Moral Residue, Sin, Death, and the Practice of Medicine
Julie D. Gunby, MSW, MTS, PhD Student, Saint Louis University, Saint Louis, MO
Medicine prides itself on bringing restoration and wholeness, yet many acts of providing health care are more morally confounded than they appear. Consider what is involved in manually removing the placenta from the uterus of a woman who has just given birth, debriding the wounds of a pediatric burn patient, performing repeated venipunctures on a neonate, or demanding that a preteen push out her baby. While these actions might be medically necessary and even morally obligatory, they are far from good. It is the purpose of this paper to identify and analyze the moral residue that frequently attaches to the performance of medical procedures. After offering a phenomenological account of the terribleness of many clinical actions, I draw on Rosalind Hursthouse’s concept of moral remainder and Bernard Williams’ concept of agent-regret to demonstrate the existence of a broad class of medical acts that require lament even where no wrong-doing on the part of the practitioner has occurred. I then show that this moral residue is not reducible to either moral distress or tragic dilemmas, nor is it resolvable under the criteria that Aquinas gives for morally mixed actions.
I contend that it is possible to give a theological account of moral residue, but the concept of regret for non-culpable actions requires an understanding of the problem of humanity’s fallen state that is atypical in the West. “In the Byzantine world where Augustinian thought exercised practically no influence… there is a consensus in identifying the Fall as an inheritance essentially of mortality rather than sinfulness” (Fr. John Meyendorff). We can think of human activity in a fallen world ruled by death as bad in more than one sense. It is not simply that a person becomes bad by being guilty or sinful. His activity is itself also shaped by the conditions of mortality and corruption – greed, lust, damage, decay, maltreatment – under which patient ailments arise and the practitioner is forced to act. The fallen condition of mortality isn’t merely the context of the practitioner’s action, it also infects the content of that action itself, making it bad (although not necessarily sinful). Given that a preteen is pregnant or a neonate is profoundly premature, any action the practitioner takes is lamentable. As opposed to the Western, juridical understanding the effects of sin as a debt in need of payment, in the East, the problem that arises because of sin is that death and mortality constitute a ``fundamentally unjust `tyranny’ of the devil.’’ Christ’s salvific work, on this Eastern understanding, is the conquering of death. Truly good (not merely non-culpable) activity can exist only where corruption and death are completely overthrown and we are made immortal through being united with Christ. Following Clement of Alexandria, the moral residue attendant to the practice of medicine is best described as spiritual harm or “entanglement with evil” rather than culpable commission or omission.
I contend that it is possible to give a theological account of moral residue, but the concept of regret for non-culpable actions requires an understanding of the problem of humanity’s fallen state that is atypical in the West. “In the Byzantine world where Augustinian thought exercised practically no influence… there is a consensus in identifying the Fall as an inheritance essentially of mortality rather than sinfulness” (Fr. John Meyendorff). We can think of human activity in a fallen world ruled by death as bad in more than one sense. It is not simply that a person becomes bad by being guilty or sinful. His activity is itself also shaped by the conditions of mortality and corruption – greed, lust, damage, decay, maltreatment – under which patient ailments arise and the practitioner is forced to act. The fallen condition of mortality isn’t merely the context of the practitioner’s action, it also infects the content of that action itself, making it bad (although not necessarily sinful). Given that a preteen is pregnant or a neonate is profoundly premature, any action the practitioner takes is lamentable. As opposed to the Western, juridical understanding the effects of sin as a debt in need of payment, in the East, the problem that arises because of sin is that death and mortality constitute a ``fundamentally unjust `tyranny’ of the devil.’’ Christ’s salvific work, on this Eastern understanding, is the conquering of death. Truly good (not merely non-culpable) activity can exist only where corruption and death are completely overthrown and we are made immortal through being united with Christ. Following Clement of Alexandria, the moral residue attendant to the practice of medicine is best described as spiritual harm or “entanglement with evil” rather than culpable commission or omission.