THE PATIENT'S PHYSICAL INTEGRITY
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.
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.
126.96.36.199 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.
188.8.131.52. 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.
184.108.40.206.1. 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.
220.127.116.11.2. 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.
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.
18.104.22.168. "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.
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.
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.
22.214.171.124. 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.
126.96.36.199. 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?