Lex Cordis Caritas - The law of the heart is Love

by Bishop Thomas John Paprocki

My dear brothers and sisters in Christ,

When I was in my third year of theology at the major seminary, I spent a semester doing an internship as a hospital chaplain in a program called Clinic Pastoral Education at Parkland Memorial Hospital in Dallas, Texas. Parkland Hospital was a fascinating place since it was a large hospital with over 900 beds and had a diverse population of patients. In one room there would be an indigent person because Parkland served as the public hospital for Dallas County. In the next room would be a wealthy person because Parkland was a teaching hospital affiliated with the Southwestern Medical School of the University of Texas and had the best doctors in town. Parkland was also the hospital where President John F. Kennedy died after he was shot by Lee Harvey Oswald.

During my internship at Parkland Memorial, I became good friends with a physician who specialized in obstetrics and gynecology, with a subspecialty in reproductive endocrinology and infertility. When visiting him and his family at their home, he would ask me about various real-life cases that presented complicated questions of medical ethics, which we would discuss in great detail. This is when I first became interested in the field of bioethics and led to me writing my Master of Divinity thesis on “Moral Considerations of Problem Pregnancies.”

One of the cases that my physician friend presented to me concerned the situation of the anencephalic fetus. Anencephaly is a severe birth defect in which all or a major part of the skull and brain are missing and occurs in about one out of every 1,000 pregnancies, but most cases end up as miscarriages. Approximately one out of every 10,000 babies in the U.S. is born with anencephaly. The moral question was whether a fetus without a brain could be considered truly human and, if not, whether the pregnancy could be terminated upon a definitive diagnosis, since arguably it would then not constitute the abortion of a human life.

Since at the time the Church did not have an authoritative teaching on this point, some theologians speculated that the dignity of human existence consists in the potential for relationship. According to this line of thinking, since the anencephalic fetus is regarded as lacking relational potential due to the absence of a functioning brain, and thereby an essential component of what it means to be human, the general proscription against abortion would not apply, for the act of abortion is considered morally evil as the willful taking of human life.

This argument was refuted, however, by the Committee on Doctrine of the United States Conference of Catholic Bishops in its 1996 statement on Moral Principles Concerning Infants with Anencephaly, which declared, “Doubts about the human dignity of the anencephalic infant, however, have no solid ground, and the benefit of any doubt must be in the child’s favor. As a general rule, conditions of the human body, regardless of severity, in no way compromise human dignity or human rights.”

A somewhat related but distinct question arises at the other end of the life spectrum, when a person has suffered a severe brain injury. Until the 20th century, death was normally determined by cessation of heartbeat and breathing. For the first time in history, a person with total and irreversible loss of brain function who is unable to move, breathe, and react — thereby appearing to be dead — could be maintained with cardiac circulation mechanically, thus exhibiting characteristics associated with living. Also, with Cardio-Pulmonary Resuscitation (CPR), we have seen how people whose hearts have stopped beating can be resuscitated, thus making the mere fact of cardiac arrest obsolete as the defining factor for determining death.

In 1968, the Harvard Ad Hoc Committee for the first time proposed a set of neurological criteria for determining death, but from the beginning concerns were raised that these criteria could be manipulated for utilitarian purposes, such as procuring organs for transplantation.

In his recent book, Determining Death by Neurological Criteria: Current Practice and Ethics, published in 2020 by the National Catholic Bioethics Center, Matthew Hanley describes how the neurological criteria for determining “brain death” have been tightened up. Specifically, a clinical examination looks for a lack of response to stimuli, and a battery of tests seeks to elicit reflexes mediated by the brain stem. Finally, an apnea test assesses the patient’s capacity to breathe. As Hanley says, “This is obviously very important, since patients who are capable of breathing on their own are not dead.” Although he describes some cases of premature declaration of brain death, he asserts that “the determination of death by neurological criteria is widely viewed as a reliable diagnosis, and there have been no confirmed reports of a patient recovering when the neurological examination was followed properly.”

Pope St. John Paul II reached this conclusion in 2000 in his Address to the Transplantation Society, in which he stated, “Here it can be said that the criterion adopted in more recent times for ascertaining the fact of death, namely the complete and irreversible cessation of all brain activity, if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology. Therefore, a health-worker can use these criteria in each individual case as the basis for arriving at that degree of assurance in ethical judgment which moral teaching describes as ‘moral certainty.’”

While we pray for all to be spared the grief of an anencephalic infant or a devastating injury of the brain, we should be aware of the guidance that the Church gives us in these tragic situations.

May God give us this grace. Amen.