Cowdin and Tuohey argue that certain trends in ethical theory and moral theology warrant a rethinking of Catholic principles; they further argue that a proper rethinking would justify certain sterilizations. Essentially, they argue that were the Church to respect the proper autonomy of medicine, it would allow sterilizations. They find that the documents of Vatican II require respect for the autonomy of sciences and culture but maintain that in some of its ethical judgments the Church has not accorded medicine such respect.
Here I am going 1) to challenge Cowdin and Tuohey’s understanding that the Church has derived its moral laws independent of consultation with medicine and that it treats medicine simply as a source of technical expertise. I am also going 2 ) to challenge their understanding of autonomy and show that the Church never permits the kind of autonomy they request for medicine. I am particularly going 3) to challenge their understanding of the principles of totality and double effect as “dispensations” from the moral order. Finally, I will argue 4) that they have provided no grounds to cause the Church to reconsider its condemnation of all sterilizations.
The Conversation of Morality and Medicine
Cowdin and Tuohey insist that Church teaching on morality needs to enter into a dialogic exchange with medicine. They complain that when the CDF and JP II discuss the relation of science, medicine, and morality they “reductively caricatur[e] the sciences merely as endeavors of instrumental reason, and suggest that if they claim to be more, they are ideological in the pejorative sense.” They assert that “the magisterium’s account in these cases fails to help in understanding how culture and the sciences contribute to moral understanding in a more constitutive way than simply providing facts, data, and information.” (14) Cowdin and Tuohey maintain that unless medicine is given its own – or perhaps more -- moral authority, it is limited only to technical competence. (12) They state that the Church allows medical practice at most to “mediate the application of independently conceived moral norms.” (12)
There are two fallacies here: 1) the assumption that moral norms are conceived independently of technical competence and 2) that the application of moral norms is a lesser activity than the “conception” of them.
Cowdin and Tuohey do not seem to appreciate the role that experience plays in the Church’s understanding of morality, nor do they seem to appreciate that morality has been in a conversation with medicine virtually since its inception. Many of the features that characterize Catholic moral thought have been developed with medicine in mind as a model, precisely because medicine learns through experience. Natural law ethics particularly draws upon experience to determine norms and in fact natural law theorists generally employ analogies with medicine to explain the proper mode of reasoning about ethical issues. Let me sketch out just some of the ways in which medicine has served as a model for morality.
Catholic moral thought has drawn enormously upon the ancients for its understanding of morality. Socrates in the dialogue the Gorgias (also in the Republic) where he is arguing against the relativism of the sophists, helps his interlocutors to understand that there is a universal moral law, by comparing a healthy soul to a healthy body. In the same way that all bodies need the same kind of things (e.g., food, exercise, sleep), so to do all souls need the same kind of things (e.g., justice, courage, temperance, wisdom, friendship). There is a universal likeness in human souls and human bodies that warrant speaking of the needs and cares of them in a universal way.
Aristotle’s description of the epistemological process in the first book of the Metaphysics draws upon medicine as a model to make a key point. There he instructs his readers that all knowledge begins with sense data, that from sense data we form memories, which allow us to make connections between one event and another. This he calls “experience”. In providing an example of “experience”, Aristotle speaks of one who notes that a certain treatment cured Socrates and Callias and many others who were suffering from the same ailment. He may then be inclined to generalize that this treatment cures those who are suffering from such an ailment. If he has generalized correctly, he would then be in possession of true opinion that would guide his art. If he came to know the reason why (or the aitia, the cause) a certain treatment cures such as a certain ailment, he would then have knowledge. While Aristotle was not demonstrating how moral knowledge is gained here, it is interesting to note that Aristotle states that all knowledge comes from experience. Certainly in the Nicomachean Ethics, he speaks a great deal of the need for habituation and experience for one to acquire virtue and to understand what virtue is. Experience is essential for understanding the principles and the particulars of any practice; medicine provides an excellent illustration of that claim.
In fact in the Nicomachean Ethics Aristotle repeatedly uses examples from care of the body to make points about ethics. When he is speaking about the mean, he speaks of Milo, the athletic trainer, who knows that all athletes should eat meat (the universal), but who also knows that ten kilos is too much for some and just right for others (the particulars) (1106b) . In Book VI (1141b15), when Aristotle is speaking of the virtue of prudence and the need for knowing both the universal and the particular, he speaks of the nutritionist who not only knows that chicken is healthy meat because it is light, but he also knows which meat is chicken and which is not. The man of experience should be able to discover the universal and to apply it correctly.
It is important to note that one does not invent universals; one discovers them. Aristotle uses medicine to illustrate his claim that one does not deliberate about ends, one discovers them. He states that the doctor does not deliberate about the end of medicine; that is a given; it is health (1112b13). The doctor deliberates about how best to achieve health. To extend the point and to multiply examples, the ethicist does not deliberate about the human good; that is virtuous activity. He deliberates on how to achieve it. The legislator does not determine that murder is wrong; he discovers that truth. His job is determining, for instance, how best to punish a murderer. Our laws permit the judge and jury considerable leeway in sentencing murderers, as they take into account, for instance, the age of the criminal and the circumstances surrounding the crime. The judge and jury are autonomous not in determining what is right and wrong (for that is not a matter of particulars) but in determining the proper punishment, which is a judgment about a particular. Flexibility is called for, but not because there are no moral absolutes. When dealing with particulars, those with the proper expertise must make the judgments. Nor is this expertise strictly technical; it takes into account the human good in many different respects and makes a complicated moral judgment.
Let me give some examples from medicine. Morality teaches that we ought never to cause lethal harm to another. Medicine will determine in its own field what causes lethal harm for patients of such and such a sort. This is not, again, a simple technical decision. When doctors determine whether to advise a patient to undergo chemotherapy or radiation treatment, many factors must be taken into account. Most doctors do so, so automatically, that it may not be immediately evident that their judgment is not strictly technical. When giving advice, they are taking into account the stamina of the patient, the patient’s life goals, and circumstances, for instance. Such decisions are morally complicated. When doctors recommend that a patient continues or cease further treatment for infertility, their recommendation is rarely simply technical; again it takes into account much about the stamina, goals, and circumstances of the patient. One final example from medicine; the Church teaches that it is moral for patients to refuse extraordinary medical treatment; in doing so they are not committing suicide but exercising the proper power of choice as to which goods they will pursue. This universal judgment is based on principles not distinctive of the medical profession alone. Some individuals may for various reasons be called to heroic action, but not all are. The medical profession can certainly help patients determine if a given treatment in their case is heroic or ordinary.
In spite of entrusting to practices their proper area of expertise and moral judgment, the Church allows no practice an autonomy in determining what universals govern the morality that they practice. Morality is based upon the nature of the human person which is not the proper object of any specific practice.
Autonomy of culture and sciences
Cowdin and Tuohey think that because a majority of physicians think that some sterilizations are warranted that this should be a decisive factor in determining the morality of sterilizations; they think that the autonomy of medicine requires this. Cowdin and Tuohey do not fully articulate for their readers the philosophical or theological assumptions that undergird their judgments. Yet, their frequent reference to a “revival of a relativized neo-Aristotelian” approach to morality and their general approval of such ethicists as McCormick and Hollenbach indicates that they are of the school that there are no intrinsically morally evil actions. They leave virtually unacknowledged that with Veritatis Splendor that school has been repudiated as a legitimate understanding of Catholic morality. Even if they reject that repudiation, they should acknowledge that it exists.
Cowdin and Tuohey’s neglect of Veritatis Splendor not only fails to alert readers to the current state of the debate within the Church between those who advocate a “relativizing” understanding of ethics and those who insist that there are intrinsic moral evils. It also causes them to promote an understanding of autonomy that is not that of the Church.
Cowdin and Tuohey seem to think that granting “autonomy” to science and culture also conveys upon them “a certain moral authority.” (12) They cite Gaudium et Spes 36 that “ created things and societies themselves enjoy their own law and values which must be gradually deciphered, put to use, and regulated by man” and GS 59 which states that culture “needs the legitimate possibility of exercising its independence according to its own principles. Rightly therefore, it demands respect and enjoys a certain inviolability, at least as long as the rights of the individual and of the community … are preserved within the context of the common good … this Sacred Synod affirms the legitimate autonomy of human culture and especially the sciences.” (8)
The authors cite various scholars, particularly Hollenbach, on the meaning of these passages. Hollenbach is cited as endorsing an interpretation that would have Vatican II endorsing the legitimate and proper autonomy of culture over Vatican I’s endorsement of reason. Hollenbach finds here a “reconceptualization of the intellectual method by which official Catholicism intends to go about addressing basic questions of the moral life.” (see Cowdin and Tuohey, p. 9 and 10). This reconceptualization based on culture would evidently give greater play to diversity and pluralism than does a morality based on reason. Hollenbach wrote these words in 1979, some 15 years before Veritatis Splendor and even then he was exploring the outer reaches of the possible meanings of these passages. It is disappointing that Cowdin and Tuohey seem to find the work of Hollenbach more compelling and worthy of analysis than they do Veritatis Splendor. Veritatis Splendor has an understanding of autonomy and the relation of culture and reason that conflicts with the largely-unarticulated understanding of autonomy operative in Cowdin and Tuohey’s paper. Veritatis Splendor seems aware of the interpretation given to GS by theologians such as Hollenbach and it rejects such interpretations. The whole of chapter 2, section I of Veritatis Splendor would be worthy of consultation by any who were assessing the value of Hollenbach’s interpretation.
The Church believes that there can be no true conflict between the demands of medicine rightfully practice, and culture properly ordered, and the demands of reason and of charity; Veritatis Splendor elaborates this belief quite fully (we will look at some key passages momentarily). Even without the claims of Veritatis Splendor, to think that there could be a conflict between reason and culture indicates a curious understanding of reason or culture or both. Reason and culture could and should be compatible; this does not mean that everything, everywhere will be the same. The reason that discovers natural law is directed towards universals; the reason that shapes culture is directed towards particulars. For instance, reason recognizes that it is a universal requirement that all human beings wear clothing and that the clothing of all cultures must foster modesty; each particular culture will determine what clothing is suited to its climate and tradition.
The relation between the reason and culture laid out by Aquinas has been the one that the Church has embraced and has not abandoned. Aquinas argues that certain actions are always opposed to reason, that is to the natural law (for man is by nature a rational creature and to act against reason is to act against nature); e.g., murder, rape, and adultery are always wrong. Some actions are always in accord with reason; e.g., giving alms, gaining wisdom, and worshipping God. No one should ever do what is always opposed to reason, but different cultures will have different ways of prohibiting individuals from doing what is always opposed to reason; e.g., the Church does not say there is only one correct way to discourage wrong doing. It does not say that there is only one correct way to encourage individuals to do what is correct (say to give alms through welfare, or private charity, or personal hands-on good works). Cultures and individuals need to determine for themselves what is the correct way to do avoid evil and do good, though they do not determine individually what is good or evil. The great value of natural law, of course, is that it enables us to transcend our cultures and our selves when the culture or our individual proclivities are not in accord with what is good. No culture should countenance racial discrimination, nor should medicine countenance the use of racial minorities for experimental purposes, for instance. If culture or medicine were the final arbiters of morality, if they were fully autonomous in moral matters, what would prevent such actions from being deemed moral? Cowdin and Tuohey and their sources seem unprepared to explain how they would avoid such difficulties.
The following lengthy paragraph from Veritatis Splendor states the Church’s understanding of the role and limitations of culture in determining morality:
The great concern of our contemporaries for historicity and for culture has led some to call into question the immutability of the natural law itself, and thus the existence of “objective norms of morality’ valid for all people of the present and the future, as for those of the past. Is it ever possible, they ask, to consider as universally valid and always binding certain rational determinations established in the past, when no one knew the progress humanity would make in the future?
It must certainly be admitted that man always exists in a particular culture, but it must also be admitted that man is not exhaustively defined by that same culture. Moreover, the very progress of cultures demonstrates that there is something in man which transcends those cultures. This “something” is precisely human nature: this nature is itself the measure of culture and the condition ensuring that man does not become the prisoner of his cultures, but asserts his personal dignity by living in accordance with the profound truth of his being. To call into question the permanent structural elements of man which are connected with his own bodily dimension would not only conflict with common experience, but would render meaningless Jesus’ reference to the ‘beginning”, precisely where the social and culture context of the time had distorted the primordial meaning and the role of certain moral norms (cf. Mt. 19:1-9). This is the reason why “the Church affirms that underlying so many changes there are some things which do not change and are ultimately founded upon Christ, who is the same yesterday and today and for ever”. (VS 53)
Clearly, this passage states that there are certain truths that transcend culture and are determinative of morality at all times and places. Culture, and science, properly constituted, cannot be in conflict with those truths.
If fact, the very passages that Cowdin and Tuohey cite from Church documents to support their call for a legitimate autonomy of culture and sciences have within them indications of the proper limitation of that autonomy. The key passage cited from GS 59 above is one such passage; it states that culture
needs the legitimate possibility of exercising its independence according to its own principles. Rightly therefore, it demands respect and enjoys a certain inviolability, at least as long as the rights of the individual and of the community … are preserved within the context of the common good … this Sacred Synod affirms the legitimate autonomy of human culture and especially the sciences.
As this passage states, the limit to the proper authority of culture and science is the rights of the individual and the community. The Church is the final authority concerning the nature of these rights. Neither culture nor science has the expertise to determine what these are; they have the expertise how to protect them in their own spheres.
Other passages that they cite from Church documents to demonstrate that the Church thinks of science and medicine as having only a technical competence, also serve to demonstrate, I believe, quite the opposite. These passages suggest that science and medicine are practices that inherently have moral dimensions in so far as they are often directly concerned with the human person. For instance Cowdin and Tuohey cite the following passage from Donum Vitae: “science and technology … cannot themselves show the meaning of existence and of human progress … one cannot derive criteria for guidance from mere technical efficiency, from research’s usefulness … or worse still, from prevailing ideologies. Thus science and technology require for their own intrinsic meaning an unconditional respect for the fundamental criteria of the moral law”(n. 2; my emphasis). The phrase in boldface indicates that the Church does not see science and technology as mere techniques which have an external morality imposed upon them. The phrase explicitly states that science and technology have within themselves a moral necessity. What is necessary for science and technology to keep in view is that they are intrinsically directed towards the human good; the efficiencies of mere technological expertise can lead scientists to lose sight of this inherent direction.
Surely Cowdin and Tuohey would acknowledge that medicine has been the source of outrageously immoral conduct, such as the Nazi doctors and the Tuskegee experiments. The culture and medicine both permitted such behavior, but natural law would not. The Magisterium would not (though members of the Church and representatives of the Church may not have advanced what the Faith itself requires.) Indeed, Cowdin and Tuohey assert that they do not think that science and medicine can ever be morally self-sufficient: in their words “Moral-medical decisions should not be immune to non-medical concerns.” (13) Is this a recognition of a need for a Church that will control medicine should it propose immoral actions? It seems that Cowdin and Tuohey do expect there to be some moral authority that transcends medicine. They need to tell us when they think such intervention is necessary and on what basis, for, otherwise their calls for autonomy of culture and science remain too amorphous and undefined.
Dispensations from the moral law
Cowdin and Tuohey admit somewhat begrudgingly that on occasion the Church has engaged in dialogue with medicine. They claim that in the development of various principles, such as the principle of Charity to allow organ transplants the Church showed that on occasion, it displays willingness to “draw moral insight from the goals of medicine and the nature of clinical practice.” (22) I share their understanding that the Church did learn from medicine in this instance (as it has in many others) but I disagree that in doing so the Church is “allowing medicine to exercise a moral influence upon behavior through dispensations from the moral law.” (23; my emphasis) To characterize the principle of double effect and the principle of totality or any judgment of the Church concerning moral matters as “dispensations” from the moral law is a very regrettable characterization of these principles. Certainly the tradition does not speak of nor think of these principles as allowing for dispensations from the law. It would no more speak of “dispensations” from the moral law than it would of “dispensations” from gravity. Neither is possible. Here I shall confine my remarks to their understanding of the principle of totality since that will suffice for me to make my point.
Cowdin and Tuohey’s error in understanding the principle of totality is rooted more in their misunderstanding of the prohibition against “mutilation” than it is in their understanding of the principle itself. Cowdin and Tuohey’s reasoning proceeds as follows. They cite Aquinas to the effect that it is immoral to maim one’s body, and that this is wrong ex defectu iuris ab agente. They then argue that most medical procedures involve maiming the body but that this moral disorder has been permitted as dispensations from the moral order through the principles of double effect and totality.
Cowdin and Tuohey neither translate nor explain the phrase “ex defectu iuris ab agente.” Literally it means “from a defect of the law on the part of the agent." Technically what it means is that an agent has arrogated to himself a power that is not rightfully his; the customary example given to illustrate this principle is that of the private citizen who takes it upon himself to execute a criminal; that power belongs rightfully only to the state. The same principle is used to explain why maiming is wrong; the agent has taken for himself a power over his body that is not rightfully his. The principle itself does not rule out the removing parts of the body or doing things that may harm parts of the body; rather it rules out doing these when one is not the proper agent for doing so. For the most part, men should not remove parts of their body or harm them because God has given them their body to exercise proper stewardship over it. But when good might be done proportionate to the harm undergone, harm of the body may be justified. (This is not proportionalism per se but the proper consideration of how instrumental goods serve the whole.)
Cowdin and Tuohey claim that attempts of justify medical interventions such as surgical “mutilations” (I fear they beg the question here by not using a more neutral term such as “amputation), involved “what can only be called creative characterizations of the medical procedure.” They find it nonsensical to describe surgical cutting as a morally indifferent act. They insist that “cutting the body contains the moral disorder of cutting ex defectu iuris ab agente.” Unfortunately they never justify this claim for they never define the phrase “ex defectu iuris ab agente.” But surgery is most certainly not immoral by reason ex defectu iuris ab agente; for if surgeons are performing surgery with the consent of the patients, they are indeed the proper agents of the action.
It is important to keep in mind that the Church has never taught that it is wrong to harm the body. It has taught that it is wrong to maim the body. Perhaps it would help to use the word “maim” to refer to that harming of the body that is wrong because of the principle “ex defectu iuris ab agente” and “mutilation” to refer to the harm that might come to the body from any action done to it. Mutilation (understood as doing something harmful to the body) is not an intrinsically evil action; it is a morally indifferent action that whose morality is determined by the intention of the agent.
The principle of totality that allows one to harm one part of the body for the sake of the whole does not involve a “dispensation” from the rule that one cannot maim one’s body. The principle of totality does not say that one may engage in the moral evil of removing a limb for the good of maintaining the well-being of the body; it says, rather, that the parts serve the whole and when they cease to serve the whole, they may be sacrificed for the good of the whole. Body parts are instrumental goods not intrinsic goods; therefore they can be sacrificed for the whole that they serve. When Aquinas articulated the principle of totality, he was not “inventing” a “dispensation” from the moral law; he was articulating how the moral law works. Surely it is nearly self-evident that it is moral to remove a gangrened limb that threatens the life of the individual; this may be mutilation but it is not maiming. Moral philosophy quickly learns from medicine that this is a good action. The job of moral philosophy is not to determine what is moral, but again, to discover it (along with medicine) and to provide a justifying rationale if one seems to be needed. In this case, oddly enough some justification seems needed, because on the face of it, on the very shallow face of it, the amputation may seem to violate the principle that one should not maim the body. Are those who amputate gangrene limbs doing a moral evil because the good of the body requires it? Not in the understanding of the Church; no maiming is going on because a gangrened limb makes no contribution to the body.
Cowdin and Tuohey argue that if the Church allowed medicine its proper autonomy it would no longer need to rely upon “dispensations to resolve conflicts between moral theology and medical judgment.” (23) They maintain that “a dispensation from the moral law demonstrates merely a recognition of the relative autonomy of reason. It does not reflect a change in the content of the moral law, but merely a change or adjustment in it application.” (23) Further on they state: “If the goals of medicine are morally good, and these goals cannot be pursued through clinical practice except by permitting or intending bodily harm, that harm which is inherent in all medical interventions should be seen as morally legitimate.” (24) Cowdin and Tuohey have set up a straw man here. The Church would never permit any dispensation from the moral law; no one may deliberately intend a moral evil (though physical harms may be intended). In respect to the judgments and principles mentioned by Cowdin and Tuohey the Church is not recognizing “the relative autonomy of reason”; it is reasoning correctly. It is not allowing a “change or adjustment” in the application of a moral law; it is applying it correctly. The Church does think medical interventions are morally legitimate and that they require no “dispensation” from the moral law.
Medical Indications for Sterilizations and Alternatives
Cowdin and Tuohey’s argument suffers not only from an understanding of autonomy at odds with that of the Church and a misportrayal of the principles of Totality and Double Effect as “dispensations” from the moral law; it also is absent a few the elements that one would need to reason carefully about sterilizations.
Cowdin and Tuohey do little to inform the reader about just which circumstances warrant sterilizations in their minds. They claim that “examples abound” of conditions that indicate a medical need for sterilizations. They list “a woman who develops cardiac arrhythmia and is taking Digitoxin; an obese woman with kidney problems; a severe asthmatic after the birth of a third child; a woman who uterus has been damaged in a poorly performed csection.” (1) No further discussion is provided of reasons why sterilization would be good for these women.
But there are many questions that begged to be asked and answered. I am not a physician but I have heard physicians say that there is no woman that they cannot get safely through a pregnancy; they certainly allow there are conditions of danger and risk, but claim that modern medicine has the means to overcome those dangers and risks. Is that simply a disingenuous boast by pro-life doctors? Certainly, one can easily surmise that women who have certain conditions would not want to risk a pregnancy but what are those conditions, how great are the risks and how frequent are they? It is not limiting the contribution of medicine to the conversation with morality to request such information but such information is something that medicine must bring to the table in the discussion.
Furthermore are all the conditions which warrant sterilizations completely irreversible? Would not there be an advantage in a method of avoiding pregnancy which would keep one's reproductive organs intact, should one recover from the medical condition that makes pregnancy a risk. Why are such concerns not discussed? I recall a conversation with a woman with a kidney condition whose doctor in the sixties told her that another pregnancy would be life-threatening. She said that at the insistence of her husband, she and her husband abstained for four years rather than practice rhythm; he wanted no risks to her health or life. (Rhythm has since been supplanted by highly effective methods of natural family planning).
When the kidney condition cleared up, they had more children. She said that nothing her husband could have done would have demonstrated better his love and commitment to her; she attributes the deep love and happiness of her marriage to having successfully negotiated this crisis in her health. Surely stories can be told of failed marriages for which spouses attribute the failure to abstinence, but such consequences are not the inevitable and necessary consequence of abstinence, total or periodic.
Cowdin and Tuohey consider not at all what alternatives there may be for women seeking to avoid pregnancy other than sterilization. They mention neither contraceptives nor methods of natural family planning. The Church’s prohibition of contraception may explain their failure to consider it as an option, but it is not clear why they fail to discuss natural family planning. Is it unreasonable to require spouses to use natural family planning to avoid a pregnancy rather than sterilization? Any full treatment of questions involving avoidance of pregnancy must take into account the claims of methods of natural family planning. A woman diligently using NFP would be assured that she would be safe from pregnancy; NFP has been demonstrated to be quite incredibly effective for those who are well-trained and determined to avoid pregnancy. Moreover, the use of NFP has demonstrably good effects on individuals and relationships, so it would seem that what the Church requires of individuals in this situation is something that is completely compatible with the human good. There are indications that sterilizations, on the other hand, have a negative impact on individuals and relationships. All this data must be presented for moral evaluators to get a full picture.
One of the “examples” given for the need for sterilizations by Cowdin and Tuohey is “a woman whose uterus has been damaged in a poorly performed c-section.” One doctor has questioned this as a reason for sterilization. Thomas Goodwin has observed that “The entire concept of the ‘weak uterus’ has remained in the realm of plausible conjecture. Yet it reportedly forms the basis for virtually all policies allowing tubal ligation in Catholic institutions in the United States.” (89) He asks “What do we know objectively about the ‘weak uterus?’ … There is no doubt that conscientious physicians have accepted that such an entity exists. Nevertheless, the first thing that strikes one who seeks information about it is that the general concept is not well-attested. There is not a single reference to the concept or any related idea in the English language medical literature in the last 30 years. This lack of mention does not prove that the entity does not exist, but the fact that the weak uterus has never been formally characterized should cause us to proceed cautiously in accepting it as the basis for a critical ethical decision-making process.”( 90) Surely one would be justified in wondering if some physicians are using the concept of a “weakened uterus” somewhat loosely and imprecisely to perform sterilizing procedures for contraceptive purposes.
In fact, Cowdin and Tuohey’s argument suggests that they are arguing for sterilization for contraceptive purposes at least to some extent. When speaking of a severe asthmatic, they add the detail that she has had three children. Would their recommendation for a sterilization be different had she had no children or fewer than three? Does three seem like enough to Cowdin and Tuohey?
Cowdin and Tuohey do not provide a straightforward and clear exposition of the Church’s teaching on this issue. While their bibliographical references direct the energetic reader to some useful sources, their failure to quote or paraphrase these sources seems not in keeping with their desire to locate their arguments within the Catholic tradition.” Since Pope Pius XII was the pope who laid out the Church’s teaching most clearly, it is not inappropriate that they concentrate most on his argumentation, but perhaps they should do more to alert readers to the fact that the Church has repeatedly endorsed that teaching since.
They give a rather sketchy and minimalist presentation of the Church’s reasons for condemning sterilizations. They state: “Pius XII’s theological understanding of the sexual faculty stemmed from his belief that this faculty existed primarily for the purpose of procreation and secondarily for the purpose of nurturing marital intimacy. This faculty does not exist for the biological health of the person, and therefore, cannot be harmed for the health of the person. Any harm inflicted to this faculty must adhere to the conditions of Double Effect. Pius XII granted no dispensation from the moral law regarding sexuality, even when such a dispensation might serve the biological, or for that matter the psychological or social function of the person.” (26)
This characterization of the Church’s teaching is garbled and unclear. The statement that “any harm inflicted to this faculty must adhere to the conditions of the Double Effect” contradicts the previous sentence. The Church allows “harm” to the reproductive faculties for an abundance of reasons, though, of course all must adhere to the principle of Double Effect, for one may not directly engage in actions that deny and thwart the goodness of the reproductive faculties. Here, caution must be exercised not to mistake the opinions of moralists for teachings of the Church, but it should be noted that moralists who accept the moral principles of the Church (unlike Cowdin and Tuohey who would reinterpret or change them) have argued that a woman threatened with rape either by a stranger or forced intercourse by her husband may morally use a contraceptive. The Church also on occasion allows the removal of a healthy organ when a sufficient good is to be obtained. One might think there would be resources there upon which they might build an argument. For instance, if one is travelling one might have one’s healthy appendix or tonsils removed if one feared being in a situation where there was poor medical care. In fact, on the basis of such precedents, some moralists who adhere to magisterial teaching, have even argued that tubal ligations should be permitted for women with weakened uteruses. Now this view has been rejected by the Congregation for the Doctrine of the Faith, but it would have been helpful for Cowdin and Tuohey to have reviewed their arguments and the reasons for the rejection of them.
Cowdin and Tuohey recognize that the Church condemns all direct sterilizations because the reproductive faculties have a special status. They identify this special status as being the ordination of the reproductive faculties to a good beyond the good of the body or the individual. This characterization is not inaccurate but it is incomplete. It would be wrong to think that the Church values the reproductive faculties especially highly simply because they make a contribution to the propagation of the species. Rather, the Church understands the life-giving power of sexuality as fundamental to self-giving meaning of sexuality and marriage. To treat the reproductive faculties just like any other organ is truly to mistreat them. Here is not the place to do a full defense of the Church’s understanding of the necessity of respecting at great cost the life-giving power of the sexual faculties, but all arguments for sterilizations that do not exhibit that they share this understanding will not be persuasive to those who reason within the tradition of the Church.
In sum, Cowdin and Tuohey’s strategy for calling the Church to reconsider its condemnation of sterilization is marked by serious misunderstandings of Chuch teaching on the nature and source of moral norms, on autonomy, on bioethical principles, and on the meaning of sexuality. They provide no impetus for moralists to turn over the decision-making on such matters as the morality of sterilization to physicians.
 I maintain that the Catechism’s claim (2297) that “sterilizations” are permitted for therapeutic purposes is an imprecise statement. What it means to say is that it will allow procedures that have a sterilizing effect for therapeutic purposes.
.. See my “JP II…
.. Declaration on Euthanasia; this category of “extraordinary” does not apply to end of life decisions only or to medical decisions only. A woman who had reproductive problems would be responsible for undertaking only ordinary means to correct them; risky drug treatments or surgery would not be morally obligatory. We have “ordinary” obligations of charity, though some may be called to such supererogatory charity such as that of Mother Theresa.
.. I am not certain why they speak of a “revival” of a relativized neo-Aristotelianism; to read Aristotle as a relativist, is I believe, a new reading of Aristotle driven not by new understandings of Aristotle, but by new needs of interpreters. Aristotle himself clearly speaks of some emotions and actions being always wrong. (EN, 1107a9) Contemporary commentators discount this passage on the basis of claims that Aristotle makes about the flexibility of ethics, but I believe they do not understand Aristotle’s understanding of what a practical science is and how it can embrace both absolute moral norms and some degree of particular flexibility.
.. Cowdin and Tuohey also tell us about Hollenbach’s later work (p. 11)
.. See, for instance, ST. I-II, Q. 91. Ad. 1: “The human reason cannot have a full participation of the dictate of the Divine Reason, but according to its own mode, and imperfectly….On the part of practical reason, man has a natural participation of the eternal law, according to its certain general principles, but not as regards to the particular determinations of individual cases, which are however, contained in the eternal law. Hence the need for human reason to proceed further to sanction them by law.” I am understanding the sanction of certain actions be human reason by law to be a reference to a certain portion of human culture, the legal code of a culture. Man can know what Eternal Reason, or God, thinks about general principles (e.g., adultery is wrong), but cannot have perfect knowledge of what God thinks about particular situations. Man must work to bring the particulars into line with the general principles.
 See S.T. I-II, Q. 94. art. 4.
.. See, for instance, ST. I-II, Q. 91, art. 2: “Wherefore, since all things subject to Divine providence are ruled and measured by the eternal law, as was stated above (a. 1); it is evident that all things partake somewhat of the eternal law, in so far as, namely, from its being imprinted on them, they derive their respective inclinations to their proper acts and ends. Now among all others, the rational creature is subject to Divine providence in the most excellent way, in so far as it partakes of a share of providence, by being proficient both for itself and for others. Wherefore it has a share of the Eternal Reason, whereby it has a natural inclination to is proper act and end: and this participation of the eternal law in the rational creature is called the natural law.
.. For a more standard interpretation of the principle of double effect, see Mangan and Boyle.
.. Similar verbal distinctions are made to distinguish one kind of “killing” from another; “murder” is very different from simply “killing a human being.”
 In fact, Goodwin goes on to say that he thinks there is evidence to “cast doubt on the weak uterus as an entity.” (90)
 See the works by Ashley and O’Rourke, Griese, and O’Donnell for presentations of Church teaching on medical ethics by those who agree with the Church’s understanding of moral principles.
 A particularly interesting portion of this statement is the following: The congregation reaffirms this traditional Catholic teaching [against direct sterilization]. It is aware that many theologians dissent from it, but it denies that this fact as such has any doctrinal significance, as though it were a theological source which the faithful might invoke, forsaking the authentic magisterium for the private opinions of theologians who dissent from it.
 See O’Donnell and Tesson.