiness of the greatest number." But (a) this implies that if you violate someone's rights (and so act inconsistently), you might be bringing about fifty people's happiness--and so this theory makes "the end justifies the means" into a recipe for doing good, of all things. Also (b) why should I care about "the greatest number's" happiness if I have to suffer for it?--unless there's something in it to motivate me to do what I have to do. So this view not only gives a silly definition of what's right and wrong, it provides no practical motivation for doing what even it calls the right thing.

The point is that, as the "deontological" theories stress, there has to be a command that makes you do what is consistent with what you are; but at the same time, there have to be consequences making it always to your disadvantage to act in any other way. Without both of these, all the discussions of morals are a waste of time; and I submit that the "natural-law" theory as I have outlined it, coupled with an afterlife of reward and punishment, is the only theory that can make sense out of why it is necessary always to avoid what is morally wrong.

3.3.2. Happiness and enjoyment

Things are not quite as rosy as they might seem, however. There are several "hidden variables" in this equation that we must take into account. First of all:

The condition of our afterlife does not depend on what we would like to be, but on what we choose to be.

Thus, if a person enjoys, say, fixing automobiles, and instead of becoming a mechanic chooses to go to college and get a degree and become a business manager, he has rejected as his goal in life the thing that he enjoys doing. Therefore, he will not, in his life after death, be "fulfilled" in the auto-fixing aspect of his life, because he had the chance to choose this as a goal and explicitly chose not to do it but to do something else. He will eternally be the manager he has chosen to be and not the mechanic he would like to be.

DEFINITION: Success is doing all the things you have chosen to do.

DEFINITION: Happiness is the knowledge that you have achieved success.

DEFINITION: Enjoyment is doing something that is emotionally satisfying.

The relation between happiness and enjoyment is this: In the first place, enjoyment deals with the fact that because of our body's particular genetic structure (as, some people are muscular, others not), our early training, and habits we have acquired, certain acts are easy to us and pleasant, and others difficult and unpleasant.

Our body, in other words, has an inclination to certain types of activity rather than others; and performing these acts results in emotional satisfaction.

These acts to which we are inclined by our bodily structure and habits, however, may not even be acts that we can morally choose. It does not follow that if an act "fulfills" some one aspect of yourself that it does not contradict some other one; and if it does so, then to choose to enjoy yourself in this way is to make an immoral choice, and therefore to be eternally frustrated.

Obviously, in this case, to choose to enjoy yourself brings the very opposite of happiness, because it sets up as a goal in life something you know you can't really achieve.

And since we are free, we do not have to choose to perform these acts. If we choose not to perform them, then they are not part of our goal in life--and therefore, the enjoyment implied in doing them is not part of our goal in life. We may like doing what is enjoyable, but if we choose not to do it, we do not want to do it.

Essentially, when you choose to do something other than what is enjoyable, what you are doing is saying that, taking all the effects of your acts into account, the sum total of the effects is "more yourself" in doing the non-enjoyable set of acts than in doing the enjoyable one. Thus, the person who chooses to be the business manager rather than the mechanic considers that he would rather have the higher status and salary that he thinks will result from the business career than the enjoyment in fixing cars.

And this is precisely what human freedom implies. We are not bound to choose what is more enjoyable; we can choose anything at all as a goal; and if that goal is in principle fulfillable (i.e. not self-contradictory), then that goal becomes part of our happiness when we achieve it, whether or not it is part of what our "built-in" inclinations headed us towards.

But this means that if we enjoy some activity, we had better choose it as a goal here in this life, because it will not occur after death unless we do so.

Now of course, this does not mean that the act has to be one of the main goals in your life; you can choose it as a hobby or avocation. Our businessman, for instance, can tinker with cars in his spare time, and so being a mechanic is part of his life, if not (now) the major part. The point is that if he rejects this as part of his life here on earth, he cannot expect to find it waiting for him after he dies.

[See also Modes, 3.4.3]

3.3.3. No forgiveness

The second hidden implication in this theory of morality and its relation to the life after death is rather horrible to contemplate. This theory makes sense out of life, because we get just exactly what we ask for, including frustration, if that is what we choose.

But once you have chosen a self-frustrating goal, there is no way you can remove the choice and its consequent frustration; it is from then on part of your eternal consciousness.

Well, suppose you realize what you have done afterwards, and then repent. What does that do?

First of all, notice that "realizing what you have done" does not mean that you made a mistake when you made the immoral choice; it simply means that you didn't (a) experience the effects that you foresaw, and/or (b) foresee all of the consequences of the act you chose to do.

But you can't be immoral in your choice if you don't realize that there's something self-contradictory about it. If the choice was the result of a total mistake (so that you didn't suspect that there was anything wrong with it), then you didn't in fact set up self-contradictory goals for yourself, and so there is no frustration in your consciousness which would carry over to the next life. Hence, an immoral choice is always a deliberate attempt to frustrate yourself at least to some extent.

With that said, then, all that repentance does is set up as a goal not having made the choice which you actually made. But this does not erase the previous choice; it merely adds the choice "I choose not to have done this." But that choice, of course, is itself self-contradictory, because you did do it. As Lady Macbeth said, "What's done cannot be undone."

Hence, the person who repents of an immoral choice is actually doubly at cross-purposes with himself: he has the self-frustrating purpose implied in the immoral choice, and he has as a purpose not to have this purpose which he has. Repentance does you no good.

But this does not mean that, once you have been immoral, it makes sense to say, "Well, as long as I'm damned anyway, I might as well enjoy myself," and to continue to make more immoral choices.

The reason for this is that there are degrees of frustration, depending on how important the goals are in your life. One immoral choice in your whole life sets up an unfulfillable goal as a goal in your life; but if this is the only one you have, then it probably doesn't figure very heavily in your definition of your "true self," and so wouldn't bring much frustration along with it.

But if you choose this goal again and again, or choose many self-contradictory goals, then these goals become increasingly important to you, your definition of "the true self" turns more and more around these acts (and consequently depends on the impossible "fulfillment" of these goals); and therefore more and more of you remains unfulfilled (because unfulfillable) eternally.

3.3.4. The afterlife and God

There are those who would react to this in this way: "But God loves us too much to leave us frustrated forever, especially if we repent of what we have done. He'll forgive us for offending him."

Unfortunately, this conclusion simply doesn't follow either from the evidence dealing with morality or the evidence dealing with what God is.

The evidence that there is a God at all (which I am not going to go into but which you can find, for example, in my The Finite and the Infinite.) indicates that God is totally incapable of being affected by anything that happens in the world; so our immoral choices do not "bother" him in any way; and so for him there is nothing to forgive.

God's "love" for us consists, not in some "affection" for us, which is "saddened" if we ruin ourselves, but in the fact that when he does something for us, he gets nothing personal out of it. Fundamentally, God's love for a free creature means an infinite respect for that creature's reality. If, then, the creature deliberately chooses to mess up his life, then it would be contrary to God's love to save him from the consequences of his choice--because it would be to take control over his life from the creature.

But this would again contradict Argument C above, because ultimate control over our lives would then only apparently be in our hands, but would actually be due to God, or "luck." A person who didn't want to be happy would then be forced to be happy in spite of himself because of "God's love." Furthermore, if God's "love" is such that the immoral person is actually going to be made happy eventually, then again it makes sense to be immoral and be forgiven than to be moral and suffer--which contradicts Argument D, and therefore contradicts the evidence that there is an afterlife at all.

Granted, the immoral choice, as an attempt to be "independent" of God (and be one's own creator totally, as if one had no limits), is objectively an "offense" against God (who set the limits), and as an "offense" against the Infinite, can be called an "infinite offense," this still does not mean that God is offended, let alone infinitely, by our silliness. So the "offense" in this sense does not need to "satisfy" the offended party, because he isn't offended (in the psychological sense).

In any case, the statement, "God loves me too much to let me be frustrated eternally" contradicts the evidence for saying that there is a God at all, as well as the evidence for saying that there is a life after death.

Remember, eternal frustration for immorality doesn't mean that you have made God angry, and he's going to get even by punishing you. All it means is that if you want to frustrate yourself, you get what you want. Your choices don't bother God; and if that's what you want, why should he do anything about it?

So a belief in a God is no way out of the mess you get into by making an immoral choice. And if you believe in a God that will save you in spite of yourself, then you believe in a God that doesn't exist, because that kind of God can't exist. Theological note on salvation

This is as far as philosophy goes. It turns out, however, that the actual truth goes beyond this in an important way; and I would not like to leave readers with a false impression, simply because in a book on philosophy one has to stop at what can be proved based on observable data.

Hence, in this section, I am going to be talking about what I believe is true and factual; but the evidence is not the data about life, but the Bible (specifically, the New Testament) and Christian tradition. There is evidence for saying that the New Testament is reporting facts; but I am not going to go into that. Suffice it that what I will be saying here is outside the realm of philosophy or science, but that this does not mean that (a) it is unreasonable, or (b) that there is no evidence in its favor.

There is scientific, philosophical evidence that our nature is "fallen"; as embodied spirits, (a) we ought not to have to die, because our spirit is by nature one that organizes a body, and if it is deathless, so should our body be--which makes a purely conscious eternal life a paradox, since for practical purposes the whole of our lives is spent being only part of ourselves. Further (b) as embodied spirits, our consciousness ought to be in complete control over itself; but our emotions can sometimes take over control of our actions in spite of our choices--in which case our own mind in its emotional dimension is at war with itself in its reasonable dimension, which is absurd, since it is the same mind.

How we got this way, philosophy cannot say; but the Adam legend sheds light on the subject. I am not going to pursue this here, however. The fact is that we are this way; and what is important for my purpose here is that this means that when we make a choice, our whole personality is not wrapped up in that choice, because (a) we do not necessarily have all the information dealing with that choice available to us (we can forget relevant facts), and (b) the conflict with our emotions makes the choice to be immoral less "totally ours" than if every aspect of our mind was completely dominated by the choice.

Furthermore, since our lives are now spread out in time, with only one small aspect actualized at any moment, it is therefore possible, while we live as bodies, for a choice to be erased without destroying the whole person. For a pure spirit, like an angel, an immoral choice can't be erased without annihilating the whole angel, because the choice isn't a "part" of him, but a dimension that permeates and "colors" the whole--just as you can't "remove" the mass of a body without annihilating the whole body, so with a pure spirit, any "act" of consciousness is not part of a system of acts, but simply a way of looking at the act as a whole.

But this is not how it is with our consciousness, since it spreads itself out in time, and especially since it is in conflict with itself. It is not (in this life) totally present to itself. Hence, there is no contradiction in (a) our repenting of a choice we have previously made, or (b) in that choice's being erased while leaving us in some sense the same person.

There are three difficulties with this, however. First of all, as I mentioned, repentance of itself cannot erase the previous choice, but only adds the choice not to have done what we have done. In fact, since the only thing we can do by ourselves is forget (which does not mean erase, but simply file out of the conscious area temporarily), then there is nothing at all we can do to erase an immoral choice we repent of. Hence, if any erasing of our choices is done, this must be by a miraculous intervention of God.

Secondly, there is no reason why God would do a thing like this. When we made the original choice, we knew what we were doing, and the repentance afterward does not change that. So to leave a person with a repented immoral choice is not unjust, unfair, unmerciful, or unloving of God.

Nevertheless, since the original choice was not something we were totally committed to, then there is no reason why God would not erase such a choice if we repented of it. It is not that he cares, one way or the other; and so there is no reason why he should do one rather than the other. But this means that a loving God might indeed do the act of erasing our sins for us.

But, thirdly, it is still true that each choice forms a dimension of our eternal lives, and that we create our personality bit by bit by the choices we make through time. Hence if a previous choice is erased, this means that in a real sense we will be from that moment a different person.

That is, a person who wants to give up a previous choice he made can't simply give it up the way he can take off a coat he is wearing. That choice has infected his whole being; everything about him is different (in some way) because of it; and hence if it is removed everything about him is going to be different in some unknown way.

Therefore, a person who repents and wants his sin erased must be willing to reject himself, to give up the person he is and become someone else. Who? Not just "the same one without the sin." In fact, the person whose sin is erased is given, in addition to the newly-formed personality, the life and thought of God himself; he becomes YHWH, or the man who is YHWH embodied, Jesus.

It is impossible to be saved and to remain the same person. He who wishes to be saved must be willing to give up his self and become a new creation--to live the life Jesus lives in addition to a transformed life of his own.

That's just the way things are. God could have arranged things differently, so that we would simply live a transformed human life after the erasure of our sins. But he chose to lift us in addition totally beyond the finite and to make us live his own life--which is something totally beyond human desires or goals (in fact, to choose to be God would be immoral for a human being, as contradicting his finiteness; this divine life must be a gift, not a goal).

If you don't want to accept this condition upon salvation, that's fine with God. It's there if you want it. He became man and died the horrible death he died, not to show us how horrible to him our sins are, but to show us graphically that he didn't care about himself and to prove that the fantastic gift is real. That is, he gave himself up to death as an example that we can, if aided by him (if we take up our cross and follow him) die to ourselves; that his love extends far beyond what is "necessary" or "merely sufficient," and that by giving his life for us it is reasonable to believe that he gives his life to us; that failure does not matter, because after death there is resurrection; that the body we lose will not, in fact (as philosophy would seem to imply) be lost forever, but by a miracle will be restored glorious--and to show a thousand other things that make life not only make sense once again for the sinner but make it beautiful beyond our wildest dreams. "No eye has seen, nor has ear heard, nor has it entered the mind of man to conceive what is in store for us."

All this is true, if in fact Jesus came back to life after he died. This is what his Emissaries, who were there, swore happened. If it didn't, then the whole thing is a noble, beautiful, wonderful fairy-tale, and a dream, and philosophy is the whole truth, and there is an afterlife, and we are eternally cursed with our sins.

3.4. The meaning of life

But with that said, let us return to philosophy and what it can tell us about our lives. Given the conclusions we have reached, what does the nature of the afterlife tell us about what life (this life plus the one afterwards) is all about?

Since we are self-determining, our life in itself does not have purpose or meaning; we give it its meaning and purpose by our choices.

What this amounts to is that it is impossible to discover what your life is "all about" or "really means," because the constitution of the human person is such that he has no built-in purpose, but gives his own life directions toward goals of his own choosing.

And there is nothing about us that means that we have to select this goal rather than that one. The moral obligation simply says "Do not try to select self-contradictory goals"; but a self-contradictory goal is not a real goal, simply because it is the opposite of itself. So there is nothing in morality that says one real goal is to be chosen rather than another; what you want to make of yourself is up to you, and is not imposed on you by (a) your nature or (b) God.

So to ask God, "What is your plan for me?" as if you could find out from him what your particular goal in life was (what he wanted you to be) contradicts the fact that he created you self-determining. His plan for you is the life you choose for yourself; there is nothing he "wants" you to be other than exactly what you choose to be. Even if you choose to be eternally frustrated, that is his plan for you: because he created you to be the master of your own eternal destiny. You make God's plan for you; it is not the other way round.

Many people would actually like things not to be this way; they would like to be like animals, which are not self-determining, and whose mature state is built-in from the beginning. Animals are not responsible for what they become; they can't help themselves. But we are, and we can. What we can't do, if this theory of life is correct, is avoid "helping ourselves," and being totally responsible for the eternal selves we will be.

What you will be for eternity depends solely on your free choices; you cannot "blame" the environment, luck, God, fate, parents or anything else, because even though these things affect the life before death, they do not force us to choose.

Thus, the eternal future state you will be in is the sum of the goals you have chosen. And this is the whole meaning and purpose of your life. It has no other.

[See also Modes, 3.4.4]

3.4.1. God as the "real" goal of life?

There are many Christian philosophers who have tried to amalgamate their Christian belief into their philosophical systems, and have called God the "ultimate goal" of any human being's life, and so the standard of and objective kind of moral "goodness."

The reasoning goes this way: The human will desires the possession of the good; but since it desires this in the abstract, it cannot be satisfied with the possession of any finite good; but possessing an infinite good could satisfy it, and therefore, the will desires the possession of God, and hence God is objectively the goal of our choices or our "final end and good."

There are several difficulties with this. First, it assumes that, if I could "want to possess" more, then I will, and won't be satisfied with the way I am. But this is not so. The goal is simply an imagined "self" that we set up as something to try to reach; and if it could be greater, this does not imply that we want it to be greater. You could enjoy listening to Beethoven's symphonies rather than Jethro Tull or Madonna; and this is an objectively higher (because more complex) type of musical experience. But it doesn't follow that you "secretly want to." Beethoven isn't better music than the Beatles, objectively; his music is more complex, more varied, more intricate, etc., but it is "better" only for the person who considers listening to complex music the ideal, rather than in being easily entertained by interesting sounds.

Secondly, for the "possession of God" to be a goal which would satisfy all possible "desire," I would have to want to possess God infinitely, because to possess him as I now do, knowing little about him and caring not that much for him is hardly the ultimate in "satisfaction." But this makes being God a goal for a creature--which, as I said earlier, is immoral, because it contradicts the finiteness of one's nature.

Hence, the possession of God is not the goal of our lives; our lives only have the goals we set for them; and the sum of these goals is the only purpose we have, and this is what being good is for us. But this varies from person to person.

Well, what of the purpose God had in creating us? Isn't that God? The reason God created us was himself, in that he recognized that his power was such as to be able to do this, and he had no need of us. But all that means is that he created us because he could; not because he "wanted" something from us. But we fulfill that "purpose" simply by existing, not by having him somehow as a goal toward which we are supposed to work.

Therefore, we give our life its purpose, which means we create the ideal which is to be our "true self," and this ideal will be eternally realized, as long as it does not involve any contradictions; and hence the life after death will be the "good life" for each of us; but in each case, the "good life" will be different.

It is now our task to look into our choices more closely, to see their relation to the actual facts, the facts we know, our emotions, and the various aspects of ourselves.

Summary of Chapter 3

Even though this theory concludes to a life after death, it can be scientific, because scientific theories, starting from what is observable, often conclude to what is unobservable, if this is the only way to save the observable data from contradicting itself.

The evidence that life continues after death is (a) that human consciousness doubles itself in one single act, which means that it is spiritual, not energy, and therefore can exist without a body; if it does so, it does so unchangingly, immortally, and eternally; (b) as an act of life, it partakes in the nature of life, which is to continue indefinitely, and so would not cease at the death of the body if it could go on; (c) if consciousness ended with death, this would mean that human goals could not be reached, which contradicts the fact that humans by nature cannot avoid determining themselves by setting goals, since human life has no built-in goal; and (d) if consciousness stopped at death, it would be reasonable to act immorally, which, as setting unrealistic goals, is the unreasonable thing to do--which is absurd.

Since forgetting depends on keeping energy out of certain areas of the brain, then the conscious life after death cannot forget, and so is the sum total of all experiences we have ever had, including all our choices, present together eternally and unchangingly.

Therefore, any immoral choice, which intends to achieve a goal which cannot be achieved, necessarily involves eternal frustration, which, even if small, is always greater than any advantage which ends with death; thus it is worth it to be moral, even if one suffers for it in this life.

Moral choices have possible goals; and since the moral person with eternally unfulfilled goals would be worse off than an immoral person, it follows that all goals will be eternally fulfilled after death (except the immoral--self-contradictory--ones). This makes it worth while to be moral.

So this theory is not an "emotivist" theory, since we saw that how you feel about things has no relation to whether your act is right or wrong. It is not just a "deontological" theory (stressing the command), since those theories don't give any practical advantage in doing what is commanded; and it is not just a "consequentialist" theory, since what is right or wrong is not defined by the consequences of the act, and it is only the consequences in the life after death that make it advantageous to do what is right.

Success is the fulfillment of goals; happiness is the knowledge that one has fulfilled goals. Frustration consists in not being able to achieve your goals. The afterlife is a happy one for the moral person. Enjoyment is doing what is emotionally satisfying; and the moral person will only enjoy his eternity if he chooses as a goal something he finds enjoyable. If what he finds enjoyable involves a self-contradiction of some other aspect of himself, this will be eternally frustrating.

Once an immoral choice has been made, there is no way a person can erase it. Repentance merely sets as a goal the self-contradiction of intending not to have made a choice which one has made, but does not erase the previous choice. Thus, any immoral choice inescapably results in eternal frustration; to make more immoral choices merely means that the frustration will be worse eternally. Since God is not really offended by the immorality, then God cannot "forgive" the insult to him.

(God can erase an immoral choice, however; and Christianity believes that he does do this if the person repents and is willing to give up his reality and become Jesus in love. But this erasure of immoral choices is miraculous, and there is no scientific evidence that it happens.)

Our self-determination means that we create by our choices the meaning and purpose of our life; in itself it has no purpose. There is nothing we can blame but ourselves for our eternal life, because our choices are under our control.

The possession of God cannot be the "real" goal of life, because it is possible to be unsatisfied when possessing God unless one possesses God infinitely, which means being God--and to have this as a goal is immoral for a creature. In fact, our purpose is the set of finite goals that we have chosen during life, and this defines what the "true self" is to be.

Exercises and questions for discussion

1. But the fact that God is really forgiving vitiates the whole argument, doesn't it? Because it means that if you deliberately do what is wrong, you can repent and everything will be OK. So the immoral person wins again.

2. It doesn't seem fair that a person who, to be moral, has given up much of what he'd enjoy doing, can't be doing those things after he dies. Isn't he worse off than the immoral person, who after all did do them for a while?

3. If there is no forgiveness for any immoral choice, isn't that cruel on the part of God, given how weak we are?

4. If there is no built-in purpose or meaning to our lives, does this imply that the life after death is a meaningless, purposeless life?

5. Suppose a person gets murdered, and as he dies he makes a purpose of his life letting people know he's been murdered. Could this allow for the possibility of ghosts?

6. If one of your goals in life is actually doing some good on earth after you die, does this mean that dead people can really change the world?



4.1. The choice as free

The theory that morality makes sense because life goes on after death seems to hang together, so far at least. It supposes, of course, that there is a difference between our acts and their consequences here on earth and our choices and their eternality. It also supposes that these choices are always under our control; because if they aren't, then (a) self-determination and eternally being what you chose to be is nonsense, because you had no control over the choice; and (b) eternal frustration for immoral choices over which you had no control would be self-contradictory and unjust. In other words, if our choices are not free (whatever may be said about our acts), then life is once again nonsense; the whole theory collapses, and so does any attempt to make sense out of life and morality.

This in itself constitutes a proof that our choices are free--at least in the sense that they are under our control. There is, however, other evidence that leads to the same conclusion; but this evidence, like that for immortality, is the proper subject of the Philosophy of Human Nature, and so will not be treated here (once again I refer you to Living Bodies for a more extended discussion).

Let me just sketch the evidence for those who simply want to see an overview of what it is.

(A) The choice, which is conscious of itself, is a spiritual act, containing the whole of itself within itself (e.g. whenever you choose, the choice includes the choice to choose now--and not postpone it--the choice chooses itself). Such an act, as directly within itself, cannot be deceived about itself (because there is nothing "between" it and itself to fool it); and since it recognizes itself as in control, then this must be true.

(B) If the choice were not free, then our idea that we could have chosen differently must be a delusion based on ignorance of what is making us choose. If this were the case, then those who have unconscious things directing them would have to feel freer than those who know what is influencing them. But neurotics do not know what is making them do things, and yet feel unfree.

(c) People feel unfree in the situation in which they choose to do something and then find that they can't carry out the choice. But if the choice is forced, then what forces the choice would also force the act; it would be contradictory for the act to be forced in the opposite direction.

Hence, the evidence confirms what we need for our theory: that our choices are free, even when our acts aren't.

[See also Modes, 3.3.6]

4.1.1. Characteristics of free choice

Obviously, we are not free in every sense of the term. I just got through saying that our acts are not always under our control. Also, when someone threatens us, even though we can choose to do what he threatens us not to do, we aren't as free as we were. So let me list the characteristics of the kind of "freedom" that is relevant to our present discussion:

1. Our choices are always under our control.

That is, it is always possible to choose any of the known alternatives (and always possible to choose not to choose now), whether those alternatives are reasonable or realistic or not.

2. Nothing unconscious can directly affect a choice. Our choices can be influenced, but only by facts we know at the time we make the choice.

The first part of this point says that options we are not consciously aware of cannot be chosen. If you don't realize (at the time you make the choice) that you can, say, leave the room, you can't at that time choose to leave the room. Further, you can't use as a motive (a "reason") for your choice some information you have forgotten at the time you make it. If you decide to buy a car and you choose to buy a less expensive one because you don't think you have the money for the down payment--and the next day your tax refund comes--the fact that the information about it was "filed" in your unconscious didn't affect the choice.

And this brings us to the second part. These facts are the reasons for which we make the choice, or its motives. We do not choose based on emotions we have, except insofar as the fact that we have the emotion figures as a reason for choosing.

Be very clear on this. When we choose to do something because we like it or it feels good, it isn't the feeling that influences the choice, but our knowledge of the fact that the act we choose will make us feel good. Similarly, if we choose to avoid some act because we are afraid, it is not the fear itself but the fact that we have the fear that is what influences the choice.

This is a very subtle little distinction, but very important.

3.The choice has control over how much each known fact is going to influence it.

That is, we choose not only the act we perform, but we choose the reasons for which we perform it, and we choose how important those reasons are for the choice.

We are not at the mercy of the "objective weight" of the motivations for the choice; we make the weight and importance of these motivators by choosing which is to be important, which is to be insignificant, and which is not to figure at all in the choice.

So, for instance, when you are wondering whether to buy an expensive suit or a stereo system instead, you weigh the fact that the suit will let you "dress for success" for your job interviews, that it will make you look nice, that it will be the envy of others, etc., against the fact that the stereo will allow you to hear Starship without distortion (?), that you can invite others to your house without shame for parties, etc. You then put these facts in an order of importance which depends on you, not on some "objective goodness." (This is where the subjectivity of goodness comes in.) You may recognize that objectively, it is more to your long-term advantage to buy the suit, but you choose to make, say, the looks of the stereo in your room the most important consideration, and buy the stereo for that main reason. You choose to ignore what your parents will say.

4.Feelings, habits, instincts, and drives affect choices only indirectly, by (a) making us unaware of facts we might have known if we were calm, or (b) creating illusions that we take to be facts.

Feelings, then, affect choices (indirectly, not directly) by creating misinformation. We then use this misinformation as the reasons on which we base our choices, thinking that we are basing them on facts. Either that, or the emotions conceal information; and we base our choices on fewer facts than would otherwise be available to us.

Thus, a person who is in love simply cannot understand what someone else is talking about when the other person says that his beloved is, say, selfish; his emotion prevents him from being aware of this. Similarly, he sees his beloved as more beautiful than she really is, because his emotions are "enhancing" his perceptions.

Note that the choices in this case are still free, and the emotions did not "force" them. It is just that they are more ignorant than they would have been if the emotion hadn't blinded the person.

5. Our acts are never free. They are ordinarily forced by our choices, but may be forced by emotions or habits in spite of the choice.

We often choose to get into habits, in fact, because we don't want to be bothered deliberating and choosing about the minor affairs of our lives. The habit amounts to a "programming" of the brain so that a given response is automatic upon a certain stimulus; as, for example, when you get into the bathroom in the morning, you reach for the toothpaste and brush.

Sometimes these habits (and emotions) can be so strong that they operate even when we choose to stop them. Then the person feels out of control. His choice is still under his control; but his act is not, because it is not under the control of his choice.

Note on terminology:

This is something else that belongs in the Philosophy of Human Nature, but has a certain relevance here.

Acts can be called analogously free when they are the acts we choose to do (because the choice is free). Thus, when I choose to type at this computer, the act of typing is a "free" act, because I could have chosen to do something else (and presumably would be doing it). Actually, the act is forced by the (free) choice.

Choices can be called "less free" or "not free" insofar as they are made under a threat. The choice is still free (choices are always free) in that it is possible to choose to act in spite of the threat; but the threat (the warning that some harm will come if you make a certain choice) makes such a choice positively unreasonable. That is, no reasonable person would (or morally could) deliberately choose harm to himself; and so threats give a person only one reasonable and/or moral option. The freedom to act unreasonably is not a realistic freedom. It is in this sense that the victim says to the robber, "You leave me no choice." Freedom from threats is sometimes called liberty.

There are other senses of "free" and "not free," but these are the ones that are apt to cause difficulties in ethical investigations if one is not aware that there are these different meanings.

4.2. The general moral rule

I think it now can be seen why it is the choice that is moral and immoral and has eternal implications; only choices are always under our control. Our acts (morally right or wrong) may or may not be, and in any case, the moral rightness or wrongness of the act may not be known to us.

Let me refresh your mind with the first statement of the moral command:

GENERAL RULE OF MORALITY: You must never be willing to do what is morally wrong (i.e. what is inhuman in some respect).

There is a lot hidden in this rule. What it says is that "to be willing" to do something wrong is the same as to choose to do what is wrong. That is, your choice is immoral even if you don't precisely want the wrongness in what you choose, as long as you see that it's there, and you're willing to put up with it.

So, the thief doesn't precisely want the self-contradictory situation of pretending he owns what he really doesn't; he just wants to be able to watch "The Cosby Show" on the set he stole, and he's willing to pretend he owns the set in order to do it. He'd rather, perhaps, watch it on his own set, but he chooses to watch it on this one. That choice to steal the set is immoral, even if the pretense is not his goal.

Now of course, you can't be willing (or choose) to do something you don't know about (as we saw above); so this willingness depends on your factual knowledge.

But this is quite a complicated subject, as it works itself out in practice; and so let us start with something fairly simple: the relation of emotions and how you feel to the morality of your choices.

4.3. Morality and emotions

Since morality depends on the choice, which in turn depends only on our awareness of facts, not on how we feel, then it would seem that emotions, habits, feelings, and drives are completely irrelevant. Unfortunately, this isn't quite true, because emotions, habits, and so on can affect information you have, and can also take over control of your actions in spite of your choice.

Since this is so, then based on the general rule above, we can make this application:

RULE: We must never be willing to let emotions force us into doing what is morally wrong.

Let us unpack this rule. First of all, what it says is that the excuse, "Well, if I go over to her house, I'll be so blind with desire that I won't know what I'm doing and so I won't be making an immoral choice" is fundamentally dishonest. Granted, at that time you might be out of control of yourself, and so your choice at that time (because of misinformation or the emotion's controlling your act in spite of a moral choice) might not be immoral.

But since you now foresee that this might happen, then your choice now to get into that situation means that you are now willing to have it happen; and so your choice now is immoral. You are actually willing to do whatever you might wind up doing when out of control.

We must choose to avoid situations where we have reason to believe that emotions or habits will blind us or take over control and lead us to do what is morally wrong.

Note first that you have to have reason to believe that this will happen; actual evidence (facts) that indicate that this result is probable. The fact that your emotions might take over control ("Things like that can always happen") is no evidence that they will take over. A man who dances with a woman he is attracted to might become so sexually aroused that he would take her out and rape her; but this possibility is not a realistic one except in the case where a person knows this has happened before to him. People in general can dance without becoming that sexually aroused; and so, even if you have never danced before, you have no reason to think that you are going to go blind with desire--and so it would not be immoral to choose to dance with someone you are attracted to.

Secondly, note that the emotions may be operating at the beginning of the situation, so that you may already be out of control to some extent.

The alcoholic, for instance, can't control himself in the presence of liquor, and he knows this. In general, then, he has to choose not to go to bars. It doesn't follow, however, that if he goes to a bar, he has (a) chosen to do so; because his need for a drink is already so strong that he might not be able to prevent his going even if he chooses not to go; or (b) he has chosen to go to the bar knowing what he is doing; because the need for a drink may be so strong as to blind him into thinking that he is just going there to meet a friend (and that's the only reason he chooses to go).

So it is a fallacy for someone observing such a person to say, "Well, if he can't control himself when he gets there, he can at least choose not to go there; and so he's to blame anyway." This might be the case and it might not; just as it might be the case that this time he can control himself when he gets there. No outsider can judge the effect emotions are having on a person's acts (so that he doesn't act the way he chooses to act) or information (so that he doesn't at this moment know fully what he is doing).

Note thirdly that very often the person himself afterwards does not know to what extent emotions took over control of the act or blinded him to information he now is clearly aware of. It is always theoretically possible to control your acts by choosing; it just doesn't work that way in practice; and so you can always say to yourself afterwards, "If only I'd tried a little harder, I could have prevented that"; and this might be true, and it might not. Or you can say, "Well, I knew that I shouldn't have done that" because you now know that you shouldn't have, when in fact at the time, you were so overwhelmed with the emotion that you couldn't think straight.

What to do when in this situation? Don't worry about it. First, if Christianity is not true, and philosophy is the whole of the truth, the immoral choice was either made or it wasn't, and nothing you can do now can change that; so there's no sense fretting about it. Secondly, if something like Christianity is true, then the Lord will erase any sin involved in the choice, if there was one; and so you confess to him your repentance of whatever you might have chosen (or to a priest, if that's what you believe), and stop worrying about it.

The point is that you are not to deliberately let yourself get out of control; but if you are out of control, to that extent you have no moral problem.

[See also Modes, 5.1.5]

4.3.1. Morality and emotional problems

Thus, we can distinguish moral from psychological problems. They do not necessarily go together, nor are they necessarily mutually exclusive. You can have both a moral and a psychological difficulty at the same time; you can be immoral and have no psychological problem, or you can have a psychological problem and not be immoral.

DEFINITION: Psychological or emotional problems occur when a person, because of emotions or habits, is out of control.

That is, whenever a person does what he chooses not to do or does not do what he chooses to do, then this is a psychological problem. It used to be called a "neurosis" when this is a constant problem. This may have no moral overtones whatever. A person may not be able to go into a dark room, for instance, because he has a neurotic fear of the dark. There is nothing morally wrong with staying out of dark rooms; and so he is out of control, but this particular neurosis does not have any moral implications.

A psychological problem that makes a person do a morally wrong act involves immorality when the person is willing to do the acts.

What this means is this: If the person doesn't care that he is doing something that he knows is wrong, the fact that he is doing this because he's neurotic (and couldn't help himself) is irrelevant; he is willing to do it, and so the choice is immoral.

So you can't use a neurosis as an excuse for doing something morally wrong.

If, however, the person chooses to avoid the acts and his neurosis forces them on him, he has only a psychological problem and not a moral one. Here, he is unwilling to do what his emotional problem makes him do.

If a person recognizes that he has an emotional problem that is leading to morally wrong acts, and he has information that a cure is reasonably possible and takes no steps to be cured, then he is willing to have the problem and so to do the acts.

That is, to refuse to be cured when you are in this situation (supposing it to be realistic that the cure would work), is the same as letting yourself be out of control when you could control yourself; and then you are obviously willing to do the acts.

However, to the extent that the cure is not a realistic possibility, or involves bad effects that make it worse than the problem itself, a person can choose not to have it in order to avoid these bad effects, and still not be willing to perform the acts the neurosis forces upon him. (This is an application of the Principle of the Double Effect, which we will see later.)

For instance, alcoholism can lead to drunkenness and other morally wrong behavior. If an alcoholic has tried to stop and even got help in stopping (say, going to Alcoholics Anonymous), and it hasn't worked--it often doesn't--he doesn't have to try every new gimmick that comes down the pike. He has to do enough to assure himself that he is unwilling to be in this condition, but he doesn't have to "be determined to lick it at all costs." It is then a psychological problem, not a moral one--and some psychological problems can't be cured and have to be lived with, just as blindness or lameness or physical problems that can't be cured have to be lived with.

Of course, the alcoholic can't say, "I've tried and failed; so now I can enjoy myself," because then he's willing to do the act. What I'm talking about is that he can say, "Well, there's nothing I can do about it, so I'm not going to worry about it as if I were a sinner, even though I'm not happy about it. After I die it'll be straightened out."

Hence, there are psychological problems that have no moral dimension at all (if they don't deal with wrong acts), and psychological problems with a moral dimension which involve no immorality (if the person is unwilling to have the problem but can't do anything about it); there are psychological problems which are also moral problems (when the person doesn't care that he is doing something wrong); and finally, there are moral problems that have no psychological difficulty connected with them (when a person is in control of his emotions or what they lead to).

Psychological problems, then, do not provide an "out" for the general rule of not being willing to do what is wrong; but neither do they trap a person into immorality in spite of himself. The question is whether you are satisfied with your condition or not; whether you would stop if you could.

4.3.2.Habits: virtues and vices

Habits can also take over control of our acts, as I mentioned; and in fact psychological problems are usually a combination of emotions and habits; and psychological problems are usually cured (when they can be cured) by some kind of acquisition of a new habit.

But this belongs in the domain of psychology, not ethics. For our purposes, what we can note is that habits are acquired by repeated actions of the same type. As opposed to the "built-in program" of the brain, which is our instinct, which appears in consciousness as the various emotions we have, we can program our brain ourselves, by repeating responses to a certain stimulus. Depending on how often and strongly we do this, the tendency to produce the response (without choosing to do so) upon presentation of the stimulus becomes stronger.

Habits do not in themselves have any emotional overtone connected with them; but insofar as the stimulus-response pattern originally had some emotional overtone (as when you get into the habit of eating six meals a day because you originally felt hungry), the emotion tends to grow stronger as the habit grows--until a certain point is reached, at which the emotion more or less ceases, and we do the act even without the emotional kick.

Because emotions tend to lead us to action, some habits are acquired without realizing that we are doing so. Many alcoholics become so simply by having a drink at a certain time of the day, not realizing that they're getting into a habit, and are becoming dependent on the drink.

Other habits, however, are deliberately acquired. Originally, we must choose to do the act each time, taking pains to remember to do it; and gradually, we need pay less and less attention, until finally the act automatically occurs. Getting into the habit of brushing your teeth in the morning and evening is an example of such a thing.

Morally speaking, once the habit is acquired, it functions in the same way as an emotional problem: if the person is satisfied with the automatic behavior, he is willing to do it; and if he does it in spite of a choice to the contrary, he is unwilling to do it. In either case, it is the choice which counts morally.

Not all habits are bad habits, of course. Hence, to acquire a habit of doing what is morally right is one that you ought to be satisfied with. For instance, if you get into the habit of honesty, so that if you were to see a wallet on the street, you would pick it up, look inside to find the owner's name, and return it intact to him with no thought that you could take anything in it for yourself, then the fact that you aren't trying to stop yourself from doing this would be equivalently a morally good choice. So even though the act is automatic, it has moral overtones, insofar as you realize what is going on and are unwilling to prevent it.

It would be immoral to let oneself acquire a bad habit if (a) one realized he was getting into a morally bad habit, and (b) made no effort to prevent it.

This is the same as getting yourself into a situation where you foresee that your emotions will take over and lead you into a morally wrong act. In this case, of course, many morally wrong acts are involved (because it's a habit), and so the situation is more serious. It doesn't follow, of course, that you will in fact be able to prevent the habit from being formed; you may already be out of control. But insofar as you are in control, to let yourself get into the habit is to be willing to do all the wrong acts you might do when the habit gets entrenched.

Some terminology:

DEFINITION: A virtue is a good habit.

DEFINITION: A vice is a bad habit.

DEFINITION: A moral virtue or vice is a habit of doing something morally right or wrong.

Not all virtues are moral virtues: studiousness is an intellectual virtue; cleanliness is a physical virtue. The following are, however, like moral virtues:

DEFINITION: The Theological virtues of faith, hope, and charity are habits that are given to us by God because of the new life he gives us. They cannot be acquired by repetition, but can be strengthened by practice.

It is outside the scope of this book to talk of the Theological virtues; I put them here to distinguish them from moral ones.

DEFINITION: The cardinal virtues are the four moral virtues on which all others "hinge," all of which are present in any moral virtue. They are good judgment ("prudence"), honesty ("justice"), courage ("fortitude") and moderation ("temperance").

The reason these are "cardinal" virtues (from "cardo," meaning "hinge") can be seen from a description of what they are as habits:

Good judgment (also called "common sense") ("prudentia" in Latin) is the habit of being aware of all the circumstances surrounding the act you are to perform and adjusting the act to agree with the reality of all the circumstances. Obviously, without this habit, a person is apt to act unrealistically, and his action is apt to be self-defeating, even though his intentions may be of the best.

The vice which is the opposite of this virtue is rashness. Here, a person knows what he wants to accomplish, and has the habit of simply doing something that he thinks will lead to the goal he wants, without considering whether, given the circumstances, his action will actually do what he wants it to do.

Honesty ("justitia" in Latin) is the habit of considering the persons involved in the action, and adjusting the act to suit their nature. It has two branches. When the virtue adjusts the act to suit the nature of the agent (oneself), then this "being true to yourself" is the same as morality itself; when it suits the act to the nature of the person(s) acted on, then it is justice. Thus, a person who does not lie is being honest with his own nature as a communicator; and insofar as he does not deceive the other person, he is being just also.

The vice, of course, is dishonesty. This too has two branches. It is immorality when it is the "fundamental dishonesty" we spoke of earlier (pretending that you aren't what you are); it is injustice when the habit pretends that the one who is acted on is different from what he really is.

There are various kinds of justice, which we will see later, when talking of rights and society. Not every just act is either "fair" or "equal."

Courage ("fortitudo" in Latin) is the virtue of getting control over negative emotions, mainly fear, so that they do not take over and either blind us to reasons for doing something or prevent us from doing what is reasonable. Notice that courageous acts are not rash ones. A person who has courage without good judgment has a vice, not a virtue. Such people are the people who run risks "on a dare" just to show how brave they are, without considering whether it makes sense (or even is morally right) to run such a risk. The courageous person will be able to run a risk, even a great one, when it is reasonable to do so; but he will not do so if it is unreasonable.

The vice opposite to courage is cowardice. Here, the person lets fear determine whether he will act, in spite of what is reasonable.

Finally, moderation ("temperantia" in Latin) is the habit of controlling attractive emotions so that the attraction will not either lead one to do what is unreasonable, or blind one to the reasons for not doing the act.

All of the cardinal virtues have to be operating in order for any one of them (or any other virtue, for that matter) to be a virtue; if either of the two types of emotions are deliberately let get out of control, then no act is able to be virtuous; if there is deliberate disregard for either the persons involved or the physical circumstances of the act, then there is no assurance that the act will be morally right.

Other moral virtues

Here is a partial list of some other habits of doing morally right acts that you can get into. These various virtues "fit under" one or another of the cardinal virtues. We could go into a study of them, but it seems to me that this would be of purely academic interest; so I will just list them.

Generosity, open-mindedness, trustworthiness, truthfulness, respectfulness, patience, leniency, kindness, humility, tolerance, sympathy, mercy, obedience, helpfulness.

This, as anyone who puts his mind to it can see, is by no means a complete list; it is here simply to suggest that there are various good habits with moral overtones that you can get yourself into by practicing the corresponding acts.

Obviously, the opposites of these virtues are vices; and the vices involve acts to be avoided.

Not every philosopher agrees on what habits are virtues and what are vices; and this is because a virtue is a good habit, and what is "good" depends on the ideal one has for what a human being "ought" to be doing. For instance, Christians regard humility ("self-forgetfulness") as a virtue; and Aristotle considers it a vice; for him pride (i.e. recognizing one's real superiority to others--if it exists) is a virtue, while for the Christian, this is a vice.

[See also Modes, 3.2.5]

4.4. Responsibility

Because habits and emotions tend to take over control of our acts, then we can say in a sense that they aren't "ours"; we could even have tried to prevent them and failed; it is almost as if someone else had done them. This brings up the question of "responsibility," which anticipates to some extent what we are going to say about conscience, but perhaps goes better here than anywhere else in a general consideration of morality and our choice.

DEFINITION: Responsibility is the attribution of an act (and its consequences) to the person whose choice could have made it different from what it was. It is also called accountability.

That is, the act "belongs" to the one on whose choice it depends. Machines and animals do things, but they are not responsible (i.e. "answerable") for what they do, because, given the stimulus, the act could not have been any different from what it was--and so it doesn't really "belong" to the machine or animal.

But persons are free, and so the acts they do as persons could be different; and therefore, the acts are in a special sense "theirs"; just as they possess their being, so they also possess their acts. Karol Woytyla (Pope John Paul II), in fact, wrote a whole book analyzing the concept of person from this distinction between acts someone "does" and acts that, as it were, "happen to" someone.

Note that humans perform all kinds of acts that "happen to" them and that they are not responsible for (such as heartbeat, falling down when the floor collapses beneath you, feeling anger when slapped in the face--and in general all that we don't have control over); and these are not acts that we really "do" as persons.

Basically, a person is responsible for whatever he had control over; i.e., what he could have prevented or altered by his choice.

DEFINITION: A person is morally responsible for an act and its consequences if (a) he understood what it was he was doing and foresaw the consequences, and (b) that he could morally have chosen to prevent it.

DEFINITION: A person is physically responsible for any act that he could have chosen to prevent (whether the choice would have been moral or not, and whether he understood what he was choosing or not.

DEFINITION: A person is legally responsible for an act that a normal person would have been morally responsible for.

What do these definitions mean? Physical responsibility is the broadest category. Any act at all that could have been different had you chosen differently for whatever reason is one you are physically responsible for.

The idea here is that it is "your" act because it didn't have to be this way; if you had made a different choice, it would have been different.

Moral responsibility means that you could have chosen differently and that the choice was an informed one, and that this different choice would not have been an immoral one. Since making an immoral choice means bringing eternal frustration on yourself, then you can never be expected to make an immoral choice; and so there is a real sense in which you "couldn't" prevent an act when to do so would mean making an immoral choice. Further, since bringing eternal frustration on yourself means knowing that you are doing so (at least in some minimal sense, such as knowing that you are going to do what is wrong), then if you don't have the information conscious, you are not in fact choosing what the act actually implies.

Hence, the act is not morally "yours" in the sense of something you could have prevented; in the first case, it would be immoral (and eternally frustrating) to do so; and in the second place, you would have no reason for doing so (because you don't know there's anything wrong with it). And so, morally speaking, it becomes like your heartbeat, which "happens to" you. You are not morally responsible for it.

Legal responsibility comes from the fact that an outside observer can't get into a person's mind and know what his knowledge is at the time he makes the choice. Hence, society can't tell, if a person violates a law, whether he deliberately chose to do so, or whether he forgot and wasn't aware that he was violating the law.

Hence, society goes on the assumption that, if the person didn't realize what he was doing, he "ought" to have realized it, because a normal person in his circumstances would have realized it; and so it, as it were, makes him responsible for his lack of knowledge, and therefore for his act.

If there weren't this concept of legal responsibility, there would be no way for society to enforce its laws without extremely gross injustice. That is, a person would be punished for something it was obvious no one in his circumstances could have helped doing (such as accidentally harming someone because of circumstances over which he couldn't have had control); or he would be allowed to escape punishment on the bare claim that he hadn't actually thought that he was doing something wrong--which makes punishment a farce.

Hence, in order to protect its ability to punish violations, society imputes legal responsibility to a person who may or may not be morally responsible for what he does, as long as he would be reasonably expected to be morally responsible. In some cases, this imputation is unjust, because the person actually wasn't morally responsible; but the injustice is an unchosen side-effect of the act by which society protects its right to punish violators.

Points to note on responsibility:

1. Responsibility is not the same as duty.

When lists of "responsibilities" are drawn up for a certain job or position in society, these are the duties connected with that position. They are called "responsibilities" because if they are not done, the person with this job is the one responsible for this. Hence, duties are "responsibilities" in an analogous sense, the way comfortable shoes are "comfortable" because they make you comfortable; or as a morally wrong act is "immoral" because if you choose to do it and know what you are doing, the choice is immoral.

The point, however, is that strictly speaking, duties are duties, not responsibilities. Remember, "responsibility" as we are using the term is the equivalent of "accountability." You aren't accountable for what you haven't done yet; and so you aren't responsible for it either.

2. you have responsibility whether you like it or not; you don't get it by accepting it.

That is, you may "accept" responsibility, which means that you recognize that you are responsible for some act of yours--or on the other hand, you may "refuse to accept" responsibility. But in either case, you have it, provided you could have prevented the act by choosing not to do it.

Similarly, if you "accept" responsibility for an act you had no control over, this acceptance does not give you responsibility for the act. A person, for example, who "accepts" responsibility for an act his employee did against his orders and secretly (so that the employer couldn't have known he was doing it) is not responsible for what his employee did because the employer did everything anyone could reasonably do to prevent it.

3. A person can only really be responsible for what actually happens.

The reason is that an act that didn't happen (but could have) isn't something that can be attributed to a person. Nevertheless, since foreseen consequences enter a person's choice (whether they happen or not), they can make the choice moral or immoral, and thus can affect moral guilt.

[See also Modes, 5.1.5]

4.4.1 Responsibility and guilt

This brings up a distinction that it is important to make. We are apt to use "guilty" and "responsible for" interchangeably; but if you look at the definitions above, you can see that we can be responsible for all sorts of good things, and no one is guilty of doing good. And I just said that you can be (morally) guilty even when you haven't actually done anything (because morality deals with the choice, whether you carry it out or not). Hence, we should define guilt.

DEFINITION: A person is guilty when he has chosen to do what is wrong or illegal.

DEFINITION: A person is morally guilty when he has chosen to do what he knows or suspects is a morally wrong act.

DEFINITION: A person is legally guilty when he is legally responsible for an act violating a law.

For legal guilt, you actually have to do something, and not only do it, but be (at least) legally responsible for it. It also has to be something legally wrong: that is, something that there is a law against. Thus, a person who chooses to murder the President of the United States, but gets sick and can't do anything about his choice, is not legally guilty of assassination or attempted assassination of the President. If he raises a gun to shoot the President and his arm is deflected and he misses, he is legally guilty of violating the law against attempted assassination (because he did actually do something in the attempt), but not of violating the law against assassination.

Interestingly, in legal guilt, you don't actually have to have made the choice in question, because of the peculiar nature of legal responsibility. If in fact you didn't make the choice (because you forgot some circumstance and thought you were choosing something else) and a "normal person" would have realized this circumstance and known what he was doing, the law assumes that you actually did make the choice in question--because it can't get into your mind to tell whether you made it and are now lying, or didn't make it and are now telling the truth. There are, however, loopholes in this; but the burden, as it were, is upon you. If you can show that you were insane at the time, you are freed from legal responsibility. Also, you can plead "no contest," which essentially is taken to be an admission, "Yes, I did it, but at the time I didn't realize that what I was doing was illegal." In this last case, however, you are still legally guilty.

In any case, legal guilt always includes responsibility for some act actually done.

But moral guilt does not, because the "law" dealing with morality commands the choice itself, and the act is morally relevant only insofar as it conforms the fact that the choice was an actual choice and not simply a daydream. That is, if you "think about" killing the President because you're writing a novel about it and you want to "get under the skin" of a killer, but you have no intention of actually doing the act, then you have not chosen to kill the President, and you are not morally guilty of it.

But if you choose to kill the President, and you get sick or your aim gets deflected, then your goal was that he die by your act; and this is what the moral command forbids. Hence, you are morally guilty of the wrong act whether your choice gets carried out or not.

However, you are not morally responsible for killing the President if you intended to do so and you got sick and couldn't actually do it. Why? Because you didn't kill him; and you can't be responsible for something if it didn't occur.

(Note that if you prevent something, you are responsible for its non-occurrence; but if you choose to do something and it doesn't get done through no "fault" of yours, you aren't responsible for it, because there is no "it" to be responsible for. You are only responsible for what happens, as was said above.)

Summary of Chapter 4

We know that human choices are free, because, as spiritual, they contain themselves and cannot be mistaken when they think they are free (as they do) and because neurotic behavior becomes nonsense if choices are not free.

The characteristics of freedom of choice are (1) that the choice is always under our control; (2) nothing unconscious can affect the choice; it is influenced only by facts we know at the time; (3) the choice has control over how much a known fact influences it; (4) feelings and habits affect choices only indirectly, by creating misinformation; (5) our acts are never free; they are forced either by choices or emotions/habits or both. Acts are analogously free when they are the ones we choose to do; choices are sometimes called "not free" when made under a threat, but this is an analogous sense of "freedom" called "liberty."

The general rule of morality is that you must never be willing to do what is morally wrong.

Since emotions can force acts or create misinformation, we must never be willing to let emotions force us into doing what is morally wrong. We must choose to avoid situations where we have reason to believe emotions will take over control and force us to do what is wrong. If we have no evidence that this will happen, or if we are already out of control, there is no moral problem; it is merely that we must not deliberately let ourselves get out of control.

Psychological or emotional problems occur when a person is out of control, particularly in a constant way; they have moral relevance only when the person is willing to do the (morally wrong) acts he can't help doing. If he thinks he can be cured and takes no reasonable steps to be cured, then he is willing to have the problem, and this is immoral. But only reasonable steps with reasonable hope of cure need be taken.

Habits are automatic behavior-patterns acquired by repetitions of acts; they function morally like emotional problems, since the person is out of control. It is immoral to let yourself acquire a morally bad habit if you see that it is beginning to happen and you do nothing to prevent it, since then you are willing to do all the acts the habit will later force on you.

Good habits are virtues, bad habits are vices; the three Theological virtues are faith, hope, and charity; they are given and cannot be acquired, but can be increased by repetition of acts. Moral virtues and vices are habits of doing what is morally right or wrong. The cardinal virtues are the four moral virtues that are presupposed in any virtuous acts: (a) good judgment, (b) honesty,(c) courage, and (d) moderation; they are habits of (a) suiting the act to the circumstances, (b) suiting the act to the people involved, (c) not letting negative or (d) positive emotions lead one astray.

Responsibility (accountability) is the attribution of an act and its consequences to the person whose choice could have made it different. A person is responsible for what he has control over. He is morally responsible for what he could morally have prevented; physically responsible for anything he could have prevented by a choice; and legally responsible for what the normal person would have chosen to prevent.

Moral responsibility implies that a person knows what he is doing and does not think he is morally forbidden to do the act. Legal responsibility occurs because we cannot know what another's thoughts are; and so we impute a kind of "moral" responsibility if the person normally would be expected to know what he is doing and realize that the act is not wrong.

Responsibility is not the same as "duty"; it deals with acts that have been done, not possible acts; it is something that a person has, whether he "accepts" it or not, and "accepting" responsibility for what you have no control over does not give you responsibility. You have responsibility only for what actually occurs.

A person is guilty when he has chosen to do what is wrong or illegal. Legal guilt implies legal responsibility for actually doing something that violates some law. Moral guilt occurs when a person chooses to do what is wrong, whether he actually does it (and so is responsible for it) or not.

Exercises and questions for discussion

1. If our choices are always free from determination, doesn't this prove that "brainwashing" won't work, and the people who claim to have been brainwashed into doing something are really lying?

2. If an alcoholic plans how he is going to get out to get a secret drink, doesn't this prove that he was free when he made the plans and so he isn't really out of control?

3. If you drive to a bar, knowing that you'll be driving home, isn't this being willing to take the consequences of drunk driving?

4. Suppose a homosexual doesn't like being homosexual, and he's heard that some psychologists hold that homosexual orientation is curable. Is he morally bound to seek counseling at $100.00 and up an hour?

5. Is it better to be virtuous and not actually to make a moral choice because you're just in the habit of doing the act, or not to be virtuous and be making conscious moral choices to do the act?

6. Are you morally responsible for doing something stupid (but not morally wrong) if you are commanded to do it by someone who has legitimate authority over you (i.e. has the right to command you to do things)?



5.1. Morality and knowledge: conscience

The material of the preceding chapter dealt, really, with the easy part about making moral choices. Basically, with emotions and habits, you can't deliberately let them take over and lead you into doing wrong acts; but insofar as you're not deliberately letting this happen, you can forget about them.

But our choices depend directly on the facts we know at the time we make the choice; and hence, our knowledge of the facts has direct moral relevance.

DEFINITION: Conscience is the factual information a person has about whether a given act of his is morally right or wrong.

This is an important definition. It isn't what we ordinarily think conscience is; and so pay attention to all of it.

First, conscience is factual information. It is not the way we feel about the act we are to perform (Guilt feelings are not qualms of conscience, because you can feel guilty about doing something you know is right). Feelings have nothing to do with conscience; conscience is your evidence that the act is right or wrong.

Secondly, conscience is the information you have; it is not necessarily all the information there is to know. As I said, you can only base your choice on the facts you are conscious of at the time you make the choice; and "conscience" is the name given to these facts insofar as they deal with morality. Conscience is a set of facts: the facts available to you here and now.


Conscience is not your opinion of the moral rightness or wrongness of something. It is the information on which you base knowledge.

Your opinion is the conclusion you come to based either on insufficient information (for knowledge) or on conflicting information. When information is conflicting, basing a choice on your opinion is immoral, because your conscience is not clear (as we will see shortly).

What is called "subsequent conscience" is the information you now have about an act you already performed, whatever your knowledge might have been at the time you actually made the choice.

Subsequent conscience is no necessary indication of the morality or immorality of a previous choice.

The reason for this is that (because of a calm emotional state you now have, or because you might have found out some new facts), your present knowledge of the rightness or wrongness of your act might not be the same as the knowledge you had when you made the choice; but the morality or immorality of the choice depends on the knowledge you have when you actually make the choice.

Therefore, "conscience" in the morally relevant sense means only the factual information you actually have at the time you make the choice.

It follows from this that "examinations of conscience" tend to be counterproductive. Mulling over past choices can't change them, nor can regretting them change them. Further, thinking over what you did in the past is apt to give you the impression that, because now you have information that the act is wrong, then you "must" have known it then; or it can make you think you were in control when you weren't (because theoretically you always can choose not to do something).

In a religious context, an examination of past choices done to be aware of them, admit one's sinfulness (insofar as one knows it) before the Lord, and recognize the situations to be avoided if possible in the future, can be a beneficial act. But insofar as this leads to anguish, it is not Christian; God is a God of peace, not a computer who needs the proper input or he won't forgive you.

There is a psychological problem called a "scrupulous conscience," which consists in a fear that you have been immoral or might be going to be immoral, without real evidence to back up the fear.

Remember, the Lord is not a spider waiting for you to step into his web so he can pounce. You are only morally guilty of something if you are willing to do it even if it is wrong; and to be willing, you have to have evidence (a real reason to believe) that in fact it is wrong.

The fact that it could be wrong based on evidence you don't know is obviously not evidence that it is wrong. You don't have to be concerned with such hypothetical possibilities.

Thirdly, conscience deals with a definite act, and is not knowledge about acts in general. It is the information on which you base the answer to the question, "Can I morally choose to do this here and now?"

Thus, the discussions about ethical issues in the second half of this book are not conscience, though that information can become part of your conscience if you use it to find out whether you can do some definite thing without being immoral. But this general knowledge can never be all of a person's conscience, because the conscience will also contain the specific information about the circumstances in which the act occurs.

For instance, the discussion later on abortion may help some woman answer whether she can morally choose to have an abortion. Her conscience will contain this information, plus the information about whether if she doesn't have it, both she and the baby will die, and so on. Her choice will be based on all the information she has at that time.

Fourthly, conscience deals only with moral rightness and wrongness. Information about other aspects of the act (such as whether it is silly or polite) are not part of a person's conscience.

So conscience is not the same as "consciousness." It is ONLY that aspect of consciousness that is (a) factual, and that deals with (b) the moral rightness or wrongness of (c) a given act that (d) you are thinking of doing.

RULE: The morality or immorality of a choice always depends on the conscience of the person who makes the choice.

Conscience is, as they say, the "supreme court" in moral matters.

[See also Modes, 5.1.6]

5.1.1. Clear and unclear conscience

Given that this is what conscience is, how does it operate on the morality of the choice? It is not perfectly straightforward, and so we have to make some distinctions:

DEFINITION: A clear conscience means that the person has no information that there is anything wrong with the act he is about to perform.

You may feel terribly guilty about doing something (such as informing on a drug pusher), and still have a clear conscience that this is the right thing to do. All the information you possess indicates that this is right, and you know of no facts to indicate that it is wrong.

RULE: When a person acts with a clear conscience, his choice is always moral, irrespective of the actual rightness or wrongness of the act.

A clear conscience is sometimes called a "morally certain" conscience. (Except that you can be morally certain that the act is wrong, in which case obviously your conscience is not clear in the sense above. A Clear conscience is moral certainty that the act is not wrong.)

The difference between "moral certainty" and other kinds of certainty is that you don't have to be able to prove that you are correct in your opinion. You don't have to have facts to back up your position, in other words; all that is needed is a lack of information against your position--and by information, I mean "facts you know."

Obviously, if you are morally certain that the act is wrong, it will be immoral to choose it. But it turns out that if you have information on both sides (so that you're not even morally certain of either), then you can't count on the fact that the act might be all right; your conscience is not clear.

Hence, "moral certainty," while a valid concept, introduces a complication that can be avoided by considering whether the conscience is clear or not.

I will take it that if you are morally certain that the act is wrong, your conscience is unclear. Usually, an "unclear conscience" means that you don't know whether in fact the act is right or wrong (you have some evidence on both sides). But it would be strange to say "I acted with a clear conscience" when you are certain that you did something wrong.

For our purposes, following the general usage of language, we will say that your conscience is clear only when you know that the act is morally right and have no evidence to the contrary. When you have evidence that the act is or might be in fact wrong (whether this evidence is conclusive or not), your conscience is unclear.

Another distinction that is legitimate but irrelevant is that between a "correct" and "erroneous" conscience. A correct conscience simply means that the information is accurate: you think that the act is all right and it is in fact morally right; or you think it is wrong and it is in fact wrong. When your conscience is erroneous you think the act wrong when it is in fact right, or you think it is right when it is wrong.

But since the choice is based on your information about the facts and not on the facts themselves, then what the facts actually are is irrelevant to the morality of the choice. Hence, as long as your conscience is clear, it doesn't matter whether it is correct or in error.

Some might say, "Well yes, but if you know that you don't have information and you refuse to find it, then this refusal is morally significant."

This is true; but the only way you would realize that there was morally relevant information to be had would be if you had some information that further investigation would be likely to indicate that the act is wrong. But this is the same as having information that there is or might be something wrong with the act, which means that your conscience is not clear. (A clear conscience, remember, means that you don't have any information that there is anything wrong with the act.)

The only time you have to find out additional information is (a) when you want to do the act in question, and when you have information indicating (b) that the information you have is inadequate, and (c) the further information might show that the act in question is wrong.

A woman, for instance, who thinks that it is all right to breast feed her child does not have to read a book on the moral benefits of breast feeding. The only time she would have to read up on the subject would be if she saw something indicating that there might be a danger to the child from breast feeding (there isn't one; I use this as an example).

A third distinction that is valid but both irrelevant and confusing is that between "vincible" and "invincible" ignorance. "Invincible" ignorance is ignorance that can't in practice be overcome, because you don't realize that you're ignorant. This is the same as having no information to the contrary, and so having a clear conscience or being "morally certain." "Vincible" ignorance, however, is "insincere" ignorance, where you refuse to find out the facts. Obviously, here you have to be in the situation above, where you have information that makes your conscience not clear.

The reason this is confusing is that the usual interpretation is that "invincible" ignorance excuses a person from immorality. This is true if you are "invincibly" ignorant that the act is wrong. But if you happen to be "invincibly" ignorant that it is right (i.e. morally certain that it is wrong), then your "invincible ignorance" will damn you.

With that said, forget about vincible and invincible ignorance. Your conscience's clarity or unclarity depends on the information you have, not information you could have.

5.1.2. Clearing an unclear conscience

Now let us look at an unclear conscience more closely. Your conscience is unclear, as I said, if you have any information that your act is or might be in fact morally wrong. The problematic situation, of course, is that where there's a doubt in your mind as to whether it's wrong or not. You may have a lot of evidence that says that it's perfectly all right, but there is at least one fact you know that indicates (directly or indirectly) that the act might really be wrong.

For instance, someone you know who's not a fanatic and who generally knows what he's talking about thinks that the act is wrong. This fact (that a knowledgeable person thinks the act is wrong) is an indication that he knows a fact you are ignorant of indicating that the act is wrong. This would be an indirect indication that the act is in fact wrong.

RULE: It is always immoral to choose to perform an act when your conscience is unclear.

Why is this? It follows immediately from the general rule of morality. If your conscience is unclear, you have information that the act you are about to perform might be wrong. To choose the act under these conditions is to be willing to do it if indeed it should in fact be wrong. You don't know that it isn't; and so you have to accept that you might be doing a wrong act. And, you will remember, the general moral rule is that you must never be willing to do what is wrong.

So your choice is immoral even if it is much more likely that there is nothing wrong with the act.

No matter how much more likely it is that the act is all right, if you have real information (i.e. facts) that indicate that it might be wrong, you don't know that it's not wrong; and this means that you would have to be willing to do wrong if you do the act.

How to acquire a clear conscience

Obviously, when your conscience is unclear, something must be done. How do you get from this state to having a clear conscience? It must always be possible to have a clear conscience, or morality makes no sense, because then you could be trapped into damning yourself no matter what you chose (as when it was unclear whether it was wrong to act, and also unclear whether it was wrong not to act).


A. Find out the facts.

If you want to perform the act (if it is all right to do so); or if you are in a dilemma where not performing the act might be wrong, what do you do?

For instance, a woman might think that it might be wrong to have an abortion; but she might think that it might be wrong not to have an abortion and give birth to a deformed child. Obviously, she's got to do one or the other.

The first thing that must be done in a case like this (if at all possible) is to find out what the facts are, so that the conscience can be cleared up.

The general rule of thumb here is to act the same way you act when you have a medical difficulty. In simple, straightforward cases you treat it yourself; in complicated ones, you seek the advice of a doctor, who has devoted his life to medical problems, and so who is likely to know what the facts are.

In the next section, on the act and the situation, I will give guidelines on how you can discover facts and clarify your conscience in reasonably ordinary situations. If this works, and you know you have found the real facts, then everything is fine; your conscience is now clear. (Remember, however, that this is not just coming to a conclusion which "in your opinion" is right, but that you know that there isn't any evidence against your conclusion. Ethical matters can often be very complicated indeed, and your own investigations can leave you wondering whether you have evaluated the facts properly. If this happens, your conscience is still unclear, and you must do the following:

1. Ask an expert.

In practice, when you can't honestly assure yourself that you know which course of action is in fact right, then what you do is rely on someone who has made a study of ethical matters; because that person will know what the facts are: that's his business.

Here, you don't have to know the expert's reasons. If he says that the act is all right, this is enough to clear your conscience, except in the unlikely case that you have actual information that he is (a) lying, (b) biased, or (c) misinformed about the situation. It's always possible that the expert could be misinformed or be lying to you; but this abstract possibility doesn't leave you with an unclear conscience; you have to have facts to indicate that he's actually doing this in order not to have a clear conscience.

So once the expert tells you that the act is all right, you now know that it is not immoral to choose it. Any mistake that might be made is the expert's problem, not yours.

2. Points to note on consulting an expert:

a. Who an "expert" is will be based on the information available to you at the time you are looking.

b. It would be immoral to go looking for someone you thought would tell you what you wanted to hear. You don't necessarily have to go looking in the other direction, of course; but if you actively try to find someone who will tell you that it is all right to do what you want to do, your intention is to do the act whether it is in fact right or not, and you simply want an expert's advice as an excuse to back you up. But then you are willing to do the act even if it is really wrong (or why not seek advice from some other expert?); and that choice to go looking for expert reinforcement is immoral, even if the expert's advice should happen to be correct. This is like a person who wants a doctor to tell him he has a "heart condition" and to prescribe nitroglycerine. Such a person isn't honestly trying to find out the facts about himself.

c. It would be immoral deliberately to seek advice from a less qualified expert in favor of someone who was more likely to know what the facts are, other things being equal. The idea in seeking expert advice is that you want to find out what the facts really are, not just get an expert to talk; and so you would seek the best advice available to you if you really wanted to know.

There might be reasons for seeking a less qualified expert, of course. If the matter is trivial, and the less qualified person is qualified (as far as you know) enough to be likely to know the facts, then you don't have to go out of your way to find the best advice. Or if consulting the best expert you know of would involve inordinate amounts of time and expense and so on, then only an extremely serious matter would necessitate going to the trouble.

d. If you know that recognized experts disagree on whether the type of act in question is wrong or not, then you may choose the most lenient view (i.e. the one that allows the most leeway), provided it has good authority behind it.

This is sometimes called "probabilism" or the "doubtful law." The point here is not whether your act is right or wrong, but whether a whole class of acts is right or wrong. If even experts can't figure out whether this kind of thing is right or wrong, then this indicates that the matter is so complex that no one can straighten it out. But any lawgiver who wants to be obeyed must make it possible for his subjects to know what he wants done; if he doesn't do that, he can't expect anyone to obey him. Thus, if the matter is so obscure that even experts can't figure out whether the acts in question are wrong or not, then this is the Divine Lawgiver's problem (or nature's, if you prefer); and so you can act as if there really is no obligation here, and be morally sure that it is all right to do so.

The view is called "probabilism" because in the case where the existence of an obligation is objectively unclear, any solidly probable opinion (no one can have knowledge in such a case) can be followed, for the reason given above.

NOTE: This is a bit of a dangerous rule to put into practice, however. There are all kinds of crazy people who set themselves up as ethical "experts"; and I would venture to say that if you considered any issue, you would find someone who presumably had qualifications saying that just about any act you wanted to name was all right.

So it might seem that any type of action would fall under the "doubtful law," and you could do anything. For instance, there were experts who defended slavery; there are experts today who defend abortions.

I think that before a person could legitimately feel secure in applying this rule, he would have to know the general orientation of the "expert" who says that it is all right to do some controversial act. If the expert seems to be rather strict or "orthodox" in his view of what human nature is, and he says it is all right to do some particular act, then he probably has valid reasons on his side. If, on the other hand, he is "compassionate" and just "doesn't want to burden people," then he probably is not reasoning but telling people what they want to hear--and he may be sincere in this; but the likelihood that he is stating the facts about what we really are is that much less.

There are those nowadays whose view is that being moral ought not to be difficult. They are "redefining" human nature into infinite "flexibility," and are simply not being realistic. Let their consciences save them; but follow them not.

This finding out the facts is, as the title of these guidelines said, usually called the direct method of clarifying your conscience. It is called "direct," not because you necessarily find out the facts directly (using expert advice and especially the "doubtful law" is certainly indirect), but because what you know is that the act you are to perform is all right. That is, using, say, the "doubtful law" you realize that it is all right to use legal tax "loopholes" and pay no income tax.


A. It is, of course, always moral to choose some alternative course of action that your conscience is clear about.

That is, if you don't want to be bothered investigating the issue, you don't have to (as was implied above), as long as you avoid doing the act. A person who isn't sure whether abortions are wrong or not doesn't have to investigate the issue, as long as she has no intention of having an abortion.

Suppose, however, this fails. Either you can't find an expert (either at all, or in time before you have to act), or having consulted one, you still think that he didn't understand the situation, and you went to someone else who still didn't seem to realize the real issue--and you're still in doubt as to whether the act is right or not.

NOTE that "being in doubt" here does not mean being worried about the act; it means knowing information that it might be wrong. "Doubt" is an intellectual, not an emotional thing in this case. Emotional doubt is irrelevant.

B. If and only if there is (a) no certainly right way to act and (b) there is no way to find the actual facts, then

1. Choose the course of action that seems morally safest.

That is, choose the act that seems least likely to be wrong or to involve the least wrongness. It has to be what "seems" least wrong, because you don't know it isn't wrong and you can't find out. If you do this, your conscience will be clear in this sense: you will know that you are trying to avoid what is wrong, and this is what moral choices are: unwillingness to do what is wrong.

In this case, anything you do might be wrong; and so you choose away from what (to you at the moment) is more likely to be wrong or from what seems worse, and you have assured yourself that your choice, even though you might be doing wrong is your best attempt to avoid doing wrong under the circumstances. Your choice is explicitly away from wrongness; you are unwilling to do what is wrong.

This is different from acting with an unclear conscience, because then you are willing to do what might be wrong (and you could avoid it). Here, there is no way you can avoid what might be wrong; and so you choose away from what is more likely to be wrong with the intention of avoiding wrongness.

This method of clarifying one's conscience is called the "indirect method," because you don't know whether in fact the act you chose was the one that in this situation was the morally right one. All you know is that you have the proper orientation of your will. All that is really necessary, of course, in morality, is to be unwilling to do what is wrong; which in this case you know, because, not knowing any action to be certainly right, you are choosing away from what is most likely wrong.

But, as should be obvious, this last step only works if there is no certainly right alternative and you have already tried the direct method and it has failed. The reason is that if you "take the lesser of the two evils" without trying to find out the facts, then you might be able to know what is in fact the right course of action; and if so, not to find out is to be willing to accept the possible wrongness in what you choose, even though it is the "lesser evil." But when you can't find the facts, then the choice of the "lesser evil" is not immoral, because you know you are doing the only thing that can avoid immorality.

Be very clear on this

You must never choose any wrongness. When confronted with two "evils," it is not moral to choose the lesser one just because the other is greater. And sometimes, if you know what the facts are, you have to choose a course of action (indirectly) involving greater wrong in order to avoid choosing wrong.

We will see this later. If the small wrong is the only means to avoid having tremendous wrong happen, you cannot choose it, and must unwillingly permit the greater harm.

But that applies when you know what the facts are. Let me now an example of not knowing. A woman is grabbed by a rapist, who holds a knife to her neck and says, "Lie still and let me rape you, or I'll kill you." If she lies still, she's choosing to let him rape her and is having sex with him; if she struggles, she's choosing to let him kill her. Both seem wrong to her, and obviously she can't consult anyone.

She chooses not to struggle, on the grounds that it's worse to die. She knows that she doesn't want to have sex with that man, and so she isn't choosing to have it; she just can't avoid it if she wants not to die. It would be absurd to say that the woman is choosing sex with the rapist, under these circumstances.

(Actually, if she knew the facts, she would know that this course of action is morally all right and that she is not in fact committing adultery. But we are supposing here that she doesn't know; all she knows is that she was trying to avoid doing what is bad. Her conscience is clear, even though she might not know what "a person" should do in similar circumstances, or why.)

2. In the unlikely event that all options seem equally wrong, then any one may be chosen with the intention of avoiding the wrongness of the others.

The reasoning is the same. You are choosing away from wrongness; and in this particular case, the choice does not involve choosing the possible wrongness of the alternative.

[See also Modes, 5.1.6]

5.2. Act and situation

I promised just above that I would give guidelines how you could find out for yourself what the facts are about the moral rightness or wrongness of a given act in most cases, so that you can usually clear up your own conscience. The key to doing so very often involves recognition of what is included within a choice

The choice to perform an act is a choice to perform a concrete act: that is, an act in a certain situation. The situation is what relates the act to the agent's humanity.

Obviously, if the situation relates the act to your humanity, then the situation can make the act inconsistent with what you are (and so morally wrong) or consistent and so morally right.

Sometimes the situation doesn't affect the moral character of the act at all. Studying in the library or in your dorm room doesn't make any moral difference; the point, however, is that various aspects of the situation can make the act consistent or inconsistent with you as its agent; and so certain acts cannot be morally chosen in certain situations, but can be chosen in others.

For instance, ordinarily it is not immoral to refuse to give a person fifty dollars. But if you have just bought something worth fifty dollars from him, then it would be immoral to refuse to pay him. "Well of course," you say. But this just illustrates that the situation can change the moral character of an act you are thinking of doing.

RULE: An act is not morally right unless every aspect of the situation makes it consistent with the nature of the agent; it is wrong if even one part of the situation makes it contradict any aspect of the agent in that situation.

To relate this to what we said about conscience above, you would have to have evidence that there might be some inconsistent aspect of the situation in order for you to have an unclear conscience. Most of the time, (as in paying what you owe someone) the aspect of the situation will shout at you; but there can be cases where you don't know; and these would be the times when you would have to consult an expert.

Note that the act itself (the physical act, independently of the situation) is always morally neutral; i.e. neither right nor wrong.

Before you leap to accuse me of being a "situation ethician," hear me out. Why is this? Because the act is an act performed by a human being--and so is an act a human being can perform. If a human being could not perform it consistently in any situation, then it would be physically impossible for him to do it.

Some might object that, since we are creatures of God in every situation, an act of contempt of God like the statement, "God, you are a stupid fool" is an act that we could never perform in any situation. But of course I just wrote that statement in a situation in which there is nothing morally wrong with writing it: as an example of a blasphemous statement. I couldn't write this and mean what I was writing; but that is part of the situation. The same would apply to any act.

Note that when ethicians define some acts, such as "murder" or "abortion" or "lying" as "wrong in themselves," the act they are talking about is a morally defined act, which includes part of the situation in its definition. For instance, killing a person in self-defense is not "murder"; removing a diseased uterus in which there is a fetus is not "abortion"; saying what is false in circumstances where what you intend to convey is a forceful presentation of the truth, (e.g. "What beautiful weather!" in a rainstorm) is not a lie--and so on.

I would not deny that "acts" like murder or abortion or blasphemy or lying and so on are "wrong in themselves," when they are defined in this ethical way. But I think that it makes for confusion when you say that "murder" is wrong and then say that deliberately executing a criminal is all right; because people think of murder either as "killing" or as "deliberately killing"; and this is not what the "act" called "murder" technically is, as defined by such people: they define it as deliberate unjust killing; and for various reasons say that capital punishment is not unjust.

But then I see no point in making a distinction between the "act" and the "circumstances," (which is what they call the situation), when you are including some of the circumstances in the "act" and excluding others. For instance, a killing is "unjust" when the one you kill has a right to life; but this is a circumstance (the person acted on).

Therefore, it seems to me to make more sense to define the act as the actual physical or mental act you perform irrespective of the circumstances. This is what is related to your humanity; and so in itself it is neither right nor wrong, until it gets related by some aspect of the situation.

The problem, really, with "situation ethics" is that it supposes, really, that you don't have any "given" humanity, and that the situation creates the moral status of the act, basically depending on how "lovingly" you act in that situation. Acts like lying (in which you contradict factual communication in the act of factual communication) are all right, according to them, when the "situation" makes it "better" (because it has good effects) to lie rather than tell the truth. If you take this view anything can be justified, and so there is no real morality. It then becomes "the right thing" to violate your own reality. Thus, "situation ethics," under the guise of being "loving," makes a mockery of morality and stands morality on its head.

But this should not blind us to the fact that it is the situation which connects the act to the humanity you have at the time you perform it; and hence the situation enters into, though it does not define the moral status of the act.

Now then, with that said, let me show how any aspect of the situation can change the moral character of the act. I will simply mention some aspects, but pay special attention (and give special subsections) to others.

Who performs the act. You, the agent. If you have promised to pay someone fifty dollars, then you have changed your nature into a "payer," and it is inconsistent with you to refuse to pay; while if you haven't promised and someone asks you for fifty dollars, there would be nothing wrong with refusing.

Whom you act on. When you promised to pay Jones fifty dollars, then you can't satisfy your nature as a "payer of fifty dollars" by paying Smith the money.

Where you do the act. It is all right to play your stereo in your dorm room; it can be morally wrong to play it under a hospital window.

When you do the act. Playing your stereo loudly at two in the afternoon in your dorm room is (probably) not morally wrong. Playing it at the same volume at two in the morning probably is.

How (i.e. in what manner) you do the act. Playing your stereo at two in the morning in your dorm room is all right if you use earphones or play it softly enough so no one else can hear you.

5.2.1. The motive

There are, as I said, some aspects of the situation that merit special attention and emphasis. The first of these is the motive for the act.


The terms motive, purpose, intention, goal, reason, and end all refer to the same thing; they are the effect for which the act was chosen. They are what you are trying to accomplish by the act you choose.

RULE: A wrong motive makes the choice immoral; but a good motive (or good intention) does not necessarily make the choice moral.

This is another way of saying that good intentions are necessary for morality, but they are not sufficient. You can't save an otherwise immoral choice by having a good intention; but of course you can vitiate or ruin an otherwise perfectly innocent act if you do it with an evil motive.

There is another sense of "intention" that you might find in ethics textbooks, which is the equivalent of the whole content of the choice, on the grounds that the choice "tends into" the whole concrete act it chooses. But this is an archaic sense, which is no longer used. For this book, the "intention" just means the effect you want the act to produce.)

So, for example, terrorists cannot excuse bombing bystanders on the grounds that "this will wake the country up and the terrible oppression of my people will cease." The intention is good--stopping oppression--but you are still choosing to kill people in order to achieve your good purpose; and the choice has eternal repercussions for you.

And on the other side, volunteering for overtime work on your company's computer is fine, but if you do it because you want to break into their payroll program and give yourself an unauthorized boost in salary, you have chosen to steal (This kind of stealing is called "embezzlement," of course).

[See also Modes, 3.3.6]

5.2.2. The means

Another of the aspects of the situation that affects the choice is that of the means you use to bring about the purpose you have.

RULE: A morally wrong means may never be chosen to achieve any purpose, however good.

This is what the old saw, "The end never justifies the means" says. The fact that you have a good intention or purpose, as we just saw, does not save a wrong means from being wrong, and the choice of a wrong means from being immoral.

Actually, if this were not true, then there would never be anything immoral. It can be said in general that what we want to accomplish in anything is something good: our development, our happiness, whatever. If the means to this good end either "became good" because of your good intention or were "ignorable" because of your good intention, then there would never be anything immoral. And in general, for those who try to justify acts by their good intentions, the more horrible the act, the better the intention.

Note, therefore, that even if the purpose is avoiding terrible wrong or harm, it is still immoral to choose a morally wrong means to do so--even if the wrongness in the means is insignificant in comparison.

This is the place where what I said earlier about the "lesser of the two evils" applies. Suppose you know a secret, and you are captured by the Evil Enemy, and you realize that by telling a little lie, you can save the world from nuclear war. Either you lie and the world is saved, or you refuse to speak and the whole world gets blown to smithereens. Can you lie to save the world?


And, in fact, if you do lie, you have chosen what is in fact the greater of the two evils. Why? Because you have chosen your eternal frustration: one that will never, never end; while the destruction of the world, though horrible, is finite. Eventually, the "quantity" of suffering you undergo will surpass the suffering the world undergoes in the days of its destruction.

When I was talking about choosing the morally safer course of action, I was supposing that you don't know the facts and can't discover them, and all courses of action seem bad to you. Then and only then do you know that what you are trying to do is avoid wrong. In the case where you choose a wrong means (even a "little tiny" one) for a good purpose, you know you are choosing what is wrong. There's the difference. You can't be avoiding wrong by choosing wrong.

5.2.3. Side effects

Another aspect of the situation that can lead to complications is effects of the act which you foresee will happen, but which you don't want to happen. They happen as side-effects of some act that has another effect that is your purpose. Are these part of your choice, or can you ignore them?

On the face of it, it would seem that you can't. It would be a rare person who would say that it was morally all right to excavate your back yard for a swimming pool if this would undermine the house on top of the hill behind you, and you knew this. The fact that your purpose was to build a swimming pool doesn't free you from responsibility for the destruction of your neighbor's house.

RULE: In general, if you choose an act, you are also choosing ALL of its known effects, even if they are effects that are not part of the purpose of your choice. Hence, if any side-effect is wrong, the choice is generally immoral.

Notice that I very carefully put "in general" there. This is one of the aspects of the situation that has a sort of "escape clause" in it, because the effect is not in the act itself as part of it (the way the place, time, and manner are), but is often divorced from the act in time, and may possibly not even occur, though the act occurs. Thus, for instance, your excavations might not in fact do any damage to the house above you, though you had reason to believe they would.

Before we get to how to use this "escape clause," notice that in general, you would still be willing, in the case above, to wreck the house, because you foresaw that it might happen and went ahead with doing what could bring it about. So even if the bad side-effect doesn't actually happen, in general, if you foresee that it might happen (i.e. not that you're "afraid" that it might happen, but you have actual facts leading you to think that it would), then you are willing to have it happen.

So, for instance, based on the Surgeon General's evidence, you know that smoking more than a pack of cigarettes a day is likely to give you lung cancer. If you choose to smoke this much (supposing you to be in control, now, not addicted to nicotine already), then you have to be willing to get lung cancer, even if you're not trying to and even if you never get it.


There are times when a side-effect of an act you chose can be against your will.

Take the case we saw before of the woman who is being raped. She is told, "Lie still and be quiet, or I'll kill you." If she lies still, she has sex with the rapist. If she screams or struggles, she dies. Both of these are effects of the act she chooses. Now if she chooses to lie still, one effect is that she saves her life, and the other is that the rapist has sex with her. Has she chosen the sex?

In this situation, no. Here, all she chose was to save her life; the other effect of the same act was an unchosen side-effect of the act which could not be avoided if she was to save her life; and to choose to scream (and so to die) would be worse.

We looked at this earlier as an example of the "choosing away from wrong"; and this in some circumstances can be what it is. It is traditionally called, however, the Principle of the Double Effect, and it is legitimized on the grounds that the effect is not actually part of the act, and in this special situation (rules for which we will give below) it can be kept out of the choice.

5.2.4. The Principle of the Double Effect

This principle is perhaps the most useful tool in ethics. It is not, as I said above, really a set of rules for the indirect method for clarifying your conscience (i.e. knowing you have chosen away from wrongness), because with this set of rules, you know which act is the correct act to choose when in a dilemma. In the indirect method, you don't know which act is actually the right one; you just know what you are trying to do. Here, you can tell which is morally right.

RULE: An act indirectly involving wrongness may morally be chosen if the following five conditions are met:

1. The wrongness involved must be in an effect of the act, not in any other part of the situation.

If the wrongness is in some other part of the situation, then it is there modifying the act you choose (as the time or manner would); and since you choose the act, you could not then keep the wrongness out of the choice. The effect is separate from the act itself, and hence can be separated from it mentally without "fictionalizing" the situation.

2. There must be at least one known right (good) effect in addition to the wrong one.

The idea is that you choose the act as causing the right effect, merely permitting the wrong one; your motive is the right one. If all the known effects were wrong, then why would you do it except for a wrong reason?

Of course, the reason why this is called the double effect principle is that you lump all the good effects together as one complex effect, and all the bad ones as one bad effect.

3. The right effect must not depend on any of the wrong effects.

Both the right and the wrong effects depend on the act, of course; but the point is that if the right effect depends on the wrong one, then the wrong one becomes a means for the right one (your motive), and you would have to choose it, as we saw when discussing the means.

So the two effects have to be independent of each other.

Note that this does not mean that there has to be a chance that the wrong effect might not actually happen. You might be morally certain that it will happen; but you still don't have to choose it if it isn't a means to the good effect and the other conditions are also met.

4. The wrong effect must not be a motive.

Obviously, if the wrong effect is one of the effects you want to accomplish, then you have chosen it. The point here is that you can't use a dilemma as an excuse for doing what is wrong; as the woman being raped can't want to have sex with the rapist, and think, "Well, it's rape, so that makes it all right." You have to be unwilling for the wrong effect to happen, except that it's inescapable under the circumstances.

5. The sum total of the wrong effects must not be worse than what would happen if the act were not chosen.

That is, you have the alternative of choosing this act with its bad side-effects, or of not choosing it. Suppose you didn't choose it, what would happen? If the effects of not choosing it are as bad or worse, then you can choose it (always supposing the other four conditions are met, of course). If, on the other hand, it would be less bad if you didn't choose the act, then you are choosing something which is worse than the alternative, and this is immoral.

This is usually phrased as "the good effects must equal or outweigh the bad ones." The trouble with this is that you can't measure "goods" as "better" than "non-bads." Not only are goodness and badness subjective in the last analysis, but the two are incommensurate. That is, a certain "amount" of goodness cannot "compensate" for some amount of badness. For instance, a thousand dollars (or even a million) does not really "equal" the loss of, say, a leg. There's no comparison, any more than a certain loudness of E-flat "equals" a certain shade of blue.

Let me finish off this chapter by illustrating with a couple of examples, showing how you would go about applying the rules.

Situation: You are trapped on the 50th floor of a burning building. Elevator shafts and stairways are on fire. The window is open, but there is no safety net below, and you will surely die when you hit the ground.

The alternatives are (a) jumping out the window and dying on the pavement, or (b) staying in the room and burning to death.

Take the first alternative. 1. The act is jumping out the window, which has nothing wrong with it except what will happen when you hit the ground (fulfilled). 2. The act has a good effect: you escape burning to death (fulfilled). 3. The escape from the flames does not depend on your death (the wrong effect), because it occurs before you die (fulfilled). 4. You are not trying to kill yourself, but to avoid burning to death (fulfilled). 5. It is at least as bad not to jump and to burn to death (fulfilled).

Take the other alternative. 1. The act (of staying where you are) has nothing wrong with it except what happens when the fire reaches you (fulfilled). 2. The act has a good effect: you don't die by hitting the pavement (fulfilled). 3. The avoidance of dying on the pavement doesn't depend on your death (because if the fire went out you would still achieve the good effect) (fulfilled). 4. You aren't trying to burn to death; you want to avoid dying on the pavement (fulfilled). 5. It is at least as bad to die by hitting the pavement as it is to stay in the room and die (fulfilled).

So in this case, since the two alternatives are about equal, you can choose either way.

We could add an alternative here which shows how the third rule works.

Situation: You try to get out the window and can't squeeze through. You search the room and find a pistol. You figure, "If I shoot myself, it'll be quick and less painful, and if I burn to death, it'll be slow and agonizing." Can you shoot yourself?

1. The act of pulling the trigger on a gun aimed at your head has nothing wrong with it except its effect (if there isn't a bullet in the gun, nothing bad happens) (fulfilled). 2. The act has a good effect: you don't die slowly and in agony (fulfilled). 3. Your death is what allows you to escape the agony of burning to death (not fulfilled).

So even though it would be worse to die by the fire, you can't shoot yourself to escape it, because then you would have to choose to die.

Let me now give an illustration of why you have to take the fifth rule in the sense I have mentioned it, rather than "weighing the good effects against the bad ones." No respectable ethician I know of would disagree with the conclusion I am going to reach in this illustration; but I think that logically, using "good vs. bad," you wouldn't have to come to this conclusion.

Situation: You are offered twenty million dollars if you will play a game of Russian Roulette just once: put a single bullet into a six-shooter, spin the chamber, point the gun at your head, and pull the trigger.

Alternatives: Take the bet, with a five-out of six chance of winning $20 million, and a one-in-six chance of dying. Refuse the bet, and be sure of not getting $20 million but also of staying alive.

Take the first alternative. 1. The act of taking the bet, and even the act of pulling the trigger on the gun has nothing wrong with it in itself (as we saw above in the burning building's third alternative); the only thing wrong is the effect if the bullet is in the wrong chamber (fulfilled). 2. The act has a good effect: you have a five-in-six chance of getting $20 million (fulfilled). 3. The good effect doesn't depend on your death--obviously; if you die, you don't get it (fulfilled). 4. You don't want to die; you want to live and collect the money (fulfilled). 5. But it is worse to have a one-in-six chance of dying than to be the way you are now.

You see, the comparison isn't between the likelihood of living with $20 million and the likelihood of dying; you might argue that with a five-in-six chance of living (which are pretty good odds) and that "reward" for it, it would be on balance worth the risk.

But the real comparison is between how bad it is if you take this alternative, as opposed to how bad it will be if you take the other one. Nothing bad is going to happen to you if you refuse the bet (you don't lose $20 million, because you don't have it now); you're no worse off than you are now if you refuse the bet. That is, you might just as well say that if you keep on the way you are, you "won't get" 20 billion dollars, or 20 trillion, or any sum you want to name. But this "not having" money doesn't mean you're actually losing anything. Not gaining (missing a possibility) is not the same as a loss.

Hence, since if you take the bet, you are putting your life in danger, and there is no harm coming to you in the alternative, you can't take the bet, even if you think the money is worth the risk.

I rest my case for my formulation of the fifth rule.

Important note on the fifth rule

Since "good" and "bad" are basically subjective, evaluating which alternative is "worse" will also be somewhat subjective. There is no problem with this if you alone are involved; since there are no "objective degrees" by which you can measure "badness," then you may avoid whichever seems worse to you, based on the data you have (i.e. avoiding false comparisons like the "loss" above of what you don't have to begin with).

But when harm to someone else is involved in the "bad" effect, then you must take what is generally regarded as worse in the society you are in as your view of the harm to the other person, and not impose your evaluation of what is "bad" on the other person.

That is, you might consider it "worse" to lose ten thousand dollars than to lose an eye (so that you would refuse an operation to save your eye if it cost that much); but you have to realize that another person could legitimately reason the other way; so that if you had ten thousand dollars and your son (who depended on you) needed an eye operation, you would have to pay it and let him have the operation.

Which is "really worse" in this case? The point here is that there is no truly objective answer to that question. You can make some kind of assessment by this procedure: "What acts can I not do if I didn't have the ten thousand that I can do if I have it? What acts can I not do with only one eye that I can now do with two eyes?" This will tell you what you are being deprived of in the two cases. But it is not simply the number of acts not able to be performed that constitutes the deprivation, it is the quality or importance of those acts in your life. But the importance depends on what your goals are, and how these acts reflect your goals; and your goals depend on your free choice, not on something objective.

So even though you can make an assessment of what is bad and what is worse, that assessment has an inescapable subjective component, and therefore must not be imposed upon another.

This means, of course, that absolute, cut-and-dried answers that apply to everyone are not possible in ethics.

I think it is well to be aware of this fact, and be honest about it. It does not mean that ethics is "subjective"; just that there are situations in which the subjectivity of "good" and "bad" enters, and where different people of good will will come to different conclusions.

But this does not really matter, because morality depends on the choice; and even though the choice depends on the facts you know, the real fact you have to know is that you are doing your best to avoid what is inconsistent with your reality here and now. God is not a spider who is sitting at the edge of a web of complexities waiting to pounce as soon as you make a mistake. The whole moral issue is whether you deliberately want to frustrate yourself or not; if you do, you can't use anything said here to get around the consequences of your choice--because the choice is its eternal consequences. If you don't, your attempt not to saves you from setting up a self-contradictory goal.

So even though ethical questions may be very complex and intricate, there is never anything to worry about. If you are trying honestly to do what is objectively right as far as you can see it, your mistakes will count in your favor.

This ends the general considerations of ethics.

[See also Modes, 5.1.7]

Summary of Chapter 5

Conscience is the factual information you have about whether the act you are thinking of doing is morally right or wrong. It is evidence, not opinion or feelings. The morality of a choice always depends on the conscience of the one who makes the choice.

Conscience is clear when there is no information that there is anything wrong about the act in question. When a person acts with a clear conscience, his choice is always moral, even if he is mistaken. Conscience is unclear if there are any facts which indicate that the act is or might be wrong, even if it is more likely that the act is morally right. It is always immoral to choose to perform an act which your conscience is unclear about, because then you are willing to do it even if it really is wrong, and this is to be willing to do wrong, which is immoral.

To acquire a clear conscience, the direct method is used if you want to perform the act that you are unclear about. In this case, you must first find out whether in fact the act is morally right. If you cannot do this by yourself, then you must ask an expert and follow his advice. An "expert" is one you have information is in fact an expert. It is immoral to try to find an expert who will tell you what you want to hear; your intention must be to find out the facts. It would be immoral to seek less qualified experts when more qualified ones are available, other things being equal. If recognized experts disagree on whether something is wrong or not, then you may take the most lenient view that has good authority behind it, always remembering that not everyone who calls himself an "expert" really is one. This is called the direct method of clearing your conscience, because if one of the above indicates that the act is all right, you know that it is something you can morally choose.

If you cannot discover the facts, the indirect method applies. It is always, of course, moral to choose an alternative that your conscience is clear about. But if there is no course of action that seems to be certainly right, then you may clear your conscience by taking the morally safest course of action: the one that seems least wrong or least likely to be wrong. If all alternatives seem equally bad, any one may be chosen with the intention of avoiding the wrongness of the others. This is called the "indirect method" of clearing your conscience, because you don't know whether you chose a morally right act, but you know that your will is directed away from wrongness. It is only applicable when the direct method has been tried and has failed. Choosing "the lesser" wrong when you are not in this situation would involve actually choosing wrong, and would be immoral.

To find out the facts for yourself, recognize that the choice is a choice to perform an act in a situation; and the situation relates the act to your nature. The act in itself is morally neutral, but any aspect of the situation is capable of changing its moral character by making it inconsistent with your nature. Important aspects of the situation are the motive (which is the same as the purpose, intention, goal, reason, or end for which you choose); if it is wrong, the choice is immoral; but if it is good, other aspects of the situation can still make the choice immoral. The means toward the purpose must not be wrong, because it must be chosen if the act is chosen for the purpose on which it depends. Even if the wrong means is less wrong than the purpose (which can be the avoiding of a great wrong), it must not be chosen if the purpose depends on it. Side-effects of an act (effects foreseen which are not the purpose) are ordinarily chosen along with the act, even though they are actually separate from the act itself.

The Principle of the Double Effect, however, is a way of keeping a wrong side-effect out of the choice of the act that produces it. It contains five rules: 1. The wrongness must be in an effect of the act, not in any other part of the situation. 2. There must be at least one known right effect in addition to the wrong ones. 3. The right effect must not depend on any of the wrong ones. 4. None of the wrong effects may be a motive (even a secondary motive). 5. The sum total of the wrong effects must not be worse than what would happen if the act were not chosen.

Since the last rule involves evaluating "degrees" of badness, it will have some subjectivity in it. There is no problem in this, except when the bad effect involves harm to someone else. Then a person must take the "worst case" interpretation, and not impose his own degrees of badness on another person.

This implies that absolute and objective answers to ethical problems cannot always be arrived at; but this does not really matter, because by following all the rules in this chapter, a person has cleared his conscience, and knows that his choice is not self-frustrating; and so has not brought eternal frustration on himself.

Exercises and questions for discussion

1. The Pope says you can't use contraceptives, and a Catholic says, "Well, I don't agree." Since each person has to follow his own conscience, does this mean that the person can use contraceptives?

2. A person has an abortion, thinking at the time that there is nothing wrong with this. Afterwards she sees the film The Silent Scream and realizes what she has done, and has to go into psychotherapy to deal with her guilt. Does she have a guilty conscience?

3. If conscience is knowledge, then obviously if you don't know something is wrong your conscience is clear. Wouldn't it help you to have a clear conscience, then, if you quit the course at this point, given that you might find out a lot about what you can't morally do?

4. If you're "clearing your conscience" by taking the morally safest course, knowing that even this course of action might be wrong, aren't you still willing to do what is wrong, and so still acting with an unclear conscience?

5. Doesn't taking the morally safest course in clearing your conscience mean that it's all right to do something that's a little wrong in order to avoid something that's very wrong? And doesn't this contradict the whole of morality, since we never do wrong unless we expect that by not doing it we will be worse off?

6. If any aspect of the act makes it inconsistent with your reality, then won't every act be wrong in some respect--since at the very least it uses up energy and causes wear and tear on the body, and this is harmful to the organism?

7. If you kill someone in defense of your own life, isn't his death the means toward your staying alive--and so doesn't this violate the third rule of the Double Effect?

Part Two:


To The




6.1. Applying ethics

In the preceding part, we discussed the specifically ethical dimension of our choices: what we basically have to do (never choose to act inconsistently with what we are), why we should bother doing this (because not doing so leads to eternal frustration), and how emotions and our knowledge of the facts are involved in our choices, and so how this knowledge affects our willingness to do wrong.

REMEMBER, a morally wrong act is one which contradicts either the humanity you were "given" genetically, or the modifications you have made of it by promises and so on.

From this point on, what we are going to be doing is exploring what the facts are about the humanity of a health-care provider, so far as we can know them, and drawing out the implications of what acts are inconsistent with these facts, and when and to what extent. The assumption here is that when people join the health-care profession, they alter their humanity into (also) being that of health-care providers. So it is immoral to be willing to contradict yourself either as a (generic) human being or as a health-care provider.

We are going to move from the general to the more specific in this investigation: first getting an idea of what health is (and so what the provider is supposed to be providing), mentioning briefly a couple of health-care-related issues of the provider's duties to himself as an individual, then discussing the relation of the provider to others in general (the realm of rights and society), and then to the patient.

Since the provider is performing a service, we will then explore the implications of this, and since it is a necessary service, we will get into the question of compensation vs. the right of the patient to receive the service.

We will then devote our attention to the physician, in his relation to the patient's life and the patient's physical integrity, then pass on to the nurse, giving particular attention to her as an assistant to a physician. Then we will discuss what mental health and unhealth are, and relate this to the provider of psychological care.

NOTE that the discussion will show that many so-called "difficult" ethical questions are not morally difficult at all, but practically "difficult" in the sense of inconvenient--or even tragic as far as this life is concerned. In this connection, it is well to keep in mind the following:

It does not matter how much you or anyone else suffers because of your being moral in this life; you (and they) are always going to be worse off if you choose what is morally wrong to avoid it.

This is a harsh saying, but it is either true, or the whole enterprise of discovering what is right and wrong is a waste of time.

For instance, the issue of abortion is said to be one of the most "controversial" and "complex" moral issues of our time. Actually, there is nothing complex about the morality of it at all, really. The only complexity is over the factual question of whether fetuses are human beings or not--and even that does not make the issue morally complex. If fetuses are human beings, you can't kill them, except under the circumstances you can kill any other human being (i.e. self-defense). If there is any doubt whether they are human beings are not, then, if you choose to kill them anyway, you are willing to kill a human being, and are morally guilty of the same thing as murder. What could be simpler? Only if you can prove beyond a reasonable doubt that fetuses are not human would it be morally right to have an abortion.

Thus the whole value question of whether the fetus would be "better off dead" than having a mother who didn't want him, and what this will do to the mother's life and health and so on is completely irrelevant, morally speaking, because the end doesn't justify the means. You can't choose wrong for any purpose, however good--as can be seen from changing the question to whether you can kill your six-year-old because you now can't stand to have him around and the whole rest of his life is going to be miserable (which might even be true).

We will discuss the abortion issue in some detail later; but this will be to find out the factual issue of whether fetuses are in fact human being (and persons), and so in fact possessed of human rights, including the right to life (they are, by the way). Once that is established, then "compassion" and so on are simply smokescreens for choosing what is known to be wrong

And once you do that, anything goes, as we are now seeing. As I write this, President Clinton has vetoed the "partial-birth abortion" ban, and thus allowed the following procedure to continue:

The abortionist prepares to deliver a live baby, reaching into the uterus to turn him around so that he comes out feet-first. He pulls out the feet, the torso, the arms, and everything but the head. He could also pull out the head, and the baby would be born, and then have legal protection against being killed.

But he leaves the head inside, so that "it" can still be called a fetus, and be legally killed. Then, holding the face, he takes a pair of scissors with his other hand and snips a hole at the base of the back of the skull, inserts a suction tube, and proceeds to suck out the brain of this squirming infant, and then, now that he's good and dead, crushes his skull and pulls out the corpse.

This "procedure" has actually been defended on the false grounds that it is "necessary to save the life of the mother." There is in fact no case in which the mother would die if the baby's head were simply removed without this grisly act of killing. The real reason for justifying it is that if it is forbidden, this creates the legal precedent of forbidding the killing of some fetuses, and there are no logically defensible grounds for not applying this to all of them.

Of the five women President Clinton had with him during the signing, alleging that their lives were saved by the "procedure" not one had an abortion that was anything but "elective." Their lives were not at risk at all.

The point of mentioning this is that there are all kinds of complications you can bring forward to obfuscate moral issues with tragic overtones. But all of this is obfuscation, not complication. Life can be tragic; but avoiding tragedy does not justify choosing wrong--because if it does, then since one person's difficulty is another's tragedy, anything is justifiable. And once that principle is taken, then the really horrendous rapidly turn out to be commonplace.

6.1.1. Informing the ignorant

There's a very important point that applies in many areas in ethics, dealing with what you are to learn (and I hope be convinced of) in the pages that follow. It would be well to keep it in mind in all considerations of ethical matters.

You have a positive obligation to provide information to a person who is contemplating doing wrong only if (a) someone else's right is involved; (b) he seeks your advice, or (c) your not providing it is the equivalent of preventing him from finding out the information. Otherwise, your providing the information can be immoral.

As to the case of rights: If you have a chance to protect someone's right and you do nothing, you have been willing that the right be violated. And (as we will see later) we cannot will any violation of any right of any person.

So even though cases involving a violation of rights are "moral issues" and in pure moral issues (i.e. not involving rights), what I am going to say in a moment applies; still, violations of rights are not just moral issues, and to remain silent is to connive in the violation.

That said, what of purely moral issues? Another person is doing wrong, and doesn't know he's doing wrong; no one's right is being violated by it. Do you tell him? There is a very narrow tightrope to walk here. Even if you are a clergyman or an ethical expert (whose business is moral rightness and wrongness), your gratuitous offering of information to a person is an interference in his control over his life; it is clear that you want him not to do something that he wants to do. So there is a question of how much this "providing of the facts" is an attempt to get him to live according to your will, not his--of how much you want control over his life (which is immoral). After all, if he's acting in ignorance, his eternal life is in fine shape; so what's your problem?

When you can intervene is when you have reason to believe he would honestly want to know the facts. The point I'm trying to make here is that you had better be very sure of your own motivation in this. Of course, if he asks you, then clearly he wants to know. But if he doesn't, and you have no reason to think he'd want to be informed, then it's not only the case that there's nothing morally wrong with "not getting involved," you shouldn't try to inform him--especially if you're not an ethical expert.

The reason this is tricky if you are a clergyman or ethical expert is that if he knows you're aware of what he's contemplating (even if he doesn't ask your advice), he may take your saying nothing as meaning that you think what he is doing is all right. He has, as it were, tacitly asked your advice by expecting you to say something if you thought he was wrong; in which case, by not informing him in any way, you are withholding information.

This does not apply if you are not an expert, however, because he has no reason to expect that you're any more knowledgeable about the facts of the moral situation than he is. So he rightly will resent your interference, unless he makes a positive gesture of seeking your advice.

Now the reason it's morally dangerous to inform an ignorant person when he's not looking to be informed is that if you do interfere, it might be that you convince him or even place a doubt in his conscience. But then if he decides to do the act anyway, he is now making an immoral choice, which would not have been immoral if you hadn't informed him. Thus,

Informing an ignorant person of a morally wrong act he is going to do can lead to his deliberately doing it anyway; in which case you are also responsible (along with him) for the immorality of what otherwise would have been a moral, but ignorant, choice.

The fact that you didn't intend him to choose the act knowing that it is wrong is irrelevant. This is a possible side-effect of what you have done; and so you can't escape responsibility for it. You might be the cause, for all your good-hearted desire, of another person's damnation; and this is a severe burden to take upon yourself.

If the person asks your advice and you give him the facts, whether you are an expert or not, then you have simply supplied him with the condition under which he makes his own choice; and so you are not responsible for it. It would be wrong for you to withhold information from a person who wants it in this situation.

The same goes for me as I write this book, and ethicians who are teaching classes. The students choose to take the class, and are not forced to (even if it's a required course; they don't have to attend the college where it's required, or pursue the career it's required for); and so if you give them the facts and they get convinced by them and make immoral choices anyway, they are responsible and not you; because obviously in writing a book on ethics or teaching ethics, you would be acting inconsistently with yourself if you (a) taught what you thought was false, or (b) didn't give out information (because, for instance, it was "controversial").

Of course, one to teaches ethics is an expert, and so has the obligation to know the facts. Those ethicians who are "compassionate" and "tickle people's ears," as St. Paul says, have a great deal to answer for when they appear before the only Judge who matters.

6.2. Health

[This topic is also briefly treated in Modes of the Finite, Part 5, Section 2, Chapter3]

Now then, what is this "health" that the health-care provider deals with? It can't in a simplistic way be said to be "what is not diseased," because mentally unhealthy people are not healthy, but it is only by a kind of metaphor that you can call them "diseased" (because there is no agent attacking the organism, no clear symptomology, no definite cure, and so on). Similarly, a person who is crippled is not healthy, but it doesn't necessarily mean he's got some kind of a disease (he may have had a football injury).

So what we will have to do is come up with what is called an "operational definition" of health and unhealth that will cover all the bases.

DEFINITION: Health is the ability to act in accordance with one's genetic potential. Unhealth is the inability to do so, because of something within the person.

DEFINITION: The genetic potential of a person is what that person could be expected to be able to do because of the particular genetic structure he has.

Thus, if you are genetically capable of seeing and you get glaucoma, you are unhealthy. You are not unhealthy, however, if you can't see because someone has put a blindfold on you. The cause of your inability has to be something within yourself to call it "unhealth."

Also, if you are born with a genetic defect that involves blindness, then strictly speaking you are not unhealthy, but handicapped. You can do all that your genes allow you to do, but not what the normal human being's genes would allow him to do.

DEFINITION: a handicap prevents a person from doing what "practically all" other human beings can do. That is, what the vast majority of humans can do, resulting in our thinking that it is "natural" or "normal" for a human being to be able to do the act in question.

This definition allows us to talk about people being mentally (or even socially or spiritually) unhealthy without implying that psychological difficulties are some kind of "disease," however often we may hear people preaching that "alcoholism isn't a choice, it's a disease." It is not a disease, but it is a case of mental unhealth.

DEFINITION: A person is mentally unhealthy if he cannot control his actions by his choices, or if he cannot access the information stored within his brain.

Basically, mental unhealth is a "bug" in the organic computer which is the brain; and since the brain is what consciousness depends on, then the malfunctioning of the brain affects consciousness in one way or another. But just as in a computer, similar results can occur from either hardware problems or defects in the program (even in different parts of it), so apparently similar "symptoms" can have vastly different causes, some organic and some due to habits. And just as debugging a computer is not a simple task, so "curing" mental unhealth is not a question of finding what kind of "disease" this is and "treating" it.

Very often, in fact, a person with a psychological difficulty is going to have to treat it as a handicap and "learn to live with it," because in point of fact, there is no practical way to get to be able to do what normal people in his situation can do.

But all this is not to say that he's not unhealthy. It's just that this kind of unhealth is not directly analogous to physical unhealth.

DEFINITION: A person is spiritually unhealthy if his idea of God and what God wants of him induces him to do inhuman things.

We can call this "unhealth," though it is a kind of intellectual mistake, and we can know that it is unhealth and a mistake because we can presume that God does not contradict himself; and if he creates people as human, he cannot want them to be inhuman.

Thus David Koresh, who led the Branch Davidians to their fiery deaths in Waco, Texas recently, was undoubtedly mentally as well as spiritually unhealthy. But his followers were spiritually unhealthy, for believing that God actually wanted them to kill themselves in the way in which they did. Similarly, when James Jones of Jonestown induced his followers to commit suicide by drinking poisoned Kool-Aid, they were spiritually unhealthy to think that God actually wanted this of them. In their case, they were in control, and so not mentally unhealthy; but they were certainly deluded. So of many "cult" followers.

This is not, of course, to say that any of these people were damned because of what they did. Insofar as this was unhealth and they thought that they were doing the right thing, then their choices were moral and they gained eternal happiness by them.

DEFINITION: A person is socially unhealthy if the cultural mores he has absorbed are maladaptive to the society he is actually in.

There are many things that a given culture regards as "natural" simply because "everyone has always done it like this," when in fact it is only within this culture that "everyone" acts in this way. If such a person moves to a different culture, he can (without being mentally or spiritually unhealthy) be very uncomfortable, and make those around him uncomfortable, by doing what it "natural" and getting frowns of disapproval. This is currently called "culture shock," and of course very often it wears off as a person learns the ways of the new culture. But when a person sticks to the old ways, he is culturally unhealthy.

For instance, a young Vietnamese refuge I know was brought up never to say "No" to an elder; and when her American sponsor brought her to the store to help her buy a wedding gown, the sponsor would ask her, "Do you like this one?" and she would answer, "Yes, yes." But after all the trousseau was bought, she secretly went back to the store and exchanged everything. She did not realize that when Americans ask a question in a context such as this, they are not saying, "I want you to buy this," but want to know how she really feels.

It does not follow, by the way, that all social behavior patterns are merely cultural, and therefore subject to change. Some of the attempts of the feminists to alter "gender-based" behavior are in fact attempts to reinvent human nature, and are backfiring. If many cultures independently of each other have developed similar behavior patterns, this is an indication (though not necessarily an infallible one) that the basis of the behavior is genetic, not social.

6.2.1. The health-care provider

If this is what health is, then what exactly is a health-care provider?

DEFINITION: A health-care provider is a person who serves others by attempting to restore them to health.

So a health-care provider is not really someone like Mom who is taking care of Johnny when he has the sniffles; in our sense of the term, a health-care provider makes a profession or business of restoring people to health. So he is serving the public in this capacity. We will have to see the moral implications in this aspect of health-care delivery as well as those entailed in "restoring someone to health."

Observe that it is sometimes the case that the one you are serving and the patient (the one to be restored to heath) are different. For instance, a nurse or assistant to a physician is directly acting on the patient, but is serving the physician (who is, of course, serving the patient).

I should note here what I will spell out in its proper place, that it is inconsistent with an assistant to do something harmful to the patient because the physician orders it. On the other hand, as assistants, nurses would be acting inconsistently if they substitute their notion of what is "better treatment" for the one they are told to administer.

Secondly, a pediatrician who treats a young child is treating the child, but serving the parents, and therefore is to defer to the parents' wishes rather than the child's (always supposing, of course, no harm to the patient). Thus, if the parents think it better for the child to have braces on his teeth and the child doesn't want them, Junior gets the braces. Similarly, if the parents refuse a non-necessary treatment, then the child does not get it, even if the child happens to want it (and might be somewhat better off for it).

Obviously also, a veterinarian is always serving the owner of the animal, though he is treating the animal. Since animals do not have rights, if the owners want the animal "put to sleep," then the veterinarian is being perfectly consistent with himself in doing what is objectively harmful to the patient by killing it.

This is not to say that a veterinarian could be justified in inflicting needless torture on an animal just because the owners want him to do so. Even though the animal does not have any right, strictly speaking, not to be tortured, such an act dehumanizes the one who does it, and so would be inconsistent with the veterinarian himself as an "empathizer."

There are peripheral aspects of the health-care profession that do not, strictly speaking, deal with restoring people (or animals) to health. Technically (at least based on our definition above), treating genetic defects is not restoring the handicapped person to health, since he can do what his genes allow him to do; it is just that his genes don't allow him to do what normal people can do (i.e. he is abnormally limited in his humanity).

But this is a technicality, since correcting genetic defects involves the same sort of knowledge as that involved in restoring a person to health, and the practical effect of an abnormal genetic limitation is the same as that of being unhealthy.

Nevertheless, since "unhealthy" tends to imply "sick," those with genetic handicaps sometimes rightly resent being treated as if they were "sick people" who need to be "cured."

So the distinction here is not just terminological. It is better to call the difficulty what it is: a genetic defect or handicap that might be corrected or overcome, rather than "unhealth" or "sickness" that should be "treated" or "cured." But it is the health-care profession that takes care of this sort of thing.

It is also the case that cosmetic plastic surgery is not really "restoring a person to health," because (except in the case of correcting disfigurements), the person simply is going to look better, and is not incapable in any sense of acting in accordance with his genetic potential. But again, this type of surgery involves the same kind of knowledge and skill as that involved in restoring people to health, and so it is a branch of the profession.

So far, then, the definitions seem to hit the kind of thing we want to discuss; so let them stand as given.

6.3. The provider's own humanity

Let us just briefly state what certainly should be obvious, but what turns out sometimes to be violated in the course of medical practice:

The health-care provider cannot be willing to do any harm to himself for the sake of restoring others to health.

More specifically, this means:

The provider must not put his life or health in danger except when the Double Effect can apply.

For instance, the practice of making new residents in hospitals work insanely long hours is morally wrong, not only for the residents but for the people they treat. This kind of "hazing" might "toughen" them for hard times ahead, but the end does not justify the means. Further, tired physicians have impaired judgment, which implies that their decisions about treatment will be apt to be harmful to the patients.

Now working when tired is not evil in itself, and so there are times when the Double Effect can apply: when there are so few doctors that the patients will be harmed by not being treated, so that there is a good effect (second rule). Obviously, the harm to the doctors that comes from working when tired (or the harm to the patients) is not the means for the patients' getting treated (fulfilling the third rule); no one wants harm to either doctor or patient (fourth rule). But only when the harm to the patients by not being treated now would be at least as great as the harm to the doctors and the potential mistreatment of the patients from the doctors' impaired state can this be allowed morally, because otherwise the fifth rule is violated.

Similarly, doctors and nurses can treat patients with leprosy, bubonic plague, ebola and other dangerous, even deadly and highly infectious diseases, insofar as (a) they take whatever precautions reason demands not to become infected themselves, and (b) the harm from the danger of their own infection is not greater than the harm that comes from letting the sufferers go untreated. (Note that it is the harm from the danger--the harm of the actual infection minus the likelihood of getting it--that is what is to be compared with the harm of letting the patients go untreated.)

NOTE that a health-care provider must be more willing than the average person to put his own life or health in danger for the sake of restoring others to health.

The reason for this is that, since diseases are apt to be infectious (and insanity, in the mental-health field, is apt to involve violent people), then health-care delivery itself as a profession is a more or less risky business. Thus, when you choose it, you are already willing to run the risks involved.

That is, it is inconsistent with a person to choose the health-care profession and say, "I'll be a doctor, but I don't want to run any risk of getting sick myself."

Still, the point here is that this willingness must not turn into reckless disregard of one's own health.

NOTE also that harm to one's health, however slight, may never be chosen as a means to the benefit of patients.

Thus, if infecting yourself with a disease in a controlled way would allow you to discover the agent that causes the disease and so find a cure for it, and if this meant that you actually had to catch the disease to learn what you needed to know, you couldn't do it--even if this would merely mean that you would get sick, and your knowledge would subsequently save millions of lives.

It was in this way, in fact, that the causative agent for malaria was discovered. The doctors involved in the research each inoculated themselves with different components of mosquito venom, and the one who got malaria showed what it was that caused it. The result was the cure; but however we may applaud the good that came out of this evil, such a course of action still may not morally be chosen.

The reason is that it would be by getting sick that you saved the others' lives; and so you would have to choose the harm to yourself. So even though it is disproportionately small compared to the harm that you would be protecting people from, you couldn't do it.

Before you bristle at this, remember that a willed harm has eternal repercussions, and harm in this life stops at death. If what I said here is not true, the end justifies the means, and the whole moral enterprise, as I have so often repeated, is a waste of time.

So you can't hide behind the "altruism" of the health-care profession as an excuse for actually choosing harm to yourself.

6.3.1. Lying

[This topic is also covered in Modes of the Finite, Part 5, Section 2, Chapter 5, and in Human Conduct, section 6.3.2. ]

There is one moral issue that is actually a violation of the provider himself, but since it deals with communication, it can act as a transition between the provider and the patient: the issue of lying.

DEFINITION: Lying is the act of communicating as a fact what is believed not to be a fact.

The essence of the wrongness of the lie is that the act of factual communication is contradicted in the very exercise of the act. So even if it's a "white lie" that doesn't do any harm to the hearer (even if it's beneficial to the hearer), you are still pretending that your act is not what it is.

Any harm that may come to the hearer because of or in addition to the fact of his deception is an added evil to the essential moral wrongness of the act of lying.

Note that in lying, you expect the hearer to believe you (i.e. to take what you say as your idea of what is really the case). But on what grounds do you have this expectation? Because the nature of this kind of activity (factual communication) is such that it reveals what you think is the case. Thus, you can't lie to someone unless you know that you are acting inconsistently with what you are doing.

NOTE, however, that not every false statement is a lie. Lies must have the intention of communicating (making the hearers believe) that what is not a fact is a fact.

First, it is obvious that mistaken statements are not lies. If you think something is the case and it actually isn't, you have issued a false statement, but you have not been willing to communicate what is false; and so you haven't lied.

Second, there are non-factual utterances, such as questions or exclamations or commands. You can't lie by saying "Are you sick?" or "What a beautiful day!" or "Go shut the door" unless the expression implies a "fact" that is known actually not to be a fact. For instance, "What a beautiful day!" implies the fact, "The day makes me feel great," and so you might be lying if you said it intending to deceive someone about the state of your mind. But in general, since these things express attitudes and not facts, you aren't lying when you utter them.

Third, there are factual statements which do not communicate what the words literally mean. For example, (a) there are ironic statements such as, "You certainly studied hard last night," spoken by the teacher to the student who is falling all over himself answering a question. In this case, what is communicated is the exact opposite of what is said. Such things are actually more forceful means of communicating a fact than a literal statement (and the meaning actually communicated is often reinforced by the tone of voice and so on). Hence, the teacher is not lying when making such a statement.

Also, (b) there are also conventional statements such as the secretary's "Mr. Smith is not in at the moment," when a visitor asks to see him. These statements are understood by everyone to not to mean a literal indication of Mr. Smith's whereabouts, but to be a way of saying, "You can't see him at the moment" without communicating the implied insult "You are not worthy of speaking to Mr. Smith." That is, if the secretary answered, "He's in, but he won't see you," this conveys an implied insult that might be false. Just as the visitor's question, "Is Mr. Smith in?" is not actually a request for information about Mr. Smith's physical location, the answer does not communicate information about his location, but answers the implied request.

So No, Virginia, the secretary is not lying when she makes that answer; and anyone who accuses her of doing it does not understand the difference between what you say and what you communicate.

Fourth, strictly speaking you can't lie by making value statements, since values depend on subjectively set standards, and the only fact involved is whether the situation in question meets the standard you set up to evaluate it--and only you can know that.

So, for instance if you go into a hospital room to visit a friend, and you say, "You look fine," when he looks a wreck, you're not really lying--on two counts. First of all, what you're trying to communicate is "I sympathize with you and want you to feel good" without saying it in an insulting way, which you would do if you said those words (since you as a healthy person would come across as condescending to the sick one). But secondly, you can also mean, "You look fine in comparison to what I would have expected," or "in comparison to someone who is at the last stages of cancer" or whatever--which is perfectly true.

And the patient generally takes these sympathetic remarks for what they are; because later on in the conversation, he might say, "Okay, now tell me how I really look," meaning that now he wants an evaluation plus the standard you are using. In that case, you'd have to say, "Well, based on what you've been through, you look pretty good," or you'd be lying--because if you now made the unqualified statement, "You look fine" when you think he looks terrible, you'd be communicating as your value judgment the opposite of what it really is, which is what he's asking you for.

NOTE that the moral obligation does not extract from you the positive duty of telling the truth, but the negative one of not communicating the opposite of what you think the truth is.

That is, there is nothing morally wrong with leaving someone uninformed, unless he has a right to know the facts; but it is always wrong to misinform someone deliberately. Lying by implication: the placebo

The distinction between what is said and what is communicated is a two-edged sword, however, and you can sometimes lie by telling what is factually true, but which you know the hearer will take in a false sense.

For instance, Anacin for years advertised that it "contains the pain-reliever doctors recommend most," implying that it had some kind of fancy prescription drug in it, when all it was was aspirin and caffeine.

One particular case of this type of lie is called the placebo (from the Latin word meaning "I will please [you]."

DEFINITION: A placebo is a medically inert substance that is made to look like a pill or a medicine capsule. The "placebo effect" consists in the fact that often if a patient believes a certain thing will make him feel better, he feels better.

Placebos are sometimes the only thing that will work with hypochondriacs (people who imagine they have diseases). Since "it is all in their head" anyway, you can't give them the standard treatment for the disease they don't have but are convinced they have; but if you give them a placebo, then the "disease" gets "cured."

Often enough also, real medical problems can get cured by placebos, since basically the body cures itself, and the mind can do wonders at directing this curing mechanism if its power is unleashed by suggestion (as hypnosis demonstrates). Just as there are real psychosomatic diseases, real physical diseases whose cause is the mind, so there are psychosomatic cures; and placebos can sometimes bring these about.

The trouble is that administering the placebo is a lie, because the act of giving to a patient sugar that looks just like a pill communicates the idea that this pill is medically effective and will cure him when it isn't and it can't. If he gets better, it isn't the pill that cured him, but his belief that it would. That is, the pill is just an occasion for his belief to effect the cure; it itself is not the cause.

Since in administering the placebo, it is the deception that effects the cure, this is using a morally wrong means for a good purpose, and is morally wrong.

Some have tried to get around this by alleging that when the physician says, "Take this and you'll feel better," he is telling the truth, because when the person takes it, he will in fact feel better. But this statement is not the lie; the lie consists in the fact that "this" is assumed by the patient to be medicine which will cure him, and it isn't.

This can be seen from the fact that if the doctor says, "This is actually just a sugar pill; but it'll cure you if you believe it will," then the cure won't happen, because the patient will realize that it itself won't do anything for him. So it's only when the patient is deceived into thinking that the pill is medicine that it will work.

In this connection, there is nothing morally wrong with "faith healing," in which someone like Oral Roberts lays hands on sick people telling them that if they have faith, they will be cured. This is not a lie. First of all, God can and sometimes does produce miraculous cures (there's certainly objective evidence that medically--and even psychosomatically--unexplainable cures have occurred in a religious context). Secondly, even when God is not involved, an unwavering belief that the cure will happen can produce a cure by the placebo effect. So in this case, it is precisely the belief that does the curing, and this is what the faith healer says. So there's no deception involved here. This applies to the kind of thing that medicine men do as well as what is done in a Christian context. Obviously, if the treatment by medicine men didn't work quite often, they would not be sought out.

There is a legitimate use for placebos, however. In testing drugs, one wants precisely to eliminate the placebo effect as the reason for the apparent ability to cure the patient. So what is done is that subjects of the testing are divided into two groups, one of which receives the medicine, and the other a placebo of identical appearance. Subjects are told beforehand that they may be receiving the medicine, and they may be receiving simply a placebo (so there's no deception involved here); and since everyone knows that he might simply be taking an inert pill, this kills the belief necessary for the placebo effect to work; and so if the medicine is really effective, a significant difference will show up between those who took the medicine and those who took the placebo.

It can happen that if the person who administers the pills knows which is real and which is the placebo, his body language can convey this information to the subjects; and so to avoid this, "double blind" studies are used, in which those who administer the pills are given them in such a way that they don't know whether they're giving a placebo to the patient or not. Public-health propaganda

A situation similar to that of the placebo is the manipulation of scientific data to influence the public to take steps to be healthy. The motivation for such things is noble, since people are often doing things which are harmful to their health without fully realizing the risks, and they don't tend to change their behavior unless the risks are "brought home" to them by exaggeration. Thus, data which prove a slight risk are interpreted as establishing a serious danger, evidence on one side of the issue is presented without evidence which supports the other side; and so on. Again, what is said is not false, exactly, as stated, but it communicates, for a good purpose, a false idea of what the facts are. This is a lie.

"Fudged" or misleading data must not be used to persuade people to do something which is beneficial to them. If they cannot be persuaded by the truth, then the chips must fall where they may.

This sort of thing is counterproductive, actually. To the extent that the public begins to realize that it is the victim of a propaganda campaign, it tends to be skeptical of all pronouncements from the office which issues such information, and becomes like the people who heard the boy cry "Wolf!"

Recent instances of this are the outrageous exaggeration of the dangers of second-hand smoke (for which there is no credible evidence that it is harmful to people's health); the scare about the chemical Alar which was sprayed on apples and is perfectly safe; concerns expressed about the dangers of radon gas (which are infinitesimal); the so-called "disaster" of global warming (which hasn't been established even to be occurring, let alone to have disastrous effects); and most of all, the myth that AIDS is a disease that "anybody" can get.

To show you how this works, in the last instance it is true that anyone can get AIDS; but the chances of getting it from ordinary heterosexual intercourse even with someone infected with the virus (provided the parties do not have other sexually transmitted diseases, especially those which cause lesions) is on the order of one in ten thousand. The problem is that the odds are very high (e.g. one in three) for things like anal intercourse with infected people and for sharing with them needles used for drugs; but being honest with the information gives the impression that the disease is a gay men's and drug users' disease, and to a somewhat lesser extent a prostitute-client disease; and that will make the public complacent.

One side-effect of the AIDS scare has been the touting of condoms as "safer sex." They used to be called "safe sex" until the falsity of this became so obvious it had to be changed. Using a condom during sexual intercourse does (in the "real world": that is, in the way condoms are actually used) tend to cut the transmission of sexually transmitted diseases about in half; so it sounds like a good idea to promote them. But (a) cutting the odds of getting AIDS in half (one in ten thousand to one in twenty thousand) is like thinking you're "more likely" to win the lottery if you buy two tickets instead of one; (b) some STD's, like gonorrhea, have a ninety per cent transmission rate, and so the odds are reduced to a little less than fifty-fifty for a single act. With five such acts, the odds of getting the disease using condoms each time is over ninety per cent. Thus, people who are safe anyway from AIDS are given a false sense of security against other STD's and are confidently having "protected" sex which in fact is not much of a protection.

The point is that well-intentioned falsehoods are not only morally wrong but can sometimes exacerbate the problem they are trying to solve.

6.4. Relations to others: rights

[This topic is treated also in Modes of the Finite Part 6, Section 1 and Human Conduct, Chapter 8.]

Of course, lying is generally not simply the contradiction of the liar's act of communicating, it also involves deception of another person, who in engaging in conversation has a presumptive right not to be deceived; so lying is also unjust. But this brings up the question of what rights are.

DEFINITION: A right is a social power to do something (or to refrain from doing something).

DEFINITION: a social power means that it is morally wrong for anyone else to try to stop you from doing the act in question.

That is, if you have a right, you don't necessarily have the physical skill to be able to perform the act. You may own an oboe, for instance, which gives you the right to play it; but you may not in fact be able to make any sound come out of it.

The way I learned about rights was that they were moral powers, implying not only that it is wrong for anyone else to prevent you from doing the act, but that it is not morally wrong for you to do it. I think this view is mistaken, because it implies that we would have no right to do what is morally wrong (and which harmed only ourselves), which would mean that others could morally intervene to stop us. I now think that this is false. If you want to harm yourself (by smoking, say), and it does no harm to anyone else, it is a violation of your command over yourself if someone else can prevent you from doing what you want with yourself.

This, I take it, would follow from the fact that God does not force people not to damn themselves if they want to (which can be inferred from the fact that if he did, the moral obligation would collapse into meaninglessness, as we saw in Chapters 2 and 3). The fact that God respects our self-determination even to allowing us to set and keep deliberately self-frustrating goals is an indication that self-determination is the true essence of a person. So it is a violation of self-determination for anyone to interfere in a person's living of his own life (as long as it doesn't affect anyone else).


You can have a right to do wrong and to harm yourself; you can be persuaded not to do so, but not forced, as long as the harm you do does not violate anyone else's right.

It therefore follows that it is morally wrong to "save someone from himself" if he knowingly and freely is choosing his own harm.

Now then, the fundamental reason we have rights is that we are persons, not that we are "equal" to other people (in spite of what Jefferson wrote in the Declaration of Independence). This is a complex issue, and I am going to oversimplify it for our purposes.

DEFINITION: a person is a free being: a being who can set goals for himself and direct his behavior toward achieving them.

As far as we know, human beings are the only living bodies who are persons. The other animals engage in goal-directed behavior, but they give no clear evidence of being able consciously to set the goal. Their attention is directed by what their genetic "program" assesses as most "beneficial" to them at the moment, based on the condition they are in. They give no evidence of being able simply to imagine themselves as different, to compare the imaginary state with their present condition, and opt for the imaginary one over either the one they are now in or the one their emotions incline them towards.

Experimenters in this field demonstrate the intelligence of chimpanzees and other highly developed animals, but they have never been able to show that they understand what the symbols they use mean, as opposed to being able to manipulate them. That is, it is one thing to make a connection (this house reminds you of Mr. Smith), and to understand what the connection is (he owns the house). The difference is extremely subtle, and setting up an experiment that would clearly reveal it is exceedingly difficult--and none so far have succeeded.

Nor, I am sorry to say, are they likely to. The difference between children and apes becomes quickly apparent as each learns words. The ape manipulates the symbols he is given, but evinces no curiosity to find what other symbols go with the objects in his world. But once a two-year-old catches on to language, he is constantly pestering people with trying to find out what names to give to the objects around him--and in fact, he makes up his own names when no one tells him. This clearly indicates more than that he knows how to use language; he knows what it does. Animals so far have given not the slightest hint of this.

But the point for our purposes is that in order to set a goal to be achieved, one must understand the relationship between the real state and the imagined one; and for this one needs the capacity that we find only in humans.

Note that persons are moral agents; that is, since they are free, they are responsible. Animals are not. It can also be shown that free beings have immortal souls, and are therefore subject to eternal reward or frustration for what we do.

So the implications of saying that animals have rights are significant. It means you can't neuter them, chain them up against their will, "put them to sleep" when it is the humane thing to do, have them medically treated when they don't want it, and so on. The "animal rights" activists understand neither animals nor rights. They want them to have "rights" only when it is convenient.

This is not to say that we don't have moral obligations toward animals; it is just that these obligations do not correspond to rights in them.

The moral implications of rights are that it is inconsistent with a person to use his self-determining activities to prevent another person from determining himself. That is, if you don't want others fulfilling themselves at your expense, then you are inconsistent if you fulfill yourself at their expense.

Thus, rights imply a reciprocity: I will let you alone if you let me alone. And since animals can't enter into such an agreement (since they can't (a) understand the meaning of such an agreement, or (b) consciously refrain from doing what the strongest influence tells them to do), that is why they cannot be the subjects of rights.

Now, to make a very long story short, even though the basis of our having rights in general is freedom, and becoming what you want to be in the future,

the basis of a given rights claim is damage to your present condition.

What this means is the following. A rights claim imposes a moral obligation on everyone else to let you do whatever it is you claim a right to do. So it restricts the freedom of everyone else. Hence, the mere fact that you want to do something does not give you sufficient grounds for preventing other people from doing what they want. So you have to show that if you can't do the action you claim a right to, you are somehow harmed. That is, that they are somehow contradicting what you now are by preventing you from doing the act.

Thus, if I am a citizen, you are contradicting my reality as a citizen by keeping me from voting. If I have a driver's licence, you contradict me as a driver if you won't let me drive my car. You contradict me as a human being if you try to kill me (since human beings are living beings, whatever their goals may be). If I enter into a contract with you and do the work you agreed to pay me for, you contradict me as a party to the contract if you don't pay me. And so on.

DEFINITION: The title to the right is the particular aspect of your reality that is contradicted if you are prevented from performing the act in question.

Thus, we have human rights, whose title is our humanity, civil rights, whose title is our citizenship, and various acquired rights like those arising from a contract or getting a licence to drive, and so on.

There are three especially important points to consider about rights:

First point: Whenever something is a human being, that something is a person, and so a possessor of all his human rights.

Why is this, if the human being is not always something that can in fact make choices? Fetuses, even if they can make choices, can't carry them out; and there has to be some stage between the fertilization of the egg and birth where the organism is incapable of making any choice at all. So how can that thing be a person?

Because he is a self-determining kind of thing, and personhood and rights do not depend on (a) whether you actually are making a choice, or even (b)whether in practice at the moment you can make a choice. They depend on whether you are a "choice-maker."

Consider the implications of denying this. If you lost your personhood when you lost your ability to make a choice, you would lose your rights along with it. Then, since you can't in practice make any choices when you are asleep, robbing you or even killing you during your sleep would not be immoral, because it wouldn't be a violation of your right to ownership or life. But that is ridiculous.

For those who argue, "But you still can make choices, because at any moment you can wake up and make them. But that would mean that people who are given drugs that render them unconscious and incapable of being awakened for, say, the next four hours are not persons during that time, and so can be killed--because they "can't" wake up and make choices in the sense that the sleeping person can. But that is also absurd.

But since there is no empirical difference between a person who has been knocked out and, say, a fetus who can't yet make choices because of the state of his body or a person in a coma who can't any longer make choices for the same reason, if you exclude these two classes of humans from personhood, then logically, you would have to exclude anyone who is unconscious, which is ridiculous.

Therefore, as long as the body is organized dynamically in a human way (as long as it is functioning as a human unit), it is a person.

Second point: Rights never extend to the violation of someone else's right.

This should be obvious. No one's right ever "trumps" another person's, no matter how "important" or "unimportant" either of them is, because rights are not based on equality or superiority or inferiority, but on the fact that a person is a free being. Rights basically are negative: you may not fulfill yourself by doing damage, however slight, to anyone else.

This is the basis of the saying, "Your right to swing your arm stops at my nose." So if you have a right to do something, you can exercise this right only to the extent that your exercise of it doesn't violate any right of anyone else.

Third point: Rights can be defended by force, by using the Double Effect.

The reasoning goes this way: Since a right is a power to do it, if I can't prevent someone from violating my right, I don't in practice have the power to do the act in question--which contradicts the right as a power.

But my act of using force, of course, does damage to the violator, and so (by definition) violates some right of his. Hence, there is a bad effect of my defending myself: harm comes to the violator. So we have a double effect.

Now the act I take to defend myself is innocent in itself (since if the violator ducks and then runs away in fear, nothing bad happens) (First rule.) It has, as I said, a good effect: my right is protected. (Second rule.) The damage done to the violator is not what protects my right, since, as I said, he may evade the damage and stop his violation, meaning that the good effect can happen without the bad one. So even if the damage actually occurs, it is not what produced the protection. (Third rule) I do not want the harm to the violator, but only the protection of my right (Fourth rule.)

Then as long as the harm to the violator is not greater than the harm I am preventing to myself (fifth rule), I can defend a right I have. That is, I cannot kill someone to prevent him from stealing my wallet, or maim him for insulting me. The damage must be proportionate to what I am protecting myself from or I also wish him harm, and this makes me the violator of his right, and not simply the protector of my own.

Note that the fact that "he asked for it" or "he deserves it" may never be the motive for doing damage to someone (however he may actually deserve it), because it violates the fourth rule. You may never morally choose harm to another human being. The double effect allows you to do the harm, but only unwillingly.

6.4.1. The right to privacy

Now then, what rights does the patient have that the provider must respect? Obviously, there are the normal human rights to life, physical integrity, and so on, which we will discuss at length later. But now let me concentrate on a few that deal with the patient as a patient.

First of all, the patient has a right to privacy: that is, to be able to conceal information about himself from other people.

To show that this is a right and not simply a desire, you have to show how the mere fact of others' knowing information about a person does damage to his human condition, whether that information is used against him or not.

The way to show this is that, as we saw, a person has a moral obligation not to misinform people about himself. But since everything you do gives some information about you to others, and since partial information can easily be misleading, then are misinforming the people around you unless (a) you fill in all the information they need to be able to make a correct judgment of your character (which is impossible in practice) or (b) it is known by everyone that you have the right to conceal information about yourself and therefore, any judgment they make based on what they have observed is based only on partial evidence. (Hence, if they judge you based on their observation, they should know they are making a rash judgment, which is their fault, not yours.)

Some of my second-semester students, for instance, get a shock when May comes and I enter class with a short-sleeve shirt, displaying the tattoo of a snake on my forearm for the first time. The don't think of the old philosophy professor as the kind of person who would have got a tattoo, let alone one of a snake. But that's part of my personality also.

So the only way in practice that you can interact with other people and not misinform them as to the kind of person you are is if you can conceal information about yourself. Therefore, you have the right to do so.

But the health-care provider has a right to do his job; and to do it, he needs information--sometimes information of the most intimate and personal nature--about the patient. Therefore., the patient has no right to conceal relevant personal information from the provider.

NOTE that only relevant information can be demanded from the patient. The health-care provider has no right to know all personal details about the patient, even those which "might conceivably" have a bearing on treating him. The provider has to have some reason to believe that the information he extracts actually does have a bearing on treatment before he has a right to expect to have it.

Providers may bristle at this, on the grounds that "there's always a chance" that information, say about a person's sex life might be pertinent to some treatment in the present or the future. But health-care providers are not God, and are not expected to be omniscient. The patient has right to privacy, and just because the doctor is treating him, that does not mean that his life has to be an open book every page of which is subject to the doctor's scrutiny. If, of course, the patient (on the grounds that he wasn't asked) conceals information which is relevant, but which the doctor wouldn't have any reason to suspect either exists or is pertinent to the case, then this is the patient's problem. He can't expect the doctor to ferret out details about his life.

The point is that, because of the provider's right to know pertinent information the patient has the obligation to freely reveal all the details of his life that he thinks might be relevant to the treatment in question.

To the extent that he doesn't do this, he can't hold the doctor responsible for acting on insufficient information.

But just because of the patient's right to privacy, the patient has a right to confidentiality of the information he reveals.

That is, information revealed to a health-care provider must not be revealed to anyone not involved in the treatment of the patient; and the more sensitive the information, the fewer people involved in the treatment have a right to know it.

Obviously, this has practical as well as moral implications. To the extent that a person knows that some socially damaging information he gives to his doctor might find its way into the general public, to that extent he is going to be motivated not to reveal it--with the resulting harm that can come from the provider's acting on insufficient information.

This is one of the problems connected with the confidentiality of testing for the AIDS virus. The mere fact that a person gets tested for HIV implies that he has done something (either committed adultery or used intravenous drugs) which put him in danger of contracting it. Very often it can be socially or personally disastrous if this impression is given; and so "mandatory testing" programs where the fact of being tested can be found out are bound to decrease the number of at-risk people who come to be tested.

Can confidential information ever be revealed? Suppose some third party will be damaged if it is not revealed, and yet the patient says he doesn't want the information to get out.

Since damage to a third party implies the right for that third party to know the information, and since no one's right extends to the violation of anyone else's right, then using the Double Effect the provider may reveal the information to the third party when the damage done by not revealing it is as great as the damage done to the patient by its revelation plus the damage done to patients in general from the undermining of confidentiality this will produce.

NOTE that since undermining confidentiality can be very serious, the damage to the third party must be extreme in order to justify the breach of confidentiality.

The point is that morally speaking, you can't say that confidential information can never be revealed; but in practice it is almost never.

That is, doctors are not like Catholic priests. Catholics believe that serious sins are not forgiven unless the sinner confesses them to a priest (or intends to do so; there's a loophole if he can't, in practice). Thus, he has to reveal it under pain of eternal damnation. If penitents believe that the priest can reveal this information under any circumstances whatever, this will motivate some to choose not to confess their sins, which will damn them--and this must be avoided at all costs. Hence, a priest may never under any circumstances whatever even act as if he knows any information about a penitent, no matter even if it is a matter of life or death or the averting of war or destruction of whole civilizations. The "seal of confession" is absolute, and breaking it is the most serious sin a priest can commit. The "seal" of the provider-patient relationship is not that serious.

NOTE that confidentiality is not breached when a person speaks (1) of what is already public knowledge, even though he has learned of it in his practice, (2) in general terms about a case, in such a way that the person involved cannot be identified, or (3) of what the provider has reason to believe the patient would want him to reveal, when the patient can't actually give permission (e.g. because he is unconscious).

6.4.2. Concealing information

Let me now put this obligation the provider has of confidentiality together with the obligation not to lie. How do you keep information secret if you can't lie to protect it.

First, the way to conceal information that must be kept secret is to keep silence or make some remark like "no comment." This must be used unless the silence or noncommittal remark in fact tends to communicate (by implication) the information.

The reason this is the primary way to conceal the information is that the methods we are going to discuss involve the possibility of misinforming as well as not informing, and so they have a bad effect.

Secondly, if simply keeping silence in fact reveals information, then you must say something which leaves the hearer uninformed.

There are various ways of doing this.

You can make a partial or an ambiguous statement (i.e. a statement that either contains only part of the truth, or one that means more than one thing), not with the intention of having the hearer take it in the wrong sense, but with the intention of having him not know which sense you intended.

Thus, if a doctor is questioned as to whether a patient of his requested an HIV test, he can say, "Look, he was here to have a heart problem checked." (Which was true, but he also asked for the HIV test) or "He's not the kind of person who would make a request like that." (True, he's not the kind of person that would do so, even though he in fact uncharacteristically did do so.) This is not a lie, because (a) there is a sense in which the statement is true, and (b) a reasonably astute hearer would realize that it doesn't really answer the question.

This kind of thing is sometimes called "mental reservation" (in which you "reserve to yourself" which of the meanings is the true one) or "equivocation" (meaning that you've voiced something with "equal" meanings). It is the reason why in law courts you swear to tell "the truth, the whole truth, and nothing but the truth." At that point, you have sworn that you will not conceal relevant information, or give partial or ambiguous statements. If you have to conceal information here, you have to inform the Court that the information you have is confidential. If the Court refuses to admit this, then you have to reveal it, because the act now of concealing it contradicts itself in violating the oath you took, and so the first rule of the Double Effect is violated.

In the case of doctors, lawyers, and priests, however, this concealment is legal. Such information is called "privileged," meaning that government cannot legally force the person to reveal it.

There was a notorious case recently in which a prosecutor in Oregon taped a criminal's confession to a priest (obviously, without the knowledge of either of them) and was going to use it in a trial, on the grounds that it wasn't "lawyer-client" information, and was only "religion," and presumably by separation of church and state, it shouldn't be privileged. The uproar at this was so enormous that (fortunately) it was not admitted (and I believe the tape was ordered destroyed. If not, it certainly should have been).

Finally, if neither concealment nor partial nor ambiguous statements can leave the hearer uninformed (since he might be clever enough to deduce from your remark what you are trying to conceal), you can sometimes make a false statement that you realize will not be believed.

"Oh, so it's all right to lie, sometimes, then." No. Remember, lying involves communicating false information. In the situation I am talking about, you are in a context where you know that the hearer will not believe your false answer "because it's the only thing you could say if you didn't want to reveal the information," and so he doesn't know any more after the interview than he did before. If this sounds "Jesuitical," remember that the moral obligation simply forbids contradicting yourself; and the closer you get to the line between contradiction and non-contradiction, the finer the distinctions you have to make.

To take our HIV case a bit further, suppose the patient is a prominent moral leader of the community, and the questioner is a reporter who wants to discredit him. He asks, "Did Reverend Smith ask for an HIV test?" (because he's heard a rumor that he did). You answer, "He came to my office to have a heart murmur checked," and he says, "But did he ask to be tested for HIV?" and you answer, "He's not the kind of person that would make such a request," and he (realizing that you're evading the issue) persists, "But did he actually ask for one, because I've heard that he did." You answer, "No, he didn't," and he (as you expect) says, "I don't believe you, Doctor."

In this context anything but "No, he didn't" (i.e. any evasion of the question) is going to reveal that he actually did ask for the test; and so "No, he didn't" now is an ambiguous statement. It would be what you would say if in fact he didn't ask for the test, and also the only possible thing you could say to conceal that he asked for the test. So the false statement is not a lie, because it communicates no information at all.

Summary of Chapter 6

An act is morally wrong if it contradicts your genetically given humanity or modifications of it that you have made by promises. We are now going to apply ethics to the human being as a health-care provider.

Note that many apparently "difficult" moral problems are morally simple, and only "difficult" in that being moral involves difficulties in this life. But it doesn't matter how much you suffer for being moral in this life, because there is an afterlife, in which you will suffer more for taking the immoral course. Either that, or all moral investigation is a waste of time.

Health is the ability to act in accordance with one's genetic potential: what you could be expected to be able to do because of your genetic structure. Unhealth is the inability to do so, because of something inside you (if you are tied up, you are not unhealthy) If you have defective genes, then strictly speaking you are handicapped, not unhealthy (i.e. you can't do what practically every other human being can do). You are mentally unhealthy if your choices can't control your acts or access to information stored in your brain. You are spiritually unhealthy if your idea God makes you think he is telling you to do something inhuman. You are socially unhealthy if your "acculturation" is maladaptive to the society you happen to be in.

A health-care provider is a person who serves others by attempting to restore them to health. Sometimes the person you serve is other than the patient, as in the case of child or animal patients.

A provider must not be willing to harm himself for the sake of his patients; he may put his health or life in danger only when the Double Effect applies. Making residents work insanely long hours in hospitals is thus morally wrong in general (and bad for the patients too). A provider, however, must be more willing than an ordinary person to run risks in treating people, because he chose to get into an inherently risky business. Note that the harm to one's health may never be the means to the benefit for people.

Lying is communicating as a fact what is known not to be a fact. Harm to the hearer is an evil in addition to the contradiction of the act itself of communication. But not every false statement is a lie. Mistakes aren't, because there is no intention to misinform. Non-factual utterances such as questions or exclamations can only be lies except insofar as they imply that you are communicating a state of mind you don't have. Factual statements may also not communicate what they actually say, such as ironic statements (which communicate the opposite) or conventional statements (which are understood to mean something other than what the words say). You don't have a positive moral obligation to communicate the truth, but simply not communicate the opposite of it. You may leave people uninformed, but not misinformed.

You can lie by implication. The placebo is an inert substance which is disguised as a medicine. If the doctor gives it to a patient, his statement, "Take this and you'll feel better," is true, because the "placebo effect" means that a person's belief that he get well makes his own mind cure him. But the belief is the result of the deception that the pill is medicine when it isn't. Thus, the act of giving the placebo is the lie, which is the means to the cure; and the end does not justify the means. Faith-healing is legitimate, because in this case, it is the belief that effects the cure. Placebos can be used in experiments when all the subjects know they might be given a placebo instead of medicine, because then they are uninformed, not misinformed, about what they are taking.

Analogous to the placebo is misleading public-health propaganda, in which scientific evidence of dangers is exaggerated in order to scare the public into avoiding acts they wouldn't otherwise take much trouble to avoid. First, the end does not justify the means; and second, such misleading information is apt to backfire, with the result that the problem becomes worse, not better.

A right is a social power to do something: no one may morally stop you. Because you are master of your life, you have the right to do harm to yourself if you want. Others can persuade you, but not force you, unless someone else's rights are involved. Rights in general come from our personhood: our freedom to direct our lives by making choices. Human beings are the only known living bodies who are persons; thus, animals do not have rights, even though we may have obligations toward them. It is inconsistent with a person to fulfill himself by preventing another person from doing so. The basis, however, of a given rights claim is a title: an aspect of your present reality which is contradicted if you can't do the act in question. Thus, you may prevent another from doing what he wants to do, but you can't do harm to him. Whenever something is a human being, he is a person, and has all his human rights. A human being is a person as long as his body is organized in a human way. Rights never extend to the violation of another person's right; no right ever supersedes another. Rights can be defended by force when the Double Effect applies: the actual harm cannot be the means to the protection of your rights, and the harm you do can't be greater than the harm you are protecting from.

Patients have a right to privacy: to prevent other people from knowing facts about themselves. If they didn't have this right, then they could not in practice avoid misinforming people about the kind of people they are (because everything they do gives information about themselves); and thus they would be lying. But the provider often needs to know intimate details about patients in order to treat them, and so the right to privacy yields to the provider's right to know. Patients must reveal all pertinent information, but have no obligation to reveal irrelevant facts about themselves. This obligation to reveal private information to providers implies confidentiality: the obligation of the provider to conceal this information from everyone not involved in the treatment of the patient. Using the Double Effect, if the concealment of the information does serious damage to a third party, it may be revealed, provided the damage would be greater than both the harm done to the patient and the harm resulting from the undermining of confidentiality (which can be very, very great). Thus, confidentiality in practice can almost never be violated. Confidentiality is not violated by speaking of information already public, by speaking in general terms so that the patient can't be identified, or by saying what the provider can presume the unconscious patient would want revealed.

One must conceal information by being silent or noncommittal ("no comment") if that will in fact conceal it. If silence reveals (by implication) the information, then something must be said to leave the hearer uninformed. This can take the form of a partially true statement or an ambiguous one, using the Double Effect and intending, not the deception of the hearer, but the fact that he knows no more now than before. If he persists, however, and not even this conceals the information, a false statement may actually be made if there are grounds for believing that the hearer will not believe you (and so will remain uninformed, not be misinformed).

Exercises and questions for discussion

1. If a person's self-determination means that the moral obligation is actually different for different people, how can there be books like this which give rules for everyone?

2. If it is immoral to choose one's own death, then is not the statement, "No one has greater love than this: to give up one's life for one's friend" advice to do what is immoral?

3. A patient claims that he can't go to sleep unless he listens to rock music--which disturbs other patients. You take away his boom box, and he claims you are depriving him of his rights. Are you? What do you do?

4. Why should we respect the rights of a Hitler or a Charles Manson, who has no respect for anyone else's rights?

5. Would a health-care provider have a greater moral obligation than an ordinary person not to smoke?

6. Mr. Clinton complains about the scrutiny every detail of his life gets from the media. Does the fact that he is a "public figure" give him less of a right to privacy (because he has chosen public life, after all) than others? To what extent, and on what grounds, does the "public" have a "right to know"?





7.1. Health care as a profession

It is often stated that health care is a profession, but with basketball "pros" and professional bridge players, it's not all that easy to see what is meant. It is not just, like these "professionals," that health-care providers make money doing something that others do for recreation.

DEFINITION: A profession is a service in which factual knowledge rather than physical skill is what is sought.

Professions, of course, like surgery or optometry, may involve physical skills; but it isn't the skills that make them professions, but the underlying knowledge.

Surgeons, for instance, were originally not considered professionals in this sense, however skilled they might be, and were classified with barbers, because you didn't really (at the time) have to know much about the human body to cut it up and sew it back together. Nowadays, the factual information you have about medicine and anatomy and so on to be a surgeon is considerable--which is by no means to denigrate the skill involved.

The point, of course, is that even though playing basketball "at the professional level" involves skills far surpassing those of us ordinary mortals, this does not make basketball a profession. And even though you have to have a lot of "know-how" to do it, that's not enough to make it qualify, because, there's not a great deal of "know-what" connected with it.

7.1.1. Expertise

Obviously, since health care delivery is a profession, then the providers are expected to have factual knowledge. It follows from this that

Health-care providers have a moral obligation to be as knowledgeable as possible in their field.

Thus, not knowing what you would be expected to know is morally wrong; you have to "keep up with the field," as the saying is. That doesn't mean, of course that you have to know every obscure article that appears in some medical journal in Zagreb. Knowledge is exploding so fast that no one can be expected to know everything even in his own field; so you must morally make only a human effort to do so. That is, there is no excuse for not knowing information in the major journals. (And it is their duty to peruse the little-known publications and report on information that ought to be more widely disseminated.)

Thus, health-care providers must devote a certain amount of time regularly to the reading of journals in their field. This is by no means a waste of time. Malpractice

But suppose a provider doesn't keep up with the field, or suppose he just can't be bothered with the duties expected of him. Obviously, this can result in harm to the patients--which, of course, violates their rights.

DEFINITION: Malpractice is the act of doing harm to someone because of negligence (i.e. failing to do something one would be expected to do).

As with responsibility, which we saw earlier (Section 4.4.), there is both moral and legal malpractice.

DEFINITION: Moral malpractice occurs when a person knows he is being negligent and does nothing about it.

In this case, the person is willing to be negligent, and consequently is willing to do the harm that might come from his ignorance or carelessness. Note that this willingness may be because "he's so busy, he just doesn't have time to keep up with the field." But the end, of course, doesn't justify the means.

NOTE, however, that since the harm that comes from malpractice is the effect of the negligence, then sometimes the Double Effect can justify the danger of harm.

A doctor, for instance, in the midst of a plague, where there are many more people who desperately need treatment than can be taken care of, might (by the fifth rule) be able to justify the possible harm done by not keeping up with the field by the probable harm done by taking time off to do it.

But it has to be some such situation as this; the mere fact that a doctor has more patients than he can handle is not enough to allow him to invoke the Double Effect (since he can give some of his patients to other doctors, and the reduction of his income is never enough to offset the potential harm to patients from negligence).

It is possible, however, to be in fact negligent without having any reason to believe that one is being so, in which case, the malpractice is not moral malpractice, and has no eternal repercussions.

For instance, a nurse on night watch might find that reading keeps her awake, and so (by her usual practice) she reads a novel while she is watching over her patients. She has done this for years, and has found it helpful, and of no danger to the patients. On one particular night, however, she becomes so engrossed in the story that she loses complete track of the time, and does not give her patient a required treatment until two hours after she was supposed to. The patient dies from the lack of timely treatment. In fact, she was negligent, and the cause of it was the novel she was reading. But she had no reason to believe that it would take her mind off what she was supposed to do, and so she is not morally guilty of malpractice.

DEFINITION: Legal malpractice occurs when harm is done to a patient by what would be negligence in "the normal person."

As with legal responsibility, the assumption is that if you did not know something, or weren't paying attention, then you ought to have known it or been paying attention, because this is what a "normal person" in your situation would have done. Of course, legal malpractice depends on how the actual law is written, and it is not our purpose here to go into this.

The point is that it is possible to be legally guilty of malpractice without morally being so

NOTE that if a person has in fact engaged in malpractice, even if it is not moral or legal malpractice (i.e. if it was an "understandable error"), he has a moral obligation to see to it that the victim's harm is compensated for.

No amount of "compensation," of course, can undo the damage that was done (because "good" gets you where you want to be and "harm" puts you below the minimum of normal human existence--we will see this shortly). Nonetheless, as far as possible, the victim is to be brought into a condition in which "for practical purposes" he can do what he was able to do before the harm was done.

The provider can use the Double Effect on this, especially if he is not guilty of moral malpractice, because then he is only physically, but not morally, responsible for the damage. So the restoring process need not cause greater harm to the person who committed the malpractice.

In this connection, the legal practice of "punitive damages" must be condemned as morally wrong.

The reason for this is that such damages (based on willful and sometimes habitual negligence) are for the sake of "sending a message" to the person for the future and to potential imitators. But this punishment for wrongdoing is actually legislation, not adjudication, and it is not the place of the law courts to pass laws.

That is, as we will see later in the chapter on the nurse, being in an organization (or a society) means allowing people to tell you what you must do, and threaten punishment if you don't do it. That is what legislation is. So "punitive damages" in fact are criminalizing the kind of actions; and a criminal offense should be punished as such, not as disguised as a civil action, which is the resolution of a dispute between parties who disagree.

The point of this is that a tort is a private wrong done by one person against another, not a crime: an offense against society (i.e. people in general). But when you "send the message" to people "You'd better not do this sort of thing, or you'll get sued and look what happens if you do," you are generalizing the action and saying that it is one that no one in the society should do to another--thus making in an offense against society, not the individual. That's legislation, and what criminal law is for.

This is a technical point, perhaps. But the practice of adding "punitive damages" to malpractice suits has several bad effects, among which are that of making the plaintiff (and especially his lawyers) rich by what is in effect a new law that is passed by the lawsuit. A person should not profit (i.e. be better off than if it had not happened) as the result of an injury. This only encourages lawsuits against those with "deep pockets."

7.1.2. Referrals

Since the provider is an expert, then obviously there are going to be limits to his expertise. What does he do when he spots something out of his field or beyond his competence?

Providers who have patients with problems outside their field or beyond their competence must refer them to another provider who has the proper expertise.

That, of course, is obvious. You don't try to treat what you're really not competent to treat, on the chance that you might luck out and do some good. But there is a moral implication to referrals.

Providers who refer patients to others must not receive compensation from the others for doing so.

These "kickbacks" put the interest of the provider and the one he refers the patient to ahead of the interest of the patient, which must be paramount. It is morally all right, if the one referred to is a good friend, for the provider to receive gifts of friendship from him as long as these cannot be construed as payment for the service of referring patients.

Generally speaking, such gifts are unethical, (i.e. they violate the codes of ethics of the providers), because they give the impression of being morally wrong and are apt to tempt people into immorality. It is a good idea to avoid them, even when not strictly morally necessary.

DEFINITION: Something is unethical (in the sense in which "codes of ethics" mean the term) if it is morally wrong or if it gives the appearance of doing or creates an incentive to do what is morally wrong.

Thus, if you do something that violates a code of ethics, you are not necessarily being immoral in the act simply taken by itself. Still, if you belong to an organization which has a code of ethics and you violate the code, you are acting inconsistently with yourself as a member of the organization, and for this reason your action would be morally wrong. That is, when you join an organization, you agree to follow the rules; it is obviously a breach of this agreement not to do so.

Thus, it is morally wrong for a member of an organization to violate its code of ethics, even though if he were not a member, he would not be immoral choosing the act.

7.2. Health care as a business

[The subject of business, values, etc. in general is treated at length in Modes of the Finite, Part 4, Section 7 and Part 6, Section 2.]

But the health-care provider is not simply a professional, who has knowledge; he is a "pro" (as opposed to an amateur) in the sense that he does something to earn a living.

DEFINITION: A service is an act performed for the benefit of and at the request of another person, who compensates the one serving.

So you're not performing a service, strictly speaking, if you do something for a person who didn't ask for it. You're just interfering in someone else's life, in this case. In a service, the one served is the one who has the control.

Similarly, it's not a service if you don't get paid (or compensated in some way) even if the other person asks you to do it. If you don't expect to get paid, it's an act of love or a favor. If you don't get paid, but you do it because the other person threatens you with harm if you don't, it's an act of servitude, not service, and you're a slave.

This last is true unless you are in an organization, or under authority. As we will see later (discussing the nurse), when you enter an organization or put yourself under authority, you agree to do certain things without any further compensation than whatever gain you get from being in the organization and sharing its benefits. In that case, the threat of punishment for the particular action is offset by the benefit from being in the organization, and so it's not slavery.

Note that in performing a service, you are subordinating the particular act to the other person, but not your reality as a human being. He controls your act, but doesn't own you. This is Marx's notion of service, which he equates with slavery; he is wrong.

7.2.1. The value of the service

Obviously, if you're going to be compensated for your service, you have to set a value on it, to find out how much you're to get paid in compensation.

This is a very complicated topic (it involves the very foundations of economic theory), and so I will just point out what we need to know to get a handle on the economics of health-care delivery.

Actually, there are two values for any service. But first of all, what are values in general?

DEFINITION: A value is a means toward a freely-chosen goal.

DEFINITION: One value is greater than another to the extent that the goal is more or less important.

DEFINITION: One goal is more important than another if you would give up the second in order to have the first.

Note a couple of things here. We choose the goals the values lead toward (based on what kind of person we want to be). This is a free choice, as I have so often stressed. We also choose the relative importance of the goals by pairing them against each other and pretending we can't have both. The one we pick is the more important, and thus "fits" our notion of ourselves better than the other.

Thus, a person who chooses a college education over buying a BMW obviously considers being educated more important than owning the car (because he could have spent his money on the car instead). Of course, he is probably just postponing the other goal, but the point is that he has chosen the one over the other. This shows that going to college is a greater value than the car.

NOTE: There is no "real value" or "objective value" to anything. Values are always subjective. The same goes for importance. Nothing is "really" or "objectively" important.

Before you bristle at this, I am going to say that some things are necessary. But let us go on for now. It follows from what I said that the server has one value for his service, and the one served another (and almost always different one) for the same service. Here are the two notions of value I talked about.

DEFINITION: The buyer-value of a service is how important the buyer thinks this service is (i.e. what he is willing to give up to get it).

DEFINITION: The seller-value of the service is the cost to the server of performing it.

But "cost" does not mean simply "monetary outlay"; I am referring to what economists call "opportunity cost."

DEFINITION: The cost of anything is what is given up for it.

Thus, the server gives up whatever he could be doing with his time in pursuing his own goals, plus whatever outlays he has to make to supply himself with materials and so on so that he can perform the service.

The buyer, then, measures the service in terms of what he gains from it; the seller by what he loses in performing it. And of course, the seller wants to be compensated, because he doesn't want to be any worse off for performing the service; in fact, he wants to be better off than he would have been if he hadn't performed it, because he's giving up working for his own benefit in aiding this other person.

Now as I say, these two notions of the value of the service may be wildly at variance with one another. You may want the service enough that you're willing to give up most of the other things you value for it; but the server may not consider that he's giving up much at all in helping you out; he may even enjoy it.

So, for instance, you value your education in, say, engineering very highly, judging by the amount you pay for it. But there are teachers of engineering who accept less pay than they could get as engineers themselves, because they happen to like to teach.

DEFINITION: The price of a service is the compromise between the buyer-value and the seller-value.

Now of course, we can assume that the buyer and the seller are real people, and the buyer is quite willing to pay less than he has to to get it, and the seller is overjoyed at taking more than enough to compensate him. The buyer-value creates a ceiling for the buyer, beyond which he won't buy, and the seller-value a floor for the seller, below which he refuses to perform the service. Somewhere in between, they agree on a price.

This is what haggling does. In modern manufacturing societies, the seller (who often has to sell to millions of buyers) can't haggle, so he makes a guess as to what's the highest price he can ask so that enough people will pay it to enable him to sell all he makes--and the buyers either take it (some with joy, because it's way below their idea of the thing's value, others reluctantly, because it's right at their value), or leave it. This is the market price, which has nothing magical about it; it's just the sell-out price. It's a kind of generalized haggling, because if the seller is stuck with inventory, he lowers his asking price; if he sells out too fast, he raises it, and so on.

NOTE that there is no "real" price for anything. Every price, including the market price, is arbitrarily arrived at, and does not reflect the "real" value of the object or service (because it has none).

Diamonds are very costly, not because it takes so much work to get them out of the ground (though that enters into the seller-value), but because people are willing to pay that money for them. Other rocks are just as rare and just as difficult to get, but no one wants them. But, interestingly, man-made diamonds are exactly the same thing as natural ones, but people are not willing to pay the same price for them. A painting that sells for millions is discovered to have been painted by a student of the Master; it's the exact same painting, and now you can't give it away. It can't be stressed enough: there is no real value for anything.

Note too that in any transaction involving values, both parties gain, or there is no transaction. That is, if the asking-price is above the buyer-value, the buyer will be worse off with it than by spending his money on what he values more; so he won't buy it. If it's below the seller-value, then the seller will lose by performing the service, and so he won't sell. Conceivably, the object could be just at one or the other of the values; but if the transaction takes place, then economists say it's marginally more valuable in both cases (otherwise, why agree?).

7.2.2. Values and necessities

If you've been thinking that this is just a wee bit utopian, you're right. There's quite a large fly in the economic ointment, and it deals with the distinction between values and necessities.

DEFINITION: A necessity is a means toward achieving a minimally human existence.

That is, without a value, you can't be the kind of human being you want to be; without a necessity, you can't (in some respect) live a human life at all.

Obviously, there are absolute necessities, like air, a certain minimum of food, and shelter, and so on, without which you die and aren't a human being at all any more. But there are also relative necessities, without which you are dehumanized: that is, forced into a condition where you can't do what any human being would be expected to be able to do because of his genetic potential. Thus, eyeglasses for a person who can see but can't distinguish objects are necessities, because otherwise he's a-person-who-can-see-but-can't-see, and that's a contradiction. That is, without necessities you suffer damage. We saw this concept in discussing rights.

Now then, what are the differences between values and necessities?

First of all, values may be freely given up; necessities can't morally be given up except to avoid deprivation of a greater necessity.

The reason is that values lead to the kind of life you want to live, and that's something you freely choose (and so can freely reject). But necessities are means for avoiding damage to the reality you were "given" by your genes, and we are morally forbidden to do damage to ourselves.

We can, of course, give up a necessity when the Double Effect applies, and by giving it up we can escape equal or greater damage; but the point there is that you don't will the deprivation consequent upon lacking the necessity; you choose to avoid the greater one.

Secondly, a person has a human right to necessities, but not to values. That is, it is morally wrong to deprive a person of necessities, unless the Double Effect applies, because this is to do the person damage.

NOTE that this does not necessarily imply that if you have more than enough and someone you know needs something you have, you have an obligation to give it to him.

The reason is that your not giving it to him does not necessarily deprive him of it, if he can get it either from someone else or by working for it; so if you have a surplus, you are not willing to harm someone else by not helping him out, even if you could do it. You are only willing to do him harm if (a) he can't get it (in practice) any other way than by being given it, (b) you are the only one (in practice) he can get it from, and (c) giving it to him doesn't cause you equal or greater damage.

In fact, giving to someone who can get the item by himself can be dehumanizing to him, because it gives him the idea that "the world owes him a living" just because he exists, when in fact we make a living by serving others, and who is he to refuse to serve? It also makes him dependent on the largess of others (or the government) and so able to relinquish control over his life; but the essence of being human is to set goals for yourself and work to achieve them. He becomes nothing more than a kind of pet of society, like a dog. Thus, you are can be doing a considerable dis favor to a beggar by giving him money. It makes you feel noble and generous, of course.

I hasten to say that it can be a good thing to help others who can help themselves but are temporarily in difficulty--provided the pitfall of creating the "spirit of dependency" is likely to be avoided. But the point is that this is a question of values, and there is no moral obligation here.

Thirdly, necessities are incommensurate with values. That is, a necessity is either of no value at all (if we have it) or beyond all values (if we don't).

Why is this? First, because, since necessities are the minimum without which we can't live a human life, we take them for granted because we are human. You don't want to breathe; you have to breathe in order to be human at all; so breathing is not part of your notion of the distinctive type of human being you choose to be; it is not a goal you have. It is part of the "given" you set out from in working toward your goals. In this sense, the "value" of a necessity is less than that of any value.

NOTE: Necessities are not important. They are simply necessary.

But secondly, if you don't have a necessity, then you have a moral obligation to give up all values to get it, at least to the point where the sum of the values you give up creates equal deprivation. (Values can accumulate into necessities if you have to give up a great many of them.) The reason is that you have a moral obligation not to harm yourself, and you have no moral obligation to fulfill yourself. So in this sense, the "value" of a necessity is greater than that of any or even all values as values.

One value can be measured against another; but no value can be measured against a necessity. "How much is this necessity worth to you?" is a meaningless question, analogous to "How much of the color red equals the tone E-flat?"

The fundamental difference between values and necessities, then, is this: The one without a necessity is threatened with harm if he doesn't get it, and his getting it "gets him back to zero" as far as his human life is concerned. The one without a value is not at his goal, and is no worse off than he is now if he doesn't get it. Thus, he can compare values with each other and give one up to get the other; but he can't compare necessities with values, because you have to avoid harm, but you don't have to be at your goal.

This is a very significant point, which is overlooked in economic theory. Modern free-market economics acts as if necessities are just "very valuable" values (and so justifies their high price based on the fact that buyers are "willing" to pay them--not realizing that the buyer is "willing" only by using the Double Effect, to avoid greater harm, as a robbery victim "willingly" hands over his wallet to avoid getting shot). Communist economics, with its "From each according to his abilities, to each according to his needs" regards values as "not very necessary necessities," and thus tends to ignore the goal-pursuing nature of human life, and to reduce everyone to a state of uniform misery.

7.3. Pricing health care

With all that theory under our belt, how do we go about setting a price on health-care delivery?

First of all, note that health care is a necessity, because an unhealthy person is in a dehumanized condition (by definition: he can't act as he would genetically be expected to be able to act), and so he remains dehumanized unless he receives health care. That should be obvious. It follows that the Liberals are correct this far: People have a human right to health care. In theory, then, it ought to be free; if you have a human right to have it, you shouldn't have to deprive yourself of any goal in order to get it. But when the Liberals go this far, they are going too far, for the following reason:

On the other side, health-care providers have a right to make their living providing health care. Thus, if sick people simply said, "Give me treatment" to the providers (doctors and drug companies), then they would be enslaving them in the process of getting health care. So Conservatives are right to think that "universal health care" harms the providers.

So we have a conflict of rights here. Not really, because rights never conflict, since no one has a right that extends to the violation of anyone else's right. Thus, sick people don't have the right to get health care without paying for it, and providers don't have the right to get paid so much that it deprives sick people of health care.

So some price must be set on health-care delivery. But what price? If we apply what we saw above to health-care, we find that in the transaction, there is a (finite) value for the service on the seller's side, but no value (i.e. either zero or infinity, as we saw) on the buyer's side. The buyer, therefore, can't say what he thinks the service is "worth," because he can't compare it with any value--so he can't haggle. He has to have the service, and so he has to accept any price the seller asks--at least up to the point of greater harm from impoverishment than from the disease.

Now what is the service worth from the seller's point of view? It is not worth whatever the market will bear, as if the provider were a manufacturer guessing what people would be willing to pay. This "willingness" is the "willingness" of a person threatened with harm to avoid the harm, not the willingness of a person pursuing a goal to give up other goals to get it. So the seller must not look to what he can get for his service, but what it is really worth to him.

But what does that mean? As we saw, it is what he is giving up to perform the service: the cost of materials and overhead and so on plus the goals he is not pursuing because he is wasting his time for the sick person's benefit.

That is, the health-care provider must ask himself, "What is the life-style I choose to live, which is the goal of my service? Living this way involves X number of dollars per year. I have Y number of patients per year. Therefore, in order to live my life as I choose, I need X/Y dollars per patient.

"But this patient is poorer than my other patients; thus, charging him the average amount is harder on him than on others. Therefore, I charge him $10.00 less than the average, and make up the difference by charging a wealthy person $10.00 more, because the $10.00 means less to the wealthy person."

Something like this already goes on; but there is another factor that must be included in the equation.

Since health-care is a necessity for the patient, the provider must not set his standard of living so high that he becomes rich from his service--because then he is exploiting the fact that the patients have to pay for his extravagant lifestyle.

DEFINITION: A person is rich when (economically speaking) he can do what the vast majority of people cannot do.

That is, a rich person is economically super-human, just as a star athlete is physically super-human, because for practical purposes he can do what "practically everyone" is incapable of doing. This is the reverse of the dehumanized person, who can't do what "practically everyone" can do.

The point above is that no one has a right to get into an economically super-human situation by taking advantage of the fact that his customers have to pay or else suffer deprivation. Even if the customers can pay, the fact that the provider is supplying a necessity says that they should not have to pay more than what is necessary to prevent dehumanization (by enslavement) of the provider. They have a right to health care, and thus have a right not to pay more than is necessary for it.

This does not mean that the providers have the obligation to charge fees that barely lift them above the poverty level.

That is, people enter a business, not simply to provide necessities, but to get themselves to their self-determined goals; hence, they have a right to more than what is merely necessary to live a minimal human existence; they have a right to what is at least a decent human living. That is, a "middle-class" existence: one that most people who work can live at.

But health-care providers have a right to more than simply a minimally "decent" living because (a) they are educated people (and so of a certain refinement), and (b) they are involved with what is often messy, degrading, and dangerous. Hence, they are giving up more than the average worker in performing their service.

That is, the cost of providing health care is generally greater than the average cost of performing a service. To be handling bodily fluids and excrement (which is sometimes necessary), to be cutting up the human body, to be closely examining people with noisome, disgusting, and highly infectious diseases, it itself something that not many people are willing to undertake, since it involves a considerable sacrifice of their notion of what it is to act in a human way.

Add to that the fact that providers often have spent years in studying and in the process have learned what the higher levels of human living are, and you can see that they in general are more apt to be aware of what they are giving up in performing their service.

Thus, the service of a health-care provider is worth more in seller-value than most other services.

A college professor, for instance, may have spent more time studying than a doctor; and so as far as this aspect of his service is concerned, the seller-value is greater than that of the doctor's. But it is a lot less stressful, disgusting, and degrading to teach a college class than it is to treat diseases; and so, since the teacher is actually giving up less, the seller-value of the service as a whole is considerably less than that of the doctor.

Note that this has nothing to do with the buyer-value of teaching as opposed to health care. Teaching has a finite buyer-value (as well as a finite seller-value); and so a price can be arrived in the market--and the actual price might turn out to be considerably above the seller-value (I may remark that usually it isn't, in the case of teaching). This is fine. The point is that the buyer-value of health care is infinite, and so the price must be based only on the seller-value, and not the "market-value," because the "market-value" is a fiction and a sham; it doesn't exist as a value. The market price never reflects any value.

Then what is the result of this?

Health-care providers have a right to make a "comfortable" living from their service (i.e. live an upper-middle-class lifestyle); but no more than that.

That is, if they see that they are becoming rich by their service, then they have a moral obligation to adjust their fees downward so that they are making no more than a comfortable living.

In addition, providers must see to it that inefficiency and waste is avoided, because the temptation to be wasteful is great, because the payers will be "willing" to pay the higher price for it.

That is, precisely because health care is a necessity, the consumer will pay whatever price he has to to get it. That means that, even if you don't charge so much that you make yourself rich, it's easy to do things in economically wasteful ways, because the money to do it this way will always be available--apparently "willingly," just as patients are "willing" to pay for any necessity.

Thus, each hospital will be able to get the latest bell or whistle of technology, so that it won't be "inferior" to St. Columban's across the street--and it can spend big bucks advertising on TV, so that patients will come there as opposed to St. Columban's. But what that results in is that there are twice or three times as many MRI scanners in the area as are needed, and these enormously expensive machines lie idle much of the day, and that money is siphoned off to advertising and so on, when it shouldn't be available for such purposes, because patients shouldn't have to pay the extra fees that enable hospitals to do such frivolous things.

Thus, health-care professionals in a given area must get together and cooperate to see to it that costs are kept to the minimum necessary to provide adequate health care in the area.

7.3.1. Government and insurance

Now since deprivation of health care dehumanizes people, and since the function of government is to see to it that no one's rights are violated, what is the role of government in the health-care field?

In general, government's role is that of moral suasion: to point out to providers what their duty is and urge them to do it.

Theoretically, if government sees that health-care costs are too high, it could legislate a cap on fees. But since health care is a necessity, this would be counterproductive in practice, because providers could simply refuse to perform the service if they didn't get what they wanted--and the government would have to give in, under pain of being responsible for the deprivation of the treatment.

That is, if you assume that providers are unscrupulous and greedy, then there is no solution to high health-care costs; because no matter what is done, the providers (who have the actual power, since they can withhold necessary services) will simply find a way around regulations to get their way--and the government will have to wink at the violations.

So when the government gets involved in the actual pricing of health care, the last state will be worse than the first.

Well, but can't the government (or even private people) give insurance, so that people (particularly poor people) can get health care without having to pay for it? I mean, if it's a right, why not have government pay for health care? That way the providers get what's their due, and the people don't have to pay (they get what they have a right to have).

NOTE that what is to be said applies to all third-party insurers, private as well as government. It is just that it applies a fortiori to government.

It sounds good, but it is in practice counterproductive, and has moral problems connected with it also. It is counterproductive because the government has exceedingly "deep pockets," and so providers, who would balk at charging high fees to private people, will have no qualms about gouging the government. Secondly, the people are paying in increased taxes; and since the government tends to be profligate with "its" money, these taxes (as we have seen in government health-care programs) will just go up and up and up and up and up. Thus, the problem of health-care costs will get much worse to the extent that the government pays for it.

The moral problem involved here is that the patient as an individual has an obligation to reimburse the person who give him the heath care. That is, the patient is not just "receiving" health care; he is receiving it from this particular provider, who is serving him, not "the government" or "mankind." Thus, there is an economic relation between the patient and the provider that is destroyed when a third party pays the bills. The provider is now serving the payer, and is simply acting on the patient--analogously to what happens when the patient is a child or an animal, as we saw.

And "the one who pays the piper calls the tune." Since the provider is serving the payer, then the payer rather than the patient determines the conditions of the service; and this can sometimes be to the detriment of the patient. (I.e., non-standard treatment called for in this case might be refused. Alternatively, the patient can be receiving treatment that he neither needs nor wants, but "this is the treatment that is called for" by the payer.)

The result is that when third-party insurers pay the bills, (a) costs skyrocket, (b) the relationship between the provider and patient is undermined, (c) necessary but non-standard treatments tend not to be done, and (d) unnecessary but standard treatments tend to be performed.

There is, however, a situation in which a "third-party payer" is morally legitimate and even necessary:

When the patient is not capable of making choices for himself, as with a child or mentally incompetent person, then someone who loves him, a parent or relative should undertake contracting and paying for his service. Thus, the benefit of the patient as a person is safeguarded.

In this case, then since Daddy is paying the bills, the provider is serving Daddy, and Daddy's will prevails (except when he chooses what is harmful to Junior). But the presumption is that Daddy loves Junior, and so this eliminates the evils attendant upon third-party payers.

But with "managed-care" insurance nowadays, we see all of the evils I mentioned above in our health-care mess today, because the ones paying the bills and directing the doctors don't even know the patient, and so tend to be concerned with the "bottom line" (which was why the organization was created in the first place).

What was a fairly decent system fifty years ago was ruined by a "compassionate" attempt to make health care available to everyone. Since enormous riches can be achieved (apparently legitimately) now in health care, it is increasingly the case that people go into the field to become wealthy, and don't enter it as a profession in which their motivation is the benefit of mankind, and they realize that they will live decently from what they are doing. And once the profit motive is the main motive for entering a field that is a necessity, it is inevitable that, as soon as government (or third parties) get involved in it, costs will go right through the roof, because the unchecked market will dictate prices, and the demand is infinite.

So what is to be done?

Some way must be found to return health care to the realm of the provider and patient. The best proposal seems to be that of "medical savings accounts," in which a person has a certain amount of money from the government to spend on health care, and spends it as he sees fit, keeping what is left over for his own use. This, coupled with catastrophic care insurance, can secure the patient's rights while reducing the incentive toward increased costs and waste.

7.4. Control of the service

The fact that health care is a service also implies that it is the patient who has basic control over the service--at least in this sense: He decides whether to have the service or not.

It follows from this that

A patient must not be treated against his will, even if he will be harmed or even die by lack of treatment.

The patient is not an "object of treatment" for the provider; he is a human being in control over his own life. If he wants to make a wreck of his life, then he is not to be stopped from doing so. It's his life.

If a person is going to harm himself, it is immoral not to inform him of what he is in fact doing; and it is moral to try to persuade him not to do it. But, as we saw, it is wrong to force him to avoid doing the harm even if it is "for his own good."

The reason is that "good" and "bad" are defined by the person and are thus subjective, and who are you to force someone to accept your subjective standards? True, harm is something objective (it contradicts the objective reality of the person); but whether harm is bad is subjective.


If a person is not in a position to realize the consequences of his actions, he can be forced not to harm himself.

Thus, psychotic people can be treated against their will, because the information on which they base their choices is distorted or blocked by their mental unhealth. Similarly, children, who have not yet learned that actions have consequences that are completely independent of the intention of the agent, can be forced to do what someone else sees is good for them (meaning, in their case, what will bring them into a position where they can make rational, informed choices about their lives).

But since it is the patient who must decide whether to be treated or not, it follows that

Patients must be given all information relevant to the choice of their treatment.

Otherwise, the choice will be made in ignorance, and the patient may unwittingly do what he would not want to do had he known.

Specifically, patients must be informed:

Of the results of the treatment, including side-effects, and how likely these are to occur. In order to be able to apply the Double Effect, you have to know what the good effects and the bad effects of your action are. This also includes dangers in the treatment, as well as dangers in not being treated.

Whether the treatment is necessary for recovery of health, or is simply beneficial. Obviously, if the treatment is necessary, you have to have it (absent greater harm from having it); if it is beneficial, then it is like any other goal which may be freely rejected.

Whether there are alternative means to the same goal which might be less costly or painful. In general, the provider, as the expert, is in charge of how the problem is to be treated; but when there are alternatives which affect the patient, the patient must be informed.

Who is actually going to do the treating. It is morally wrong for the high-paid specialist to undertake the treatment and actually have one of his neophyte assistants do it "under his watchful eye" unless the patient knows that this is what is going on. This is called "ghost surgery," in which by the time the switch is made, the patient is under anesthesia.

Information learned in the course of examination and treatment which the patient may find useful to managing his life. The patient is not a "subject" the provider is "working on," but a person who has requested a treatment. Therefore, he has the right to know anything relevant about himself that is discovered in the course of treatment. This includes such things as that he is dying, so that he can prepare himself. It is not for the provider (or the patient's family) to "protect the patient from unpleasantness" by concealing such vital information. It also includes whether the provider has made a mistake and the consequences of the mistake, so that the patient can take steps to correct it; as well as whether the provider does not really know what is wrong with the patient; in short, all information which the patient might find useful.

On the other hand, the provider does not necessarily have to inform the patient about things like alternative forms of treatment which do not have consequences for the patient, and might lead to the patient's second-guessing the provider. In general, details of the treatment which are not relevant to the choice of treatment or to the patient's life need not be revealed.

7.4.1. Experimental treatment

There are a couple of topics deserving special consideration under this notion of the fact that it is the patient who controls what the service will be. The first of them is medical experiments.

It is not morally wrong to perform medical experiments, even risky ones, on patients, provided the patient is fully informed and is not pressured by any perceived threat into entering the experiment.

First of all, the patient is the one who is to decide whether he is to take part in the experiment or not; and so he must be made aware (a) that this is an experiment, (b) all the dangers and so on (including non-dangerous side-effects, particularly unpleasant ones) and their likelihood, and (c) whether there is a control group that he might be part of (which, of course, is not going to get the actual medicine).

Second, the patient must not think he is going to be worse off if he refuses to join the experiment. It is not enough to say that there won't be any punishment; the patient must have ample reason to believe that it is true. For instance, prisoners may believe that in theory they are free to refuse without reprisal, but that "in the real world" they're going to suffer for it. Employees may believe that refusing to join the experiment might signal a spirit of uncooperativeness to their employers, resulting in being passed over for promotion, and so on.

Where there is reason to believe that possible experimental subjects will be suspicious of what will happen to them if they refuse, it is morally wrong to recruit subjects. They have to consent freely, in the sense of with no pressure whatsoever.

NOTE that it is morally legitimate to offer rewards for being part of an experiment. A person is still free if offered a reward, since this involves values and goals, which may be freely given up. He is not free if he perceives a threat, since morally we must avoid harming ourselves.

Can experiments ever be done on human fetuses or embryos?

Since human fetuses and even embryos and fertilized human eggs are in fact human beings (and therefore persons), no experiments may be performed on them, since they cannot give free consent.

Now of course the assertion that fetuses and especially embryos and eggs are persons is "controversial," I realize that some may bristle at this blanket prohibition. I intend to prove in the next chapter the point I am making here, which is that experimenting on an embryo or fetus is the equivalent of using an unconscious person as the subject of an experiment. He can't refuse, because he's not conscious. Such experiments are morally forbidden even if they do no harm to the subject.

It is also morally wrong to experiment on any body which probably is not but may be a human being, such as anencephalic babies.

Anencephalic babies are those which have a genetic defect which forms a body without a brain (i.e. without any more than a brain stem, which controls breathing and the vegetative functions of the body). Since this is a genetic defect, and since the genes determine not only the individual "given" traits of the body, but the kind of interaction of the body parts, it can be argued that (since a body without a brain has no possibility of functioning as a human being), the body is not in fact organized with the human unifying energy, in spite of the fact that both of its parents were human. We know that there are some living bodies (human cells grown in a tissue culture) which have human genes, but are not in fact living a human life, because what unifies them is not the human unifying energy.

Still, since (a) this unifying energy cannot be directly observed, and (b) since it is possible that the unifying energy is human but just can't express itself properly because it doesn't have the proper organs to do so, there is reason to conclude that monster births such as anencephalic children are human. The argument that they are is, I think, much weaker than the argument that they aren't. But it is reasonable, and so this leaves an objective doubt as to whether they are human or not.

But to experiment on them would be to act with an unclear conscience, which would mean to be willing to do a morally wrong act. And that, of course, is always immoral. And since the question cannot be settled, the doubt will always be there; so they must be let alone.

Now then, there are a couple of moral considerations about the experiment itself:

No experiment that involves actually doing harm to any person may be performed, no matter what the benefits to mankind may be.

This should be obvious, because you would have to choose the harm, since it is the means to the good purpose, and the end never justifies the means.

Persons in a control group must receive standard treatment for illnesses they have.

This is actually a kind of corollary of the preceding. It would be nice if you could have control groups who got simply a placebo and received no treatment at all; because giving them the standard treatment for what is wrong with them will complicate the experiment. But that would be the equivalent of choosing harm to the members of the control group, because (a) they are in a dehumanized condition, and (b) you can get them out of it (or relieve them), but you are keeping them in this dehumanized condition "for the sake of science and the benefit of mankind." You can't do that.

7.4.2. Mutual respect

Since the provider is at the service of the patient, even though it is the provider who is the expert, he must treat the patient with the deference due to any human being. Specifically,

Health-care providers must be on time for appointments they make with their patients. If they cannot keep an appointment on time, they must inform the patients, give the reason, and let them know how long the delay is likely to be.

Doctors are apt to think that, because they deal with necessities, their time is "very important," and that if it's a question of the doctor keeping the patient waiting or the reverse, then "obviously" the patient's convenience yields to the doctor's.

Remember, however, nothing is objectively important. My time as a teacher (particularly of ethics, where I deal with eternal happiness and misery) is just as valuable (i.e. as valueless) as that of any doctor. There is reason that I should yield my time to him.

It is true, however, that doctors deal with necessities; and so if I demanded that the doctor keep his appointment on time, which would involve his giving short shrift to the one before me, then I would be willing to have him possibly harm other patients for my sake, which is clearly immoral. So, yes, I do morally have to yield to the doctor when he is late. The assumption behind this, of course, is that the doctor was delayed because of some necessary service--some emergency, for instance--to others, and not because he wants to take time off to listen to Rush Limbaugh.

But if he's going to be late, he owes me the courtesy of informing me, and of telling me how late, so that I can do something better than read back issues of Newsweek with the time before I see him.

The practice of overscheduling appointments "on the chance" that someone might not show up or that some might be very brief, and then the doctor might have some idle time, is morally wrong and must be stopped.

This would be another instance of the doctor's considering himself and his time as somehow "above" that of his patients.

7.5. Quackery

The fact that the patient is the one in control of the service might seem to imply that he has the right to choose treatment that is "controversial" when in fact it is known that there is no medical benefit from it, and any "cure" comes from the placebo effect.

Because it is easy to deceive people desperate for a cure with fake treatments that sound plausible, it is morally legitimate for government to outlaw such quack "treatments" and allow only treatments that have objective evidence that they are medically effective.

The assumption, when a person chooses some "treatment" he has heard touted by advertisers and promoted with anecdotal "evidence" of cures, is that he wants to get better. But even if the treatment is safe and does no harm, if there is no objective evidence that it will actually do what it is said to do, then providers may be forbidden from offering it to people, on the grounds that what they are persuasively offering is a lie and a deception. No one has a right to be harmed, since a right is a moral power; and deception is an objective harm. Hence, no one has a right to be taken in by these quacks, even if he wants to be.

Summary of Chapter 7

A profession is a service in which factual knowledge rather than practical skill is sought. Since health-care delivery is a profession, it follows that the provider, as an expert, must be as knowledgeable as possible in his field, which means that he must devote some time regularly to reading the major journals.

Malpractice is the act of doing harm to someone because of negligence; with moral malpractice, you know you are negligent and do nothing about it. In cases of emergencies, like plagues, the Double Effect can sometimes justify the danger that one might (because of distractions) do harm. Legal malpractice occurs when harm is done by what would be negligence in "the normal person." Any person who engages in malpractice (even if not moral malpractice) has a moral obligation to compensate the victim: to bring him as far as possible into the condition he would have been if the harm had not occurred. The legal practice of "punitive damages" for willfully negligent people is morally wrong, however, because it is passing laws from the courtroom. No one should profit (be better off) from being harmed.

When a problem is outside a provider's field of expertise, he must refer the patient to someone competent to treat it; but he is to receive no compensation from the other person for his act of referring. An act is unethical if it is either morally wrong or gives the appearance of being so, or creates an incentive to do wrong. A person belonging to an organization is being morally wrong if he violates its code of ethics (even if the act in itself is not wrong) because he is inconsistent with his agreement to obey the rules.

Health care is also a business, engaged in to make money. A service is an act performed for the benefit of and at the request of another, who compensates the server. Thus, the service has two values. A value is a means toward a freely-chosen goal. X has a greater value than Y if the goal is more important: if you would give up the other for this one. Since goals are subjectively set, there is no real or objective value or importance to anything. The buyer-value of a service is how important the service is to him (what he would give up to get it); the seller-value is the cost (what is in fact given up, including time) of the service to the server. The price is the compromise between the two values; there is no "objective" price or value for anything. In any transaction involving values, both parties gain, because if they don't, they won't enter the transaction.

But necessities, means for achieving a minimally human existence, are not the same as values. (1) Values may be freely given up; necessities may not be, except using the Double Effect to avoid deprivation of greater necessities; (2) We have a human right to necessities, but not to values. This does not imply that we have to give necessities to others unless they can't get it by themselves or from someone else. It may be good to give to them, but it is not necessary, and can even be dehumanizing by depriving them of taking control of their lives. (3) Necessities are incommensurate with values; they have zero value if we have them, and are beyond all values if we don't. Necessities are not important, they are necessary; we don't want them, we take them for granted and have a right to all of them.

Health care is a necessity, and hence a human right. But the provider has a right to make a living from his service, or he is a slave. But since the value of his service is the only value (the buyer-value is infinite), he has to assess what he is actually giving up in performing the service and charge accordingly, adjusting also his fees so that the poor are charged less than the rich (who are hurt less by a higher fee). Since health-care providers must be educated, and since their service is often messy, risky, and degrading, they are giving up more than most by their service, and so have a right to a "comfortable" living (an upper-middle-class one), but they can't morally make themselves rich (economically superhuman) from it. Providers must also see to it that waste and inefficiency are reduced as far as possible.

Government's job is to exercise moral suasion in this matter; if it gets involved in setting prices, they will be immorally high. Using third-party payers is also morally wrong, because they make the provider serve the payer rather than the patient, and relieve the patient of his obligation to the provider; and practically speaking, they greatly increase prices. (If a person is not mentally competent, third parties [relatives] who love the patient may morally contract for the service.) The best solution to the "managed care" mess is that of catastrophic insurance plus "medical savings accounts," by which people are given a certain amount of money which they use to directly pay their bills (and can keep if they don't use it all).

Since health care is a service, the patient has basic control. He may not be treated against his will, unless he is a child or mentally unhealthy in such a way that he can't be expected to realize the consequences of his choices. Patients must be given all information relevant to the choice of their treatment: (a) what the results and side-effects are likely to be, (b) whether the treatment is necessary or only beneficial, (c) who is going to do the treating, and (d) information relevant to the person's life learned in the course of the treatment, such as whether he is dying, whether the provider made a mistake, whether the provider knows what is wrong with the patient.

Medical experiments are not morally wrong as long as the subject is fully informed and perceives no threat of any harm if he refuses (he can be offered rewards, but not think he will be harmed). Since human fertilized eggs, embryos, and fetuses are persons, they may not be experimented on, since they can't give consent. Dubiously human bodies, such as anencephalic babies, must not be experimented on, since to do so one would have to be willing to experiment on another human without his choice. The experiment cannot actually do harm to the subject as a means to achieving its goal; and members of control groups must receive the standard treatment.

The patient also deserves respect as a human being who is in control of the service. Providers must keep appointments on time, except when necessity dictates a delay; in which case, they must inform the patients, and let them know how long the delay will be, so that the patients can use their time productively. Is morally wrong to overschedule appointments to make sure that the doctor is kept busy; this is putting him "above" the patient.

Quack "treatments," which can't show by objective evidence that they do any good, may be outlawed by government, even if patients want them; because they want them because they have been deceived, and deception is an objective harm, and no one has a right to be harmed, since a right is a moral power.

Exercises and questions for discussion

1. A provider discovers a new treatment for a disease, but refuses to publish it because others might use it and deprive him of the patients he will get if he is the only one who knows how to do it. This is certainly selfish, but is he being immoral?

2. A patient has told you that if he finds out he has cancer, he will commit suicide. You discover that he has an incurable cancer, with about two years to live. Should you keep this information from him to prevent his choosing to kill himself?

3. To say that a provider can't morally make himself rich from his practice is to say that the really outstanding providers can't get the recognition that they deserve, and is to put them on a lower plane than basketball players and movie stars. How just is this?

4. If parents are responsible for their children's welfare, and the provider is serving the parents in treating the children, to what extent must the wishes of the parents prevail over the interests of the child, if any?

5. Can a doctor refuse to treat smokers, on the grounds that if they didn't want to get lung disease, they shouldn't have smoked?

6. But doesn't the outlawing of quackery mean that unconventional treatments which go against established medical practice (but which nonetheless work and are breakthroughs) will be suppressed. Why should we deprive patients of treatments that might save their lives?



8.1. The physician

The questions we have so far treated apply to all health-care providers: doctors, nurses, psychologists, dentists, researchers, and so on. We will now be getting more specific, and will begin with ethical issues mainly faced by those people called "doctors": physicians. Of course, what is said will apply to all providers who deal with the aspects of the patients we mention.

DEFINITION: A physician is a person who serves other human beings by seeing to their physical health.

Obviously, veterinarians are "physicians" of animals, where as physicians as such treat human beings. Physicians differ from psychologists in that they deal with physical health, while psychologists and psychiatrists deal with mental health. This is not to say that the physician doesn't care about his patients' mental health; it is just that he is not specifically trained to treat it.

The first question that arises about the physical status of a patient is his life.

8.2. What human life is

[For an in-context discussion of this topic, see Modes of the Finite, Part 3, Section 1, Chapter 7, and especially Part 3, Section 3.]

The primary question here is one whose answer can be scientifically arrived at, but by the science of philosophy, not that of medicine or even, strictly speaking, biology. Philosophy uses biological evidence, but the biological evidence turns out to be such that it can't, by itself, say what life is, or what constitutes human life as opposed to the life, say, of a human cell in a tissue culture. But this does not mean that the philosophical answer is a matter of opinion or is not scientific, or is "up for grabs."

Now, to be sure, physicians are more interested in when a body is living a human life than in what human life in fact is; but they are increasingly facing issues in which apparently human things are being "defined by society" as not human (as no longer human, or as not yet human, or as something other than human); and unless they have a clear notion of what makes a body a human body, they will be parties to the kind of horrors we found in Hitler's Germany--which, after all, was the result of the society's "definition" that Jews weren't really human.

So the issue is crucial, and it is essential to have objective evidence about it.

DEFINITION: A body is alive when its parts are interacting in such a way that the body functions as a dynamic whole.

That is, the objective difference between a living body (any living body) and a corpse is that the living body is a dynamic unit. It does things as a unit, and is not simply a set of parts that happen to be connected together. When the body ceases to function as a unit, even if some parts are still active, it is dead and a corpse. No biologist would dispute this. Thus,

DEFINITION: the life of the body is the interaction of the parts: its unifying energy.

This is what philosophical and religious writings are actually referring to when they talk of the "soul." The human soul, as was implied by the arguments in Chapter 3, can act without organizing a body (and so is immortal); but what it is as a soul, is precisely the energy uniting the body (the interaction of the parts), without which the body is an inert lump of decaying flesh.

Biologists generally recognize (because it is obvious) that when the body is alive, its parts are interacting, and when it's dead, they're not; and so they should have no problem with the "soul" in the sense we mean it. But I'm not going to use the term, because they get understandably nervous in talking about a spiritual soul in the human body, which can exist and act without the body at all, because the evidence that this happens is not biological. And they think it makes the soul a kind of "something" that is driving the body, rather than simply the way the parts of the body are behaving together or "cooperating," if you will, so that the whole body acts as a unit. But the latter is what we mean, even though it turns out that in the case of the human being, this interaction goes beyond being a mere interaction.

One thing we can observe about the unifying energy of any body is this:

The unifying energy keeps the body at an energy level higher than can be accounted for by the physics and chemistry of the parts themselves.

Obviously, if this is the case, it follows that when the parts are not interacting in a living way, then the parts themselves, which were maintained in an unstable, high-energy state by the unifying energy, will move down to their natural physico-chemical equilibrium. Thus,

Decay of the parts (i.e. going back to their lowest, "ground-state" equilibrium) is a sign that the body is not alive.

We are getting into medically useful territory already. But we have not settled the question of when the body is living a human life, since obviously there are many kinds of living bodies, all of which are alive. The next step is this:

The kind of living body is determined by the kind of unifying energy it has.

This has to be the case, because bodies in fact change their parts all the time (by eating and getting rid of waste) and are recognizably the same living body, even though their parts are different. Bodies can live even with inorganic parts, such as plastic hearts, as long as they perform the same function as the original part of the body does.

The problem here, however, is that the unifying energy (the interaction of the parts) is not observable from outside the organism, for the simple reason that it unifies the parts into a whole and excludes from the unity any "foreign object." Hence, any measuring or observing instrument introduced into the body to get a look at it would automatically not be acted on by it, because it would be recognized as something not to be unified into the body.


We must use indirect evidence to find out what kind of energy is unifying the body.

To do this, we know that the unifying energy makes the body function as a distinctive unit. Therefore, the behavior of the body argues to the kind of unification it has.

But we know that sleeping people are still human beings, fundamentally capable of doing human things; and so they must be still organized in a human way.

Thus, distinctively human behavior is a sufficient condition for knowing whether something is a human being; but it is not a necessary one.

That is, if something that looks human is talking or playing the piano, then it must be a human being, because only human beings can do that. But if it's not doing this, or even any other distinctively human act, it doesn't follow that it's not human (because the person could be asleep).

We also know that no organism that does not have in its cells the human genetic structure is a human being; because only bodies with this type of genetic structure ever exhibit human activity. Hence, here we have a necessary condition for being human: without it you aren't one.

But human corpses have the human genetic structure in their cells, and human cells (e.g. skin cells) grown in a tissue culture also have the full human genetic structure and are alive. But they are not human, because they can never do anything but what skin cells can do, and so are not fundamentally capable of human behavior. So not everything, and not even every living thing, with the human genetic structure is a human being.

Thus, though having the human genetic structure in the cells is a necessary condition for being human, it is not a sufficient one. Hence, it is not what human life is either.

Then where does that leave us? Presumably, with the fact that the genetic structure of an organism limits the unifying energy to being nothing more than (a given example of) a given type of unifying energy. So we were right in saying that it has to be the kind of unifying energy in the organism as a whole that is the "kind of life" the body is living.

And this discussion allows us to conclude the following:

If a body is a living body (i.e. functioning dynamically as a unit), and if it is a whole organism, and not a part that is artificially nourished and kept alive, and if its cells have the human genetic structure, then the presumption is very strong that it is a human being.

This does not absolutely settle the issue, however, since there are organisms like caterpillars which obviously are living bodies; but they turn into butterflies, which, with the same genes, are obviously dynamically organized in a totally different way, arguing to two different forms of unifying energy at different times in the same organism. This shows that a given genetic structure can be compatible with more than one unifying energy.

How would we be able, then, to settle the issue? By seeing why we argue that there are two different unifying energies in this case. And we argue this way because (a) the unifying energy builds a unit with different sets of organs (as the caterpillar has no real legs and many pseudo-legs, no wings, and so on, while the butterfly has six legs and wings), and (2) these organs adapt it to different living activities such as crawling and flying, eating leaves or eating nectar, etc.

If a body went through "phases" but still was fundamentally capable of doing the same things, especially if it had organs that seemed to adapt it to doing the things it was only later actually going to be able to do, then this would argue to a single unifying energy on both sides of the change of phase.

Thus, a boy before puberty and a youth after puberty are very different in many respects; but the prepubescent boy already has testes, even though these do not produce sperm, and so make no sense for his life before puberty. The organ is activated after puberty, but it is there before puberty, arguing to the fact that even before puberty, the body is already organized as a sexual kind of thing. That is, no one calls a ten-year old not human because he can't do all the things (specifically sexual ones) that an adult human can do--because he can do so many distinctively human acts that there is no real doubt that the body is organized in a human way.

Hence, the only reason for saying a body has different unifying energies at different times is if it has different sets of organs at different times, adapting it to entirely different sets of living activities.

Before going on, let me make this very clear:

While it is not absolutely straightforward to say whether X is a given kind of being or not, it is not a matter of "choice," any more than it is a matter of choice that the earth is round, or that bodies are composed of atoms. It is something that is objectively and empirically discoverable, not something for you or for "society" to "create" by its perception of things.

So Hitler was absolutely wrong when he proceeded to read Jews out of the human race; and even though the German people went along with him, they were objectively wrong too. Jews, just like any other human being, have the human genetic structure in their cells--which is observable under a microscope--have basically the same organs as any other human being, and behave because of those organs in basically the same way. The shape of their noses is irrelevant, just as is the color of skin of a Black person or the shape of a Japanese person's eyes.

We all believe this. Now you have seen the objective evidence that what you believe is factually true.

8.2.1. Abortion

Now let us apply what has been said to the beginning of life. We can immediately say this:

Human sperm and human eggs are not human beings.

Why? Because (a) they don't have the full human genetic structure (each has only half the human chromosomes), (b) they have none of the human organs, and (c) their life activities are completely different from human ones. Actually, no one since ancient times doubts any of this.

In ancient times, it was thought in some circles that the sperm was a kind of "seed" (that's what the word means, actually) of a human being, with a "homunculus" ("little human being") wrapped up in it, the way a chicken can sometimes be seen inside an egg shell just before it emerges. But the biological evidence against this now is overwhelming.

Then does human life begin with the zygote: the fertilized egg, or is this and the embryo like a caterpillar, which only later will be reorganized into a butterfly.

The problem with a theory that asserts this is that the very earliest organs seen to develop are organs that make no sense for the life inside the uterus. Granted, the very first visible organ is the heart, but the second one you can see is the eye. Why have an eye, if there's nothing to see? And very rapidly, the embryo develops all the other organs like ears, mouth, lungs, stomach, hands, legs, etc., etc., none of which are of any use to an organism that is being fed "intravenously," so to speak, by the umbilical cord, and has nowhere to walk and nothing to grab. The only organ which is specifically adapted to life inside the uterus, in fact, is the umbilical cord itself, which is obviously an IV tube, necessary because the organism is not adapted for life in a watery environment.

Since this building of organs only adapted to extra-uterine life happens from the very outset, there is no reason for saying that the human body is ever organized in any pre-human way.

Thus, if the fertilized egg/embryo/fetus is a living unit, then it is a human being, and therefore a person. But perhaps it is a part of the mother, and is living with the mother's unifying energy, the way the other parts of her body are.

The problem with this is that a living body is primarily a unit, which means that the parts function for the sake of the whole organism. So if the embryo/fetus is a part of the mother, it would have to be functional for the good of the mother's body.

But the biological evidence dealing with this is the following: (a) The mother's body tries to reject the implantation of the embryo, which (like a tapeworm or other parasite) produces chemicals blocking the rejection. Thus, the mother's body is treating the embryo as a foreign, invading body. (b) The early development of the body tends to cause "morning sickness" in the mother, which mothers can tell you is hardly something that is beneficial to the mother as a whole. (c) The embryo in developing will take chemicals (such as calcium) from the mother's body if the mother doesn't take enough in as food, and the embryo will develop normally at the expense of the mother. (d) Occasionally, the blood of the mother and the embryo are incompatible (different rhesus factors), such that if they mix, the mother's blood will kill that of the embryo.

Hence, there is no evidence that the egg, embryo, or fetus ever functions as a part of the mother's organism, and abundant evidence that it is a foreign body which happens to be inside the mother.

But is the embryo, at least, actually a living unit, or is it like the cells in a tissue culture, which have no dynamic unification among themselves. Some biologists have argued from "twinning" in early fetal development that at this stage, the embryo is actually a mass of cells, not a unified organism.

What twinning means is this: At the earliest stages of development, if you separate the cell mass into two parts, each part will grow into a whole organism, the identical twin of the other (obviously, since they have absolutely the same genetic structure). This is, in fact, how identical twins occur. But if they grow into separate, distinct units, then they couldn't have been a single unit beforehand, could they?

Oh, yes, they could. If you take a mature geranium plant and cut off a branch (which clearly was unified into the whole organism as a part of it) and put it in water, it will put out roots; and then you can plant it, and Voilà! An identical twin of the plant. You can cut the arms off a starfish, and each arm will grow into a whole starfish, and the starfish will grow back the missing arm. But that doesn't mean that a starfish is "an unorganized mass of cells." It clearly has unified, integrated behavior; it's just that its unifying energy (which obviously, as the interaction of the parts, permeates the organism) is not destroyed in the part when it is taken off, and so can regenerate replacements for what is missing.

This is potentially the case with any organism, since it built all its parts in the first place; it is just that when organisms get very complex, there isn't enough energy available to regenerate parts and cause all the behavior that the organism is capable of; and so it sacrifices the one for the other.

And there is the fact that, from the very beginning, embryonic development occurs in a definite, regular, systematic way, in an unbroken sequence right up to adulthood. So, once we see that "twinning" can occur in organisms which clearly are units, we can say:

There is ample evidence that the fertilized egg/embryo/fetus is a dynamically organized unit, and so is a living body, distinct from the mother.

And since, as we saw, the unifying energy of this body can't be other than the human unifying energy,

The human being begins to exist as such at the moment when, at fertilization, the human egg's organization is disrupted and the body begins developing toward human adulthood.

So a human embryo is not a "potential" human being; he is already an actual, living human being, and, as we saw, since anything organized as a human being is a person,

The human egg/embryo/fetus is a person, with all his human rights, including the right to life.

Now then, let me take up the arguments on the other side.

First, "a woman can do what she wants with her own body." But, even if this were true, a pregnant woman is two people. What she does to her fetus is done to a different body, not her own.

"Abortion is a private matter, between a woman, her God, and her doctor." But since abortion involves a third person, it is no more a "private" matter than a mother's killing her six-year-old in the "privacy" of her home is a private matter.

"No one should impose his moral values on anyone else." Then the woman should not impose her values on the fetus by taking his life. Abortion opponents are not trying to make women live up to moral standards; they are trying to protect people (fetuses) from being destroyed because the mother is subjecting them to her mistaken moral standards.

"A fetus is no more a human being than an acorn is an oak tree." An acorn is organized in a different way from the way the young, developing oak is organized, and it will stay an acorn forever unless it is planted. The fetus must develop into an adult or die.

"Don't be silly. Embryos look more like fish than human beings. No one can call that a human being." It isn't the way something looks that makes it human. That same "argument" was given for "proving" that Black people "couldn't" be human beings.

"The rights of the mother are more important than the rights of the fetus." No one's right ever extends to the violation of anyone else's right.

"Well, maybe the fetus is biologically 'human,' but it's clearly not a person, because it can't exercise its freedom the way people can. Then sleeping people lose their personhood, and with it their rights; so you can kill them too.

"But personhood isn't an all-or-nothing, black-or-white thing; people develop; and at the early stages, there's no real, practical difference between an embryo and a tadpole." Or between a three-week baby and a frog. If personhood depended on whether a person could exercise his freedom, then all you'd have to do to take personhood away would be to tie somebody up. Granted, the personality of a person (the way he interacts with others) develops; but personhood (the fact that something is a free being) and personality are very different things; and it is personhood, not personality, that is the basis of rights.

"Who is going to take care of all these unwanted babies?" Ask that same question of the unwanted six-year-olds, and see if the answer is, "Then kill them."

"But even if fetuses are people, there are some times when you are forced into a tragic choice, and a person has to be sacrificed for the greater good." Beware. Hitler is just three steps ahead of you down that road. The end never justifies the means. Once you deny this principle, any morally wrong act, however heinous, can be justified.

"This is just another instance of men oppressing women." Half of the people killed in abortions are women. Killing is pretty oppressive.

"I'm not pro-abortion, I'm pro-choice. I don't favor having abortions, I think they're abominable, but I think women have to have the option, if contraception fails." It's only that choice that matters. What about the choice to do drugs? To have five husbands? To become a prostitute? To smoke? To carry a gun? To kill her six-year-old? You really think women should have the option to kill people?

"Well, it's only your opinion that fetuses are people." Then why are there laws protecting your life? it's only your opinion that you are a person (prove it); and if someone doesn't think you are and wants you out of the way, then they should have the option of killing you.

"But it's not just my opinion; the majority of people agree with me." We're back to Hitler's Germany again.

"But the point is that this is a moral matter, and you shouldn't have a law against it." Killing you is not a moral matter? If it is, there shouldn't be a law against it?

These are the actual "reasons" given for allowing abortions. As you can see, many of them refute themselves and those that don't ignore what is being done in an abortion. There are in fact no serious arguments that the fetus is not a person, which is, of course, what would have to be established beyond a reasonable doubt in order to make killing fetuses allowable.

Then why are people arguing this so fervently? The basic reason is that a woman cannot be equal in sexual irresponsibility to a man unless she can kill her children and get away with it. It is a question of what the feminists insist on calling "reproductive freedom," and you have to understand where they are coming from if you want to grasp their mindset.

A man can impregnate a woman and not even be aware that he has done it. There are no biological consequences for him. But a woman who gets impregnated obviously has consequences. So she can't be as "free" as the man is unless she can get rid of the consequences (supposing the contraceptive not to have worked) before they become burdensome.

But if she can't be as "free" as the man is, she is unequal to the man in this respect. Hence, the option to have an abortion must be available, or women are unequal to men.

That's the logic--such as it is--of their position. The obvious answer is that irresponsibility is not a measure of superiority, and instead of perpetrating horrors to make women as evil as men are, they should be working to force men to take the consequences of their sexual activity: to take care of any children that result from their acts.

Note that it's not only the slaughtered children who suffer from the blindness of women who are trying to be "equal" in this way. As I write this, the National Review reports that the evidence about the safety of RU-486, the so-called "abortion pill" is being falsified. When it was reported, for instance, that there were "no complications" from a clinical test, and one doctor declared that this could not be true, because he himself had treated at least one woman who had lost a lot of blood from the pill, the answer was, "We didn't mean that there were no complications to the subjects; we meant that there were none to the test.

So the pill will probably be approved as safe when it isn't. Once you buy a big lie that actually kills people, what's the problem with little lies that only cause things like bleeding?

But enough of this. The point is that

It is always immoral to choose to kill a fertilized human egg, embryo, or fetus, for any reason whatever. The only time he may be killed is when the Double Effect allows the death to be kept out of the choice.

But it never does, does it? After all, you can never say that the fetus is an "unjust aggressor," and so killing in self-defense wouldn't arise. This is not so. Though the fetus is clearly formally innocent (because he can't make a malicious attack against the mother), the fetus's development inside the mother conceivably could in fact bring about her death. For instance an ectopic pregnancy (one where the fetus implants itself in the fallopian tube instead of the uterus) will result in the mother's death if the fetus is not removed before viability.

Now traditional ethicians get around the difficulty of "killing the fetus" by removing the whole fallopian tube (with the fetus inside) on the grounds that "there's something wrong with the organ," and so you're removing a diseased organ, which happens to result in the death of the fetus. They call this "indirect killing." But in fact, there's no "diseased organ" there; what's wrong with the organ is that the fetus is growing in it, and the fetal growth (here) is killing the mother. So the cure is really not to take the tube out, but the fetus.

But the point is that you don't have to pretend that the organ is the problem to make this (like all cases of self-defense) "indirect killing" (i.e. killing in which the death is not chosen). First, in self-defense, whether the attacker is innocent or guilty is irrelevant. Innocent or guilty, he has a right to life, because the right follows from his humanity, not from his virtue or vice. Hence, he can't lose the right. But, as we saw in discussing the Double Effect and rights, you can perform an act which results in the death of an attacker without choosing the death.

So in all cases where a fetus's development (for whatever reason) will with moral certainty result in the death of the mother (i.e. barring a miracle) before the fetus can survive a normal or Caesarean birth, then the fetus may morally be removed from the mother even if this results in his death. It is the removal of the fetus which saves the mother, not the death (babies have survived abortions, after all), and so the death is not the means for saving the mother's life. And in the case we are discussing, where the mother will die before viability, it is either remove the fetus and choose the mother's life, or do nothing and have both die.

But in cases of removing the fetus, the means of doing this that involves the least damage to both parties (mother and child) must be chosen.

Current abortion practices of killing the baby with saline solution (i.e. acid, in effect), or pulling him apart limb from limb may be safe for the mother, but are incredibly barbaric. We don't kill rats that way. It may be that the only decent way to save a mother's life and not butcher her child would be for her to have a hysterectomy, which would, of course, render her unable to have any more children. But a child is not to be sacrificed so that Mommy can have a different one that she'd like better.

8.2.2. Fetal tissue experimentation

Well, supposing abortions or miscarriages (which medical people call "spontaneous abortions) have occurred. Use of this tissue for experiments or medical purposes does not fall under the prohibition against experimenting with live fetuses (which we saw in the preceding chapter), because this is dead tissue, no longer a person with rights

Is it all right to use the tissue for research, or for medicines, since fetal cells have properties that are lost later on in human development? There is, for instance, a theory that introducing fetal brain cells into an adult brain with Parkinson's disease might trigger the development of neurons that would correct the problem.

There is no moral problem in itself with using fetal tissue of bodies that have not been killed for the purpose (which would obviously be wrong, since the end does not justify the means), but the Double Effect would permit tissue only from miscarriages, not from abortions.

The reason is that in the real world, the fact that "something useful" can be done with the tissue would provide an incentive for a woman to consider an abortion. Perhaps she would not get an abortion just for that purpose; but it could form a reason which would tip the scales for her. Thus, it tempts people to do what is morally wrong; and since this is the case, it is an evil side-effect of the act, and one serious enough (since it is in fact a temptation to commit homicide) to negate the beneficial side-effects from using the tissue.

If tissue only of miscarriages is used, then this incentive is not present; and hence, there is no problem with using it for experimentation and possible cures.

8.2.3. "Test-tube babies"

Sometimes a woman can't have a baby by normal sexual intercourse (say, because of a blocked fallopian tube); but it is possible for her to gestate a child if an egg is removed and fertilized (in the "test tube"; actually, a Petrie dish), and then placed within her uterus, where he implants and grows. Is there anything wrong with this?

First, there is nothing morally wrong with technologically assisting the act of sexual intercourse from doing what its function is. You just can't contradict any of its functions in the process.

Thus, if a man's sperm is too weak to reach the egg, then sperm deposited in the woman may be propelled by a syringe closer to where the eggs actually are. So the fact of assisting someone by technology in having a baby is not the problem.

The real difficulty here is that in the process of creating the fertilized egg, many eggs must be fertilized, only a very few of which will be implanted. But every one of those fertilized eggs is a person. Thus, many human beings are caused to exist and then let die simply for the satisfaction of the mother's gestating a baby of her own.

The deaths of all the people (the fertilized eggs) involved in the process of external fertilization, while not the means toward the good effect, is an evil effect far outweighing the evil of the woman's disappointment in not having a baby of her own.

Other methods of having a baby, such as artificial insemination, will be discussed in the section on the patient's physical integrity. This one belongs here, because it is a question of ignoring the life of the human being at its beginning.

8.2.4. Monsters and mutants

To form a transition between the beginning and the end of life, let us note that not every birth is of a healthy, normal baby; and some are of things that are so grotesque that it is reasonable to say that they aren't human at all. What are the moral issues here?

Any living organism resulting from the sexual intercourse of two human beings has a presumption in favor of its being a human being (i.e. dynamically organized in a human way), however defective it may appear. Hence, unless there is evidence that this is something so far removed from any human resemblance that there can be no doubt, the organism must be treated as human, under pain of being willing to kill what might in fact be a (defective) human being.

That is, if what is born is simply a leg, then even if it has living cells in it, that's certainly not a human being. But an anencephalic baby (one without anything more than a brain stem inside the skull) might have the human unifying energy, which for some reason was blocked from forming a brain; in which case it would be a human being.

Obviously, this is a matter of the people's conscience. Where some would find a reason to doubt, others would not; and both sides can be justified in extreme cases like this. The point is that the moral course of action is to give the benefit of any doubt to the organism.

This implies the following, however:

No organism which is dubiously human may be killed in order to provide fresh organs for transplants. Even though it might not be killing a human being, it also might be, and so one would have to be willing to commit homicide for a good purpose. This is morally illegitimate.

So the people who have qualms of conscience about "harvesting the organs" of anencephalic children (taking out hearts or livers, etc. while they are still alive) to save others' lives are right on the money. They must be allowed to die naturally (we will discuss this shortly); and if this makes the organs unusable, then so be it. Even if the end is saving lives, it never justifies using a morally wrong means, still less that of choosing to snuff out a life.

8.3. Death and dying

Nowadays, it is more or less taken for granted that death "is" the cessation of brain activity. If that is so, then there are plenty of cases of resurrection from the dead, because it is not uncommon for a person to recover consciousness (and even health) after his brain has stopped acting for a minute or so. "Oh, well," is the answer, "we mean cessation of brain activity for a certain length of time." Clearly, then, it is not the cessation of brain activity which is what the death is, because that would make death be a certain length of time, which is absurd. A length of time is not the opposite of life.

This is the result of "phenomenalism" in science, where the reality is supposed to be (or to be "defined as") the observation which establishes it. But if phenomenalism were true, the sun's color at sunset would be or "be defined as" red, which would mean that the sun really changes color when it sets. But it isn't the sun which changes color (after all, there are people a quarter around the globe who are seeing it at noon, and as its usual yellowish-white), but the fact that some of the light has got filtered out by the thick air on the horizon. No, what something is and how you recognize it are two different things; and confusing them can be significant.

For instance here, to say that death is the cessation of brain activity clearly means that you can't be alive if you haven't got a brain to be active; and so "by definition" embryos aren't alive until they develop their brains. But that's absurd, because it means that plants aren't living things either.

Don't kid yourself; people actually argue this way. It's one of the sophisms by which they justify abortion, for instance.

Then what is death? Once we have the answer, then we can deal with how we recognize when it occurs.

Obviously, death is the cessation of life. But we saw at the beginning of this chapter that a body is living a human life when it is dynamically organized with the human unifying energy.

DEFINITION: The death of a human being is the fact that his body is no longer organized by the human unifying energy.

That's what death is, but it's not very helpful in practice, because the unifying energy, as I said, is not directly observable from the outside; and the parts can be in fact interacting in a human way when the body is asleep or in a coma, and is not exhibiting the common signs of life. In those cases of the first few minutes of "brain death," the body is not showing any sign of life; but it must be alive at least in those cases in which the person recovers.

8.3.1. When death occurs

There is a clue that I gave earlier that will help us. I said that the unifying energy keeps the living body in a high-energy state. So when it is not present, the parts of the body lose energy and decay. As I also said, decay is the sign that the body is no longer alive.

Now there are times when an isolated part of the body can begin to decay without this implying that the unifying energy is not there; when it is for some reason cut off from the rest of the body. For instance, if you cut off the blood supply to your hand, it will begin to decay; but you are still alive. You have to do something fast, though, because this decay can rapidly spread through the body and kill you; and usually what has to be done is to remove the decaying organ to save your life. We will see the morality of removing organs in the next chapter.

But if the part is not isolated, its decay indicates that the body is no longer being maintained in its high-energy condition; and since this is one of the main jobs of the unifying energy, this means that that energy is no longer there.

But organs decay at different rates; and for various reasons, such as taking an organ to transplant it into a sick person who needs it, you want to find out as closely as possible when the decay has actually begun, to remove the organ while it is still as fresh as possible. Ideally, from the point of view of the recipient, this would be while the person is still alive (and there's no decay at all); but in the case of a heart or a lung, this will kill the donor, and the end doesn't justify the means.

It turns out that the brain begins to decay very rapidly; and it is obvious that the body can't function as a unit without the brain (once it is formed, it becomes a necessary condition for human life, even though its activity is not life itself).

The latest information I have is that when an electroencephalogram is used to determine "brain death" (in an adult; in neonates, it is even more complex), it involves taking two readings six hours apart with no brain activity detected--coupled with the absence of certain drugs or low body temperature (as from a victim taken out of cold water) which could depress the brain activity leaving the person still alive.

The point is that it is not perfectly simple in practice to determine when the body is not organized in a human way; and I leave it to the experts in the field to come up with the safest indication that the body is not alive. All I am trying to do here is to say what it is that these procedures are looking to establish.

Of course, in ordinary circumstances, one can be sure death has occurred by the ordinary signs (no heartbeat, breath, eyes dilated and fixed, etc.) After a certain length of time, there is no doubt of death, though it is less easy to come close to the exact moment when it occurred.

In any case, whatever the practical difficulties in discovering this are,

When it is determined that the brain is no longer functioning, one is morally certain that the body is a corpse, and it may be treated as such.

It is possible that one might sometimes make a mistake in such a determination. But the point is that there is no moral guilt in doing so. God is running the universe, and human beings are supposed to act on their human knowledge, and were not created omniscient.

It is possible after death to keep some organs artificially in the high-energy state they are naturally kept in by the body's unifying energy, and so prevent them from decaying, so that they can later be used by another body. There is nothing morally wrong with doing so.

Whether these organs are technically "alive" or not is an interesting speculative question, since if they are left to themselves, they will immediately begin to decay. A living body is one which spontaneously maintains itself in its high-energy state. Machines and so on can be maintained in high-energy states (as when you have your foot on the accelerator of your car, or have your computer plugged in); but they have no internal need or ability to keep themselves at this level; they just run down.

Cells in a tissue culture might be said to be absorbing nutrients from the medium; but this might also be a mechanical sort of activity, and not a strictly high-energy maintenance (although I am inclined to think that it is, but a lower level of life than that of the organism).

But when you get to the level of the organ, the unifying energy of the organ as such does not seem to be a high-energy unification; the high energy is due, it seems, to the unification of the body as a whole.

The point is, of course, that the body is made up of parts that have their own (sub)-unifying energy, which is under the control of the unifying energy of the body as a whole. Whether these sub-unifications are actual living energies (i.e. unnaturally high in terms of physics and chemistry) is not clear; what is clear, however, is that the genetic structure of the organism builds these subunits with their unification.

But since they aren't the human unifying energy, these parts then are just objects, and can be manipulated and transferred to other bodies and so on; because, even though they're made of human cells, they aren't human bodies because they lack the human unification.

8.3.2. Respect for the corpse

But can you morally harvest organs from a corpse? After all, even though it isn't a human being, it's a human body, and you can't just treat it like a lump of garbage, can you?

Even though the corpse used to be a human being, it is now a different kind of thing, and is in itself deserving of no special respect.

The Catholic Church enjoins respect for the corpse on the grounds that it is what used to be a body organized with a spiritual soul, and was a person; and, analogously to defacing a portrait of someone, acting disrespectfully to the corpse insults the person (who is, of course, still alive, though beyond being affected by what goes on in this world).

There is a point to this, and I would not deny it. But it still remains that in itself, the corpse is nothing more than decaying chemicals; and in that sense, it is no more deserving of respect than human excrement (which used to be a part of the body). Obviously, to the extent that contemptuous actions against the corpse imply contempt for the person, this would be a morally wrong expression of a relationship between people. But this need not be the case.

Therefore, corpses may be harvested for useful organs, or cut up and used for experiments, or even examined for medical or artistic training, or used for any reasonable purpose.

You can't use people for such things, because they have rights; but corpses don't have any rights.

Corpses may also morally be disposed of by burning, especially when this would protect people from diseases that might be caught from normal burial.

Nothing that the Catholic Church enjoins is inconsistent with what I just said. It is just that if a person shows the respect that the Church demands, he is doing a good act, beyond what is strictly required by the reality of the situation.

I should point out that the Catholic Church allows cremation, especially in the circumstances of possible infection. Cremation need not be an act of contempt.

8.3.3. Suicide

I said that a person's self-determination gave him a "right to do wrong," in the sense that if he knowingly wanted to do what was wrong, he is not to be prevented from the act. But perhaps it isn't even morally wrong to kill yourself, if you are in fact the master over your life.

But using "mastery" to say that we can stop living is a fallacy. You don't have "mastery" in the sense that you can act inconsistently with the reality you were given genetically; and one of the "givens" is the fact that you are alive--and that the basic tendency of life, as we saw in the discussion of the life after death in Chapter 3, is to continue indefinitely; and in the human case, this means immortally. So in fact you can't stop living, even though you can stop living as a body. But a person who wants to kill himself wants to stop living altogether, which is impossible.

Hence, it is morally wrong to choose one's own death. But because a person is self-determining, it is moral only to try to persuade him not to kill himself, not to prevent him from doing so.

The persuasion can be pretty forceful, depending on what evidence one has that the person doesn't really realize what he's doing to himself, and what kind of emotional state he is in. In the extreme case,

If the person gives evidence that he is blinded by some emotional problem, then he can be restrained against his will from killing himself, on the grounds that he is not capable of making a rational decision in this state, and in his normal state would choose not to do it.

Thus, the mere fact that a person wants to commit suicide (a fortiori if he is just saying he wants to commit suicide) does not necessarily prevent you from stopping him. Severe depression often carries with it a desire to commit suicide; and even though the person may talk perfectly rationally, what is driving him is a blinding force.

As a clinically depressed person myself (I am on medication for it, because my brain does not produce enough of the chemical that takes one out of a sense of despair), I can vouch for this. There have been times in my life when the urge to kill myself has been all but overwhelming, like the urge of a heroin addict for the drug. Luckily, I was able to say to myself, "This is all based on the way you feel, and it's just a feeling; it's not a fact that things are the way they seem to you." I didn't really believe this in the "conviction" sense of believing; but I knew it was true. I had to train myself to act on abstract knowledge, not conviction.

But this now raises the point of assisted suicide, particularly, physician-assisted suicide. If the person is in his right mind, and says he doesn't want to go on living, and if for some reason he is incapable of killing himself (he's in bed, for instance, and paralyzed, and can't get the pills), does the fact that you have no right to prevent him from killing himself imply that you can or even should help him?


Even if a person has a right to do what is morally wrong, he has no right to ask anyone else to help him do it.

This is obvious when you think of it. If a person wants to rob a bank, and needs you to drive the getaway car, can you drive it, on the grounds that he's the one who's stealing; it's his choice, not yours?

No, because you are willing for the bank to be robbed, and therefore the morally wrong act has entered your choice.


If you assist a person to commit suicide, no matter what the reason, you are willing for him to die, and this is the same in practice as choosing his death--which is morally forbidden, because it violates his right to life.

The fact that he doesn't want to live doesn't deprive him of the right to life, because he has that right as a human being, not because he is a consistent human being. We saw this in discussing self-defense and the alleged "forfeiture of the right to life" on the part of the attacker. You can't forfeit your right to life.

Thus, while it may be compassionate to kill a person and put him out of his misery, and while it may be better that he die now rather than suffer twenty more weeks of agony, blaspheming and cursing God and you for torturing him like this; the end still doesn't justify the means. As I have stressed so often, once you say the good purpose you have allows you to do wrong to achieve it, morality collapses into nonsense.

There are added evil effects to allowing doctors to assist in suicides that make it a very serious wrong to permit such a thing.

The added evils are that a person who is dying realizes that the longer he hangs on, the more of a burden, financially, physically, emotionally, and in every other way he is being to those he loves. And this very fact may tempt him to ask to be killed when he doesn't really want to.

Pressure from family members, who are not necessarily the most loving and unselfish of people, can also coerce consent from someone (particularly when weak from severe disease) which he would not otherwise give. Thus, it is not going to be clear whether it's "his own free choice" or not.

It has also been shown in places where this is allowed that, by a perversion of the argument I gave for saying that people might say they want to die because of emotional problems, sometimes those who actively do not want to die are treated as if they were not in their right minds ("How could he want to live in those conditions? He has to be crazy."). So their "real intention" of doing away with themselves is read into what they say, and they are murdered in the name of "compassionate concern for what their real wish was."

And this leads right up to the "life not worth living" that was the basis of Hitler's horrors. Some bureaucrat decides what kind of life is the kind of life only crazy people would want to continue, and people who have this kind of life are removed from it, kicking and screaming and pleading for mercy. "Compassion," as the Third Reich shows, gets remarkably hard-headed when people don't seem to want to conform to our idea of what's "really" good for them.

And, again taking the Third Reich as the model, it is amazing how many new kinds of life are deemed "not worth living" as time goes on. From clearly insane people, it spreads to deformed, then to the cripples, then to the "misfits," and then to just about anyone society finds a nuisance to have around.

Don't think I'm exaggerating and just telling horror stories. Already in this country, we are killing by starvation babies who have nothing more wrong with them than Spina Bifida and Down Syndrome, who can grow up to live happy, if restricted, lives.

I was once teaching a class in which a nurse was advocating putting such people out of their misery for their own sake and the sake of everyone else. I turned to the man in the front row and asked, "What do you think of this?" He answered, "She would have killed me, because I wasn't crippled this way by an accident. I have just what she was talking about. And I don't want to be killed." "Oh, well," she answered. "You're a special case." Oh, yes?

Just as the permission of abortions has led to the outrageous barbarity of the partial-birth abortion, the callous disregard for life which is inculcated in looking at the value the life has instead of respecting the reality of the living person is bound to do the same thing--just as it has been demonstrated to do historically.

If we keep on the way we are going, we are doomed.

8.3.4. Postponing death

But does this imply that you have to make heroic efforts to keep a person alive, even though you know you are going to fail?

No. Remember, the moral obligation is fundamentally negative; and it translates in this case to, "You must never choose the death of another person," or "You must never be willing for him to die." It does not say, "You must positively choose to keep him alive as long as you possibly can."

But aren't those the same thing? Not at all. Not being willing to harm your health does not mean that you have to get yourself into the best physical shape you could possibly be in; because there are lots of conditions in which, though you can't do all you might be able to do, you're not acting in contradiction to yourself.

Similarly here. If a person is dying, and there's no reason to believe that he's going to survive whatever disease is killing him, then you aren't choosing his death when you refuse to postpone the death by pumping up his body so that he can prolong the agony another six weeks. You haven't avoided the death, merely postponed it. So by not postponing it, it isn't the death that you're choosing, but avoiding the agony.

But we have to make a distinction here; it is a clarification of what is traditionally called "ordinary" and "extraordinary" means of preserving life:

DEFINITION: Life-maintaining measures are those actions done for us which any person needs to keep alive.

DEFINITION: Death-postponing measure are those actions which force the body to do actions it will no longer do by itself.

Whether these actions are "ordinary" or involve "high technology" is really irrelevant. For instance, supplying water to a person is a life maintaining measure; but even for normal people, it is nowadays done by means of elaborate water purification and delivery through sophisticated city water systems. On the other hand, cardio-pulmonary resuscitation (the "kiss of life") doesn't use fancy equipment, but it's clearly a death-postponing action.

So the first moral implication is this:

One cannot refuse life-maintaining measures (even if they involve sophisticated technology) without choosing a person's death.

In the case of refusing life-maintaining measures, you are not "letting someone die," you are taking away from him the way he, like anyone, stays alive. Hence, the act is an act of removal, not an allowing of something to happen; and so it is an act that causes death.

Now true, the act of not feeding or giving water to someone in itself is not morally wrong, since if the person is not starving or dying of thirst, then no harm is done; so one would think it would be possible to use the Double Effect here.

And it is possible but since the act causes death, the only thing that would allow this kind of action is saving a life. That is, you can't do something that causes death unless that same action causes someone else not to die. Otherwise, the evil effect is greater than the good effect. So, for instance, if someone is in terrible pain, and you take his water away from him, you have shortened the time he is in pain, but you have also caused him to die; and in this case, it is the death itself that is compared with the evil of the pain avoided. The fact that "he's going to die anyway" is irrelevant; you would be choosing his death, because it doesn't balance with the evil avoided.

On the other hand,

If a person is dying, then refusal to continue death-postponing measures is possible without choosing the death, using the Double Effect.

Here is where "he's dying anyway" can be relevantly invoked. What the death-postponing measures do is prevent the body from doing what it is trying to do: die. They keep the person alive, to be sure, but not by supplying what the body needs to stay alive, but by taking over some act that the body is no longer performing. Sometimes, the body can be kept alive indefinitely this way, and sometimes these measures are relatively simple, technologically speaking; but the essence of the situation is that they are preventing the body from dying because of what it's not doing (or doing inadequately).

Now then, if these measures are removed, the body dies of whatever with it is killing it. If it is emphysema, from the fact that it can't get enough oxygen by itself; if it is kidney failure, because the kidneys cannot clear the body of poisons; if by removing a pacemaker, because the heart can't pump blood to the rest of the body; and so on.

Thus, the act of removing death-postponing measures is not what causes the death; what causes the death is the disease, which is being held in abeyance by these measures.

Hence, removing death-postponing measures is not of itself performing an act which causes death, even though, by the nature of things, death will in fact result. But in point of fact, what will result from this is not death itself, but the fact that the death occurs sooner than it otherwise would.

Because of this, when removing death-postponing measures, one can now compare, not death with the evil effect avoided, but the shorter with the longer time span before death. If the time before death is happy, productive, and pleasant, but somewhat more expensive than it would be without the disease, it can easily be that to shorten the time involves a greater evil than the expense avoided. But if the only thing that is happening during this time is pain and agony for the patient, as well as expense and anguish for his loved ones, then the evil of a longer period of this is greater than the evil of a shorter one; and so the death-postponing measures may be (and sometimes morally should be) removed. No good purpose is served by them, and a bad one is produced.

A rule of thumb to decide whether the act is one of life maintenance or death postponement is to ask, "What is the patient dying of?" If the measure is removed, and he dies of what he is dying of (e.g. kidney failure), then it is legitimate; if the measure is removed and he dies from its lack (e.g. of starvation or thirst), then it is morally wrong.

Now of course, all of the rules of the Double Effect have to apply. That is, you can't use the fact that your rich uncle is on a respirator and you unplug him so that he'll die and you'll get the inheritance before he changes his will, because, then the death itself is wanted (in this case to avoid the evil of your facing bankruptcy. But the death is what produces this, so you actively want it). Therefore: (1) the act must be the act of removing death-postponement, not life maintenance; (2) there has to be a good effect also from this (you can't do it just for the hell of it); (3) the death itself can't be the means to what you want--it has to be just a question of not prolonging the dying process; (4) you can't have the death as a motive for "pulling the plug"; and finally, (5) the evil of the life as shortened life has to be no greater than the evil of the prolonged life.

Now then, there is one final detail on this matter:

Measures which ordinarily would be life-maintaining can in a given case be death-postponing, if they force the body to take in nutrients when it is either actively rejecting them or incapable of taking them.

That is, just as it is possible to force the body to absorb enough oxygen by putting the patient on a ventilator, it is also possible to force the body to absorb food by, say, a feeding tube introduced into the stomach. Why do you introduce the feeding tube? Because the digestive system has shut down. In this case, the feeding is not simply maintaining the life of the patient; he has digestive-system failure, and you are actively preventing the failure from killing him.

But that was precisely what we meant by death-postponing measures. What does he die of if you remove the tube? In one sense, starvation; but really, he dies of digestive system failure. So by removing the tube, you are not starving him to death, you are allowing him to die. You are not starving him any more than you are choking to death the person you remove from the ventilator.

If, on the other hand, he is dying of cancer, and you stop feeding him, what does he die of? The cancer? No, he dies of starvation. So you have starved him to death. You didn't "allow him to die; you killed him." (Of course, he could be dying both of cancer and of digestive system failure, but you see what I mean.)

The federal courts have recently said that they see no difference between allowing someone to die and killing him. This shows extreme moral obtuseness on their part (not surprising, given the other decisions that have been handed down by them). There is all the difference in the world; in the one case, you can't avoid choosing the death, and you are killing; in the other, you avoid choosing the death, and you are just not fighting nature any longer.

But suppose a person wants to be kept alive as long as possible. Can you "pull the plug" in this case? Well, it depends.

In general, since a person controls his own life, then if he wants to be kept alive by death-postponing measures, his wishes must be respected. The exception to this would be certain times when his use of the equipment would deprive another person, who could be cured, of using it.

That is, if Mr. Jones is dying and wants his life prolonged as long as possible by using the only ventilator available, he must be allowed to use it, though he has no chance of recovery, and all it's going to do is postpone his death another six weeks or so. But if Mr. Smith is also dying unless he uses the ventilator, and Mr. Smith has a good chance of recovery if he uses it, then Mr. Jones may be taken off the ventilator against his will, because in effect his use of it is killing Mr. Smith. In the case in which they are both likely to die anyway, it's first come first served; you can't choose which life is "more important" than which other one.

There are also other extreme cases in which people's death need not be postponed even if they want it to be. If the methods to do so are horrendously expensive, draining resources away from other people who can be cured, while the only thing that is going to happen is that the person's death is put off for another few days, then again his desire to put off the inevitable is causing harm, and the harm can be significant enough to overbalance the evil effect of shortening his life.

This will perhaps be more and more a consideration in years to come. The point is that as long as you are talking about death postponement and not killing or "letting die" in the sense of starving to death, it can be moral to act in this way. The "living will"

Before ending this chapter, I should mention the "living will." It is obviously not a bad thing for a person to declare beforehand that he doesn't want death-postponing measures taken if he is dying and unconscious and incapable of expressing his wishes.

But there are some serious difficulties with putting this into a legal document. It means, for one thing, that the document is what legally acted on unless it is legally revoked. But it's quite possible for you to change your mind between the time you sign the document and the time you wind up in the hospital. But if you tell the doctor, "I want to be kept alive as long as possible. Don't pull the plug," and you just say this and don't revoke the will legally, the doctor is bound by the legal document, and must remove the life support, or face prosecution, in spite of the fact that he knows you don't want him to.

Further, in spite of the turgid and redundant prose of legalese, these documents don't tend to make the proper, precise distinctions, and you may be giving someone permission to kill you. This is true in the State of Ohio in 1996, for instance.


(1) On the first page, add what appears in boldface to the paragraph that reads:

In the event I am in a terminal condition, I do hereby declare and direct that my attending physician shall:

1. Administer no life-sustaining treatment except for the provision of artificially or technologically supplied nutrition or hydration;"

(2) On the second page, cross out the whole paragraph that is written in capitals (I will print it below) and initial your crossing. Be sure you don't check the box and initial that. Here's the paragraph:


(3) Add the following to the bottom of the document:

This declaration shall be null and void if in the future I explicitly declare, in writing or orally in the presence of witnesses, that I wish life-sustaining treatment to be administered.

The problem with the declaration as it stands is that it uses "life-sustaining" to mean what I called "death-postponing," but it includes also what I called "life-maintaining" actions, as is clear from the omission on the first page of mention of nutrition and hydration when the declarer is in a "terminal condition." If you sign the document as written, you are instructing your physician to starve you to death if you're going to die (of something-or-other) anyway.

Now, as I mentioned, sometimes withdrawing a feeding tube is in fact postponing death; but sometimes it isn't. And the point is that if you're going to "let a person die" rather than kill him, you have to let him die of what he is dying of, not "let him die" of starvation or thirst, unless these are related to (i.e. part of) what he is dying of.

With the changes I mentioned, the document isn't perfect, but it is at least morally acceptable (i.e. as amended, it wouldn't allow the withdrawal of nutrition and hydration when this they are death-postponing; but there's no way you could change it to allow this without adding several pages, and if you're going to be ambiguous, you had better take the morally safest course). Personally, I think it's a good idea to do something like this, because for various reasons (fear of lawsuits), some physicians will go to absurd and torturing lengths to keep their patients alive.

Let me end this long chapter with this remark, connected with what I just said:

The lack of a clear notion of what death is and what postponement of death means has sometimes resulted in actual corpses' parts being kept alive for prolonged periods, days and even months after it is obvious (to anyone who knows) that the body has ceased to be organized as a unit. This is obviously not morally acceptable.

Summary of Chapter 8

A physician is a person who serves other human beings by seeing to their physical health. This chapter deals with the patient's life. A body is alive when its parts are interacting in such a way that it is a functioning unit. The life of the body is the interaction of the parts: the unifying energy. This energy keeps the body in a high-energy state, which is unstable from the point of view of physics and chemistry. Decay is the return to the low "ground-state" energy of the parts when no longer organized by the living unifying energy; so decay is a sign that the body is not alive. The kind of living body is determined by the kind of unifying energy it has; but this energy is not observable from outside, and so one must infer it from evidence.

Distinctively human activity (talking, reading) is a sufficient condition for knowing that something is a human being, but not a necessary one, since humans exist without doing these acts; and the human genetic structure in the cells is a necessary condition, but is not sufficient, since corpses also have this. A human being is a body which is (a) alive, (b) a whole organism, not a part of one, (c) with cells that have the human genetic structure. We can rule out in the human case more than one type of unifying energy at different times, since the organs are adapted from the very beginning to the life outside the uterus: the life, in fact, of the adult. There is thus objective evidence about what a human being is, and so it is not a matter either of personal choice or of what society thinks.

Human sperm and unfertilized eggs are not human; they are organized in a different way. The fertilized human egg/embryo/fetus is not a part of the mother, because parts act for the benefit of the whole, and (a) the mother's body tries to reject implantation, (b) early fetal development often makes the mother sick, (c) the fetus will take nutrients from the mother's body even at the mother's expense, and (d) sometimes the two bloods are incompatible in a deadly way. Thus the egg/embryo/fetus is a foreign body who happens to be inside the mother. This body is a unit, in spite of the possibility of "twinning," because of the organized way it develops; twinning can occur in lesser organisms even at the adult stage, where the body is clearly a unit. And since development is straight to adulthood (with no "caterpillar" stage), then the human being exists from the moment of fertilization. Thus, the human fertilized egg/embryo/fetus is a person, with all his rights, including the right to life.

It is always immoral to choose the death of a fertilized egg/embryo/fetus for any reason whatsoever. But using the Double Effect, an action may be taken which will result in his death but only to save the mother's life. The action is that of removing the non-viable fetus from the mother (whether one removes along with him the organ he is in or not); it is the removal that saves the mother, not the death, the death is not wanted, and if in this case the fetus is not removed, both mother and fetus will die (because he is not capable of surviving without her). If a woman can wait until viability and the fetus can be born, she obviously must do so. In removing the fetus, the manner of doing so must do the least damage to both fetus and mother; this may involve removing the whole uterus, rendering the mother sterile.

Tissue of fetuses dead as the result of a miscarriage may be used for experiments or for medicinal purposes; but there is an evil effect of using tissue from aborted fetuses; the fact that the tissue is going to be used "to save lives" can then be an excuse (if not the whole reason) tipping the scales for a woman to have an abortion; and so this evil effect overbalances the possible benefits of having all this extra tissue available.

If a woman can't naturally conceive, there is nothing wrong with technology's assisting the natural process of reproduction; but no part of the reproductive act may be contradicted in order to have a baby. Thus, a man's weak sperm may be artificially propelled farther into the woman; but there are other assistances that are not morally acceptable. Here we can mention human eggs fertilized outside the mother ("in vitro," "test tube babies"), to be implanted in her. The life-relevant problem here is that in order to do this, many persons must be created, only a few of whom will be implanted, and so have a chance to live. Human lives must not be sacrificed to a woman's desire to have a child of her own.

The presumption is that any living body resulting from the sexual intercourse of two humans is a human being; but there are bodies with genetic defects so severe that sometimes it is obvious, and sometimes it is probable, that they are not human beings. Any dubiously human body must be treated as human, because otherwise (by the rule of doubtful conscience) one would be willing to do harm to a human being. Thus, harvesting organs of living anencephalic babies is morally wrong, even if they might not actually be human beings.

The death of a human being is the fact that his body is no longer organized with the human unifying energy. The sign of death is decay. Since the brain decays rapidly, and since the brain is a necessary condition for unified human functioning, then a significant sign of death is the lack of activity in the brain for enough time that it is morally certain that decay has set in. Then the body is a corpse.

It is morally acceptable to keep parts of a corpse alive artificially, so that they can be used for good purposes (e.g. transplants), because in itself the corpse is simply waste material, to be disposed of. While it may be good to show respect for it because of the person it was, it is not morally necessary to do so, except when not doing so is an actual insult to the memory of the person (who is, of course, still alive, though not as a body).

One's control over oneself does not extend to being able to choose one's own death, because to do so contradicts the given aspect of life as tending to continue indefinitely (and one doesn't actually go out of existence, which is what is wanted). So suicide is morally wrong; but because of a person's control over himself, if he chooses his death rationally and knowingly, he must not be forcibly prevented from carrying out the choice.

Nevertheless, he has no right to have someone help him kill himself, if he can't do it himself, because the killer would also have to choose his death, which is immoral; the fact that he wants it is irrelevant. If doctors assist in suicide, this adds the evils of putting pressure on the sick to agree to assisted suicide, for others to "decide for them" or "in their real interests," which ultimately will lead to many unwilling people being killed because their lives are a burden to others or society.

But a dying person need not postpone death as long as possible, because not to prevent nature from doing what it is doing is not the same as choosing the death itself. Life-maintaining measures are those which any person needs to stay alive (supplying food and water, etc.). Death-postponing measures are those which force the body to do what it will no longer do by itself. One cannot refuse to administer life-maintaining acts (whether technologically simple or complex) without choosing death, except in the case of saving someone else's life, because the act of refusing the measures causes the death; and so the Double Effect requires saving a life to balance it. This is true even if the patient is dying (of something else) anyway.

But if a person is dying, removing death-postponing acts is not what causes the death, but the underlying disease; thus, what is caused by the removal is the shortening of the process of dying, not the death itself. In this case, the evils to be compared are the circumstances of the shorter or longer dying process (e.g. more or less time to continue a happy but doomed life; more or less time of agony and suffering). These circumstances can justify (and even require) the refusal to fight the dying process any longer.

The rule of thumb to decide these cases is "What is the person dying of?" If the person will die of the underlying disease, removal is morally legitimate. If the person dies of starvation or thirst before he has a chance to die of the disease, then this is killing him. Sometimes, measures which are usually life-maintaining can actually be forcing the digestive system to act, when it is shutting down; in this case, the "feeding" is a death-postponing measure, and its removal means the person dies of digestive system failure, and is not starved to death.

If a person wants death-postponing measures to be used, they must be used, unless his use is going to result in the death of someone who could be cured, or unless they are outrageously expensive, taking resources away which imply that many others will be unable to be cured. In that case, the Double Effect can justify stopping the life support even against the patient's wishes.

The "living will" is in itself not morally wrong, if the document makes clear that life-maintaining measures will always be taken, and that a mere oral statement before witnesses will revoke it. As things now stand (at least in Ohio), it in fact instructs doctors to starve the patient to death if he is dying anyway.

Lack of clarity on what death is has led to actual corpses' parts being kept alive for long periods, in the name of "keeping the person alive." This is morally wrong.

Exercises and questions for discussion

1. What of the argument that, even if the fetus is a person, he has no right to use another's body to keep alive, and so the woman may "unplug herself" from this invader of her body, unless she has invited him in by choosing to get pregnant. Hint: consider this in the light of Siamese twins.

2. Does the fact that experiments involving the fertilization of human cells that are going to die imply that there might be some knowledge that is morally forbidden for human beings to acquire?

3. Can a woman have a child in order to use the child's kidney to save his dying brother's life?

4. Suppose a person is in a persistent vegetative state, and life support is removed, and he still lives. How long does he have to be tended, fed, and so on, if he will never recover consciousness?

5. A dying patient is in great pain, but is so weak that giving him enough painkiller to make him comfortable will probably kill him. May he be given the painkiller?

6. Three people are dying, and each needs the only available ventilator. What criteria should be used to determine who gets it. How do you avoid "playing God" in this case?



9.1. The Principle of Totality

Now we pass on from the mere fact that the patient is alive to one of the characteristics of a living body: that, even though it is a system of many parts, those parts interact in such an intimate way that the body is first and foremost a unit. If you kick a dog in its hindquarters, you find its teeth in your leg--not because of some mechanical connection between the hindquarters and the teeth, but because you assaulted the dog, and the dog is responding.

The unifying energy, in fact, builds all the parts of the body as tools so that the body will be capable of doing what this type of body can do. The Greek word organon (from which, obviously, we get the word "organ" and "organic"), means "tool."

We owe the organic theory of living bodies to Aristotle, who realized that the organs were instruments which existed to enable the body as a whole to function in various ways.

But since this is so, it follows that it is the body as a whole that is what "really" exists and functions; and so when some part contradicts the functioning of the whole, then the part is acting inconsistently with itself as a part.

DEFINITION: The Principle of Totality states that the whole organism is what primarily exists, and the parts and their good are subordinate to the good of the whole.

But we must not be too hasty on this. What this seems to be saying is that the parts are simply expendable at the whim of the whole person; but that's not quite true. The parts exist too, even though their existence and their functioning is secondary to the whole. So it doesn't follow that you are acting consistently with yourself if you contradict a part for the sake of some greater fulfillment of the whole.

Actually, it's impossible to do this, strictly speaking, because the whole is made up of the parts, even though it's not just the sum of them; but if some part is violated, then the whole is in some respect violated, and so it can't be fulfilled as a whole. What this "fulfillment as a whole" actually means is that some other, more important part or aspect of the person is fulfilled at the expense of the part that is violated. But that's precisely what morally wrong conduct consists in.

9.1.1. Mutilation

Still, since the parts exist and function for the sake of the whole, it follows that if they are detrimental to the whole and its functioning, they contradict their reason for existence; and so in this sense are expendable.

But the body functions through the parts, each of which has one or more special activities it performs when activated by the Unifying energy; thus, there really is no distinction between what the part does and what the body does. It isn't as if there's a "unifying energy" which is sitting there inside the body pulling switches; the unifying energy is the interaction of the parts, and is not really distinct (in one sense) from them (at least from their "cooperation"; it is their cooperating, not "something" which directs it).

Be very clear on this: what the part does, the whole, primarily speaking, is doing. So the various capabilities of the parts are capabilities of the whole person, first and foremost.

Thus, if you disable a part so that it can't perform a function, you are primarily speaking disabling yourself and preventing yourself from performing that function.

So if you remove the part of the body (say, the eyes) that enables your unifying energy to make the body do a certain act (to see), then you have blinded yourself. You are still a "seeing thing," because you are fundamentally organized as a seeing body; but you can't see, because you don't any longer have the part that you see with. But this blindness is in principle curable, because your body is fundamentally a seeing body, which after all built the organs for seeing in the first place; and so if some "bionic eye" could be invented and placed where you tore your natural eyes out, you would be able to see again (that is, all you would need is a tool that responded to light and stimulated the optic nerves with the proper electrical impulses; and once those impulses got the brain, you'd again be able to see). So there is a real sense in which you can see even after you've blinded yourself. But of course, there's also a real sense in which you can't. You've got yourself into the contradictory position of being a seeing-thing (one that can see)-that-can't-see.

The point I am making is this:

The body that lacks an organ that has a certain function is in a contradictory condition. It cannot perform the function, because it lacks the organ; but it can perform the function because the unifying energy enables it to perform the function. Thus, it both can (in principle) and cannot (in practice) do the act.

Obviously, this is inconsistent. But the moral command says that you must never act inconsistently with what you are; and so

It is morally wrong to remove an organ when that involves depriving the body of some function it has as a human being.

DEFINITION: Mutilation is the removal or permanent disabling of some part of the body which deprives the body of some function that it is genetically capable of.

As we will see shortly, not every removal of a part of the body is a mutilation (if it doesn't deprive you of a function). But, sticking with mutilation, we can take a step beyond the moral prohibition above and say:

No one may morally choose the mutilation of any human being, either himself or any other person, even if the other person wants to be mutilated.

The reason why you can't choose to mutilate yourself, of course, is because you would deliberately be putting yourself in the position of not being able to do what you can do.

And of course, it's obvious that it would be wrong to mutilate another person against his will. But what about the person who doesn't care about the act he's depriving himself of, and in fact who positively wants not to be able to perform the act. He's doing to himself what is morally wrong, but he may not realize this (and your arguments may not make him doubt that he's right), and so his choice may be moral. But he can't perform the act by himself, and needs a doctor's help to do it. Can you do it for him?


The reason why it's immoral to mutilate a person who wants you to do it is analogous to the reason why it is immoral to assist another person's suicide. Even if the other person, in his ignorance, doesn't think that there's anything wrong, the fact still is that he's going to be in a self-contradictory position afterward, and you realize this; and so you can't avoid choosing to get him into this self-contradictory condition. So you would be willing to make a person unable to do the act he is able to do. This is immoral, irrespective of what he thinks or wants.

So you have to refuse, even if there's no other way he can do an act that he thinks is perfectly all right. His conscience can't govern yours.


If a person wants to do what is wrong, even what is damaging to himself, you may not force him not to do it. The most you can morally do is give him the relevant information about the act and its consequences.

And in this connection, it would be well to remember what I said in section 6.1.1. about informing the ignorant. Removing diseased organs

But it may seem as though no one would ever in practice ask another person to mutilate him; but it's not all that uncommon, really. In fact, some of the instances of mutilation will probably surprise you.

But before we get into this, let me mention the times when the act of mutilation is morally permissible. Obviously, it's when the Double Effect applies, since the moral problem is not the removal of the organ but the effect of not being able to perform the act it enables you to do.

If an organ is malfunctioning, and the malfunction cannot be corrected except by removing the organ altogether, it may be removed.

The reasoning is obvious. (1) The act of removing the organ is all right in itself, since if it had no function, there would be no problem. (2) The act has a good effect; it corrects the malfunction. (3) It isn't the inability to act which produces the good effect; it's the absence of the organ which corrects the malfunction it was doing. The inability to act as it normally would is a different effect of the same act (and, since the organ is malfunctioning, you can't perform this act anyway). (4) You don't want to lose the ability to act. And finally (5), the continuation of the malfunction must be at least as bad for you as the inability to act.

This last rule, as always, leaves room for subjective judgments. Some cases are obvious. Your hand is gangrenous; if you don't remove it, you die; if you remove it, you can't pick up things. No contest. But others aren't so clear. You keep getting infected tonsils. If you remove them, you lose this line of defense against infected lungs. If you don't remove them, you seem to be encouraging infections. Probably, you would remove them.

Some of these mutilations can be extreme. A person who has seizures may be able to get rid of them by having a frontal lobotomy: cutting off the nerve connections between the malfunctioning frontal lobes of the brain and the rest of it. It stops the seizures, but the person is brought into an all-but-vegetative state. So even if the effect of the mutilation is extreme, it can sometimes be justified to escape extreme harm. Removing healthy organs

There's not really a serious moral problem with what we were just talking about. People instinctively recognize that it's all right to get rid of an organ that's doing you harm, except when the harm you're doing to yourself is greater than the harm you're saving yourself from. It's just that I've spelled out what's behind this (correct) rough-and-ready reasoning process.

But of course, if you don't really know the theory, the seat-of-the-pants reasoning process can get you into trouble. And it often does, in fact.

It is morally wrong to remove healthy organs from a person on the grounds that they might get infected.

This sort of thing is done infrequently now, if at all, but when I was a child, it was a common, routine operation to remove tonsils and adenoids from small children, reasoning that the operation is more painful later. Well so what? There may not be an operation called for later. So you would have to choose the deprivation of the function, because as far as you know, the act is not going to have its good effect of keeping you from having an infected organ. You have no reason for saying it will become infected.

But there is a specific case of this which I want to mention:

Circumcisions except for correction of actual medical problems are morally wrong.

That is, the foreskin of the man doesn't serve much of a function; but it does protect the head of the penis and its sensitivity. So it does have some function. Many doctors routinely circumcise boys on the grounds that they won't clean underneath the foreskin, and it's apt to get infected; so they get rid of it at the beginning to avoid this problem. But the end doesn't justify the means. If you want boys not to get infections from dirt under the foreskin, train them to keep themselves clean. You have no right to presume that they'll neglect themselves and mutilate their bodies "for their own good."

It's interesting that there's such a hue and cry about female circumcision going on recently, as a horror that is somehow an example of men's oppression of women. Not a word has been said about the fact that men have been mutilated by circumcision for millennia, and it's still going on. Even if female circumcision is more serious, the principle of genital mutilation is that it's a mutilation, and as such it's only justifiable to correct a medical problem, not for aesthetic or social purposes.

The case of the circumcision of Jewish men, however, is different. If God wants you to be circumcised, then, since he has absolute control over you and every aspect of yourself, you would be being immoral as denying your relation of servitude to God if you refused to be circumcised. Similarly, if God orders the circumcision, there's no moral problem with a doctor (of any faith) circumcising a Jew. Even if the doctor doesn't believe in the Jewish religion, he doesn't know for certain that it's false; and so if he refused to do what might be a command of God, he'd be acting on a doubtful conscience. This same argument applied to Abraham when God told him to sacrifice Isaac. Supposing Abraham to be convinced that God ordered this, then it would have been immoral for him to refuse (even if God hadn't stopped him at the last minute).

It should be obvious that what I've said about Jews would apply to any religion that enjoins circumcision. In the case of other, more destructive practices (especially against others, and more especially against non-believers) which people believe are commanded by religion, one can conclude that, since God created all his human beings and gave them rights, the people who believe these things are spiritually unhealthy, and have no real grounds for their belief. And so, using the Double Effect, they can be prevented from doing harm.

There are circumstances, however, when the Double Effect would allow a mutilation of a healthy organ:

A health organ may morally be removed in the course of an operation to remove some other organ if (a) it might malfunction in the future, (b) the situation of another later operation to remove it would be dangerous, and (c) the function it performs is relatively insignificant.

What you're doing here is balancing off the bad effects of what might happen if you don't take the organ out while you've got the body open against the bad effects of what will happen if you do. It can sometimes be the case that the operation is justified. For instance, since the appendix either has no function, or has a minimal one, there would generally be nothing really wrong with taking it out if you're already operating on something nearby, and it's there for the taking. It's not something you just do without thinking, but you don't have to agonize long and hard about it.

There are far-out cases, even, in which you can possibly justify having an operation for the express purpose of removing a healthy organ which might malfunction: if, for example, the person is going into a situation where he couldn't get cured if the malfunction occurred. For instance, if someone astronaut is going to be spending five years in a rocket going to Mars, then it might be a wise thing for him to have his appendix removed; because the Martians might not be set up for human abdominal surgery. Organ transplants

If you can sometimes mutilate yourself because a healthy organ might malfunction under circumstances in which it couldn't be treated, then it should be obvious that it's morally all right to remove a healthy organ so that you can donate it to someone else. But there are a couple of things to be said.

Since it's not the removal of the organ that's the problem, but the effect of preventing you from doing something (or making it more difficulty for you to do something), then the Double Effect, as we have been seeing, applies.

Here you would be comparing the bad effect on yourself of having the organ removed with the bad effect on the other person of going without the donated organ. You might say that in order to get what they call "proportionality," you'd have to compare bad effects on yourself with bad effects on yourself--since after all, you're the one who's going to lose, and the other person is independent of you.

But objectively speaking, you are no more worthy of being benefitted or being protected from harm than any other person; and so you need not make your own benefit (or avoidance of harm) the motive of your actions. Hence, it is legitimate to balance off the harm to you against the harm to the other as if you were equals--as in this respect you are.

With that in mind, let us apply the rules: (1) The act of removing the organ is all right in itself. (2) The act has a good effect (the other person is saved from harm by having the organ). (3) The harm done to you is not the means toward the good effect, but is an independent side-effect of the act; if nothing happens to you, the good effect is still achieved. (4) You don't want the harm to yourself. (5) The harm done to you must be no greater than the harm you have saved the other person from.

So, for instance, if you want to donate a kidney to someone who needs it, the harm to you is that you lose your "backup" kidney. But you can, in fact, function as well with one kidney as with two. (You can even function pretty well with only part of one.) The other person is saved either from dying or from a life of going to a dialysis machine frequently. Sounds like a good bargain.

(Before going on, let me mention something that is a bit off the point: Since organs exist for their function, then an organ may be replaced with anything that performs that function (even something inorganic or purely mechanical) as long as it does no damage to the body. If it does, of course, then you have to use the Double Effect and evaluate the possible damage done by having the implant against the possible damage done by not having it.)

Thus, in spite of the pseudo-science that alleged that silicone gel breast implants caused sickness, reputable scientific evidence indicates that they don't; and so it was not wrong of Dow Corning to use them even for cosmetic purposes.

But to return to donating organs, this must be said:

No one ever has an obligation to donate an organ to another person, even to a close relative or loved one, because each person is responsible for his own welfare, and while it might be permissible to donate the organ, it does do damage to yourself; and you never have to do damage to yourself for any purpose.

The reason for this is subtle. If you had to donate the organ, then you would have to perform the act irrespective of its bad effect on you. But the Principle of the Double Effect is a way of choosing the act without choosing the bad effect by choosing the act as producing the good one, and only recognizing the (unwanted) fact that it also has a bad effect you can't avoid if you want the good.

But if you choose the act because you have to, then you're doing it because it's obligatory, meaning that if you don't do it, you suffer. So you're not using the benefit to the other person as the way of avoiding the bad consequences, you're looking solely to the consequences on you, which are bad. Hence, it can't be consistent for you to choose the act because you have to; because that would mean that not to choose what is bad for you would be bad for you.

So you can do it consistently out of generosity, making the other person's benefit your goal; but you can't do it out of self-interest. When put this way, it should be obvious.

But it follows from this that

No pressure of any kind should ever be put on any person to donate an organ to another person. It has to be an act of love, not an act a person does to escape something bad for himself.

This doesn't mean that a person who volunteers might not feel misgivings about the procedure, and be emotionally reluctant to go through with it. It is dangerous, after all. The point is that the person should not be put in the position of using the Double Effect to think of what bad things will happen to him if he does or if he doesn't.

The answer to Question 3 of the Exercises of Chapter 8 should now be obvious. I asked whether a woman could have a child in order to provide a donor of a kidney to save the life of her son. But since the infant would be incapable of giving free, informed consent to this act, still less of making it an act of love on his part, the answer is No.

Not only that, but can you imagine the psychological effect on the child when he realizes that the reason he was brought into the world was not that his parents wanted someone to love, but so that he could be mined for spare parts for someone else? You'd have to be pret-ty strong, psychologically, to be able to handle this.

So let me say it formally:

Children may not be caused to exist in order to provide organs for others; in general, it should not even be suggested to a child that he should give an organ for another person, because, given their dependent condition, a suggestion is the equivalent of a command. If the child spontaneously suggests it, it may be permitted provided it is absolutely clear that he knows the risks, that he has no obligation whatsoever, and that he wants to go ahead anyway. Fetal transplants

The topic I now want to discuss has actually not yet come up medically in all its ramifications as yet, but let me mention it. Suppose there is a fetus in a dying woman, and it is possible to save him by transplanting him into the uterus of a living woman, may it be done? This at the moment (when talking about a fetus, not an embryo) is just a theoretical possibility; but what would be the morality of it if it could ever be done?

Since the fetus (a) is a person, and (b) is going to die if the transplant is not made, then if the other woman is willing to finish out the gestation, so to speak, and act as mother, the Double Effect would allow it. The damage to the fetus is obviously much more severe than the harm of being brought up by someone who is not his biological mother; and we can assume that the woman is not going to die from this operation.

But this should be said:

The experiments that have to be done to make such an operation possible would doubtless involve harm and death to many, many fetuses (not to mention women); and so there is probably no way in which the technique of doing such a thing could morally be developed.

At present, of course, what we have is frozen embryos, who are human beings (generally, the leftovers from in vitro fertilization); and the experiments perfecting the technique of implanting them in women have been done (whether morally or not); and so, it is now possible to save the lives of many of these otherwise doomed people by implanting them in women who are willing to adopt them.

Given the present situation, then, this implantation is morally legitimate, as making the best of a bad situation.

But the practice of making banks of frozen embryos must stop. There are already all sorts of legal problems about who the parents are; and there are attempts to destroy them as if they were not people, when in fact they are. People must not be created "in the interest of science" or for adults' ability to fulfill their desire to be parents.

In fact, as I was writing this, word came from England that a huge "batch of frozen embryos" was going to be "destroyed." Why? Because the law says that after five years they have to be. Why? To avoid the "problem" of having these babies born years after their father and mother are dead. But that clearly recognizes that the donor of the egg is the mother and that of the sperm the father. So it's not the case that people don't know what is going on here; it's just that they blind themselves to any aspect of it that they find inconvenient to consider if it restricts "reproductive freedom." Incidentally, just a few days ago, the Pope suggested that women adopt these embryos. It's nice to know that the Pope is on your side. Sterilization

But in considering the removal of healthy organs using the Double Effect, you have to beware of the Third Rule: that the evil effect can't be what brings about the good effect. Well, but who would want that? Lots of people. Remember, in this case, the evil effect is the inability to perform a function that your body can perform. Well, sometimes that inability is desirable, because if the function does get performed, bad things follow from it.

DEFINITION: Sterilization is the act of removing or disabling the sexual organs in such a way that what is left of the organ cannot reproduce.

The sexual organs have as one (not the only one, but one) of their functions that of causing children to exist. But if you can't afford (either financially, physically, or emotionally) to support a child and you have a child, then you'd be depriving that child of his right to be brought up in a human way; and hence,

A person has a moral obligation not to have any children who might be harmed by the lack of resources of the parents to support them.

That is, the notion that "God will provide" as an excuse for scattering children all over the landscape as if you were Johnny Peopleseed is a fallacy. God gave us minds to use; and if you have reason to believe harm will come from your action, you have no grounds for expecting God will save you from your lack of good judgment. (And experience shows that God does in fact leave us prey to our own folly; he certainly will not provide if you can't be bothered providing yourself.)

Well then, the answer should be obvious, shouldn't it? If you have a moral obligation not to get pregnant, sterilization (which obviously is going to keep you from getting pregnant) has to be okay. Right?


The end doesn't justify the means.

Consider the situation. You have your "tubes tied" so you won't get pregnant (or, if you're a man, so you won't get anyone else pregnant). (1) The act you are performing on the organ is all right in itself; if the organ had no function, there'd be nothing wrong with it. (2) The act definitely has a good effect: you don't have a child who can't be brought up as a human being because you're incapable of it. (5) This good effect vastly outweighs the evil effect of the fact that your sexual organ can now only do part of what it normally can do; it can still perform other functions connected with sexual intercourse, and so the evil effect is minimal (and even happens naturally, after all, after a certain length of time). (4) You don't exactly want your sexual organs to be able only to do part of what they do; you'd dearly love to have a baby if you could afford to bring it up.

But (3) it is the fact that your sexual (reproductive) organ cannot reproduce (because it has been disabled) that brings about the good effect of not having a child you can't afford.

Hence, it's a sophism to say you don't really want to be incapable of reproducing. Of course you do. If you are capable of reproducing, the effect you're trying to achieve doesn't get achieved: you might have a child you can't afford. It is because you have got yourself into being a person who can reproduce (in principle) who can't (in practice) reproduce that you achieve the effect you want.

Thus, when it is the inability to reproduce that is the means toward the purpose for which you are sterilized, you can't avoid choosing the evil effect of the mutilation, and this is always immoral. It doesn't matter that the evil of mutilation in this case is much less than the evil you are trying to avoid. The end never justifies the means.

But what about the Biblical injunction, "If your eye is an obstacle to you, tear it out and throw it away; it is better to enter life maimed than be thrown into the garbage dump [Gehenna, the Valley of Hinnom behind the Temple, the symbol of hell] with two eyes."

Jesus had to be speaking in hyperbole here. First of all, it is better to go to heaven maimed than to suffer eternal frustration with an intact body--which was the point he was making. But if you make your body maimed, even if the part, your eye, say, "is an obstacle," you are acting inconsistently with yourself by mutilating yourself; and so you wouldn't in fact be entering life at all.

That is, faced with this text, you have three choices: (1) You can interpret it as I did, saying that Jesus was just stressing the fact that heaven is a greater good than anything (even seeing) on this earth, and that anything earthly should be sacrificed to get it--but not actually implying that you should mutilate yourself (except when the Double Effect applies, as we saw above, where the evil effect is not chosen). Under this interpretation, Jesus's statement is consistent both with the absolute value of heaven and the moral obligation. (2) You can interpret it literally, in which case (since Jesus is God) he would be commanding you to mutilate yourself when your eye or your hand was an occasion of sin to you. But in that case, you'd better stop with the eye and the hand, since Jesus gave no permission for the mutilation of the fallopian tubes or the testicles. That is, you can't "understand" Jesus to have meant more than he actually said under this interpretation; because then what he meant was for you to use your common sense in understanding him--but if you use common sense in understanding him, you're back in Interpretation (1). (3) You can say that Jesus made a mistake in this case. But if he did, then he's not God and is just a lousy philosopher, certainly no more worthy of being listened to than I am. After all, I've had years and years of training and reading up on what the best minds of the world thought about these matters, and Jesus was just a carpenter who had some nutty ideas.

I pick Interpretation (1).

"But then you're condemning these poor people to bringing into the world unwanted children who can't be brought up decently." Now wait just a minute. Even if your eye is an obstacle to you, you don't have to tear it out to avoid seeing sinful things; you can close it. If getting pregnant is not morally possible for you, there are ways of not getting pregnant that don't involve sterilization. Sterilization is only one means to avoiding pregnancy; the point is that it happens to be a morally wrong means.

The Double Effect, however, permits performing an act on a diseased sex organ which also as a side-effect sterilizes the person. If this sterilization also prevents there being children who cannot be brought up decently, then this added good effect can be rejoiced in in this case.

The whole point about the moral obligation is that it commands us to avoid pretending. If you can't afford any more children, and you learn that you have a cancerous uterus which has to be removed, then you don't have to pretend that the fact that you'll never have children is some kind of disaster. It's unfortunate that you're now in the situation of being-able-and-not-able to get pregnant (just as any sterile woman is); but you're not equivalently choosing to be in this situation if you recognize that it has a good effect that you're glad of.

The way to assure yourself that this is the case is simply to ask the question, "Would I have had the operation if my uterus weren't diseased?" If the answer is No, then obviously, you didn't choose the self-contradiction. "Sex changes"

If you can't sterilize yourself in order to avoid bad, even terrible, effects from pregnancy, what I am going to say about "sex-change" operations should come as no surprise.

It is morally wrong to remove or alter the sexual organs so that a person can appear to be or have sexual intercourse as if the person were a member of the opposite sex.

A person's sex is determined by the X and the Y chromosomes in every cell of his body; and, depending on whether you have a Y chromosome or not, this will build the whole body into a male body or a female body, with distinctive skeletal structure, distinctive hormones, distinctive musculature, distinctive metabolism, a distinctive nervous system, and (yes, feminists) distinctive perceptive and thought patterns, as well as distinctive sexual organs. And since the human body is a unit, then obviously changing one or a couple of these parts (the external sexual organ and perhaps adding hormones) is not going to make a person a member of the other sex.

You can't even have sexual intercourse the way the member of the opposite sex does, because (a) you don't have the same nerves around your "new" organ that the other sex has, and (b) (however much you might think so), you don't have the same emotions and so on during the act that the other sex has.

The "woman trapped in a man's body" is in a psychologically contradictory condition; but it is not the condition he thinks it is. That is, he thinks of himself as a woman, and thinks he thinks like a woman; but this doesn't mean that he actually is mentally the same as a woman; he is just "mentally the same as" what he believes a woman's mentality to be. There are no objective grounds for saying that this attitude is that of an actual woman.

So the fact is that a man who has had a sex-change operation is not a woman at all; he is a mutilated male. The same goes for a woman. A person's sex is something biologically objective, not something that depends on appearance, still less on some kind of "social construct."

Morality is essentially accepting the limitations you are given, or as the "Serenity Prayer" says, you "can't change," but only can pretend are changed. The "transsexual" is either deluded or immoral.

Now there are complications here, of course. There are cases of true hermaphrodites, who have genetic abnormalities which result in the person's being born with both sets of sexual organs. But apparently, it's not possible actually to become an adult of both sexes, and so before puberty, one of the sets of organs must be removed. In that case, it has to be decided which sex the person will be. Sometimes an answer can be determined by looking at the chromosomes. A normal man has one X and one Y chromosome; a normal woman, two X chromosomes. But some people have duplicates of them; and if the person has more X than Y chromosomes, it would seem logical to opt for being a female adult, or if more Y than X, a man. But, as with all practical cases, you have to take everything into account, and things can get very complex and messy--without altering the essential moral aspect of the situation.

9.1.2. Non-mutilations

But I said earlier that not every removal of a part of the body is a mutilation. It is time to discuss the cases in which it isn't.

For instance, as St. Augustine said somewhere, facial hair on men has to be for the sake of appearance, since it serves no other function. It follows, then, that your control over yourself allows you to trim your beard (cutting off part of it), or even shave it all off, if you don't like the way you look with one. You're fulfilling the function of facial hair by removing it in this case. If the unshaved hair makes you look ugly, then it is not serving the only function it can reasonably be said to have; and since "ugliness" is the aesthetic equivalent of "badness," there are no objective standards for beauty and ugliness; and so if it's ugly to you, it's ugly in the only meaningful sense of the term.

Similarly, you can trim your fingernails with no moral problem (I'll bet it never even occurred to you that there could conceivably be a moral problem in cutting your fingernails); though, since they strengthen the tips of your fingers making it easier to grasp things, removing them altogether (supposing you could do this) might be a mutilation, insofar as it hindered your grasping ability.

Not even doing things to parts of the body that have functions is necessarily a mutilation. For example, piercing the ears (whose function is hearing) or nose or (God save us, the other parts of the body that are being pierced nowadays) is not a mutilation, because this cutting of holes in the body doesn't keep the part of the body in question from doing any of the things it used to be able to do. It just means that you can also hang rings and jewels on strange parts of yourself.

Nor is getting a tattoo, or even cutting yourself in order to make a pattern of scars in your face, say, a mutilation. These things may involve dangers (for instance of infection in the case of tattoos or loss of blood in the scarring), and so the act of doing such things may have moral overtones; but the "disfigurement" of the body is not a mutilation. After all, even though the body may be disfigured to everybody else (who think that the results are ugly), it is obviously a beautification of some sort to the person who does it to himself, or he wouldn't have done it.

As long as I have brought up the subject of disfigurement, let us be clear about it.

DEFINITION: A disfigurement is a permanent change in the appearance of the body that the person disfigured considers ugly.

So, for instance, if you put a tattoo of a skull on somebody's cheek, most people would think you disfigured him; but, since the standard of beauty and ugliness is subjective, the only standard that is relevant is that of the person himself. So if he likes it, it's not a disfigurement.

Also, you wouldn't really be disfiguring a person if while he was asleep, you put on him one of those children's stick-on "tattoos," which can be washed off, even if he didn't like it--because the change is not a permanent one.

But obviously,

While it is morally wrong to disfigure another person, it is not immoral to assist a person in permanently changing his appearance, unless a mutilation (or, of course, some fraud) is involved.

And the reason is simply that a person has control over the way he looks, and so there's nothing immoral in his choosing to look different, even by something as drastic as scarring or branding himself. So if he wants you to help him, this is not the same as assisting someone to mutilate himself, because no objective wrong is being done.

Someone might demur at branding. It would seem on the face of it that placing a red-hot iron on a person's arm, causing him to scream in pain and burning him severely enough to give him a permanent scar, has got to be doing him damage. We're supposing, of course, that he's asked you to do this for him.

First of all, the pain in itself is not relevant, because pain is a sign that harm is coming to the body; so it's the harm and not the pain that's what's bad. But the burning of the skin is a temporary condition that doesn't prevent the person from doing anything that he can do; so it doesn't curtail his activities, and so is not a mutilation. (Granted, if it doesn't heal, there's a problem.) The scar tissue, of course, is simply the restoration of the body to where it was, for practical purposes, before the branding; and so ultimately, aside from the change of appearance, no damage was actually done. So, while it is bizarre and might be dangerous (if the burn is too severe or gets infected); it's not wrong.

I happen to have a Black friend who got one of these things as a member of some fraternity. I mentioned to him my amazement at his getting this, since he's Black and that's what Whites used to do to their slaves. He answered, "It's a Black thing; you wouldn't understand." I guess I wouldn't. But then, I don't really understand my own tattoo.

When I mentioned "fraud" above, I mean that it would be wrong to assist a person in changing the way he looked if you knew that he was doing this to escape being arrested, or so that he could commit some crime without anyone's realizing that it was he. But of course, the wrongness then would be your cooperating in whatever the evil enterprise was, not in the actual change of appearance. Cosmetic plastic surgery

This brings up the issue of plastic surgery. There are obvious cases of plastic surgery whose function is to correct disfigurement; and there should be no moral problem with these, given what we have said already.

But plastic surgery can be pretty serious and dangerous. Can cosmetic plastic surgery (i.e. surgery done just to make you look better) be justified?

There is nothing morally wrong with cosmetic plastic surgery, if the dangers in the operation are balanced against the bad effects of the dissatisfaction with the appearance one wants changed.

If you have a nose that makes you self-conscious and causes you distress, this discomfort at the way you look can justify whatever dangers there may be in having the shape of your nose altered. The same goes for any other change of appearance. Obviously, the more dangers there are in the operation (and the surgeon has to level with you), the greater the discomfort you have to have with keeping the appearance you now have.

There is one economic issue here. Since purely cosmetic plastic surgery (as opposed to restoring a normal appearance after burns and so on) is not the restoration of heath from an unhealthy state (the person is not dehumanized by his condition, but just doesn't have the appearance that is his goal), then this is a question of values, not necessities, and so the surgeon can morally charge whatever price he thinks the market will bear, and has no moral problems with becoming fabulously wealthy from his service.

That is, if he wants to charge twenty thousand dollars for such an operation, then the patient who consents obviously thinks that the operation is worth more to him than whatever else his twenty grand will buy; because if he doesn't, he simply says, "No, thanks," and keeps the other goals he has and gives this one up. So the patient who consents to the operation gains more than the twenty thousand is worth to him; and the surgeon obviously gains more than he loses in performing the operation. The fact that the surgeon gains a hundred times as much as the seller-value is irrelevant; he's not taking advantage of anyone.

So if you want to get into medicine and become rich and still be moral, there is a way: become a plastic surgeon.

9.2. Suppression of functions

So much for removing or permanently disabling a part of the body. But it is also possible to prevent a part of the body (and so yourself) from performing an act by temporarily suppressing its functioning, as with closing your eyes or putting your fingers or cotton in your ears. In neither case is this a mutilation, since, though the part of the body in question can't (at the moment) perform its act, all you have to do is open your eyes or take whatever it is out of your ears, and the act will happen. So you are capable of doing the act in a sense that you're not capable of in mutilation--even though in some sense you're incapable of it.

But does this minor sense of "incapable" make the suppression inconsistent, and therefore morally wrong? The fact that your eyelids obviously have the function of preventing you from seeing should give you the clue.

First of all,

Since a living being has control over its activities, and it exercises this control through the parts of the body that (under the proper conditions) perform the activity, it follows that it is morally legitimate not to exercise an ability you have, absent any harm to the body (i.e. other than the "harm" of not doing what you could be doing at the moment).

That is, it would be obviously wrong never to eat, because you'd starve yourself to death this way; but there's no reason why you can't refuse to eat now.

If a person chooses never to exercise an ability he has, this puts him in effect in the practical position of saying he doesn't have it when in fact he has it. But since (a) no single refusal to act now is wrong (as we just saw), this evil is the effect of the whole series of acts taken as a whole, and is not in any one of them. Therefore, the Principle of the Double Effect applies.

Suppose you have talent as a pianist, but you don't like playing the piano. Does your "burying of your talent" mean that you have been immoral? No. (1) Not playing the piano at any given time is not wrong; the evil, such as it is, would consist in never doing so, as if you couldn't when in fact you can. (2) It has a good effect: you aren't doing something you don't like doing. (3) The in-effect-denial that you have an ability to play is clearly not the means for avoiding playing today or yesterday or the day before, because it only happens after your life is over, when it's the case that you never played the piano. (4) You're not trying to pretend that you're a pianistic lout; you just don't like to play. And (5) the displeasure you get from practicing and practicing and playing could easily overbalance the displeasure others get from not hearing you.

This means, naturally, that you have to interpret the Parable of the Talents in a way that priests and preachers don't interpret it. They take it that if you've been given an ability by God, it's wrong not to exercise it (even, according to some, to the full). In the story, the master gives various slaves various huge sums of money [talents: a large weight of gold or silver] to invest while he's gone, and when he comes back, he rewards those who return to him more than he gave them, but to the one who simply returns what he was given, he takes what he has away and drives him out. This certainly seems to imply what the preachers say.

But it can't, if Jesus also said, "It is a good thing for a person ['Blessed is he'] to make himself a eunuch for my sake." Obviously, this is the refusal to exercise the "talent" of sexuality. So my interpretation is that the "talent" in question is the Good News of Salvation (the Gospel) which is given not only for one's personal use, but to be shared with everyone else. A person who receives the message and hides it within himself has missed half of what Christianity is about--and ultimately will lose whatever it was he though it was going to do for him. The reason for this is that Christianity is all about love, and concern, not for one's own fulfillment, but for others.

Pretty obvious, of course. But now apply this to a person who chooses to stay a virgin. Isn't he denying his sexuality? Of course, in effect. But there's a lot to sexuality (some of which we'll see in this part of the chapter), and it might be that "the right person just never came along," or the person wants to show that he loves God more than his carnal urges and wants to offer this lack of giving himself emotional satisfaction as a sacrifice to his Master. Again, there's nothing wrong with not having sex at this moment (or at that one, or that one); there's the good effect of not having sex inconsistently or showing one's love for God, or whatever; the in-effect-denial of one's sexuality is only at the end, because the person is not sterilized, and so at any moment could engage in sexual intercourse if he wanted to; he's not trying to pretend that he's an a-sexual being; he just has a reason for not exercising his sexuality; and finally, the bad effect of the denial can easily be overbalanced by the deprivation of whatever good comes from the denial. So yes, it's okay to choose to be a virgin.

Now for the second step:

Since the person has control, and it is not wrong not to exercise the act, then he may take active steps to prevent the act from occurring, short of permanently disabling the part in question, which would be a mutilation.

So when you put your fingers in your ears, you are "disabling" your ears at the moment, but not incapacitating them; and so there's nothing wrong with this. It's just that you don't want to hear something, and you don't have any "earlids" analogous to your eyelids; so you can make some of fingers or cotton or plastic.

For this reason, there is nothing wrong with using painkillers and other chemicals that suppress certain functions, as long as no harm is done to the body.

There can be a problem here. Pain's function is to alert the person to something that is wrong with the body, so that the damage (whatever it is) can be corrected. So, what a toothache really is is your body's way of saying, "Go see a dentist." Now once you've got the message and called the dentist, who's going to see you next Tuesday, the pain is serving no purpose by its insistence. Hence, there's obviously nothing wrong with shutting it off; and you can use chemicals if you want for this purpose. If, however, you feel a pain and just take a pill to get rid of it, then you might be ignoring damage that is being done to your body, and deliberately to refuse to get damage corrected is to be willing to be damaged, which is immoral.

Even this, however, is not something unqualified. I lift weights, and from time to time get muscle pains in my chest, which feel like what I am told are the symptoms of a heart attack. I have gone to the hospital on several instances "because you should never ignore chest pains," and found (as I expected) that my heart was in fine shape, and it was just strain on my muscles. Now, I consider it silly to go through the two days of tests and so on that the hospital does with all the expense to my insurance company and the medical system; and so I just don't go anymore, in spite of what my doctor says.

This may very well mean that some day the Real Thing might happen, [Note: in 2003 it did] and I will ignore it, and croak [I didn't, and obviously didn't]. Well, so be it. I have a reason for thinking that it's a false alarm, and no reason for thinking that I have a heart problem. And since I don't smoke or drink, or eat lots of fat, and I exercise, I consider that I don't have a doubtful conscience in these cases.

To take an example not using drugs, a doctor can morally wire an obese patient's mouth shut (with his consent, of course), so that he can only drink liquids through a straw and can't eat until his stomach has shrunk back into a condition in which he'll feel full when he's had all the calories he needs for a day. This is not a mutilation, because at any moment the wires can be removed, and the patient can eat.

9.2.1. Irrelevant uses of parts

The third step is this:

A person's control over himself allows him to use any part of the body for some function it does not have in itself, as long as no mutilation is involved) in doing so.

What I'm saying here is that there's no problem with using your ears (which obviously are organs of hearing) to hold up your glasses, which has nothing to do with the "purpose" of your ears. You can even use some part of your body in such a way that it suppresses its proper function, as long as this isn't a mutilation, and the suppression is only temporary. If you walk on your hands, you obviously can't use them for picking up things while you're doing so; but you haven't made them permanently incapable of picking up things.

9.2.2. Recreational drugs

A sub-question that arises here is this: If you can use drugs to suppress functions that you don't want, and if you can use parts of your body for purposes other than "nature intended," can you morally exercise your self-control by taking drugs that make you feel good, even though they don't do your body any good? Even though they might be addictive? Even though they might in the long run do damage to your health?

Let us take these one at a time.

It is not morally wrong in itself to take substances into your body which do not benefit the body, just because they give you a pleasurable feeling.

They're not doing you any good, and they're not doing you any particular harm; but they make you feel good. No problem. Thus, it is morally acceptable to drink coffee or cola or other things that "pep you up," even though these substances have no food value at all.

Even if the substances cause dependency, there is nothing in itself morally wrong with taking them and becoming habituated, even addicted, to them.

Addiction, strictly speaking, means a change in the chemistry of your body which makes it impossible or very difficult to function without the chemical in question. Now you would think (particularly from all the ink that has been spilled on this subject) that this is ipso facto a bad thing; but it isn't at all.

After all, we deliberately acquire habits all the time, and when they're beneficial to us, we call them "virtues." But what is a habit but an act that is automatically connected to a given stimulus, so that we are "out of control" to a greater or lesser degree when presented with the stimulus? You've gotten into the habit of eating three times a day, and so you're dependent on food at these times; or perhaps you're like me, and you've lifted weights regularly for twenty years or so; if you skip a day, you hurt all over--much more than you do by lifting. You are dependent on the exercise. And so on.

Dependency in itself is not bad; if you're dependent on something that's beneficial to you, then what's the problem? And so, even if the drug you're taking is addictive, and even if it's addictive in the strict sense, that mere fact is not enough to make taking it morally wrong.

Caffeine, for instance, could be said to be mildly addictive, as the headaches of anyone who has tried to quit drinking it can testify. But there's nothing wrong with getting into a (reasonable) coffee-drinking habit, because no harm is done to you by the caffeine, and you feel better with it.

If the drugs cause harmful side-effects, the Double Effect can sometimes allow their use, depending on the degree of the harm.

Here's where you have to be careful, though. In the case of smoking, the harm can be significant if you smoke more than a pack of cigarettes a day. You run a real risk of dying from this. Hence, if you choose to start smoking, or find that you're smoking more than a pack a day, don't. Some people can keep themselves down to ten or fewer cigarettes a day; there's no moral problem here, since the risks of serious harm are slight, and can be overbalanced by the pleasure foregone.

If you already smoke, even enough so that you're seriously harming your health, must you quit (if you can, of course, you addict)? Not necessarily. If you're seventy, and have been smoking five packs of cigarettes a day for forty years and haven't yet got lung cancer or emphysema or whatever, then you can balance off the severe evils of withdrawal against the chance that you'll shorten your life by smoking, and you can keep on with a clear conscience.

In general, of course, quit if you can. If you can't, then you're out of control and have a psychological problem, as we saw in Chapter 4, and not a moral problem, unless you don't care.

Other drugs, like alcohol, marijuana, cocaine, peyote, LSD, heroin, etc. have the characteristic to a greater or lesser degree of inducing you to look unrealistically on the world and misinterpret what the facts are about it. This can obviously lead to acting inappropriately with the real situation; and since these drugs tend to be addictive, to choose to use them is to be willing to get into a situation in which you act in a way that is inconsistent with the reality of things; and this is immoral.

So it's not really the fact that these drugs are addictive that's the moral problem with taking them, and not even the fact that they might to physical harm to the body; it's that they make you essentially psychotic (in my sense of the term); you think things aren't the way they really are, and so you act inconsistently with the reality of things. You think you're in control when you're not; you think you're witty when you're being idiotic; you think people love you when they can't stand you (or vice versa); you think you can drive a car when you can't; you jump out the window thinking you can fly over to the other side of the road, and so on. Not good.

Stay away from these things. Some of them are so powerful and so addictive (and they make you feel so terrific) that one use and you're hooked. You don't want that.

9.2.3. Multi-dimensional functions

We run into another problem dealing with our control over our acts in that some functions we have are not single, but have many aspects to them. Now I am not talking about multi-function organs, but about a function that has different aspects to it.

That is, the penis obviously has both the function of eliminating liquid waste and of sexual expression. It is clearly not morally wrong to use it for one of its functions and not the other at any given time (indeed, it would be a little difficult to see how it could ever be used for both of its functions at the same time).

So clearly you are not acting inconsistently with a multi-function organ if you use it at any given moment for only one of its many functions.

But some functions themselves are multi-dimensional. Is it consistent with them to use them for only one aspect of themselves?

Let us take up the function of eating first. This has the dimension of supplying the body with the nutrients it needs, and also an emotional dimension. Now you can argue that the emotion--in this case gustatory pleasure--is nature's incentive to perform the act, and so the act is "really all about" nourishing yourself. But the fact is that not all the foods that the body needs taste good, and not everything that tastes good is something that the body needs; and so, while these two functions are interrelated, they are distinct, and can be separated. The "purpose of the faculty of nutrition" is really not relevant here in the discussion as I am making it.

And the reason is that

Since we have control over ourselves, we can make as our purpose for performing the act (our motive) any or all or none of its dimensions. We can do it for a purpose that has nothing to do with what it does in itself, as long as this does not contradict the act.

Thus, for example, it is morally all right to eat (1) because you like the taste of what you are eating, and you don't care whether it's nourishing or not (i.e. your motive is purely the emotional dimension); (2) because you want to get healthy, and you don't care whether it tastes good or not (your motive is the nutritive dimension); (3) because you like the taste and you want to get healthy by eating this carrot (your motive is both); or (4) because your friend is sitting down to lunch, and you eat something just to keep him company (even if you don't particularly like the taste and it's not going to help your health--in which case your motive is neither of the dimensions of the act itself). The motive you have is the effect you choose when you initiate the act, and it may be (as in the first three cases) nothing beyond the act; but may also be (as in the fourth) something completely different, which uses the act simply as a means. As long as you don't contradict the act, it should be obvious that you can be indifferent to what it does in itself as long as it accomplishes what you want.

Obviously, however, it would be morally wrong to eat something that made you sick because it tasted good, or because someone asked you to do so. That would be using the act of eating in such a way that it contradicts the nutritive dimension of the act.

The reason I called the pleasure dimension the emotional dimension, is that I can't really see any moral problem (or really, even the possibility) of eating and contradicting the emotional dimension of eating; though you could argue that it would be possible to eat because you hated the taste of something, which would contradict the emotion as a pleasure.

But even this is pretty far-fetched, for the following reason:

A pleasure is in itself the conscious aspect of a drive that attracts you to something. But in itself it is just a emotion or feeling; and since humans have self-control, a feeling is a human pleasure if the person wants to feel it and a pain if he doesn't, irrespective of what in itself it reports.

This is a little tricky, but you can see what I mean with a couple of examples, I think. Alcohol, since it is basically a mild poison, tends to be rejected by the body; and so your instinctive reaction to tasting it is to spit it out as "tasting bad." But the taste in itself is just a certain kind of taste, and you can actually get to like the taste as a taste by tasting it often enough. It's that you now interpret this as something good; it's the same taste, but it now has a new label. Remember, "good" and "bad" are what conform to your expectations.

This is why people can actually find pleasure in the most bizarre things, such as being whipped, or torturing or killing other people--and, by the same token, can find pain in what everyone else calls "pleasure." There are some people who find the violent sensation of sex actually unpleasant. Ordinarily, when a person finds pleasure in something that actually does him damage or is morally wrong, this pleasure is called a "perverted" pleasure, since it attracts him to doing what is damaging or inconsistent with himself. It is "turned aside" (per-versio) from what pleasure's function in itself is. Note that a perverted pleasure in itself is not evil; in itself it's just a sensation. So, if a person finds it pleasant when someone beats him up, the pleasure is perverted; but if he doesn't seek out this feeling, there are no moral overtones connected with it.

Similarly, young people seem to derive a lot of pleasure from riding roller coasters and experiencing the sensation of terror at falling from great heights while perfectly safe; or from seeing horror movies full of gore and guts, which is obviously experiencing what I would call "disgust" as a pleasure. These pleasures are in the strict sense perverted; but there is nothing morally wrong with enjoying them as long as the enjoyment is in a context in which it is not an incentive to do a self-destructive or inconsistent act.

The point is that what is thought of by a human being as a pleasure is a feeling that he defines as "good," and a pain as what he defines as "bad." These may or may not have anything to do with the instinctive drives of attraction or aversion.

At any rate, that's why I said you can't really contradict the pleasure-aspect of eating. If you eat "because it tastes bad, and I like to eat what tastes bad," then you're just engaging in a little semantics; it tastes good to you. If you eat it because it tastes bad but you want to get your eating under control so that your taste won't keep you from eating what's healthy, you haven't contradicted anything objective about the act, because the "badness" of the taste is subjectively defined by you.

But you can contradict or suppress the other dimension of the act in the exercise of the act, and if you do this you are pretending that the act is only part of what it is. That is, your action is saying that the act of eating is only an emotion-producing act and has nothing to do with nourishment of the body, when in fact it has both of these dimensions.

To eat and then throw up or take a laxative so that the food cannot be digested is to use the multi-dimensional act of eating as if it had only the emotional dimension. You are suppressing one of the dimensions of the act in the very act itself, and so are acting as if the act were only part of what in fact it is. This is morally wrong.

Moralists call it gluttony. But it is recognized as wrong even in the apparently amoral health-care field, in which it is called bulimia, or "eating disorder" in general. It's "sick" to do things like this--and, of course, if it's carried on long enough, it can do harm your health. But it's not just the effect on your health that makes it undesirable; it's the fact that it's acting inconsistently with what eating is, in one respect.

Obviously, the moral obligation of the health-care provider in these matters is the following:

A health-care provider cannot help a person eat and block the digestive system from digesting what he eats.

He can help him not eat. As we saw, he can even take such drastic steps as wiring the mouth shut. He can also help the person medically not to eat so much by means of chemicals like appetite suppressants, or even by introducing an inflated balloon into the stomach, to take up some room so that the person will feel full by taking in less food. None of these measures pretend that the act is just an act of producing an emotion.


An intestinal bypass, in which the intestine is severed near the stomach and the stomach-end attached farther down the intestine, thus shortening the intestine so that not all of the food can be digested, is morally wrong.

When you think about it, that's a medical way doing what you do when you throw up; it pretends, in the case of part of the food, that the eating of it is only for the sake of the gustatory and emotional satisfaction, and has nothing to do with adding calories and so on to the body. Sexual inconsistencies

Almost everyone instinctively recognizes this. But the logic dictates that we apply the same thing to other multi-dimensional acts we have, of which sex is the glaring example. Beware. What I am going to say is "controversial," and your hackles are probably going to rise; it's heresy in our modern times to say that anything about sex that "both people enjoy" is wrong.

But really now. If a person can only get sexual satisfaction by being beaten to a pulp while he's having sex, and his partner only gets turned on when he sees the other as a bloody mess, there's nothing wrong with this? They'll kill each other. Oh yes, and as the "snuff films" show, there are those who get their kicks this way.

What about those who can only get satisfaction by having sex with ten-year-olds? Suppose the ten-year-olds are willing? Don't tell me that they "really" aren't. Even in my childhood, I saw some little Lolitas, female and male, who weren't "being victimized" by old men, but were going after all the old men they could get at every opportunity. But even if the kids want it, you mean to say there's really nothing wrong here? Or suppose you happen to be sexually attracted to your mother or father, and find that the attraction is mutual? There's nothing wrong with carrying through on your feelings? What about if your dog turns her rump to you?

If all of this is okay, it's amazing that sexuality is the only human activity that has no limits at all. But no one believes this. You are shocked by my suggestions (at least I hope so, at least by some). So the question is, what are the objective facts about the act, and the objective inconsistencies?

DEFINITION: The act of sexual intercourse is a multidimensional act with three facets: an emotional dimension, an interpersonal dimension, and a reproductive dimension.

Now this is not a book of sexual ethics, so we won't go into the whole of it here. But there are some aspects of it that do affect health-care providers, and so you have to understand some of the moral implications in order to do your job right.

As with eating and other multi-dimensional acts, it is not morally wrong to exercise the act for only one or even none of its actual dimensions but for some other purpose; but it is morally wrong to exercise the act as if it had only one or two of the three dimensions that it has.

Once again, it's quite moral to have sex because it feels good, or because you love your spouse, or because you want a baby, or for any two or three of these purposes--or even because it's Tuesday and you agreed that on Tuesday night you were going to have sex. Also, as with eating, it's not really possible to engage in sexual intercourse because you don't enjoy it, so you can't really contradict the first dimension.

But, for example,

Masturbation exercises the sexual act as if it had only the emotional dimension and did not have any interpersonal dimension or reproductive dimension.

But the act is not just an act that feels good, any more than a three-dimensional cube is a line, or eating is just tasting. One sign of this, by the way, is that it's very difficult to masturbate without fantasizing about having sex with someone else while you're doing it. Interestingly, if a man masturbates in order to provide sperm for the doctor to inseminate his wife with, because he loves his wife and she wants his baby but can't have it naturally, he intends all of the "purposes" of sex (he wants to express his love for her, and he wants there to be a baby), but the act he performs has only the pleasure dimension, and what happens to the sperm afterwards is not part of the act. So even though he wants all that the act in itself implies, the act he performs is a lie, because it's only (as he exercises it) part of what it in fact is.

This is one reason why I'm not at all happy about talking about the "natural purposes" or "natural ends" of the act, especially when you make a hierarchy of them. It would imply that if you want the purpose, then the act is automatically consistent. It also implies that the "primary purpose" might override the "secondary ones" and allow you to contradict them--which, if the "hierarchists" are right, would logically allow you morally to rape a woman if you wanted to have a child by her. That way lies madness.

Hence, if you need a man's sperm for any purpose, you can't get it by asking him to masturbate for you. Sorry, but that's the way it is. It's directly analogous to your getting the contents of a person's stomach by asking him to throw up for you. You get a sample of sperm the way you would get a sample of stomach contents: by extracting it, not by asking him to have inconsistent sex.

An even more glaring inconsistency, directly analogous to bulimia, is the following:

It is morally wrong to engage in sexual intercourse and suppress the reproductive dimension while exercising the act.

To show what I'm driving at here, just replace "reproductive" with "interpersonal." Suppose you are attracted to a woman and you want to have a baby by her, but she doesn't want to have anything to do with you. So you grab her and force her to have sex with you--which makes you feel terrific. Your motive is (a) pleasure, and (b) a child; but you are acting as if the other person and her feelings and life were irrelevant; or in other words as if you were the only person involved. And so you contradicted the interpersonal dimension of the act.

So rape is an act of inconsistent sex. It's not just a forcing of someone to do something against her will; it contradicts one aspect of what sex itself is, in the very exercise of the act.

But of course, if that's true of the interpersonal dimension, by what logic do you say that it's not true of the reproductive dimension?

As is the case with sterilization, there may be valid, and medically or morally compelling, reasons for not getting pregnant. But the end doesn't justify the means. As the ejaculation of sperm shows, the act is a reproductive act, even when it does not actually reproduce. The sperm itself makes no sense as "heightening love"; it is human sex cells, which are looking for an egg to fertilize. Obviously it doesn't add to the love-aspect (the interpersonal dimension) of sex, since so many have done so much so often to get rid of it "because they love each other too much" not to.

The point is that it is either stupid or intellectually dishonest to say that the act of sexual intercourse does not have a reproductive dimension to it, even though it doesn't always actually reproduce. That's another reason for not talking about the "purpose" of the act. An act of sex between an old man and an old woman won't reproduce because she has no more eggs, and he might be sterile too. But that doesn't mean that their act doesn't have a reproductive dimension; it's a reproductive kind of act, and the fact that it doesn't actually accomplish reproduction is due to the circumstances surrounding the act, not to a difference in the act as exercised.

Be very clear on this. Just as not every act of eating actually provides nourishment to the body, every act of eating has a nutritive dimension to it, and if you suppress it (by whatever means) you are being dishonest with it and pretending that it's not what it is; so, if you suppress the reproductive dimension of sex, you are being dishonest with the act. It is not simply a pleasurable act that expresses love; it is also a reproductive kind of act.

Note that the means by which you suppress the reproductive dimension is irrelevant. If you do it by an intrauterine device, by a condom, by a pill, by an injection, by an implant, or by any other of the multitudinous ways people have invented for having anti-reproductive sex, it doesn't matter. You are still trying to exercise what is a reproductive act as if it weren't reproductive.

But two things shout at you that you're lying and pretending: The sperm is ejaculated, and why, if the act "in itself" has nothing to do with reproduction? And what happens if the contraceptive fails? The act succeeds. The contraceptive, therefore, tries to block the act from being what it is.

And this isn't like putting your fingers in your ears and blocking hearing. When you block your ears, you aren't exercising the act of hearing. When you use a contraceptive you're exercising the act as if it weren't what it is. There's all the difference in the world.

Before taking the next step, let me draw out the conclusion relevant to the health-care provider.

Since contraceptive sex is morally wrong and inconsistent, a provider may not prescribe contraceptives or give advice on how to practice contraception, or even send the person to someone else who will do so.

The reason is, of course, that if you did any of these things, you would be willing to have the inconsistent act occur, whether the patient knows what the real situation is (and is immoral) or not. He would be doing what is objectively morally bad for him; and he has no right to demand that you help him in acting inconsistently with himself.

Of course, if he wants to use a contraceptive, it's not your place to "educate him on the evils of contraception," as we saw with informing people about morally wrong acts. No physical harm is done (well, most of the time none is), and so you would simply be trying to act as his conscience, and that's not your job. But you still can't help him do what you know is a morally wrong thing.

Of course, if he asks you for a contraceptive and you refuse, and he asks you why, then you can tell him that the act he wants to perform is objectively fraudulent, and why; but if he says, "That's silly," you don't have to insist; and you should say, "Sorry, but that's the way I see it; and so you can't get one of those things from me."

"But my God! People can't be sterilized, and they can't use contraceptives! You're condemning them to become baby factories!" Nonsense. There's one absolutely certain way to avoid becoming pregnant. Refrain from having sex.

"What! That's impossible." Of course not. It's not even immoral, as we saw. "But we're talking the real world here." Yes, indeed, and the real world doesn't end with death, remember. If this life is the only life, go ahead and do what you like. But it's not. And nobody said that being moral was going to keep you from hardship in this life. But this notion that it's impossible "in the real world" not to have sex unless you can do so consistently with the act is pure propaganda. Granted, it's not easy; but fifty years ago enormous numbers of people were doing it; there were lots and lots of people who got married as virgins.

So "they're going to do it anyway" is a copout. They are if you convince them that they are, and that it's not realistically possible for them to refrain. But if you told people that "in the real world" it was impossible to keep from shooting someone who "dissed" you, you'd soon find that "they're going to do it anyway," and the only thing you could do about it would be to give them rubber bullets.

Think of it this way. It seems from recent studies that kids are going to smoke anyway. So hand out filter cigarettes to them and promote "safer smoking." Sound stupid? Make the application.

--And, of course, it's not as bleak as I painted it above. Not every act of sex actually reproduces. In fact, there are only certain times of the month that a woman is actually fertile even during her fertile years. At other times of the month, she's sterile, and there is nothing wrong in itself with having sex at these times of the month.

Why? Because the act has its reproductive dimension, even though it can't actually reproduce because there doesn't happen to be an egg to be fertilized. But that's something that occurs after the actual act, which is the same act as it would have been if there'd have been an egg there. The point is that we're not like the other animals, which wait until reproduction is likely before they engage in sex. We have minds, and we can make the distinction between the reproductive dimension of the act and the actual effect of that dimension.

There are in practice ways of determining with accuracy when these sterile days of the month are: when the act will not in fact result in offspring. This is not the old rough-and-ready "rhythm" method of guessing; it involves taking temperatures and noting secretions and so on.

Now then, using the Double Effect, you can exploit this knowledge of the fact that on certain days the act will not reproduce. (1) There's nothing wrong with having sex on those days; the act is what it is; it's only the effect that's different. (2) There's a good effect of having sex only on those days: you don't have a child you can't afford to raise. (3) The non-reproductiveness of the series of acts (implying that your sexuality-as-such, rather than the act, is not reproductive, which is the only bad effect here) is clearly not the means toward not having a child, since this only occurs after all the acts are over. (4) You would have a child if you could afford one--and if the act should fail, you will accept the responsibility of the child. This, by the way, is necessary even for those who want to use contraceptives, which after all are not perfect either; it's either that, or kill a human being. (5) And the small evil connected with the fact that the rest of your sexual life is not actually reproductive is clearly overbalanced by not having a child who cannot be raised decently.

So this is morally legitimate. Now don't go saying, "But it amounts to the same thing! I mean, if you're going to all that trouble not to have a baby, why not just use a contraceptive? You're getting the same results."

True, you're getting the same results. And you get the same results if you make a million dollars by working for it or by stealing it. It amounts to the same thing, doesn't it? And you get to Los Angeles if you fly there or you walk there. So flying is the same thing as walking, isn't it? The results are not what is the issue here. No one denies that the results of not having a child you can't afford are very good; but the end doesn't justify the means.

There is a morally right means of not having children, and there is a morally wrong means, and they are not the same. And no amount of saying that "they amount to the same thing" is going to make wrong right.

But it follows that

It is perfectly moral to counsel someone in the "sympto-thermal" method of conceptive control. But not in contraception.

(By the way, this shouldn't be called, "birth control," because the term leaves the door opening to "controlling birth" after conception by killing the kid; and "family planning" is just a euphemism. You're trying to control whether a child gets conceived or not. Say what you're saying; this whole area has been muddied over with words that seem to mean the opposite of what they actually mean.)

Now to take the other side of this attempt to perform the sexual act as only part of what its multi-dimensional reality is,

Artificial insemination, even by the sperm of the husband, is morally wrong, because the act of insemination is a sexual act that pretends that it is only reproductive and has no emotional or interpersonal dimension to it.

That is, the doctor certainly doesn't want to arouse the woman, still less have her have sexual feelings toward him; and so this act of sex (and it is an act of sex, because sex is what reproduces, isn't it? What else does?) is purely and simply reproductive, and must not involve either pleasure or an interpersonal relationship between the two parties actually engaged in the act.

But there is more to this.

Artificial insemination, unless it is done by the husband of the woman, and using his own sperm, creates the additional evil of an ambiguity as to who the father of the child is; and this deprives the child of his right to a father.

That is, irrespective of the inconsistency of artificial insemination in itself, we are talking about what, short of the right to life, one of the most fundamental rights of a child: to know who it is that he has claim on for support and nurture. Since the child can't survive without assistance from adults, then he has a claim on someone to give him the means to grow up into being a self-sustaining human being (an adult). But who does he have the claim on? The "village" that "it takes to raise a child"? Nonsense. They had nothing to do with causing him to exist, and so they have no responsibility toward him.

No, the child has a claim on those whose choice caused him to begin to exist, and these are his biological parents.

Only when the biological parents cannot or will not discharge their duty of caring for the child is it permissible, using the Double Effect, for someone else to do so.

That is, for someone other than the biological parents to raise a child is making the best of a bad situation; it is never a positive good, because the child has a right to be raised by both biological parents, since he needs both and they are jointly responsible for his existence.

But since this is so to create confusion as to who is the person to discharge the obligation of parenting is to violate the child's fundamental right, a right, as I said, just short of the right to life itself.

This particular right is completely ignored in our present culture.

To apply this to artificial insemination, ask yourself the following question: Is the father of the child (i.e. the one who caused him to begin to exist, and is therefore responsible for him) (1) the one whose sperm it is, or is it (b) the one who impregnates the woman, or is it (3) the husband of the woman? The answer is Yes.

That is to say, without either one of the first two, the child couldn't begin to exist at all; but without the third, the child can't be brought up decently. So all three are jointly responsible for the child; the three are in fact the "father." And from this it follows that the one whose sperm it is must be the one who actually impregnates the woman, and is her husband so that the child can be raised decently.

Therefore, any physician who performs artificial insemination not only does something morally wrong in itself, but perpetrates a serious injustice against the child.

That is, suppose the person whose sperm it is says, "Look, he's not my kid. I never went near the woman. How can you say I got her pregnant?" Then who got her pregnant? The doctor? You think doctors are going to admit this?

You see what I mean? What recourse does the kid have when both male parties to the conception can deny fatherhood?

Needless to say (so I'll say it), since the child has a claim on his biological parents, then

"Surrogate motherhood" is a fraudulent contract, because it contracts to deny the child his support from his real parents, and even before conception substitutes others in their place.

The woman who is supposed to be just the "incubator" for the "fetus" is (in the real-world case) the one whose egg is fertilized with the husband of "mommy's" sperm, and so is in fact the real mother of the child. And if (in the other case) she has the fertilized egg implanted in her and "simply" gestates the child, then the child has an ambiguity as to who is the real mother analogous to the ambiguity as to who is the father. So a double injustice is perpetrated on the child in the name of giving the "mother" and the "father" (who didn't impregnate either his wife or the surrogate) the satisfaction of having "their own" child. What a travesty of child-bearing!

A "surrogate mother" contract is a contract to do evil, and so it morally ipso facto null and void, and must be legally forbidden; and any health-care provider who is involved in such an agreement is an accessory to a very serious wrong against the child.

Children, as I said, are not to be subordinated to adults' notion of "fulfillment."

Our country is mad. It will do all kinds of inconsistent things in order not to have children--sometimes making women sterile (not surprisingly) in the process. But then when they want a child, it will allow all sorts of horrible things in order for them to have children "of their own." Meanwhile, of course, the "unwanted children" are torn to pieces and thrown in the garbage.

And in the name of the advances in medical technology!

Summary of Chapter 9

A body is not merely alive, but its parts interact in such a way that it is first and foremost a unit; hence, the Principle of Totality says that the whole organism is what primarily exists, and the parts and their good are subordinate to the good of the whole. But since the whole exists in the parts (as well as vice versa), you can't contradict the part for the sake of the whole.

What a part does, the whole, first and foremost, is doing. So if you remove an organ with a given function, you become a person who (as the whole) can do an act which you can't do (because you lack the part). This is inconsistent. Mutilation, which is the removal or permanent disablement of a part which deprives the body of some function it has, is morally wrong. You may not choose mutilation, either of yourself or someone else, even if he wants it, because this is to be willing that the person be in a self-contradictory condition.

If a person wants to do harm to himself you may not morally force him not to do so, because he controls his reality. You have a positive obligation to inform him only when not informing him is the equivalent of withholding information that he (openly or tacitly) is asking for. If not, and you put a doubt in his conscience, and he chooses to do it anyway, you have converted a moral (but ignorant) choice into an immoral one. This makes you responsible as well as he for his immorality.

If an organ is malfunctioning, and removing it is the only way to correct the malfunction, it may be removed, when the Double Effect applies. The act of removal in itself is all right, the inability to act is not the means to the cure, and the harm done is no greater than the harm avoided.

In general, healthy organs may not be removed because they might malfunction. Thus, adenoids and tonsils may be removed only to correct an actual medical problem, and the same goes for circumcision of boys. A healthy organ may morally be removed in the course of an operation to remove something else if it might malfunction and the danger of removing it later outweighs the harm done by the removal.

Organs may be removed to be donated to others when the Double Effect applies; i.e. when the harm done to the donor is no greater than the harm corrected in the recipient. But no one ever has an obligation to do this, because that would mean that he was doing it to avoid harm to himself, and it is inconsistent to do harm to yourself for the sake of avoiding harm to yourself. No pressure of any kind must be put on anyone to donate an organ, which means that in general, the act must not even be suggested to children, because of their vulnerable position. They can be allowed to donate organs only if they initiate the suggestion, and then only if it is clear that it is completely spontaneous. A fortiori, children must not be conceived in order to provide organs for needy brothers or sisters.

Theoretically, it would be moral to transplant a fetus from a dying mother to a living one, if it could be done; but the experiments necessary to make it possible probably could not morally be performed. Embryos that already exist may be implanted in women to prevent these tiny people from dying, provided the women are willing to be mothers to them.

But when the inability to perform the organ's function is what is desired, then the organ may not be removed or disabled. Thus sterilization, in which the disabled organ cannot reproduce, cannot be done except as a side-effect of curing a diseased organ--even if there are drastic evils (even death) connected with getting pregnant. The reason is that it is the inability to reproduce that avoids those evils, and so the evil effect (the inability) is the means to the good effect, and the end never justifies the means. You cannot mutilate yourself to prevent yourself from doing wrong with the intact organ.

"Sex changes" are morally wrong, because they don't in fact change the sex of the person, and only allow him to pretend (in some respects) to be the opposite sex.

But not every removal of a part of the body is a mutilation, because not every one prevents a function. Cutting hair or fingernails is an obvious example. Holes may be cut in the body, it may be tattooed or even branded or scarred; these are disfigurements only if the person does not want the permanently altered appearance. Insofar as these things are dangerous (i.e. may involve infection), they have moral overtones; but a person has control of how he looks. As long as no function is prevented, there is no problem. Cosmetic plastic surgery, therefore, is moral; and since, when it is done to look better, it is a value, not a necessity, it is morally legitimate for the surgeon to make himself fabulously wealthy from this practice if he wants to.

Our control over our acts allows us to suppress functions without disabling the organ permanently, when this is the equivalent of not exercising them. It is even morally legitimate never to exercise some function one naturally has, such as to choose to remain a virgin; because the denial of oneself as a sexual being comes only at the end of one's life (no single act of refusing does this), and this can be overbalanced by what is avoided by not having sex.

It is therefore not wrong to take means to prevent the act from occurring, whether chemical or mechanical. Painkillers are moral, as long as the person does not ignore the harm that the pain is warning of; wiring an obese person's mouth shut so he can't eat and can only sip small amounts is also legitimate.

A person may also use any part of himself for a purpose it was not naturally built for (such as holding up glasses with your ears), even if this temporarily suppresses the function of the part, as long as no mutilation is involved. It is also not morally wrong in itself to take recreational drugs just because they make you feel better, even if they are addictive (because to become dependent is not of itself bad; it is good to be dependent on what is good for you, for example), as long as (a) no damage to oneself results from this (as in smoking) or (b) the drug does not give you an unrealistic view of things, so that you might act on misinformation (as with LSD, cocaine, alcohol, morphine, marijuana, etc.) But, for example, caffeine is all right to become addicted to.

Some organs have more than one function, as the penis eliminates waste and also is used for sex. It is not wrong to use the organ for one of its functions and not the other.

But some functions are multidimensional; in the exercise of the act, several interrelated things occur. A multidimensional act may be exercised for any one or all or even none of its natural dimensions as long as there is no attempt to suppress one of the dimensions in the very exercise of the act. This would be to pretend that the act is only partly what it is.

Eating has an emotional and a nutritional dimension. It is wrong to eat and throw up or take a laxative or otherwise prevent the absorption of the food eaten, because this would be saying that the act has only the taste-dimension when it is more than this. While it is not wrong to wire the mouth shut or put a balloon in the stomach so that less food will be eaten, an intestinal bypass cutting the intestine and attaching it lower so that not all the food eaten will be digested is wrong.

Sex has the three dimensions: the emotional, the interpersonal, and the reproductive, though not every act of sex actually results in offspring. Any one of these (or even none) may be the motive for a given act of sex; but none of them may be suppressed without the act's being essentially a lie: inconsistent with what it really is. Thus, masturbation treats the act as if it were merely emotional, when in fact it has an interpersonal dimension (as the fantasizing during it shows) and a reproductive dimension (as the ejaculation of sperm shows) as well. If a doctor wants a man's sperm, therefore, he can't morally ask him to masturbate to get it (any more than he could ask him to lie for any purpose), because the end doesn't justify the means.

It is also morally wrong to engage in sexual intercourse and by contraception of any time suppress the reproductive dimension of the act, even when having a baby would be a great evil to be avoided; again, because the end does not justify the means. (For the same reason, you can't rape a woman--denying the interpersonal dimension--in order to have a baby by her.) It follows that it is morally wrong for a provider to give contraceptives to a patient, or give advice on how to use them, or to send the patient to someone who will do so, because that would be to be willing to have the inconsistent act occur. You don't have to try to persuade the other person not to use them, but you can't connive with him to do so.

There is nothing wrong, however, with exploiting the fact that the act doesn't always fertilize an egg, and to find out when these times occur (by studying temperature and secretions and so on), and to limit conception this way, because the act is still a reproductive kind of act, and the non-conception is an accidental effect. It is also not wrong to counsel people in this sympto-thermal method of conception control.

Artificial insemination pretends that the act has only the reproductive dimension and is not interpersonal or emotionally satisfying, and so this is also morally wrong. When the act is done by someone other than the husband of the woman or involves someone else's sperm, it does a severe injustice to the child of making it ambiguous who his father (on whom he has a right to depend) is. "Surrogate motherhood" also makes it ambiguous who the mother of the child is, as well as pretending that the surrogate mother is not the real one when she is. So it is triply morally wrong, and a fraudulent contract which is morally and should be made legally null and void.

Exercises and questions for discussion

1. In amniocentesis, a needle is inserted into a pregnant woman's uterus and some of the amniotic fluid removed. This fluid contains cells from the fetus, and so genetic defects of the fetus can be detected. Is this removal of the fluid a mutilation, and is it morally justifiable, and if so, under what circumstances?

2. Can a person who chooses to remain a virgin take drugs which suppress sexual desire?

3. John was born with six fingers on his hands. May the sixth finger be removed, if it is perfectly functional?

4. A woman who has had to have one breast removed asks her doctor to remove the other one so that she will be symmetrical. May he do so?

5. Can a doctor remove a uterus from a patient who has cancer elsewhere in her body, but whose uterus is only probably cancerous?

6. If a woman can't conceive because her fallopian tubes are blocked and the eggs cannot move down to where they can be fertilized, can the doctor take an egg from where it is and move it down below the blockage so that it can be fertilized and she could have a child?



10.1. The nurse

There are certain special issues that concern other health-care providers than physicians; and I am going to take them up here in relation to the providers that are most concerned with them. First, let us consider nurses.

Obviously, a good deal of what was said in the two preceding chapters will be of interest to nurses, since they deal with the patient's life and physical integrity.

There is a view of nursing that says that nurses have a kind of specialty of their own: that of the "whole patient," meaning the patient's physical and mental and social and spiritual health and their interrelation. I could stand corrected on this, but it strikes me that in order to make this more than nice-sounding palaver, the nurse who was competent in this "specialty" would have to have an M.D. and Ph.D.'s in psychology, sociology, and Theology; and I know of no one, let alone most nurses, who actually has these credentials. A little learning is a dangerous thing; and people who think they know something because they've had a couple of undergraduate courses in something (or a couple of graduate ones, for that matter), can be a menace when treating people unhealthy in these various ways. And you can bet that someone who had all those Doctorates wouldn't want to be called "nurse."

This is not to denigrate nurses; but let's not pretend that things aren't what they are. Basically (or at any rate for our purposes),

DEFINITION: a nurse is someone who is an assistant to some other health-care provider.

This may involve considerable knowledge and skill, of course. If you're going to assist a physician, for instance, he's not going to want you to be asking him what he means every other sentence; and so he's going to assume that you have enough of a background to be able to interpret him correctly. And you have to know enough to be able to spot difficulties that need to be reported to the doctor; and so on.

But these are medical details, however important they may be, and don't of themselves have ethical overtones. The main ethical issues involve what it means to be an assistant.

DEFINITION: An assistant is one who places himself under the authority of another person.

DEFINITION: Authority is the right to command someone else.

DEFINITION: A command is a statement that has a sanction attached to it.

DEFINITION: A sanction is a threat of punishment (or the punishment threatened).

If there is no sanction, you are making request or offering a suggestion or advice, of the form, "It would be nice if you would..." This sort of thing means that the person will be better off if he does it; and so it gives a person the choice of adopting it as a goal or not. On the other hand, when you command someone, you are telling him that he's going to be worse off (because of what you are going to do to him or withhold from him); and since people have a moral obligation to avoid choosing their harm, you leave him "not free." That is, he's free in the sense that he can choose to disobey and harm himself, but he's not morally free because he can't morally choose to harm himself.

Note that when you engage the services of someone, you do not put him under your authority, because you can't tell him how to perform the service. What you've done is enter into a contract with him, saying, "I want to get rid of my infection, and I'll pay you thirty dollars to free me of it." So it's a mutual give-and-take, with benefits on both sides.

But the person in authority can tell you not only the final result, but how to accomplish it, and also it is irrelevant whether you benefit from the command or not; he's just going to see to it that you suffer if you don't do it. So when your mother told you as a child to take out the garbage, included in this was not simply getting the stuff out to the curb, but going around to the various waste bins, in what order, and emptying them into the bag, and when the bag was to be placed on the curb, and so on; and the fact that you found this procedure less than "fulfilling" made no difference whatever. You did it or faced a week without dessert.

But then why would anyone voluntarily put himself under authority, and "give up his own will" to someone else? Ordinarily, it is done because something that needs to be done can't be done by any single individual, or even by a bunch of individuals each of whom has his own idea on how to go about it; only a coordinated effort of everybody will get the job done. (Think of how a football team would fare if in the huddle all the players had to "come to a consensus" on how to run the play.) This means that one person has to be picked out to say, "This is what is going to be done," and the rest have to say, "Yes, sir!" and do it.

Cooperation among individuals (many acting as a unit) implies commands with their sanctions and authority.

So if something can't be done by just one person, and people have to cooperate to do it, then authority is necessary, and the assistants have to be willing to be commanded. Thus, if nurses don't do what they're told, they can expect to be punished--to have privileges taken away, to have their pay docked, to be fired. That's what you agree to when you agree to be someone's assistant.

10.1.1. Immoral and unjust commands

Obviously, the treating of a patient, especially in a hospital, has to be a cooperative venture; the main health-care provider has to have assistants. But note that these assistants, particularly nurses, often have more contact with the patients (whom the doctor is serving) than the doctor; and so they might well have information that the doctor lacks.

Since nurses are cooperating with doctors in treating patients, then the patients' benefit is the primary goal of the cooperative venture, and so this gives the nurses more of a moral obligation than simply that of following orders blindly.

First of all,

A "command" that is beside or contradicts the purpose of the cooperative venture is a null command, because the commander has exceeded his authority.

That is, assistants do not turn their whole lives over to the commander, but only that part of their lives that deals with the purpose for which they are cooperating. Hence, when the commander proceeds to tell them what to do outside the "common goal," as it is called, this is not a true command, and need not be obeyed. But let me spell out the moral implications of this a little more clearly.

DEFINITION: An unjust command is one that goes beyond the authority of the commander.

DEFINITION: An immoral command is one that commands the subject to do what [his conscience tells him] is morally wrong.

Remember, conscience is the factual knowledge you have about the moral status of the act in question; it's not just your feeling or opinion. It's obvious that an immoral command contradicts itself, because the commander expects you to obey basically because it's inconsistent with you to put yourself under authority and then not do what you're told. So he knows it's immoral for you to choose to disobey; but then if he commands you to do something morally wrong, on what grounds can he expect you to obey the command?

An assistant must always disobey an immoral command. Any command that will harm the patient is ipso facto immoral.

You are never permitted under any circumstances to choose what is morally wrong, and especially to choose to harm the patient; and so you can't hide behind, "But he told me to." It's still your choice, and you knew it was wrong.

But of course, the commander may not think there's anything wrong with what he's telling you to do; and your conscience is not his.

Furthermore, in the case of the doctor and the nurse, he is the expert and you are the assistant, who doesn't know as much as he does, at least as far as medicine is concerned. So we have to make some qualifications here.

First of all,

If you think a command is immoral, you must consult with the commander to see if he has reasons why the act would not be morally wrong; and if you still know that he is telling you to do what is wrong, you have to tell him you cannot obey and give your reasons for it.

Remember, this is a cooperative venture, and so you can't simply disobey and leave the doctor thinking that you've done what he told you. But if you say that you can't obey, and he tells you to go ahead and do it anyway, you still have to disobey, even if it gets you fired.


In the case of a doubt after consultation as to whether the act commanded is wrong or not, then the morally safest course, ordinarily, is to do what is commanded.

The reason for this is the following: You're not sure that what you're told to do is wrong, but you think it is. The doctor has heard you out and he says, "I know what I'm doing; there's nothing wrong with this; just go ahead and do it." The doctor is the expert in medicine and you're not, and you have no right to presume that he's a moral idiot (unless, of course, you have reason to believe this); and so the presumption is that he's more likely to be right than you are. Hence, the morally safest course is to do what he says.

This is one of the cases where the doubt of conscience often can't in practice be removed by consulting an ethical expert, because you very often have to obey or disobey before you can trot off to your local parish for an interview. So in general, you can only disobey if you know the command is immoral or unjust.

Now then,

An unjust command may be obeyed when the Double Effect applies.

In this case, you're not being commanded to do something wrong. It may be perfectly all right in itself to do what the doctor wants you to do; it's just that it's not part of your job description, and so he has no right to command you to do it. For instance, a doctor has no right to command a nurse to write the thank-you note to his host for the party he attended last night.

Now there's nothing wrong with doing this for him; it's just that he's not asking this of you as a favor, and is expecting you to do it because he's your boss and he thinks of you as his servant. But you're a nurse, not a secretary.

In general, what should be done in a case like this (if you can get away with it) is make it clear that you'll do it as a favor, but it's not part of your job description, and not something he has a right to expect of you. On the other hand, in the real world, this might have the bad effect of his thinking of you as uncooperative, and making your working for him miserable enough so that it offsets the bad effect of doing as if you were commanded something that was an act of generosity. So the Double Effect can allow you to do it.

In general, you should disobey (politely, and telling him you're not going to do what you're told and why); but you don't have to if it's more trouble than it's worth. The reason why it's preferable not to obey is that "obedience" to this non-command gives the person the impression that he can command others to do whatever he wants, and so it can have rather far-reaching implications.

Remember, "Give him an inch, and he'll think he's a ruler."

10.1.2. Morally correct commands

All, however, is not necessarily perfectly straightforward if the command is neither immoral nor unjust. It is conceivable that there is nothing morally wrong with it, but it is still not a wise command. Do you have to obey it anyway?

If you know that a command is unwise, you have an obligation to inform the commander of the facts you know that make it unwise. Then if after receiving the information he still issues the command, you must obey.

The reason you have to inform him is that he's not omniscient (even if he thinks he is), and might change his mind based on the information you give. If you don't inform him, you are willing that the unwise act be done, because you have a chance of preventing it and you refused to take it. Note that all you have an obligation to do is provide information he might not have, not to persuade him to rescind the foolish order.

There's nothing wrong with trying to persuade him, because, after all, stupid actions can do harm, and certainly don't do good. But you have to beware of being insubordinate here. He's the boss and the expert, and you're the assistant.

And if he hears the information and still tells you to do the unwise thing, you have to do it. Otherwise, you're in effect saying that you'll "obey" (i.e. do what you're told) when it seems good to you to do it, and not otherwise. But in effect that means that you'll do just as you would if you were not under orders. But this is clearly inconsistent with the fact that you are under orders.


If you know that your commander is prone to issue unwise orders, and he has a superior, then you have a moral obligation to document this and inform his superior, so that steps can be taken.

If you don't, then once again you're willing to have these unwise things done, because you know they're unwise and you might be able to prevent them by giving information to the people who can do something about it.

So yes, you do have an obligation to be a "whistle-blower," in spite of your early training not to tattle on people. Once again, however, beware of becoming a person who nit-picks what his commander is doing and runs to his superiors with the news that he's not perfect. The Double Effect allows for a good deal of human frailty before taking action against it is required.

Can you ever disobey legitimate orders? In general, No, of course; but there are exceptions:

You may disobey the letter of the command when you are clearly doing what was intended by it.

Obviously, you are to do what the commander wants you to do. If he tells you to do something, he presumes you are intelligent enough to realize what he wants; and so sometimes the literal thing he commanded doesn't exactly express his intentions. In that case, you do what he wants, not what he said. Be careful of this, however. At times, what seems like an "obvious misspeaking" is an unconventional order that was intended as stated. It is better to make the commander clarify himself and become annoyed with you than to presume that he doesn't "really mean" what he says.

A nurse, for instance, who is told to administer an intravenous injection of sodium bicarbonate in cardiac arrest, knowing that this can be dangerous to the patient, interprets the command as due to fatigue on the doctor's part and doesn't administer it. It turns out that the doctor was not giving the conventional treatment, and due to the lack of this injection, the patient dies.

Where this rule generally applies is not in individual commands, but in cases where there is a standard procedure that is in place, and you know that the situation is inappropriate to the procedure. In the obvious cases of this, you don't have to go running to the doctor and say, "I really shouldn't be doing this to this patient, should I, Doctor?" when both you and he know darned well that you shouldn't.

And with an individual command when the situation changes between the time when the command was issued and the time you are to carry it out, and it is no longer appropriate, and the doctor is not there to be consulted, you may do what it is obvious he would want you to do. But you must tell him afterwards that you did it, because he is the one primarily responsible for what is done, and so should have control.

And for this same reason,

A person under authority must not act on his own initiative in anything substantive, unless the Double Effect demands it.

That is, in the case where taking matters in your own hands is the way to avoid considerable harm, then you can interpret the intention of the commander's "first, do no harm" as paramount. So the Double Effect can allow you to do something on your own.

I had an actual case reported to me before I wrote the first version of this book. Nurses are (wisely) forbidden to prescribe medicine without a doctor's orders. A nurse in an emergency room had a patient dying of poisoning brought in, but there were no doctors available at the moment. She called the poison control center and was told to administer ipecac (something that makes you throw up). She asked for a doctor's orders to do this, and was told that there were no doctors in the poison center either. While she dithered, the patient lost consciousness--after which you couldn't administer the ipecac, and ultimately died of the poisoning.

In minor matters, however, in day-to-day details, the assistants may carry out their duties as they see fit, without asking for orders on how to do them. They may presume that everything is fine in these cases unless they are told differently.

Doctors are not going to bother themselves with details of how nurses go about the ordinary business of nursing, even though the doctor, as commander, is primarily responsible for what they do. You can assume that he wants the standard things done by the mere fact that he hired you; and if he wants something non-standard, he'll tell you. The point is that you don't have to force him to be explicit.

In other words, use your head in all of this.

One final point about the obligation of an assistant:

Assistants have a moral obligation to speak well of and even think well of their commanders, as far as this can be done without being untruthful.

I'm not saying here that you have to close your eyes to the obvious, or pretend that your commander is a paragon when he isn't. But you do have an obligation to look on him and what he says and does in the most favorable light possible, for the simple reason that it is a good deal harder to obey a person you despise. And if you talk badly about him, then you are encouraging others to despise him and so disobey him.

This is obviously a moral obligation that is one of the most ignored of all. Keep it in mind.

Now then,

Insofar as an assistant is an expert in his own right, such as an anesthesiologist who is helping a surgeon, the commander must defer to the assistant's area of expertise, and cannot simply command as if he (the commander) knew best.

This type of assistant has a kind of counter-authority over the commander in his field of expertise, because he is more like someone the commander is engaging the services of rather than hiring to be under orders. True, he is assisting the surgeon during the operation, and what he does is secondary to what the surgeon is doing; but he is really performing the service of administering anesthesia for the surgeon, and it just happens that it is to be done under these conditions. The point is that it is the anesthesiologist who makes the decisions about the specific anesthesiological issues, not the surgeon.

10.1.3. Responsibility of the assistant

You will (I hope) remember that, back in Chapter 4 I discussed responsibility, and said that it came after the act, as accountability for what you had control over.

We now have the situation where a person under orders is not morally in control of some of the things he does, and has control (in the sense of could prevent) things that other people do. So let us spell out what the responsibility here is.

First of all,

Assistants are not morally responsible for what they do in obeying legitimate commands, even unwise ones (provided they have informed the commander). The reason is that they cannot morally not do the act, and so the control is in the commander's hands, not theirs. (Yes, you can say, "It wasn't my fault; he told me.")

In this case, the commander and only the commander, is responsible for what you do.

Assistants are responsible for

Any act of disobedience, even a legitimate one, because they could prevent the act by obeying. Notice, when they legitimately disobey, they are responsible for what they do, but not guilty of it, because the act was a good act.

Any act of obedience to a foolish command when the commander was not informed, because the command might have been rescinded if the commander was told what he was doing. Hence, the control is in the hands of the assistant. Of course, in this case, both the commander and the assistant have joint responsibility, since either could have prevented the act.

The interesting thing here is that you are responsible for what the commander does in this case, because your giving or withholding the information affects his choice and his act.

Any act of obedience to an immoral or unjust command. In this case, you can morally disobey, so you are morally responsible for obeying. If the command is immoral, you are also morally guilty, even when the commander (by ignorance) is not. So here you can't hide behind, "I was only obeying orders." You had an obligation not to obey this one.

In the case of an unjust command, you are responsible for the obedience whether or not the Double Effect allows it, because the command always could have been obeyed; but you are not morally guilty, because by the supposition, it is not morally wrong to do the act (otherwise the command would be immoral, not simply unjust).

In both of these cases, you are also responsible for what the commander commands if you don't inform him of the immorality or injustice of his command.

Any act done not under explicit orders, but done while under orders, even when interpreting what the commander "obviously" wants. Since the commander didn't actually tell you to do the act, even if it's what he would have wanted, you are the one in control, because you are actively interpreting him. So if you make a mistake and don't do what he would have wanted, you can't blame him.

Any harm to the commander that comes or might come from thinking or speaking badly of him. Since you're the one with the nasty thoughts or words, then the consequences of these thoughts or words are yours. Now of course, if his bad conduct forces you to recognize it, you are not responsible for harm that comes from the conduct; it isn't your recognizing the truth that did him damage, but what he's doing himself.

Obviously, if you tell the truth to his superior, you are responsible for the consequences of what you say (which may harm him), but not morally guilty of the harm, because you had to tell on him to avoid the harm that he was doing.

10.1.4. Cooperation in evil

I also said as far back as Chapter 3 that basically, morality commanded you not to be willing to do what is morally wrong. You may be in a situation where you are an assistant to someone you know is doing wrong. To what extent can you even be his assistant without going along with the wrongness, and so being willing that it be done?

If the moral wrongness is not simply something that is inconsistent, but is something that violates a right of another person, you may not even be an assistant of the perpetrator.

The reason is that in this case, you have an obligation to prevent the violation of another person's right or you are willing to allow the violation which is, of course, the same thing as to will to violate it. But if you assist a person who is violating someone else's right, even though he doesn't think he's violating any right of anybody, you can't be unwilling to allow the violation. You are at the best indifferent to it, not opposed to it.

Think of it this way. Suppose you were hired by a slave-owner, and were helping him, even if not directly, with his oppression of the slaves. Obviously, you are making life easier for him, and so easier for him to continue oppressing the slaves, and so you are indifferent to the fate of the human beings he is using as animals, and conniving at making it easier for him to do so. You can't say, "I care about the slaves' rights."

So, you can't be an assistant of someone like Dr. Jack Kevorkian, even if he thinks he's benefitting mankind by helping people kill themselves, and even if you're not directly assisting in that service. For instance, you can't be his secretary.

But the obvious application in our present day is to abortion. Anyone who assists in any way a person who performs abortions makes it easier for the person to perform the abortions. Therefore, the assistant is at best indifferent to the rights of the people being killed, and is conniving in abortion. This is true whether or not he assists in the actual abortion.

Also, no one who knows what the truth is may morally serve in any capacity in a hospital in which abortions are performed.

The Germans didn't have to serve in the death camps to be morally guilty of what was done to the Jews; by simple complacency and indifference, they made it possible for the horrors to be performed.

And, propaganda by the "pro choice" people to the contrary, a worse than Hitler is here.

But suppose the doctor performs vasectomies to sterilize men who want to be sterilized. He's doing what is morally wrong, but he's not violating a right of the other people, because even though he's doing objective harm to them, they want the harm to be done. Further, neither he nor they think that they're doing harm.

Note that in this matter

Not to do anything whatever to demonstrate your opposition to abortion is to be willing that it happen. You can't morally be indifferent to the violation of others' rights without conniving in the violation.

Now this doesn't mean that you have to go out and picket abortion clinics. But if the subject comes up, for instance, you can't just not say anything to show that you're opposed. Even if that's going to lose you some friends, not do so indicates that you're willing that lives be sacrificed to your convenience of having your friends not be uncomfortable.

After all, the fewer assistants and supporters abortionists find, the more difficult it will be for them to perform abortions. And let's face it; the indifference of the majority is the real support they have. Look at smoking, and how the lack of indifference on the part of many has curtailed it.

But now, aside from a violation of rights, can you be an assistant of someone who does morally wrong things? Suppose a person who performs vasectomies, which sterilize men, wants an assistant. Can you take the job?

It depends. If the person does for practical purposes nothing but vasectomies, or if he makes this his main business, then if you worked for him at all, you would be willing for these acts to be done, and would be an accessory to the wrong. So you can't assist a person whose main business is doing something that is morally wrong.

This is true even if he thinks it's morally all right, and even if his patients see nothing morally wrong with it. The fact is that it is wrong, and you know that it's wrong; and so even though they're not being immoral in doing it (because of their ignorance), you would be immoral if you helped in it.

Well now, suppose the physician is not a vasectomist, but every now and then performs vasectomies. What then?

You may assist a person who occasionally does what is morally wrong without being willing that the wrong be done, as long as you don't help in the act itself.

Obviously, if you assist in the actual act, then you're not unwilling for it to be done; your actual help shows your willingness that the act be done. That should be obvious.

But that's not the case if you help the person who happens to perform the act, because he's doing all sorts of other good things, and those you can morally choose.

You may even morally do things like sterilize instruments which may be used in the morally wrong procedure, as long as they aren't instruments that have no other use but this.

Obviously, if you're going to work for somebody like this, you have to come to an agreement with him. You have to tell him, "Look, I'll work for you, but I believe that vasectomies are morally wrong; and while I'm not trying to be your conscience and prevent you from doing them, my conscience won't allow me to help you do them. So if you'll exempt me from working on vasectomies, I'd be glad to be your assistant in everything else." If he agrees, then morally speaking you're home free.

Obviously, if there is some kind of emergency in your service, and people would be harmed unless you assisted at what in fact is a morally wrong act, the Double Effect would permit the assistance.

For instance, the doctor is performing another operation, and (forgetting that you have qualms of conscience about vasectomies) he decides that he's going to perform a vasectomy while he's at it, rather than schedule another operating time. If you walk out as soon as you discover what he's up to, then the patient may die or be severely harmed because the doctor suddenly has lost his assistant. Clearly, you are staying there not because you want the vasectomy, but solely to prevent harm to the patient.

Finally, as I said before in another context:

If someone wants a morally wrong procedure performed, you may not tell him that you (or this hospital) can't perform it, and then give him advice on where to go to get it done.

In that case, you are willing that the act be done, and so morally speaking, you might just as well be doing it yourself. This would apply to telling someone where to go to get advice on contraceptives, for instance, or abortion.

You can't hide behind "Well, it's a legal procedure, and he has a right to know." He has no right to know from you. No one can ever claim a right for anyone else to do wrong. Legally, of course, he might have a right (depending on what the laws are); and so you might have a legal obligation to inform him. But you have a moral obligation not to inform him; and so any law that would force you to do so is an immoral command, and must not be obeyed.

10.2. The psychologist

So much for nurses. There are a number of moral issues that are specific to psychologists also. Now first, a psychologist, medically speaking, is someone who doesn't have an M. D., and so who cannot prescribe medicine; only psychiatrists are also medical doctors and can prescribe drugs for treatment. But I am going to deal with both together, and I said "the psychologist" just for convenience. I am speaking of anyone in the field of mental unhealth, which, as I said in Section 6.2. is the inability to control one's actions by one's choice, or to have access to information one would be expected to have.

The first thing to do is be very clear on what we are talking about here.

The problem in mental unhealth is not bizarre behavior, or self-destructive behavior, or feelings of inadequacy or hopelessness, or not fitting into society, or unrealistic views of life, or unhappiness. The problem is lack of conscious control over one's acts or one's information.

All of the above may be signs of mental unhealth; but there are eccentrics who could perfectly well do what normal people do and simply choose not to; there are people who do themselves damage and know they are doing so and don't care; there are people who feel inadequate because they recognize that they are inadequate, and hopeless because in fact there is no hope; there are people who don't fit into society because society refuses to accept them; there are people who are perfectly sane and simply aren't knowledgeable enough to think that life isn't what they believe it is (think of all the atheists, who believe that this life is the only one--and they call themselves the rational ones); and there are people who are unhappy because life has stepped all over them.

10.2.1. The mind

But obviously a person is not mentally unhealthy if he can't control his legs because he's crippled, but only if there's something wrong with his mind. But what is the mind, he asked, with another of those questions that have no answer. Oh yes, it does.

DEFINITION: The mind is the ability to be conscious.

It isn't consciousness itself, but whatever it is that makes us capable of being conscious. We are conscious at some times and not others (as when we're fully asleep and not dreaming); and when we regain consciousness, one and the same consciousness takes up where it left off, so to speak, so that we're not subjectively aware that there's been any break (we argue to breaks by external signs). Obviously, there has to be something there during the unconscious period, which can "turn on" again, so that consciousness can resume.

Not to make this into the long story that it should be if you analyzed it carefully, the mind is the brain. When the brain is active in a certain way, you are conscious; when it is inactive or active in other ways, you're not.

Note that the brain is not consciousness; it is a physical part of you which (a) enables consciousness to turn on and off, (b) selects which conscious act you have at any given moment (by which nerves are active), and (c) channels consciousness along various paths, and links it with behavior.

Note also that consciousness ordinarily has a good deal of control over these functions. You can keep yourself awake when you want to, you can fall asleep at a time (more or less) of your choosing; you can concentrate on what you want to concentrate on, and you can keep yourself from doing what you feel like doing if you choose. All within limits, of course.

Now then, the brain (the mind) functions as an extremely complex computer, with the nerves as the "bits" that are either on or off. Each act of every nerve (well, perhaps nerve-complex, and perhaps only certain types of nerve-complexes) has its own form of consciousness associated with it; even the act of the "operating system" itself has its own form of consciousness.

DEFINITION: Emotions are the conscious aspects of the various operations of the mind as it directs consciousness from the stimulus that caused it to behavior.

Mental unhealth, then, consists in a malfunction of these operations of the brain-computer, such that consciousness loses the ability to direct what the mind is doing.

You have "lost your mind"; and since what has got out of control is the mind's "operating system," it's not surprising that mental unhealth is called having an emotional problem. It isn't the emotions you have that are the problem; it's that the emotions are either inappropriate to the situation that caused them, or that they have so much energy to them that either you can't access the information that's there and waiting to be used, or that they take over control of your behavior contrary to your choice. Mental unhealth and immorality

The first issue to straighten out is one that we discussed in Chapter 4: the relation of mental unhealth and moral and immoral choices. Let me expand just a bit on it.

Choices are immoral insofar as you choose to do what you have reason to believe is wrong. Choices imply action: they are consciousness directing the energy-flow in the brain. "Choices" which you have no intention of carrying out aren't choices; they're daydreams. So if you actually carry a choice into action, the action merely confirms that it was a choice and not a daydream.

Now then, if some emotion is so strong as to blind you to the facts when you make a choice, the morality of the choice depends on the facts you actually have in your consciousness, not what you could have known. This should be obvious by now. Similarly, if an emotion is so strong that it's going to cause behavior whether you choose to do the act or not, the morality behind the action depends on whether you were willing to do the act or whether you chose to prevent it but couldn't.

It is this relation of lack of control between the choice and the information or the behavior that constitutes mental unhealth, not either the choice itself nor the information itself nor the behavior itself.

Let me illustrate the permutations of this by an example. Psychologists nowadays no longer say that homosexuals are mentally unhealthy. This is in part true, and in part it isn't.

A homosexual who is in control of himself and who sees nothing wrong with homosexual sex is neither mentally unhealthy nor immoral when he engages in homosexual sex.

In point of fact, the act is morally wrong, because obviously the act of homosexual sexual intercourse contradicts its reproductive dimension (the ejaculation of sperm shows that it has this dimension; but of course this makes no sense in the context of the act). So this homosexual has an intellectual problem, not a moral or emotional one (the same sort of intellectual problem that people have who see nothing wrong with contraception).

He may well also have a social problem which could amount to social unhealth, insofar as the people around him disapprove of his behavior, thinking it (rightly, in this case) morally wrong.

(a) This is society's problem when the disapproval extends to the disapproval of him as a person and people seek him out to "punish him for his perverted behavior," when that behavior is not in fact violating any right of any person (if he's not "recruiting" people into homosexual sex, but only doing it with people who want to), and he's not flaunting his conduct. People tend to disapprove (rightly) of heterosexuals who engage in foreplay in public too. People are not to be persecuted because they don't act according to others' moral standards, as long as no one's rights are violated.

(b) But the problem is his social unhealth if he wants the rest of society to accept his conduct as "equal" to theirs, just because he sees nothing wrong with it.

That is, the homosexual activist, who wants society to recognize homosexual sex as a "different lifestyle" is in fact doing to others what he wants them to stop doing. He is condemning others for thinking that it's wrong for anyone to engage in this activity (which he sees nothing wrong with). But that means that he's condemning them for disagreeing with his moral position on the matter. But clearly, he is disagreeing with their moral position on the matter; and so in condemning them, he's condemning himself. He won't tolerate their moral position, and he wants them to tolerate his. That is, his position is not one of "live and let live," because in fact he wants them to change their moral position of non-acceptance; and so he doesn't accept their position as morally valid, and wants it stopped.

This social dimension of homosexuality applies, mutatis mutandis, to all the variants of homosexuals I mention here.

A homosexual whose homosexuality blocks him from understanding that there is anything wrong with the act is mentally unhealthy, but has no moral problem. Here, he doesn't really have an intellectual problem either, because he's intelligent enough to understand the issue, but his emotional attachment to the act simply won't let him see it.

A homosexual who recognizes that homosexual sex is wrong and chooses not to engage in homosexual sex, and actually doesn't do the acts, is neither mentally unhealthy, nor is he immoral, nor does he have an intellectual problem. He may not be happy, but he's in control.

Now he may have an "emotional problem" in that he's attracted sexually to people he can't actually have sex with, morally. (That's why he's unhappy.) But he's not, strictly speaking, actually mentally unhealthy, because he can control himself. It might be that a psychologist may reorient him sexually (there's a question on whether, for a "true" homosexual, whatever that is, this is possible, but let that ride); but it's not, strictly speaking, curing his unhealth.

I should say that, insofar as he doesn't want to feel the emotion and feels it in spite of himself, he could be said to be mentally unhealthy, given that the tendency the emotion implies is toward a self-contradictory act (and so the tendency is "objectively disordered"). But this isn't mental unhealth in the strict sense, as can be seen from the following: It would be a little difficult for, say, a married man who has lustful urges (that he doesn't act on) toward other women to call himself "mentally unhealthy." Everyone else would call him "perfectly normal."

A homosexual who recognizes the act is wrong and says, "But this is the way I am, and so I'm going to do it anyway," when he could keep himself from having homosexual sex if he wanted to, is being immoral but has no mental unhealth. Indeed, he does not even have a problem with his emotions, because he wants to have them.

A homosexual who recognizes that the act is wrong and doesn't want to do it, and still finds himself doing it, is mentally unhealthy, but has no moral problem.

A homosexual who recognizes that the act is wrong and finds he can't help himself, and then says, "Well, I might as well accept myself for what I am," is both mentally unhealthy and immoral.

The point, of course, is that mental unhealth does not excuse you from being immoral; that depends on what your choice actually is, whether you are in control of the information or your actions or not. Implications for treatment

The case of the homosexual is instructive, because all of the examples given above actually exist, and some of them are mentally unhealthy in the strict sense, some are mentally unhealthy in a treatable sense, and some are not.

First of all,

Psychological treatment may not be given to people who are not mentally unhealthy.

Practically speaking, the treatment won't work, because the person isn't out of control, and so how can you get him back into control? But morally speaking, to treat someone for a "disease" when in fact all that's wrong with him is that he's doing something that "normal people don't do" is a morally wrong interference with a person's choosing his own goals: his own "lifestyle." It contradicts the essence of humanity.

Thus, it would be wrong to treat (as was done in the past) the "mental unhealth" of homosexuals who see nothing wrong with homosexual sex, or who don't care that it's wrong and want to do it. You can't hide behind, "They must be crazy, or they wouldn't want to do such a thing." They are in control.

By the same token,

Treatment must not be refused to those who are mentally unhealthy and want to be treated.

The exact opposite of what I just mentioned is being perpetrated on homosexuals now, in many cases. Since homosexuality is not any longer considered mental unhealth, some psychologists will actually resist allowing homosexuals who want to get rid of their orientation, or stop performing acts they don't want to perform, to receive treatment. "It's not a disorder; don't treat it." Well in this case it is mental unhealth; as much mental unhealth as the person who wants to be able to go into dark rooms and can't make himself do so.

The third point we can learn from the above discussion is this:

If the mental health of a person leads him toward behavior that is morally wrong, his treatment must not consist in getting himself to accept himself for what he is, in the sense of being willing to behave in the way in question.

This is another sin against homosexuals who are at war within themselves and go for psychological treatment. Very often the "treatment" has as its goal "coming to terms with yourself" and recognizing that this is the kind of person you are, and not feeling guilty when you act according to your nature.

Much, for instance, is made of any shred of evidence that homosexual tendencies are "innate," as if this made any moral difference. Actually, the jury is still out on this issue (if it ever will be in); but in fact it makes absolutely no difference whether you got your orientation from your genes or your early environment, or whatever. The fact is that it is a tendency to do what (in one respect) contradicts itself; and so it is "unnatural" in the moral sense, whatever it is in the biological sense.

That is, there are people who are genetically blind, genetically lame, genetically stupid. Suppose the genetically blind person's blindness could be cured, is the fact that it's genetic a reason you shouldn't cure him? That he should "accept himself for what he is, and rejoice in the way he goes around bumping into things"? He has to accept himself as blind, to be sure, but he certainly doesn't have to be satisfied with it, still less embrace it.

The homosexual is a sexual cripple, however he got that way. This is not to denigrate him, any more than it is denigrating the blind person to say that he's handicapped. And the homosexual has to accept the fact that he's homosexual (at least temporarily, if his orientation can actually be changed), but he must never be satisfied with the behavior that the tendency leads toward.

Put it this way: Suppose Jeffrey Dahmer's psychological need to cut people in pieces and have sex with the parts were genetic. Therefore, he should be counseled to accept himself and not feel guilty about his behavior?

Getting rid of guilt feelings can be a goal of psychological treatment only when there's nothing to be guilty about.

If the person is doing things that make him guilty, then obviously he ought to feel guilty. Too much of what goes on in our culture consists in the following reasoning:

I am doing something evil, and I feel guilty about it.

I don't like to feel guilty about what I am doing.

Therefore, I will define it as all right, and persuade myself (or psychologize myself) out of my guilt feelings.

And there are too many psychologists, infected with the theory that guilt is just guilt feelings, who are too ready to do too much of this to too many, for too great a fee.

Now then, one final point, before we go on to psychological methods:

A person whose mental health consists in inability to access information may sometimes be treated against his will.

The reason is, of course, that he doesn't (because he can't) have access to the information he can base a rational choice on. You can break down the barrier that is keeping information from his consciousness even if he doesn't want you to, using the Double Effect.

But here, you have to have reason to believe (a) that he actually is unaware of the relevant information; (b) that he's doing what he would not want to do if he had it; and (c) that he would want you to force the information upon him.

You have to be careful of this, because as I said, it's very easy to say of someone, "He must be crazy if he wants to do this kind of thing; he must not know what he's doing."

For instance, as I wrote the above, there was speculation that the person who bombed Centennial Olympic Park in Atlanta was the security guard who "discovered" the knapsack containing the bomb, and who saved many people from the blast. It seems as I now write that there isn't yet any evidence that he's actually the one. I certainly don't want, by this example, to imply that I think him guilty of the crime, or even that he's the type of person I'm going to describe. But to illustrate what I am saying here, let us suppose that the person who planted the bomb was a security guard who wanted the glory of being the one who rescued hundreds of people from a horrible death.

One would certainly think that a person who would set a bomb to blow up a place so that he could be a hero as he rescued people from being hurt, has to have no unavailability of loose screws that he could stuff the bomb with. So in all probability he's mentally unhealthy, and just pictured himself saving all those people and didn't really consider that he was the one who was blowing them up and that he might not save all of them and that he'd probably get caught and be even more despised and go to jail and all the rest of it--he probably had this heroic picture and "I'll show them!" so strong in his mind that it blocked out everything else.

But it's also possible that he realized the implications of what he was doing, and so did have access to the relevant information, and was or was not in control of carrying out the plot (in which case he either wasn't mentally unhealthy at all, and was simply depraved, or was mentally unhealthy in the behavioral but not informational sense).

In the first case, he could be treated against his will; in the second, he could be treated only if he wanted treatment.

(In any case, by the way, supposing the actual guard to have done the act, we must pray for him and help him; but we have to be protected from him and everyone else like him.)

10.2.2. Methods of treatment

A few remarks are in order about the moral implications of certain types of psychological treatment.

Treatment can be divided into two categories: psychophysical treatment, such as surgery, drugs, and the borderline cases of narcotherapy and hypnotherapy; then purely psychological methods of what is now called "counseling" or just "therapy."

As far as psychophysical methods of treatment are concerned,

Surgery, drugs, or shock treatments are morally legitimate, subject to the rules of the Double Effect.

Many of these things have serious, even drastic side-effects; and obviously if they do, then the harm that is to be avoided has to be that much greater. In all cases, you are fooling around with the brain, analogously to tinkering with the motherboard on your computer; and any time you do that, you had better know very well what you are doing, because tiny changes can produce enormous effects.

In my own case, for instance, I was in the experiment testing the antidepressant I took regularly for several years afterwards; and I discovered that as the dosage was increased, the depression was removed--up to a point. After that, a tiny increase brought the depression back with a vengeance. And at that point I was only at about a quarter of the normal dosage. An unwary psychiatrist, not knowing how sensitive his patient is, might prescribe the normal dose, and find that his patient has killed himself in despair.

This caution goes double for things like hypnotherapy, in which the doctor (by his words) takes over control of the "operating system" of the brain (what I in Living Bodies call the "instinct"), giving him a control over it that the person does not consciously have himself. The trouble is that if you try to treat someone this way, you might wind up by hypnotic suggestion "rewriting" part of the program of the brain; and when the person gets back into the real world, this might clash with something else he has there, making the last state worse than the first.

I heard a story (which may be apocryphal) about a man who quit smoking by being told under hypnosis that he couldn't stand it. It turned out that the reason he was smoking in the first place was that it was being used as an escape from his hatred for his wife--whom he then killed.

I may be going out on a limb in saying this, but many if not most psychological problems are a way of coping with a fear of one sort or another (at least, that's Freud's view): of avoiding something that you just can't stand to experience again. When the avoidance involves undesirable behavior, it is not necessarily desirable simply to correct the behavior.

Obviously, I'm not breaking any new ground here. The point is that you can use these things, but you have to know what you're doing, and you still have to be extremely careful, or you can be doing more damage than you're correcting.

As to psychological methods, the Freudian approach basically is that the brain has created a series of shunts around the horrible experience, which generally happened when very young; and so the behavior is a way of keeping it out of consciousness. His idea was that if you could get to reexperience it now in your adulthood, when you know that such things aren't the end of the world, you might be able to cope with it. You can't just be told (or know intellectually) what it was; you have to be able to get back "into" it, the way you get "into" a movie, and go through it emotionally again--which, of course, is the thing you're terrified of doing. If you can manage it, then you've broken down the barrier into that area of the brain, and can gradually get to use it again.

The approach itself is perfectly legitimate, and the therapy, though often extremely lengthy, is apt to work. The moral problem with this approach is that it could create a false conscience in a person, and leave him thinking that because his problem is psychological, particularly if it involves guilt, then guilt is just a feeling that can be psychoanalyzed out of you. But there is objective as well as subjective guilt, as I think I've shown in these pages.

Behavior modification, the other major theory of treatment, is not concerned with discovering the source of the mental unhealth; it takes the undesirable behavior and treats it like a bad habit that you can be trained out of. Situations with only a very few of the characteristics that trigger the behavior are introduced and you learn to cope with them; and as you learn, more and more of the characteristics are brought in until finally, you don't have any problem behaving the way you want in the original situation.

You don't necessarily need a therapist to guide you through this. If you find yourself trapped into undesirable behavior in certain situations, there's nothing to prevent you from devising your own pattern of gradual behavior modification, and taking step by step at your own pace. It's tough, but basically that's what we do whenever we want to get rid of a bad habit or acquire a good one.

Again, this method tends to work, and there's nothing morally wrong with it in itself. Its moral problem would come when the retraining would take the form of doing something morally wrong. The fact that you're trying to get out of a psychological difficulty is no excuse for deliberately doing something wrong as a means to get out of it.

I am a terrible subject of psychotherapy. At one time, I began by telling the therapist, "You're the psychological expert, and I'll do what you tell me, if I can. But I'm the moral expert, and I decide whether something is right or wrong, and if I think it's wrong, I won't do it." He said, "But that's going to tie my hands. Do you think I'd tell you to do wrong?" I said, "Maybe not what you think is wrong; but I know what's wrong. So that's the way it's going to be." He looked at me strangely, probably for daring to think that there was any right or wrong that you could know.

The last method I want to mention, group therapy, is extremely dangerous. Putting psychologically vulnerable people together and getting them to "be honest with the way they feel"--particularly about each other--can be absolutely devastating to them. No matter how much good it may do for a person to get his feelings for another out into the open, and no matter how much you might insist that these are "just feelings and not facts," it can be completely shattering to find out that someone you thought loved you and had high regard for you actually holds you in contempt. It takes a very strong psyche to be able to withstand that kind of assault; and very strong psyches are precisely what you don't have here.

I have heard from psychiatrists I respect that these things can do a great deal of good; but from my experience with them and just on common-sense grounds, my impression is that the Double Effect would not allow them. I would have to be thoroughly convinced that the dangers I see (and the terrible effects I have seen) do not occur before I would think that they could morally be allowed. One person's mental health is not to be sacrificed to another's.


There is a morally dangerous attitude underlying a good deal of psychotherapy: that we are not free, and that we are simply to be altered into behaving "acceptably," the way animals are trained.

Granted, the definition of "acceptable" behavior is generally left to the patient. But a patient, especially a vulnerable one, is not an animal to be retrained or a lump of clay to be remolded; he is a free individual, who isn't trying to get changed, but to get back into control, so that his choices once again govern his behavior.

10.3. The researcher

Strictly speaking, of course, a person engaged in medical or biological research is not a health-care provider; but he's in the health-care field, and his research leads to methods of health-care delivery.

I have already spoken of using people in experiments, in section 7.4.1. They have to know that they are in an experiment, and what risks they run in being in it, and so on, so that they can make rational choices of whether to run the risks. They have to receive standard treatment if they are in control groups, and no harm may be done to them in order to achieve the goal of the research.

But there is one "hot topic" that hasn't been treated: that of genetic engineering. Is it morally acceptable to fool around with the genes of any living thing? If so, can you morally fool around with human genes in the name of curing genetic defects, and so on?

First of all,

There is nothing morally wrong in itself with changing the genetic structure of a living organism. We do that every time we breed organisms--indeed, every time we have sex and have offspring ourselves. So the mere fact of creating an organism which has a genetic structure different from any other organism is morally acceptable.

True, this genetic manipulation is happening in the laboratory and not by grafting or breeding two different strains of the species; but in principle it's the same thing. So, certainly in the case of other organisms, there is no moral problem with genetic engineering in itself.

There is a danger in engineering the genes of microorganisms such as bacteria or viruses, however. A strain toxic to the organisms (including the human ones) could be produced, and if it gets out into the world, it could cause incalculable and unstoppable harm. Insofar as there is any real reason for thinking this might actually happen, the Double Effect would not allow it.

The reason, of course, is that this "Andromeda strain" could produce such destruction that the harm would vastly outweigh any benefit from the newly created beneficial organisms. Hence, unless there are safeguards such that (to those who know what the objective situation really is) there is no reasonable doubt at all that this could occur, it is immoral to choose to perform such experiments.

Let us suppose that there are such safeguards. True, if there's no reasonable doubt and you happen to be mistaken, then we're all doomed. But then, if an asteroid hits us, we're doomed. If some crazed bomber gets hold of some nuclear weapons and starts flinging them around, we're doomed. If the world warms up ten degrees or cools down ten degrees (which might happen if twenty volcanoes of a certain magnitude erupted in a year), we're doomed.

"Unless the Lord guards the city, it is a waste of time for the guards to stay awake." There is no way we can be safe. So it is perfectly moral to pursue these researches even if there is the theoretical possibility that we'll be bringing the Apocalypse upon us. Ultimately, the Lord is running the universe, and all he asks is that we be reasonable.

There is, however, one thing that is being done that must be stopped:

The practice of patenting of genetically engineered material, with the enormous economic rewards to be gained from the monopoly over the new organism, creates a morally unacceptable incentive to be careless in the race to be the first to get in the patent application. The law allowing patenting of these things must be rescinded--and as soon as possible.

It's just too much to ask of human nature for people to take all the necessary time to be meticulously careful if they know that someone else is on their heels in developing a certain useful new organism. It's a recipe for sloppy work. That's a real danger, no less real than the danger of getting lung cancer from smoking.

But now what about human genes? First of all, there is nothing wrong with studying and mapping the human genetic structure, so that we can know where genetic defects lie.

But this knowledge must not be exploited to the harm of anyone.

That is, finding out whether a fetus has a genetic defect so that he can be killed (pardon, aborted) is clearly morally wrong because the motive is evil. But also, if a person is known to have a genetic defect which will result in some serious disease twenty years from now, this knowledge cannot be used to deny him insurance; which would mean that he is to be harmed (denied treatment) because of the defect. This is also morally wrong.

But of course, if you have this knowledge, then steps might be able to be taken to head off the sickness (or even correct the genetic defect); and so the knowledge in itself is not an evil thing.

I will also go out on a rather thin limb and say:

There is nothing wrong with altering or manipulating human genes in such a way that the body's structure can be changed, as long as this does not involve doing harm to any human being.

What I mean is (a) you can't use human fertilized eggs or embryos for this purpose, because there are bound to be risks involved, and these human beings can't give their consent. You can use unfertilized eggs or sperm, because, of course, they aren't human beings.

I think the theory as it now stands is that it might be possible to put an altered human chromosome into a virus in such a way that when the virus is injected into a person with a chromosome with a defective gene on it, the virus will induce the cells to replicate themselves using the altered gene instead of the defective one.

For instance, if you could get a normal chromosome in a virus and infect someone who had sickle-cell anemia, then it might be that the infection would replace the defective chromosome, and the person's body would then produce normal blood cells.

Certainly, the effect of such experimentation is very good. The experimentation itself does not necessarily involve anything inconsistent (as I say, when two people have sex, they are "genetically engineering" the baby); the motive is not to create human mutants or monsters, but just the opposite, and so everything seems in place for the Double Effect.

The moral caution here is to be sure that the experiments leading up to the good results do not result in harm greater than the benefits to be envisioned--and that the persons running the risk of possible harm know what they are doing and are willing to undergo it.

--I could go on and speak of issues dealing with hospitals and veterinarians as well as unconventional treatments such as acupuncture; but I already mentioned in passing the main moral concerns here (e.g., the obligation of hospitals to cut down inefficiency and waste), and this book is too long as it is. So let this be the end of my pronouncements on ethical considerations in the field of health-care delivery.

Summary of Chapter 10

There are issues mainly of interest to other providers than physicians. A nurse is an assistant to another health-care provider. An assistant is under the authority of someone else, and authority is the right to issue commands, which are statements that have sanctions attached to them; a sanction is the threat of punishment if you don't do what you're told. People put themselves under authority when certain goals can only be achieved if many people cooperate; cooperation implies authority and sanctions.

A command that exceeds or contradicts the authority of the commander is null. It is immoral if it commands you to do what (your conscience says) is morally wrong, and unjust if the act is not morally wrong, but the authority has no right to tell you to do it. You must disobey any immoral command; but you may obey an unjust command if the effects of disobeying are worse than the effects of obeying. If you disobey, you must consult with the commander and give him your reasons. In the case of doubt whether the act commanded is morally wrong, the benefit of the doubt goes to the commander, and so the morally safest course is to obey.

If a command is not immoral or unjust, but simply unwise, you must inform the commander of your reasons for thinking so, in case he doesn't know the information; then if he issues the command anyway, you must obey. If you know he is prone to issue stupid commands, then you have an obligation to let his superior (if any) know, so that corrective steps can be taken.

You may disobey the letter of a command when you are obeying what is clearly meant by it; but you must be careful not to "interpret" commands to suit your own ideas, since this contradicts you as under authority. You may disobey if the situation changes, and it is clear that the commander would have rescinded the order. You must not act on your own while under orders, except (a) when the Double Effect applies, or (b) in minor, everyday duties that the commander assumes you know enough to do. You must speak and think well of your commander, insofar as it is possible consistent with the truth, because it is hard to obey when you despise the commander.

An expert assistant (e.g. an anesthesiologist) is really someone whose services are engaged; and so the commander can't really tell him what to do in his own field.

An assistant is not morally responsible for what he does in obeying legitimate commands, even stupid ones (if he has informed the commander), since he cannot morally disobey. He is responsible for: (he has moral control over) (a) any act of disobedience, even when he morally must disobey, (b) any obedience to a foolish command if he has not informed the commander, (c) any obedience to an immoral or unjust command, (d) any act not explicitly commanded, but by way of interpreting what the commander would want done, and (e) any harm that comes from thinking or speaking badly of the commander.

You cannot assist any person or group that violates the rights of another; thus, you cannot morally work in any capacity for an abortionist or in a hospital that performs abortions. This would be to facilitate (even indirectly) the injustice of killing someone. You cannot be simply neutral in such a matter. You cannot morally assist a person who makes as his main business services that are morally wrong, even if no one's rights are violated; but you may morally assist a person who occasionally does morally wrong procedures of this nature, as long as you don't help in the procedure itself, which would be being willing that the procedure be done. In an emergency, the Double Effect would allow assisting in the actual act. If someone wants something morally wrong (such as advice on contraceptives), you may not give it, nor may you direct him to somewhere where he can get it. To do so would be to be willing that the wrong act be done. You do not need to try to persuade him out of it, however (unless it involves a violation of someone's right, as an abortion). The fact that some of these things are legal is irrelevant; if the person has a legal "right to know" about them, he has no right to know from you.

The psychologist treats mental unhealth. This is the lack of conscious control over one's information or actions, not bizarre behavior or feeling bad. The mind is the ability to be conscious, and this is the brain; it is not consciousness, but what shuts consciousness on and off and what controls the flow of consciousness (when the consciousness is not controlling itself by controlling the brain). The brain acts like a complex computer, and emotions are the conscious aspect of its "operating system" at work. Thus, mental unhealth is a malfunction of the operating of the computer, and it shows up as an emotional problem.

Mental unhealth occurs when, because of a brain malfunction, consciousness either cannot access information that should be available to it, or cannot direct behavior. If the person does what is wrong and does not know it but, whatever his emotional state, is in control of himself, he has an intellectual problem, not a moral or mental one; if his lack of knowledge is due to inability to access information, he is mentally unhealthy, but not immoral. If he knows what is wrong but doesn't care, he is immoral, but not mentally unhealthy. If he knows it is wrong and can't help doing it and tries not to and fails, he is mentally unhealthy and not immoral; if in this situation, het "accepts himself" and is satisfied with doing it, he is both mentally unhealthy and immoral. All these combinations are possible.

Psychological treatment may not morally be given to people who are not mentally unhealthy, whatever their behavior may be, because this infringes on their control of themselves. Treatment may not be refused to those who are mentally unhealthy and want it. When treating someone whose unhealth leads him to morally wrong acts, the treatment must not consist in getting him to "accept himself" and think he is not guilty doing the acts. Feelings do not determine rightness or wrongness, and you can never be willing to do wrong. Ridding yourself of guilt feelings can be a goal of treatment only when there's nothing to be guilty about. A person whose mental unhealth consists in inability to access information may be treated against his will, if it is clear that this is what he would want if he could know the facts. But one must be careful in not "reading into" the situation.

As to methods of psychotherapy, psychophysical methods are morally acceptable, even drastic ones, when the Double Effect applies and the harm done is less than the harm avoided. Psychoanalysis is legitimate if it does not create the false conscience of thinking that because you are acting due to a psychological problem, this fact allows you to be willing to do wrong acts. Behavior modification is legitimate if the retraining process doesn't involve doing something morally wrong to get yourself out of the undesirable behavior. Group therapy, involving people with fragile psyches "getting things off their chest" about each other, is extremely dangerous, and may very well not be allowed by the Double Effect, because the harm can be very great. In general, the attitude that people are like animals to be trained, and whose behavior can be externally controlled and molded, is a morally wrong attitude. The object is not to change the person's behavior, but to get him in control of it.

The main problem of research not discussed is genetic engineering. This in itself is not morally wrong, since organisms naturally "engineer genes" every time they have sex. But there are dangers, which morally must be provided for. If there is any reason to believe that manipulation of genes might produce a toxic organism that could escape into the environment, the research must not be done; but there must be a real reason to believe that this actually can happen, not the mere theoretical possibility that it might. But since patenting such altered organisms encourages carelessness in the race to be first because of huge sums to be gained, this practice must stop. Even human genes may be altered, as long as no human being, such as a fertilized egg or embryo, is harmed, and those in the experiments know the risks and are willing to run them. Any genetic defects discovered by genetic mapping must not be used against a person.

Exercises and questions for discussion

1. Should communications between nurses and patients be privileged? Can a nurse morally keep information from the doctor?

2. May nurses form unions to see to their interests? Discuss the moral implications of this.

3. If patients are being treated by an incompetent doctor, and the nurse has told the administration to no avail, may she inform the patients that the doctor is incompetent and that they should find someone else?

4. If a psychologist sees that the treatment is not getting anywhere, should he tell the patient and let him go, or keep him in the hopes of a breakthrough later?

5. A judge has sentenced a homosexual caught violating the vice law to treatment. He tells you that he is only there because he was ordered to be, and has no interest in being "cured." But if you do not treat him, he will go to jail. What do you do?

6. A clearly psychotic patient protests violently against being sent to a mental hospital, which can help him. You see that his relatives want him sent there to get rid of him and for various selfish reasons. Should you have him committed anyway against his will?