Bioethics-Part-4-1.pptx bioethics bioethics

summary of the Bioethics

1. Ordinary and Extraordinary Care It is generally held that one can ethically forgo extraordinary means of continuing life but is obliged to continue ordinary means of care. At the end of the 20 th century, the Catechism of the Catholic Church upheld this tradition:

2. Discontinuing medical procedures that are burdensome, dangerous, extraordinary or disproportionate to the expected outcome can be legitimate; it is the refusal of “over-zealous” treatment. Here one does not will to cause death; one’s inability to impede it is merely accepted.

3. Ordinary means are all medicines, treatments, and operations that offer a reasonable hope of benefit and that can be obtained without excessive expense, pain, or other inconvenience. Extraordinary means are all medicines, treatments, and operations that cannot be obtained or used without excessive expense, pain, or other inconvenience or that, if used, would not offer a reasonable hope of benefit. - Fr. Gerald Kelly

4. Advanced Directives In 1983, at 25 years of age, Nancy Cruzan lost control of her car and was thrown into a ditch. Although she was resuscitated at the scene of the accident, she never regained consciousness. Nancy was diagnosed as being in PVS, and physicians estimated that she could live for another 30 years being supported by feeding tubes.

5. Advanced Directives In describing her condition, her father stated that “since the accident, she has never had what we felt was a thought-produced response to anything. We feel the most humane and kind thing we can do is to help her escape this limbo between life and death.” Given the prognosis, the family requested that the feeding tube be removed and Nancy be allowed to die.

6. Advanced Directives When the Missouri Rehabilitation Center refused the request, the family took the case to the lower courts, which ruled in their favor. This affirmation was overturned by the state supreme court on the basis that the state’s greater duty to preserve life outweighed any right that the parents might have to refuse treatment for their daughter.

7. Advanced Directives In December 1989, the Cruzan case became the first of the right-to-die cases to be heard by the Supreme Court of the United States. In its decision, the Court upheld the Missouri Supreme Court position that not even the family should make choices for an incompetent patient in the absence of “clear and convincing evidence” of the patients’ wishes.

8. Advanced Directives In a five-four decision, the Court ruled that states do have these rights for the following reasons: The state has a right to assert an unqualified interest in the preservation of human life. A choice between life and death is an extremely personal matter and requires clear and convincing evidence of choice.

9. Advanced Directives Abuse can occur when incompetent patients don’t have loved ones available to serve as surrogate decision makers.

10. To accommodate the clear and convincing evidence standard required by the court, three friends of Nancy came forward claiming to have had conversations with her prior to the accident in which she expressed the conviction that she would never want to live the life of a vegetable. As a result, the State of Missouri no longer opposed her parents in this action, and the feeding tube was removed. Nancy Cruzan died shortly after the removal.

11. thankyou NANCY BETH CRUZAN MOST LOVED DAUGHTER – SISTER - AUNT Born July 20, 1957 Departed January 11, 1983 At Peace December 26, 1990

12. The call for clear and convincing evidence in regard to these cases increased the interest in advanced directives . There is, however, no uniformity in laws on living wills and surrogate decision makers. In some states, the advanced directives go into effect only if a patient is terminally ill and death is imminent.

13. In others, the physician is given civil and criminal immunity from prosecution when he fails to honor the living will, when in his judgment continued treatment may be of benefit to the patient and if it is a good-faith action based on medically valid reasons. Under some state laws, advance directive instructions to refuse treatment may not be honored while a woman is pregnant.

14. Due to the inconsistencies and limitations found in these statutes, many authorities recommend the use of durable power of attorney over a living will. This allows you to name someone as proxy, with the authority to make medical decisions on your behalf should you become incompetent and unable to make the decisions yourself.

15. Living Will Statement

16. I, ___________, am of sound mind, and I voluntarily make this declaration. I direct that life-sustaining procedures should be withheld or withdrawn if I have an illness, disease, or injury, or experience extreme mental deterioration, such that there is no reasonable expectation of recovering or regaining a meaningful life.

17. These life-sustaining procedures that may be withheld or withdrawn include, but are not limited to: Cardiac resuscitation, ventilator support, antibiotics, artificial feeding and hydration. I further direct that treatment be limited to palliative measures only, even if they shorten my life. Specific instructions:

18. Specific instructions regarding care I do want: Specific instructions regarding care I do not want: My family, the medical facility, any physicians, nurses, and other medical personnel involved in my care shall have no civil or criminal liability for following my wishes as expressed in this declaration.

19. I sign this document after careful consideration. I understand its meaning and I accept its consequences. Date: _________ Signed: _____________ Address: ____________ This declaration was signed in our presence. The declaration appears to be of sound mind and to be making this declaration voluntarily without duress, fraud, or undue influence.

20. Signed by witness: ______________ Signed by witness: ______________

21. Proxy Decision-Making Standards The courts have created standards for the allowance of decisions by proxy. Complicating these issues are two groups of cases – one involving competent individuals who become incompetent without expressing their wishes, and a second group, the mentally retarded, who may never have met the criterion of competence.

22. Proxy Decision-Making Standards If a patient, due to mental retardation or some other factors, was never in a position to formulate a decision regarding acceptance or refusal of care, often the physician, hospital, or a family member may seek resolution of the problem from the courts prior to implementing a decision.

23. Proxy Decision-Making Standards Under the doctrine of parens patriae , the state accepts these cases on the basis of a legitimate duty, abiding in the principles of beneficence and nonmaleficence . This duty requires the protection of citizens under legal disability from harms they cannot themselves avoid. In cases in which individuals were incompetent to decide for themselves, the courts have generally used the best-interest standard .

24. The best-interest standard most often takes into account such tangible factors as harms and benefits, physical and fiscal risks. In health care, the courts might rely on such truisms as “Health is better than illness,” and “Life is preferable to death.” In cases in which children have been denied life-preserving care by their parents, the state has often overturned the parental decisions based on the best-interest standard.

25. The substituted –judgment standard maintains that the decision about treatment or nontreatment must remain that of the patient, based on the principle of autonomy. The fact that a previously competent patient becomes incompetent to make a decision for himself does not take from him the right to self-determination. A substitute is selected who is required to act in proxy for the patient – that is,

26. to make the decision that the incompetent patient would have made if the patient had remained competent.

27. Informed Nonconsent What is to be done in cases involving competent patients who understand the nature of their conditions and the consequences of refusing care and choose informed nonconsent ?

28. Elizabeth Bouvia was a 28-year-old quadriplegic suffering from severe cerebral palsy. During her hospitalizations, she asked that her pain be controlled and that she be allowed to starve herself to death. Physicians and hospital authorities refused her request, and she was force-fed through a nasogastric tube to maintain body weight. She requested that the feeding be stopped, and the hospital refused

29. even though her competency was not questioned. Bouvia went to court several times during the next several years, making media headlines and becoming a symbol of the right-to-die movement. The lower courts affirmed the hospital’s decisions, but these decisions were finally overturned by the appeals court.

30. The court in its ruling determined that the fact that Bouvia was young and therefore had a potential for a long life was essentially irrelevant. The decision stated that the time allotted for continued life was not the issue, only the perceived quality of that life, and that “if a right exists, it matters not what motivates its exercise.” Although the Bouvia case did not affirm a basic-right to die, it did become a landmark decision regarding the right to informed nonconsent .

31. Several critical elements were reinforced by the court decisions: The acuity of the patient is irrelevant to the allowance of treatment refusal. The patient’s right to refuse care is not dependent on having a terminal illness. There is no meaningful legal distinction between mechanical life support and nasogastric feeding; both are invasive.

32. The patient’s own perceived view of her quality of life and the treatment requirements necessary to preserve it are of paramount importance. The fact that Bouvia could potentially live for another four decades and be a productive citizen could not overcome her autonomous choice to refuse care. Distinctions between withholding and withdrawing care are legally irrelevant.

33. Do Not Resuscitate (DNR) Orders Mildred is an 85-year-old with terminal cancer admitted to the hospital for chemotherapy. Because of her poor prognosis, she is approached about a DNR order. In response, she requests a full code be provided. Your intern suggests that you take the middle ground and sign a “slow code”, where the response is purposely inadequate, most often used to provide comfort to family, and not intended to resuscitate the patient.

34. Should you request a “slow code”? While perhaps compassionate, they are always deceitful. Can a DNR order be written even though she has refused that option?

35. Language of DNR Code : A call for cardiopulmonary resuscitation efforts. In the hospital setting, a code would usually contain all the elements of advanced cardiac life support, which includes oxygenation, ventilation, cardiac massage, electroshock as necessary, and emergency drugs. These are sometimes announced as “code blue” or some other designation to signal the emergency team of the need to respond.

36. Language of DNR No Code : DNR (do not resuscitate). A written order placed in the medical chart to avoid the use of cardiopulmonary resuscitation efforts. In previous times, the charts were often labeled with devices such as “red tags” or “purple dots” to designate DNR status.

37. Language of DNR Slow Codes : This is a practice whereby the health care team slows the process of emergency resuscitation so as to appear to be providing the care but in actual fact is only providing an illusion. The intent of the practice is more for family comfort than patient benefit.

38. Language of DNR Chemical Code : Similar in intent to the slow code. In this practice, the team provides the drugs needed for resuscitation but does not provide the other services. There is a real question as to whether slow codes, chemical codes, and other forms of resuscitation that contain only partial efforts are appropriate for anything other than theatrics.

39. DNR Guidelines DNR orders should be documented in the written medical record. DNR orders should specify the exact nature of the treatments to be withheld. Patients, when they are able, should participate in DNR decisions. Their involvement and wishes should be documented in the medical record.

40. DNR Guidelines 4. Decisions to withhold CPR should be discussed with the health care team. 5. DNR status should be reviewed on a regular basis.

41. CPR and ACLS are interventions that could theoretically be offered to all patients within the hospital. By the 1970’s, it became obvious that it was not in the best interest of certain patient groups to be resuscitated, and hospitals began to initiate policies governing DNR (do not resuscitate) orders .

42. Even given the wide use and acceptance of DNR orders, the selection of patients still raises some concern. In our age of cost containment and stretched resources, do DNR patients belong in intensive care units? Studies show that these patients in ICU are sicker, have longer stays, have poorer prognosis, consume more resources (both human and fiscal), and have a higher mortality rate than do non-DNR patients.

43. The initiation of DNR orders is best performed after an understanding by physicians, patients, family, and staff has been reached. This is an area in which value preference will make a great deal of difference.

44. Baby Doe In the spring of 1982, an infant known as Baby Doe was born with an esophageal-tracheal fistula and trisomy 21, a form of mental retardation known commonly as Down syndrome. The esophageal-tracheal fistula needed immediate surgery if the infant was to be fed. The decision of whether to do the surgery would not have been questioned for a normal infant.

45. Baby Doe The physicians split in their recommendations as to whether to provide the surgery in this case, the parents with court concurrence elected to refuse the surgery on behalf of their child, and the infant died. The parents based their decision on their view that it would not be in their son’s best interest to survive, since he would always be severely retarded.

46. Baby Doe In 1985, the Department of Health and Human Services provided a final draft of the Baby Doe regulations regarding the treatment of handicapped children. If there is available treatment for the condition, it must be provided. The regulations provided three exceptions:

47. Baby Doe When the infant is chronically and irreversibly comatose. When treatment would only prolong dying. When the treatment would be futile, or inhumane.

48. Baby Doe Regardless of who the primary decision makers are, the ethical problems remain. Whereas parents have a right to privacy and to be left alone in their decisions in regard to their children, this is not an absolute right and does not extend to child abuse. What is the child’s best interest in these cases?

49. Organ Donation The field of organ transplantation had its inception in the early 1950s. From the very beginning, its development has been accompanied by difficult ethical questions in regard to when it is permissible to remove organs, who should receive them, and how it is to be financed.

50. Organ Donation Advances in technique and the development of powerful immunosuppressive drugs have made it possible to transplant hearts, lungs, kidneys, livers, bone marrow, skin, corneas, and pancreases from cadavers. In all areas of transplant technology, the survival and success rates are progressively improving, with areas such as cornea transplants having a success rate in restoration of sight nearing 100%.

51. Organ Donation Most public opinion polls show high public support for organ donations, although not all cultural groups have shown the same level of acceptance. Some traditional cultures have strong reservations based on issues such as the need for body integrity at burial.

52. Organ Donation Most donors have been young adults who were in excellent health until an unexpected and unpredictable event, such as an accident, murder, suicide, or intracranial bleed, brought on brain death. The acceptance of brain death criteria has been critical to the successful practice of organ donation.

53. Organ Donation However, the need for a rapid determination of brain death creates a situation in which families are forced to deal with the horrors of sudden loss and the potential donation of a loved one’s organs virtually in the same instant. Organ donation is a purely voluntary decision that must be clearly conveyed before an individual’s organs are available for transplant.

54. Organ Donation The need to obtain family consent in a time of grief and stress has been a major barrier to organ procurement. Health care providers are often loath to make the request and put further stress on a family at a time of loss. Some have argued for a public policy of “required request”, which would remove the decision from the health care provider and make the inquiry of the available family part of the procedures for discontinuing life support in hopeless cases.

55. Organ Donation Volunteerism and public education have not provided adequate supplies of organs for donation, and the gap seems to be widening. Others have argued that when volunteerism fails to provide adequate scarce resources, the free market may be a better way to secure the needed organs. If organs were bought and sold on the open-market, the supply would increase.

56. Organ Donation For some, the very thought of selling tissue or organs is morally repellant. Yet if we believe that the individual is the sole owner of his organs, then it would seem that he would have as much of a right to sell his property as he would in donating it.

57. Organ Donation Would the placement of organs on the open market raise the price and thus disenfranchise the poor? Would the poor be exploited and coerced into selling their organs or the organs of their deceased loved ones in times of severe need? Would the placement of organs on the open market create an international trade in which organs were transferred from developing nations to rich ones?

58. Organ Donation In regard to matched organs such as kidneys, is the forbidding of the selling of a single kidney on moral grounds by an individual who needs the money to keep his family from starving a strange form of paternalism and self-righteousness? Which is the greater harm: the starving family or the individual with a single kidney?

59. Organ Donation Some have advocated harvesting the organs of prisoners. For prisoners who have been given the death penalty, could a nation keep such individuals alive for harvesting until a buyer needed a particular body part?

60. Killing Children for Parts : A member of the Knights Templar drug cartel was arrested in Morelia, Mexico and charged with kidnapping and killing children for their organs. One group of children kidnapped while on a school beach outing was found in a refrigerated container. The number of children murdered by this organization for body parts is still unknown.

61. Nepal’s Organ Trail : Kavre , a small district in Nepal, is ground zero for the black market organ trade in that country. Preying on the poor and uneducated, a well-organized and well-funded group of organ traffickers have offered payments for what they call a “piece of meat” often with the promise that it would “grow back”. It is estimated that more than 300 people of the district have been victims of kidney traffickers in the last five years.

62. Legal and Social Standing of Euthanasia What is our societal motive as we move to embrace a right to die? Are we doing so out of love and compassion – or because we have ceased to value the lives of those who are old, weak, sick, and vulnerable? Do individuals seek euthanasia because they want to control this part of their lives, or do they do so because as a society, we have made the dying more frightening than death itself?

63. Legal and Social Standing of Euthanasia In June 1990, Janet Adkins ended her life in a secluded county park with the assistance of the now infamous, Dr. Jack Kevorkian. By the end of June 1998, Kevorkian had participated in over 130 similar events using his suicide machines ( Thanatron , Mercitron ). Adkins, the first, is also perhaps the most troubling.

64. Legal and Social Standing of Euthanasia At the time of her death, Adkins’s memory loss from Alzheimer’s disease was still at the stage of forgetting to take her purse or missing a tennis lesson. The last evening of her life was spent among friends in cogent conversation regarding the music of Bach. Prior to her death, she had arranged with a therapist to assist her family through the bereavement period.

65. Legal and Social Standing of Euthanasia These are not the activities of someone who normally is thought of as the classic candidate for assisted suicide. For a period of time, Kevorkian, his death machine, and his attendant legal problems, brought euthanasia and physician-aid-in dying (PAD) to center stage.

66. Legal and Social Standing of Euthanasia Euthanasia – bringing about the death of a person who is suffering from an incurable disease or condition actively, as by administering a lethal drug, or passively, by allowing the person to die by withholding treatment.

67. Legal and Social Standing of Euthanasia Active Euthanasia – actively assisting the process of dying (e.g. Mercy Killing). Passive Euthanasia – ceasing therapies that prolong life so that death can occur.

68. Legal and Social Standing of Euthanasia Voluntary Euthanasia – actively assisting the process of death for someone who has requested assistance in the dying process. Involuntary Euthanasia – bringing about the death of someone suffering from terminal illness or intractable pain without the request or consent of the individual. (Can this constitute murder?)

69. The direct killing of a human being, even if they were terminally ill, is always against the Fifth Commandment (“You shall not kill”). Only God is the master of life and death. It is, of course, permissible to support a dying person and supply them with all medical and human care so as to alleviate suffering. This is a work of mercy and is in accordance with the command to love thy neighbor.

70. In  Evangelium Vitae,   Pope John Paul II said, “We see a tragic expression of all this in the spread of euthanasia, disguised and surreptitious, or practiced openly and even legally. As well as for reasons of a misguided pity at the sight of the patient’s suffering, euthanasia is sometimes justified by the utilitarian motive of avoiding costs which bring no return and which weigh heavily on society.

71. Thus it is proposed to eliminate malformed babies, the severely handicapped, the disabled, the elderly, especially when they are not self-sufficient, and the terminally ill. Nor can we remain silent in the face of other more furtive, but no less serious and real forms of euthanasia. These could occur for example when, in order to increase the availability of organs for transplants, organs are removed without respecting objective and adequate criteria which verify the death of the donor.

72. To claim the right to abortion, infanticide, and euthanasia, and to recognize that right in law, means to attribute to human freedom a perverse and evil significance: that of an absolute power over others and against others .”

73. Pope Benedict said: “Respect for the right to life at every stage firmly establishes a principle of decisive importance: life is a gift which is not completely at the disposal of the subject.”  

74. Dysthanasia is the term for futile or useless treatment, which does not benefit a terminal patient. It is a process through which one merely extends the dying process and not life  per se . Consequently, patients have a prolonged and slow death, frequently accompanied by suffering, pain and anguish.

75. Orthotanasia refers to the art of promoting a humane and correct death, not subjecting patients to misthanasia or dysthanasia and not abbreviating death either, that is, subjecting them to euthanasia. Its great challenge is to enable terminal patients to keep their dignity, where there is a commitment to the well-being of patients in the final phase of a disease.

76. Health promotion and bioethics are joined for the defense of life and have the common goal of improving quality of life and respecting human dignity. Dying with dignity is a consequence of living with dignity and not only surviving with suffering. Life should be lived with dignity and the dying process, which is a constituent part of human life, should occur with dignity. Therefore, we should demand for the right of a respectful death, including reflecting on excessive therapeutic methods. From this perspective, nurses are key to the preservation of patients' dignity.

77. Legal and Social Standing of Euthanasia The allowance of a deadly process to proceed without intervention is generally acceptable in the US when the treatment is futile, and no possibility of patient benefit exists.

78. Time To Go Pardon me, doctor, but may I die? I know your oath requires you try As long as there’s a spark of life To keep it there with tube and knife; To do cut-downs and heart massages, Tracheotomies and gavages. But here I am, well past four-score.

79. Time To Go I’ve lived my lifetime (and a little more) I’ve raised my children, buried my wife. My friends are gone, so spare the knife. This is the way it seems to me I deserve a little dignity…

80. Time To Go Of slipping gently off to sleep And no one has the right to keep Me from my God: when the call’s this clear No mortal man should keep me here.

81. Time To Go Your motive’s noble, but now I pray You’ll read my eyes, what my lips can’t say Listen to my heart! You’ll hear it cry; “Pardon me, Doctor, but may I die?” -Anonymous

82. It is important to differentiate between killing (involuntary euthanasia) and suicide. Tom Beauchamp offers a precise definition of suicide that separates it from the process of passive or active voluntary euthanasia. A person has committed suicide when: That person brings about his or her own death; Others do not coerce him or her to do the action; and

83. Death is caused by conditions arranged by the person for the purpose of bringing about his or her death. Suicide differs from euthanasia in that the health care provider does not participate in the act of bringing about death.

84. Any physician who becomes involved in the suicide of a patient must first be assured that the patient is indeed in a hopeless situation and not just suffering from treatable depression, common in individuals with terminal illnesses.

85. Prior to his conviction, the real problem with Dr. Kevorkian and his death machine (the Mercitron ) was determining whether his patients committed suicide, whether he was practicing voluntary euthanasia, or perhaps murdering these unfortunates. When he built the machines, advertised in newspapers, videotaped the events, purchased the lethal dosages, arranged for undisturbed sites, put in IV lines, and finally arranged for postmortem press conferences, had he stepped beyond being a mere observer when the patients push the button to release the drugs?

86. The hospice movement may offer relief for the terminally ill patient and lessen the need for legislating physician-assisted suicide or euthanasia. Hospice programs are set up to provide palliative care, abatement of pain, and an environment that encourages dignity, but they do not cure or treat intensively. The basic philosophy of hospice is that dying is a natural part of life. These are specialized units designed to reduce suffering and provide humane care for the dying.

87. Switzerland’s Suicide Tourists “Going to Switzerland” has become a euphemism for assisted suicide. As many as 200 individuals a year travel to the country for the sole purpose of ending their lives. The only safeguard is that it cannot be carried out for “self gain”. Swiss right-to-die organizations, such as Dignitas , charge a membership fee of more than $5,000. Studies have shown that 21% of their customers

88. Switzerland’s Suicide Tourists s ince 2008 did not have a terminal or progressive illness. Many customers were able to travel to Switzerland, see a physician, and die – all in a single day.

89. “It is harder morally to justify letting someone die a slow and ugly death, dehumanized, than it is to justify helping him to escape from such misery. This is a case at least in any code of ethics which is humanistic or personalistic , i.e., in any code of ethics which has a value system that puts humanness and personal integrity above biological life and function.” - Joseph Fletcher

90. Mutilation - a n action which deprives oneself or another of a bodily organ or its use. The mutilation may be either direct or indirect. Direct mutilation is a deliberately intended act that of its very nature can cause mutilation. If the effect is not directly intended, it is called indirect mutilation.

91. Mutilation belongs to the category of murder. The difference is that mutilation is partial destruction, whereas murder is the total destruction of a person's physical life. Moral law is concerned with mutilation because no one has absolute dominion over the body, and the violation of this principle is an offense against God's sovereignty.

92. Nevertheless, a person has the right to sacrifice one or more members of the body for the well-being of the whole body. Thus it is permitted to amputate any organ of the body in order to save one's life. However, lesser reasons than danger of death also justify mutilation. The removal or suppressing the function of any organ of reproduction is in a moral category of its own. It is never permitted when the purpose is directly to prevent conception or pregnancy.

93. Strategies of Moral Decision Making Process

94. Strategy Operational Definition 1. Recognizing your circumstances Thinking about origins of problem/s, individuals involved, and relevant principles, goals and values; considering one’s own role in causing and/or resolving the problem.

95. Strategy Operational Definition 2. Seeking outside help. Talking with a supervisor, peer, or institutional resource, or learning from others’ behaviors in similar situations.

96. Strategy Operational Definition 3. Questioning your own and others’ judgment. Considering problems that people often have with making ethical decisions, remembering that decisions are seldom perfect.

97. Strategy Operational Definition 4. Dealing with emotions Assessing and regulating emotional reactions to the situation.

98. Strategy Operational Definition 5. Anticipating consequences of actions Thinking about many possible outcomes such as consequences for others, short and long term outcomes based upon possible decision alternatives.

99. Strategy Operational Definition 6. Analyzing personal motivations Considering one’s own biases, effects of one’s values and goals, how to explain/justify one’s actions to others, and questioning ability to make ethical decisions.

100. Strategy Operational Definition 7. Considering the effects of actions on others Being mindful of others’ perceptions, concerns, and the impact of your actions on others, socially and professionally.

101. Other Pertinent Ethical Principles

102. Principle of Well-Formed Conscience This is to say that with the light of reason, human beings can know which path to take, but they can follow that path to its end, quickly and unhindered, only if with a rightly tuned spirit they search for it within the horizon of faith.

103. Principle of Well-Formed Conscience “ Conscience is a judgement of practical reason that helps us to recognize and seek what is good and to reject what is evil.”

104. Principle of Well-Formed Conscience The Church offers the following processes in forming one’s conscience: When examining any issue or situation, we must begin by being open to the truth and what is right. We must study Sacred Scripture and the teachings of the Church. We must examine the facts and background information about various choices. We must prayerfully reflect to discern the will of God.

105. Principle of Well-Formed Conscience The US Catholic Catechism for Adults adds: The prudent advice and good example of others support and enlighten our conscience. The authoritative teaching of the Church is an essential element. The gifts of the Holy Spirit help us develop our conscience. Regular examination of conscience is important as well.

106. Principle of Well-Formed Conscience The formation of a well-formed conscience must take into consideration the complementarity of faith and reason.

107. Principle of Moral Discernment C apacity to  discern —to observe and make sense or meaning—is central to one's ability to make ethical choices and to take  moral  action. The fundamental definition for  Christian discernment  is a decision-making process in which an individual makes a discovery that can lead to future action. In the process of  Christian spiritual discernment ,  God guides the individual to help them arrive at the best decision.

108. Principle of Moral Discernment Wisdom  is (uncountable) an element of personal character that enables one to distinguish the wise from the unwise while  D iscernment  is the ability to distinguish; ability to make judgement .

109. Principle of Common Good and Subsidiarity Subsidiarity  is an organizing principle that matters ought to be handled by the smallest, lowest or least centralized competent authority. Political decisions should be taken at a local level if possible, rather than by a central authority.

110. Principle of Common Good and Subsidiarity C ommon good   (general  welfare) refers to either what is shared and beneficial for all or most members of a given community, or alternatively, what is achieved by citizenship, collective action, and active participation in the realm of.

111. Principle of Common Good and Subsidiarity Principle of solidarity   is a fundamental principle based on sharing both the advantages, i.e. prosperity, and the burdens equally and justly among members.  

112. Principle of Legitimate Cooperation The Principle of Legitimate Cooperation (also known by some as the Principle of Material Cooperation) comprehensively explains what it means to cooperate or participate in evil in a morally acceptable way. The reason we need this principle at all is that, as we are all painfully aware, the wheat and the weeds are growing up together in our world. Certain folks are doing evil and other citizens are brought, by dint of necessity, into different levels of cooperation with the evil or wrongdoing.

113. Principle of Legitimate Cooperation Cooperation in evil is morally acceptable, then, (a) when the cooperator’s action is essentially good (the cooperator directly intends a moral good [both as a means and as an end] (b) while merely tolerating evil effects [the evil falls outside the will of the cooperator— praeter intentionem   or  per accidens ]) and (c) when the cooperator does everything reasonably possible to eliminate or at least limit the likelihood of scandal.

114. The principles governing cooperation differentiate the action of the wrongdoer from the action of the cooperator through two major distinctions. The first is between formal and material cooperation. If the cooperator intends the object of the wrongdoer's activity, then the cooperation is formal and, therefore, morally wrong. Since intention is not simply an explicit act of the will, formal cooperation can also be implicit. Implicit formal cooperation is attributed when, even though the cooperator denies intending the wrongdoer's object, no other explanation can distinguish the cooperator's object from the wrongdoer's object. If the cooperator does not intend the object of the wrongdoer's activity, the cooperation is material and can be morally licit.

115. The second distinction deals with the object of the action and is expressed by immediate and mediate material cooperation. Material cooperation is immediate when the object of the cooperator is the same as the object of the wrongdoer. Immediate material cooperation is wrong, except in some instances of duress. The matter of duress distinguishes immediate material cooperation from implicit formal cooperation. But immediate material cooperation — without duress — is equivalent to implicit formal cooperation and, therefore, is morally wrong. When the object of the cooperator's action remains distinguishable from that of the wrongdoer's, material cooperation is mediate and can be morally licit.

116. We cannot formally cooperate in morally wrong activity, because we cannot intend wrong conduct. For this reason, the Vatican held that no Catholic healthcare facility could ever formally cooperate in providing sterilizations - that is, no facility could perform sterilizations on the basis of an institutional policy that welcomed and sanctioned routine sterilizations.

117. I n the category of superiors, there was the servant who transported letters for his master to a woman with whom he was having an affair. How could the subordinate continue his employment in that situation? Concerning partners, there was the case of the spouse who practiced birth control methods against the will of the partner. What were the conditions by which the partner could engage in legitimate marital relations with the one practicing such methods? Finally, concerning clients, there was the judge who, among other activities, ruled on couples petitioning divorce; the nurse who assisted a physician who was performing an illicit operation; the priest who distributed communion to a known sinner; and the craftsperson who made, among other items, emblems for the local Masonic temple.

118. Principle of Totality and its Integrity The Principle of Totality states that all decisions in medical ethics must prioritize the good of the entire person, including physical, psychological and spiritual factors. This principle derives from the works of the medieval philosopher St. Thomas Aquinas, who synthesized the philosophy of Aristotle with the theology of the Catholic Church.

119. Principle of Totality and its Integrity According to the philosopher Thomas Aquinas, all of the organs and other parts of the body exist for the sake of the whole person. Because the purpose of the part is to serve the whole, any action that damages a part of the body or prevents it from fulfilling its purpose violates the natural order and is morally wrong. This is called the “principle of totality.” However, a single part may be sacrificed if the loss is necessary for the good of the whole person. For example, the principle of totality would justify the amputation of a gangrenous limb, because the person could die if the gangrene spreads.  

120. The human body is an integral part of the human person and is therefore worthy of human dignity. It must be kept whole. No body part should be removed, mangled or debilitated unless doing so is necessary for the health of a more essential body part or the body of a whole. An unessential or redundant body part may be removed for the good of another person.

121. Applications: Surgeries that needlessly remove body parts or organs are immoral. Tattoos and piercings are not inherently immoral but they may be immoral if they deface the body by quantity or content. Torture is a moral evil because it seeks to dis-integrate the body and the spirit.

122. Applications: Self-mutilation is self-hatred expressed through in spite of the body. That chemical contraception effectively shuts down a healthy bodily system is part of what makes it immoral. Even if the pro-choice argument that an embryo is part of the woman’s body rather than an independent human person is true, it should not be removed except when its presence endangers the woman’s life.

123. Principle of Personhood The Church sees in men and women, in every person, the living image of God. The Church, therefore, recognizes that every human being is unique because he or she was willed by God as an unrepeatable person, created out of love, and redeemed with even greater love. The dignity of each and every human being is central to the social doctrine of the Church and we are called to treat all people with the greatest respect, knowing that they are an individual created and loved by God.

124. Principle of Personhood The Catholic Church believes that society must respect the freedom and dignity of the human person. The social order exists for the sake of human beings and must be guided by what a human being needs for a dignified life. It is not the other way around . This principle cannot be overstated. Human beings should not be used as means of reaching or achieving certain goals. He is, rather, an end in himself.  

125. Pope John Paul II in the Encyclical  Centesimus Annus : “…the right to life, an integral part of which is the right of the child to develop in the mother’s womb from the moment of conception; the right to live in a united family and in a moral environment conducive to the growth of the child’s personality; the right to develop one’s intelligence and freedom in seeking and knowing the truth; the right to share in the work which makes wise use of the earth’s material resources, and to derive from that work the means to support oneself and one’s dependents; and the right to freely establish a family, to have and to rear children through the responsible exercise of one’s sexuality. In a certain sense, the source and synthesis of these rights is religious freedom , understood as the right to live in the truth of one’s faith and in conformity with one’s transcendent dignity as a person.”