natural law, the object of the act, and double effect

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Natural Law, the Object of the Act, and Double Effect: Moral Natural Law, the Object of the Act, and Double Effect: Moral

Methodology for Catholic Health Care Ethics Methodology for Catholic Health Care Ethics

Travis Stephens

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NATURAL LAW, THE OBJECT OF THE ACT, AND DOUBLE EFFECT: MORAL

METHODOLOGY FOR CATHOLIC HEALTH CARE ETHICS

A Dissertation

Submitted to McAnulty College and Graduate School of Liberal Arts

Duquesne University

In partial fulfillment of the requirements for

the degree of Doctor of Philosophy

By

Travis R. Stephens

December 2019

Copyright by

Travis R. Stephens

2019

iii



By

Travis R. Stephens

Approved: November 07, 2019

________________________________ ____________________________

Gerard Magill, PhD Joris Gielen, PhD

Professor of Health Care Ethics Associate Professor of Health

Vernon F. Gallagher Chair for the Care Ethics

Integration of Science, Theology, (Committee Member)

Philosophy and Law

(Dissertation Director)

_________________________________ _____________________________

Joris Gielen, PhD Peter Osuji, PhD

Associate Professor Assistant Professor

Center for Health Care Ethics Center for Health Care Ethics

(Center Director) Committee Member

__________________________________

Kristine Blair, PhD

Dean, McAnulty College & Graduate

School of Liberal Arts

iv

ABSTRACT



By

Travis R. Stephens

December 2019

Dissertation supervised by Dr. Gerard Magill

Pope John Paul II’s Encyclical Veritatis Splendor is the first and only magisterial

document that systematically articulates a moral methodology for Catholic moral theology. This

dissertation makes explicit the methodological connection between Vatican teaching and the

United States Bishops’ Ethical and Religious Directives for Catholic Health Care Services. The

thesis of the dissertation explains the systematic connection between Natural Law, the Moral

Object of the Act, and the Principle of Double Effect and by extension the ethical Principle of

Cooperation. Second, the thesis applies this complex moral method of official teaching to health

care ethics.

Following the introduction, chapter two discusses the moral method of Natural Law and

the Moral Object. Chapter 3 relates this explanation to the Principle of Double Effect. The

subsequent chapters apply this moral method of official Catholic teaching to Catholic health care

v

ethics, focusing on several emerging topics to emphasize the relevance of the theoretical

approach. Chapter 4 discusses Health Care Ethics Consultations, especially engaging the

Principle of Cooperation (enlightened by the Principle of Double Effect) with regard to

prohibited health care services in Catholic health care. Chapter 5 considers the use of the

Principle of Double Effect to justify bilateral salpingo-oophorectomies for BRCA mutation

carriers and the uses of contraception for victims of sexual assault. Chapter 6 discusses the use of

sex reassignment therapies for gender dysphoria and the use of contraceptive methods for non-

contraceptive benefits.

vi

DEDICATION

I dedicate this dissertation to my mother Kathy Jean Stephens, and to my father David

Rae Stephens.

vii

ACKNOWLEDGEMENT

I am grateful to my parents for instilling in me a determined work ethic and a longing for

knowledge. I am also thankful to my brothers Aaron and Kyle for their inspiration and support. I

am indebted to all the teachers who have taught me throughout my years of learning. I am

especially grateful to those to wrote letters of recommendation on my behalf from Saint Meinrad

Seminary and School of Theology for entrance to Duquesne’s doctoral program in Healthcare

Ethics, including Dr. Keith Lemna, Dr. Robert Alvis, and Fr. Denis Robinson. I am appreciative

to Bishop Timothy Doherty for introducing me to the field of Healthcare Ethics and allowing me

to work as a liaison for the Diocese of Lafayette-in-Indiana. I am ever grateful to Dr. Elliott

Bedford for being both a mentor and a colleague in the field of Healthcare Ethics. I am

appreciative of the prayerful support that the priests of the Diocese of Lafayette-in-Indiana

provided throughout these years of studying and writing. I am especially indebted to Fr. Pat

Click, my pastor during these years of study, who was especially encouraging and supportive. I

am also grateful to the parishioners of Saint Louis de Montfort, especially the Seven Sisters who

prayed countless hours for my successful completion of the dissertation.

Finally, I express my heartfelt gratitude to the faculty and staff of Duquesne’s Center for

Healthcare Ethics. Special thanks to Dr. Joris Gielen, Fr. Peter Osuji, and Dr. Kristine Blair for

their role as committee members for my dissertation defense. I am also indebted to Glory Smith

for helping me attend to all of the requirements for the program. Most importantly, I am

sincerely and eternally grateful to Dr. Gerard Magill for guiding me through the entire process of

climbing the mountain of writing a dissertation from the very beginning to the very end. I am

especially thankful for Dr. Magill’s tireless labor of reviewing drafts, making invaluable

recommendations, and kind support. I cannot imagine a better dissertation director.

viii

TABLE OF CONTENTS

Page

Abstract…………………………………………………………………………………………..iv

Dedications……………………………………………………………………………………….vi

Acknowledgment………………………………………………………………………………...vii

Table of Contents………………………………………………………………………………..viii

CHAPTER ONE – INTRODUCTION……………………………………………………………1

CHAPTER TWO – NATURAL LAW AND THE MORAL OBJECT………………………….45

2A. Natural Law………………………………………………………………………...45

i. Natural Law……………………………………………………………..46

a. Law…………………………………………………………………...46

b. Eternal Law and Natural Law………………………………………..47

c. Self-Evidence of Practical Reason…………………………………...48

d. Happiness, Natural Inclinations, and Reason………………………..51

e. Principles of Natural Law and Basic Human Goods…………………55

ii. Naturalistic Fallacy and Natural Law…………………………………56

a. Ergon Argument……………………………………………………...57

b. Essentialist Understanding of Morality……………………………...60

iii. Natural Law and the Perspective of the Acting Person………………61

a. The Primacy of the First-Person Perspective………………………...61

b. First-Person Perspective in Veritatis Splendor………………………64

iv. Contraception and Natural Law……………………………………….66

a. Inseparability Principle……………………………………………...67

ix

b. Responsible Parenthood and Chastity……………………………….68

2B. Moral Object………………………………………………………………………..69

i. Aquinas’s Action Theory……………………………………………….70

a. Intrinsically Evil Acts…………………………………………………70

b. Intention to Action……………………………………………………71

c. External Act: Materia Circa Quam and Proximate End………………74

ii. Naturalistic Fallacy……………………………………………………..78

a. Genus Moris Versus Genus Naturae………………………………….79

b. Manualism and Proportionalism……………………………………..80

iii. Moral Object and the Perspective of the Acting Person………………82

a. Avoiding Eventism…………………………………………………....83

b. The Socratic Principle………………………………………………..84

c. Personalism in Veritatis Splendor……………………………………86

iv. Object of Contraception………………………………………………..89

a. Manualism……………………………………………………………89

b. Proportionalism……………………………………………………...91

c. Rhonheimer…………………………………………………………..91

CHAPTER THREE – PRINCIPLE OF DOUBLE EFFECT……………………………………113

3A. Double Effect from Aquinas to Knauer……………………………………….....113

i. Aquinas and Double-Effect Reasoning…………………………….....113

ii. Antoninus to Gury……………………………………………………..116

iii. Jean Pierre Gury………………………………………………………124

iv. Peter Knauer…………………………………………………………...128

x

3B. Contemporary Formulations of the Principle of Double Effect………………...133

i. Finnis, Grisez, and Boyle: Defending Craniotomy…………………..133

a. Eight Cases that Illustrate Intention………………………………...133

b. Perspective of the Acting Person……………………………………135

c. Debunking Unsound Arguments against Craniotomies…………….137

d. Defending Craniotomies…………………………………………… 138

ii. A Thomistic Response to Finnis, Grisez, and Boyle…………………140

iii. Intended and Foreseen in T. A. Cavanaugh………………………….144

a. Double-Effect Terminology…………………………………………144

b. Intention/Foreseen Distinction……………………………………...145

iv. Euthanasia Versus Terminal Sedation……………………………….149

a. The Catholic Church: Euthanasia and Terminal Sedation…………149

b. Joseph Boyle: Euthanasia and Terminal Sedation………………….150

c. Intention/Foreseen Distinction: Euthanasia and Terminal

Sedation……………………………………………………………..153

v. Hysterectomy Versus Craniotomy……………………………………153

a. Direct Killing in Abortion…………………………………………..154

b. Defending Craniotomies……………………………………………154

c. Craniotomies and Hysterectomies…………………………………..156

vi. Terror Bombing Versus Tactical Bombing…………………………..157

a. Traditional Just War Theory………………………………………..157

b. Just War, Terrorism, and Nuclear Deterrence……………………...158

c. Terror Bombing and Tactical Bombing…………………………….160

xi

CHAPTER FOUR – HEALTH CARE ETHICS CONSULTATIONS AND

COOPERATION……………………………………………………………………………….175

4A. Health Care Ethics Consultations……………………………………………….175

i. Health Care Ethics Consultations…………………………………………175

a. Proficiencies………………………………………………………….177

b. Veterans Health Administration……………………………………...181

ii. Principles and Topics for Health Care Ethics Consultations……………185

a. Autonomy……………………………………………………………..186

b. Non-Maleficence and Beneficence…………………………………...190

c. Justice………………………………………………………………...193

4B. Principle of Cooperation……………………………………………………….....197

i. Principle of Cooperation………………………………………………198

a. Cooperation and Double Effect…………………………………….198

ii. Cooperation and Sterilization………………………………………...202

a. Sterilization…………………………………………………………203

b. United States Bishops’ and Cooperation……………………………205

c. The Object of the Cooperator……………………………………….207

d. The United States Bishops’ 2018 Articulation of Cooperation……..212

iii. Contemporary Contributions to Cooperation……………………….213

a. Rejecting the ‘No Difference Argument’……………………………213

b. M. Cathleen Kaveny’s Appropriation of Evil……………………….215

c. Double Effect and Appropriation…………………………………...218

d. Appropriation and Fetal Tissue Remains of Elective Abortion…….219

xii

CHAPTER FIVE – OOPHORECTOMIES AND EMERGENCY CONTRACEPTION………233

5A. Risk Reducing Bilateral Salpingo-Oophorectomies…………………………….233

i. Clinical Explanation…………………………………………………...233

a. Discovering BRCA1 and BRCA2……………………………………234

b. Cancer Inhibition…………………………………………………...235

c. Prophylactic Treatments……………………………………………236

ii. Double-Effect Reasoning……………………………………………...239

a. Totality……………………………………………………………...239

b. Double-Effect Reasoning…………………………………………...242

c. Object of the Act…………………………………………………….244

iii. Health Care Ethics Consultations…………………………………….246

a. Genetic Testing……………………………………………………...247

b. Genetic Discrimination……………………………………………..247

c. Confidentiality………………………………………………………248

iv. Catholic Health Care Policy…………………………………………..250

a. Prohibiting Sterilization…………………………………………….251

b. Non-BRCA Mutation Carriers……………………………………....253

5B. Emergency Contraceptive for Victims of Sexual Assault………………………255

i. Clinical Analysis……………………………………………………….255

a. Menstrual-Ovulatory Cycle…………………………………………255

b. Physiology of Contraceptives……………………………………….262

ii. Principle of Double Effect……………………………………………..268

a. Object of the Act…………………………………………………….268

xiii

b. Nominalism, Manualism, and Proportionalism…………………….275

c. The Object: Contraception and Self-Defense……………………….279

d. Genus Moris………………………………………………………...282

CHAPTER SIX – SEX REASSIGNMENT SURGERY AND CONTRACEPTION………….307

6A. Sex Reassignment Surgery for Gender Dysphoria……………………………...307

i. Sex, Gender, and Gender Dysphoria…………………………………307

a. Defining Sex………………………………………………………...308

b. Defining Gender…………………………………………………….310

c. Gender Dysphoria…………………………………………………..312

d. Sex Reassignment Therapies………………………………………..314

ii. Objections to Sex Reassignment Therapies………………………….315

a. Medical……………………………………………………………..315

b. Philosophical……………………………………………………….319

c. Theological…………………………………………………………323

iii. Totality and Double Effect…………………………………………….328

a. The Principle of Totality and Integrity………………………………328

b. Principle of Double Effect…………………………………………..331

6B. Non-Contraceptive Benefits of Contraceptives………………………………….336

i. Clinical Analysis……………………………………………………….336

a. Intrauterine Devices as a Contraceptive……………………………336

b. Long-Acting Contraceptives………………………………………...338

c. Non-Contraceptive Benefits of Contraceptives……………………..341

ii. Object…………………………………………………………………..345

xiv

a. Contraception, Casti Cannubii and the Manualist………………....345

b. Proportionalistic Reformation of the Moral Object………………..348

c. Keeping the Object of the Act in the Genus Naturae……………….349

d. The Object of Contraception……………………………………….352

e. The Object of Using Contraceptives for Non-Contraceptive

Benefits……………………………………………………………..353

iii. Principle of Double Effect…………………………………………….354

a. Thomistic Formulation of Double-Effect Reasoning……………….354

b. Intention…………………………………………………………….356

c. Proportionality and Abortifacient Risk……………………………..357

CHAPTER SEVEN – CONCLUSION…………………………………………………………380

BIBLIOGRAPHY………………………………………………………………………………385

1

CHAPTER ONE – INTRODUCTION

There is longstanding discourse in Catholic moral theology regarding the relation

between Natural Law, the Moral Object of an act, and the Principle of Double Effect and

Cooperation. Thomas Aquinas produces the first comprehensive and systematic account of

Natural Law and the Moral Object of the act in his Summa Theologica.1 In accord with Aquinas,

official Catholic teaching holds that certain Moral Objects are intrinsically evil.2 In addition,

Aquinas also introduces the first formulation of the Principle of Double Effect, which combines

discourse on Natural Law and the Moral Object of an act to explain the legitimacy of an action

with a good and bad effect.3 Similar to the Principle of Double Effect, the Catholic moral

tradition uses the Principle of Cooperation to determine when and to what extent one’s actions

may contribute to the immoral action of another. Not surprisingly, robust debate continues over

the meaning and relevance for morality of each of these concepts.

The most comprehensive account in Catholic official teaching of Natural Law, the Moral

Object of an act, and their relevance for the Principle of Double Effect and the Principle of

Cooperation can be found in Pope John Paul II’s encyclical Veritatis Splendor. This is the first

and only Papal encyclical that explores moral theology from a systematic perspective. As a

result, Pope John Paul II reaffirms the existence of intrinsically evil acts,4 yet continues to

approve the complex ethical principles of double effect and of cooperation.

The Catholic Church in the United States adopts this stance of Pope John Paul II to

articulate its official teaching on health care ethics in the Ethical and Religious Directives for

Catholic Health Care Services.5 Surprisingly, however, the United States Bishops do not adopt

the moral method Pope John Paul II articulates in Veritatis Splendor. This dissertation discusses

2

the connection between the method of Veritatis Splendor and the United States bishops’ Ethical

and Religious Directives.

The thesis of the dissertation has two related goals. First, the thesis explains the

systematic connection between Natural Law, the Moral Object of the Act, and the Principle of

Double Effect and by extension the ethical Principle of Cooperation. Insofar as cooperation

effectively adopts the standards of double effect reasoning, the thesis title only lists the Principle

of Double Effect. Second, the thesis applies this complex moral method of official teaching to

health care ethics.

Insofar as the Ethical and Religious Directives apply this approach to many well-known

issues, a consideration of the relevance of the Church’s moral method for emerging issues

(referred to in the analysis), in health care is undertaken. A major emerging issue deals with

ethics consultations that, although commonly undertaken in Catholic health systems, is not

addressed at length in the Ethical and Religious Directives. The dissertation relates this topic

with the ethical Principle of Cooperation that is adopted to resolve disputes in ethics

consultations regarding the provision (or not) of particular commonly accessible health services.

Another two major emerging issues are becoming increasingly problematic for Catholic health

systems, yet are not addressed explicitly in Ethical and Religious Directives: oophorectomies and

sex reassignment surgeries, each related to issues regarding contraception. Each of these

emerging issues are discussed in the applied chapters of the dissertation.

The sequence of the analysis in the chapters of the dissertation is as follows. Chapter 1

provides an Introduction. Chapter 2 discusses the moral method of Natural Law and the Moral

Object of the Act. Chapter 3 relates this explanation to the Principle of Double Effect. The

subsequent chapters apply this moral method of official Catholic teaching to Catholic health care

3

ethics, focusing on several emerging topics to emphasize the relevance of the theoretical

approach. Chapter 4 discusses Health Care Ethics Consultations, especially engaging the

Principle of Cooperation (enlightened by the Principle of Double Effect) with regard to

prohibited health care services in Catholic health care. Chapter 5 considers the use of the

Principle of Double Effect to justify bilateral salpingo-oophorectomies for BRCA mutation

carriers and the uses of contraception for victims of sexual assault. Chapter 6 discusses the use of

sex reassignment therapies for gender dysphoria and the use of contraceptive methods for non-


CHAPTER TWO – NATURAL LAW AND THE MORAL OBJECT

Chapter two explains the role of Natural Law and the Moral Object of the Act in the

moral method of Catholic teaching. Each section focuses on the scholarship of two contemporary

ethicists—John Finnis and Martin Rhonheimer—who have made a pivotal contribution to the

debate on this approach.

2A. Natural Law

The first section addresses the role of Natural Law in Catholic moral theology including

divergent formulations.

i. Natural Law

a. Law

In the Summa Theologica, Aquinas discusses Natural Law in the context of law.6 This

subsubsection analyzes Aquinas’s understanding of law, from the perspective of Martin

Rhonheimer’s Natural Law and Practical Reason: A Thomistic View of Moral Autonomy.7 Most

importantly, for Rhonheimer, the precept of reason is an act of the will expressed not in word,

4

but action.8 One derives the normative principles of Natural Law, which are speculative in

nature, by reflecting on the process of practical reason in action.9

b. Eternal Law and Natural Law

Natural law is the eternal law of God written on the heart of each human person.10 All

creatures participate in the law which God promulgates, but humans participate in the law

uniquely insofar as they also providentially govern.11 John Finnis explains Aquinas’s

understanding of participatio in his Natural Law and Natural Rights. 12

c. Self-Evidence of Practical Reason

Just as the first principle of metaphysics is self-evident, so the first principle of practical

reason is self-evident.13 R. A. Armstrong in Primary and Secondary Precepts in Thomistic

Natural Law Teaching identifies what Aquinas means by self-evident.14 Using Kevin L.

Flannery’s Acts Amid Precepts, I highlight a parallel between the ordering of theoretical knowing

and practical knowing in Aquinas.15 For Grisez, in “The First Principles of Practical Reason: A

Commentary on the Summa theologiae, 1-2, Question 94, Article 2,” self-evident principles are

not mere tautologies, that is, restatements of what is already given.16 Finnis relates the concept of

the self-evidence of principles or precepts of Natural Law to the rationality of the notion that any

state of affairs may exist without further explanation.17

d. Happiness, Natural Inclinations and Reason

In The Perspective of Morality: Philosophical Foundations of Thomistic Virtue Ethics,

Rhonheimer highlights the difference between an authentic eudemonistic ethic and one that only

seems oriented toward happiness, but really constitutes hedonism.18 For Rhonheimer, action

concerns appetition, that is, striving for a good that corresponds to the substantive form of the

human person, which is both body and soul.19 The inclinations for the good correspond to each

5

aspect of the human condition—inanimate, animate, and rational.20 Insofar as the soul consists of

both intellect and will, happiness is that which one rationally wills for its own sake.21

e. Principles of Natural Law and Basic Human Goods

Each principle of Natural Law corresponds to the natural inclinations in humans, which

corresponds to all three of the above-mentioned classes of inclinations.22 Armstrong relates the

principles of practical reason to human inclinations,23 while Finnis relates it to basic human

values.24 Perspectives diverge on the above depending on one’s perspective regarding the

Naturalistic Fallacy.

ii. Naturalistic Fallacy and Natural Law

The Naturalistic Fallacy originates in G. E. Moore’s Principia Ethica, where, building on

David Hume’s assertion that “ought statements” do not derive from “is statements,”25 he argues

that moral good is not physical good.26

a. Ergon Argument

In Fundamentals of Ethics, Finnis takes issue with Aristotle’s “ergon argument,” in the

Nicomachean Ethics that is, where he argues that insofar as the human person’s function is to

reason, they ought to act in accord with reason.27 Finnis insists that since this argument is

theoretical, not practical in nature it contributes nothing substantial to Aristotle’s ethics.28 Ralph

McInerny29 and Martin Rhonheimer30 both take issue with Finnis’s dismissal of Aristotle’s

function argument, which I further elucidate here.

b. Essentialist Understanding of Morality

Rhonheimer rejects what he calls an essentialist understanding of morality, of which

Heinrich Rommen,31 Joseph Pieper,32 Ralph McInerny,33 Steven Jensen,34 R. Hittinger,35 and

Steven A. Long36 are leading proponents.37 They conflate metaphysics with morality, contending

6

that morality perfects being. Their methodology is no different than that of the proportionalists

they reject including: Peter Knauer,38 Josef Fuchs,39 Louis Janssens,40 Bruno Schuller,41 and

Richard McCormick.42 Avoiding the Naturalistic Fallacy places moral decision making in the

first-person perspective.

iii. Natural Law and the Perspective of the Acting Person

a. The Primacy of the First-Person Perspective

Rhonheimer, in “The Cognitive Structure of the Natural Law and the Truth of

Subjectivity,” upholds the subjective primacy of the Natural Law.43 Rhonheimer rebuts critics

such as Jean Porter who assert that he falls into spiritualism, 44 rooting actions in the human

person that is a substantial union of body and soul.45

b. First-Person Perspective in Veritatis Splendor

John Paul II, following Aquinas, understands Natural Law to be a divine light of reason,

which God imprints on humanity in creation.46 This subsubsection follows John Paul II’s

articulation of the subjective nature of the Natural Law in Veritatis Splendor. A first-person

perspective on the Natural Law best explains the Catholic Church’s argument concerning the

immorality of contraception.

iv. Contraception and Natural Law

a. Inseparability Principle

Paul VI, in Humanae Vitae establishes the inseparable connection between the unitive

and procreative significance of the marital act in Natural Law.47 Rhonheimer, in Ethics of

Procreation and the Defense of Human Life: Contraception, Artificial Fertilization and Abortion

establishes this connection between the Natural Law and the Inseparability Principle.48

b. Responsible Parenthood and Chastity

7

Following Paul VI’s lead,49 Rhonheimer connects the Church’s prohibition against

contraception to the virtue of chastity, insisting that periodic continence, a substantive part of

responsible parenthood, is the inherent means for growth in it.50 This line of reasoning concurs

with John Paul II in Man and Woman He Created Them: A Theology of the Body.51

The Natural Law is foundational to how the practical intellect formulates the good in the

Object of the Act, which the following section elucidates.

2B. Moral Object

This section addresses the role of the Object of the Act for Catholic Morality.

i. Aquinas’s Action Theory

a. Intrinsically Evil Acts

This subsubsection follows the development of the concept of intrinsically evil acts,

which Servais Pinckaers, in “A Historical Perspective on Intrinsically Evil Acts,” traces

beginning with Augustine and continuing through Peter Abelard, Peter Lombard, and

culminating in Aquinas.52

b. Intention to Action

This subsubsection follows Finnis’s interpretation of Aquinas’s action theory in Question

11-20 of the Prima Secundae of the Summa Theologiae, in his Aquinas: Moral, Political and

Legal Theory.53 Above all, Finnis highlights the distinction between choosing (electio) and

intending (intentio), which correspond to distinct aspects of willing, the proximate end and the

ultimate end, respectively.54 In concert with the will, Rhonheimer observes that the intellect acts

in extension when engaging in practical reason.55 The proximate end corresponds to the Object

of the Act.

c. External Act: Materia Circa Quam and Proximate End

8

Joseph Pilsner, in The Specification of Human Actions in Saint Thomas Aquinas holds

that Aquinas uses the relationship between form and matter in a substantial being to illustrate the

analogous relationship that ends have for action.56 Once again, the identification of the Object of

the Act with the proximate end and the materia circa quam, which Sousa-Lara illustrates is

helpful for understanding the distinct properties of the external act.57 Just as one’s position on the

Naturalistic Fallacy affects the formulation of the Natural Law, so it affects the formulation of

the Object of the Act.

ii. Naturalistic Fallacy

a. Genus Moris Versus Genus Naturae

According to Rhonheimer, the greatest mistake of consequentialists is the presumption

that morality is reducible to technical decision making,58 which, for Finnis, amounts to reducing

doing to making.59 In this regard, many Thomistic ethicists mistakenly presume that morality

derives from metaphysics, which constitutes the Naturalistic Fallacy.60

b. Manualism and Proportionalism

Precisely insofar as the manualists and proportionalists subscribe to the Naturalistic

Fallacy—presuming that ethics derives from nature—they constitute two sides of the same

consequentialist coin. Servais Pinckaers, in The Sources of Christian Ethics demonstrates that

Ockham’s nominalism is the source of the Naturalistic Fallacy, rather than authentic Thomism.61

Proportionalists, such as, Peter Knauer reduce moral evil to causing evil in the world,62 which

constitutes eventism for Rhonheimer63 and Finnis.64 Failing to avoid the Naturalistic Fallacy

precludes a first-person perspective for morality. The following subsection addresses these

deficiencies.

iii. Moral Object and the Perspective of the Acting Person

9

a. Avoiding Eventism

Rhonheimer, in “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a

Central Teaching of Veritatis Splendor,” argues that eventistic morality reduces the Object of the

Act to intention, rendering choice insignificant.65

b. The Socratic Principle

The Socratic Principle contends that it is better to suffer evil than to do.66 Insofar as

proportionalism does not pass the test of the Socratic Principle, Finnis and Rhonheimer reject

it.67

c. Personalism in Veritatis Splendor

This subsubsection follows the personalistic approach to morality in John Paul II’s

Veritatis Splendor.68 John Paul II rejects the proportionalistic approach precisely because it

denies a personalistic approach.69 Accordingly, he reaffirms the existence of intrinsically evil

acts.70 Only a first-person account of the Object of the Act provides an adequate perspective for

defining the Object of the Act of contraception.

iv. Object of Contraception

a. Manualism

John T. Noonan Jr., in Contraception: A History of Its Treatment by the Catholic

Theologians and Canonists demonstrates that the manualists reject contraception on the

physicalistic objection that the Object of the Act constitutes onanism.71 Pius XI’s rejection of

contraception follows similar lines of reasoning.72

b. Proportionalism

Proportionalists such as Peter Knauer have no problem with contraception so long as a

commensurate reason exists for intending it in the physical world.73

10

c. Rhonheimer

Rhonheimer contends that Humanae Vitae only makes sense according to a personalistic

approach to morality, that is, one that grounds morality in the human person, a composite of

body and soul.74 Accordingly, Rhonheimer defines the Object of the Act of marital union as

loving bodily union.75 With reference to chastity, he defines the Object of the Act of

contraception as a choice against the natural means for growth in chastity, which periodic

continence, a constitutive part of responsible parenthood affords.76 The Object of the Act is an

important criteria of the Principle of Double Effect, which the following chapter examines.

CHAPTER THREE – PRINCIPLE OF DOUBLE EFFECT

This chapter analyzes the Principle of the Double Effect in light of the preceding

articulation of the Natural Law and the Object of the Act.

3A. Double Effect from Aquinas to Knauer

This section traces the historical development of the Principle of Double Effect beginning

with Thomas Aquinas and concluding with the proportionalist Peter Knauer.

i. Aquinas and Double-Effect Reasoning

The first subsection explicates Thomas Aquinas’s use of Double-Effect Reasoning in the

Summa Theologiae where he uses it to explain killing in self-defense.77 In accord with

Augustine, Aquinas objects to one intending to kill another person, for any reason, since this

violates an exceptionless moral norm.78 For Aquinas, the death of an assailant is praeter

intentionem, that is, beside the intention of the agent, which in this case is self-defense.79

Aquinas’s formulation concerns proportionality, which reflects one’s intention both in terms of

the proximate end and ultimate end. In addition, Aquinas uses Double-Effect Reasoning in his

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discussion of scandal80 and adorning dress.81 Commentators on Aquinas develop divergent

interpretations of the Principle of Double Effect.

ii. Antoninus to Gury

The second subsection of this paper follows the development of the Principle of Double

Effect through the commentaries of theologians that follow Aquinas up to Jean Pierre Gury. The

analysis begins with Antoninus’s development of Double-Effect Reasoning concerning scandal

and alluring dress in his Summa Theologica Moralis.82 Following Joseph T. Mangan’s influential

analysis of the Principle of Double Effect, “An Historical Analysis of the Principle of Double

Effect,”83 I consider Cajetan’s contribution.84 The Dominican Vitoria restricts Aquinas’s

understanding of intention in the passage pertaining to killing in self-defense, contradicting the

broad interpretation of intention that includes the proximate end—Object of the Act—as well as

the ultimate end.85 Suarez neglects any discussion of the proximate end altogether.86 J. Ghoos, in

“L’Act a Double Effet Ètude de Théologie Positive,” holds that John of Saint Thomas is the first

to put the Principle of Double Effect into its modern form.87 Many of the adaptations in the

Principle of Double Effect from the Thomistic commentators influence Gury’s formulation.

iii. Jean Pierre Gury

Jean Pierre Gury, in his Compendium theologiae moralis is the first to apply the Principle

of Double Effect to the rest of moral theology.88 Christopher Kaczor observes that for Aquinas

the proportionality criterion consists of weighing acts, while for Gury it involves weighing

effects.89 This demonstrates the casuistic devolution of the Principle of Double Effect up to

Gury. Proportionalists such as Peter Knauer adopt Gury’s formulation of the Principle of Double

Effect.

iv. Peter Knauer

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The final section analyzes Peter Knauer’s use of the Principle of Double Effect in “The

Hermeneutic Function of the Principle of Double Effect.”90 In accord with the casuistic

formulation of Gury, Knauer understands the proportion criteria to involve weighing effects. In

addition, however, Knauer understands the proximate end to be the effect, that is, the ultimate

end.91 To justify an action which causes a negative effect, one must have “commensurate

reason.”92 John Paul II, in Veritatis Splendor rejects the proportionalistic articulation of the

Object of the Act.93 In part, this motivates ethicists to formulate non-consequentialist versions of

the Principle of Double Effect, which the following section explores.

3B. Contemporary Formulations of the Principle of Double Effect

This section analyzes the use of the Principle of Double Effect by contemporary ethicists.

i. Finnis, Grisez, and Boyle: Defending Craniotomy

a. Eight Cases that Illustrate Intention

John Finnis, Germain Grisez, and Joseph Boyle, in “‘Direct’ and ‘indirect’: A Reply to

Critics of Our Action Theory,” offer eight cases that illustrate the complexity of the first-person

perspective of action in their action theory.94 These eight examples highlight the distinct roles of

intention regarding the first person perspective, notwithstanding the tendency to conflate its role

in ethics and law, especially under the influence of Jeremy Bentham.95 Moreover, these examples

highlight errors in the precise formulation of the Object of the Act, the first criteria for the

Principle of Double Effect.

b. Perspective of the Acting Person

Finnis, in Aquinas: Moral, Political and Legal Theory, demonstrates the distinction that

Aquinas highlights in his On Evil between the broad and narrow sense of intention.96 Broadly

speaking, intention includes the Object of the Act, which one can only know from the

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perspective of the acting person.97 In accord with Augustine in his Contra mendacium,98 Finnis,

in Moral Absolutes: Tradition, Revision, and Truth contends that exceptionless moral norms do

exist that one ought never to violate.99

c. Debunking Unsound Arguments against Craniotomies

Finnis et al. reject seven unsound arguments against craniotomies that reduce morality to

cause-effect reasoning.100 Put another way, these arguments reduce the genus moris to the genus

naturae.101 In addition, they reaffirm their acceptance of the Church’s prohibition against direct

killing.102

d. Defending Craniotomies

Finnis et al., reject Kevin F. Flannery’s argument that the means of a craniotomy contains

the death of a child.103 In addition, they refute Jean Porter’s argument in “‘Direct’ and ‘Indirect’

in Grisez’s Moral Theory,” that their theory depends on the indivisibility of performance.104 The

physical circumstances of an act, including its consequences are not negligible to the

determination of the Object of the Act. The following subsection accounts for this without

relegating the derivation of the Object of the Act to the physical.

ii. A Thomistic Response to Finnis, Grisez, and Boyle

Cavanaugh argues that Finnis et al.’s argument relegates moral decision making to the

conceptual.105 For Cavanaugh one communicates intention not only by words, but actions as

well.106 Duarte Sousa Lara, in “Aquinas on Interior and Exterior Acts: Clarifying a Key Aspect

of His Action Theory,” articulates a distinction within the exterior act that accounts for the

connection between the physical act and that which the agent chooses, the latter corresponding to

the Object of the Act.107 Another way to distinguish the physical from the moral is the distinction

between intending and foreseeing.

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iii. Intended and Foreseen in T. A. Cavanaugh

a. Double-Effect Terminology

Although several formulations of the Principle of Double Effect exist to distinguish what

one intends versus what one does not intend, Cavanaugh contends that the intended and foreseen

distinction is the best, because it they avoid confusions that others do not.108

b. Intention/Foreseen Distinction

For Cavanaugh, it is impossible to conceive of certain actions without an evil intention,

for example euthanasia, terror bombing, and craniotomies.109 To determine intent for actions that

do not necessarily include an evil intent, James Sterba recommends asking if the foreseen

negative effect helps explain why one is choosing a particular action, thus connecting intention

to the Object of the Act.110 Following the distinction that G. E. M. Anscombe makes between

practical and speculative knowledge,111 Cavanaugh holds that intention is practical, while

foreseen effects are speculative.112 The following subsections apply the intending/foreseeing

distinction to concrete ethical dilemmas, beginning with the distinction between euthanasia and

terminal sedation.

iv. Euthanasia Versus Terminal Sedation

a. The Catholic Church: Euthanasia and Terminal Sedation

Ethicists often use the Principle of Double Effect to differentiate in health care ethics

between euthanasia and terminal sedation. In Declaration on Euthanasia, the Congregation for

the Doctrine of the Faith condemns intentionally killing another person by an act of omission or

commission to relieve pain or suffering.113 At the same time, the Church acknowledges that

circumstances exist where pain relievers that medical clinicians use to treat pain, foreseeably, but

unintentionally, expedite the dying process by depressing the respiratory system.114 More current

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research indicates that when done properly, continuous, deep sedation does not shorten life.115

Insofar as the Church prefers for patients to be awake to spiritually prepare for death, Double

Effect justifies sedation when the patient experiences great distress.

b. Joseph Boyle: Euthanasia and Terminal Sedation

In “On Killing and Letting Die,” Joseph M. Boyle, Jr. formulates an argument defending

the moral distinction attributable to the Object of the Act and the Principle of Double Effect

between killing and letting die.116 Boyle rejects claims by Michael Tooley in “A Defense of

Abortion and Infanticide,” that there is no moral distinction between killing and letting die,117

insisting that the distinction centers on intention.118 When killing in euthanasia, one intends the

death of the person to relieve pain, whereas by allowing one to die, one does not necessarily

intend the person’s death, even if one foresees it.

c. Intention/Foreseen Distinction: Euthanasia and Terminal Sedation

Using the intention/foreseen distinction, Cavanaugh emphasizes that in euthanasia, the

physician chooses the death of the patient as a means to relieving pain.119 Relieving the patient’s

pain does not suffice—as it does in terminal sedation. Thus, in euthanasia, the Object of the Act

is murder, whereas in terminal sedation it is relieving pain. The following subsection highlights

the connection between circumstances (including consequences) for the Object of the Act.

v. Hysterectomy Versus Craniotomy

a. Direct Killing in Abortion

The Church clearly prohibits direct abortion, that is, killing an unborn child either as a

means or an end to one’s action.120 At the same time, circumstances arise where, for

proportionate reasons, a physician may perform an indirect abortion, for example by performing

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a hysterectomy on a woman with a gravid cancerous uterus.121 This is a classic application of the

Principle of Double Effect.

b. Defending Craniotomies

According to four criteria, Grisez122 and Boyle123 argue that craniotomies do not

constitute direct killing. This position, they argue is consistent with that of H. L. A. Hart’s.124

Cavanaugh asserts that Boyle and Grisez so narrowly define craniotomy that it excludes the

death of a child, however, R. A. Duff insists that it is impossible to define craniotomy without

the death of a child.125

c. Craniotomies and Hysterectomies

Using the Intention/Foreseen distinction, Cavanaugh holds that the craniotomy, unlike the

hysterectomy of a gravid cancerous uterus, inexorably entails the death of the child, which means

that one cannot avoid intending the death of the child by intentionally performing a

craniotomy.126 Thus, Cavanaugh objects to their narrow, conceptual definition of the Object of

the Act for a craniotomy. The distinction between terror bombing provides another opportunity

to clarify the distinction between intending/foreseeing.

vi. Terror Bombing Versus Tactical Bombing

a. Traditional Just War Theory

Here, I explicate the criteria for just war theory according to James F. Childress in “Just-

War Theories: The Bases, Interrelations, Priorities, and Functions of Their Criteria,”127 which

has recourse to the Principle of Double Effect to justify collateral damage.

b. Just War, Terrorism and Nuclear Deterrence

Finnis et al., in Nuclear Deterrence, Morality and Realism argue that the United States

ought to abandon the nuclear arms proliferation race for the common good of the people of the

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Soviet Union, even though they are not likely to reciprocate.128 This is because deterrence

involves the retaliatory killing of innocent civilians, which violates an exceptionless moral norm,

the Object of the Act of mass murder.129

c. Terror Bombing and Tactical Bombing

Cavanaugh uses the intention/foreseen distinction to further highlight the immorality of

terror bombing in contrast to discriminate tactical bombing.130 The terror bomber intends to

maim civilians as a means to achieving the end of victory, whereas the tactical bomber destroys

an enemy’s ability to wage war by strategically targeting combat installations, foreseeing, but not

intending to harm non-combatants.131 Thus, the Principle of Double Effect justifies the

unintended, yet foreseen death of non-combatants.

The preceding chapters provide a theoretical foundation in Catholic moral method to

discuss applied topics emerging in health care ethics, which in turn further elucidate the

abovementioned theory. The next chapter examines the ethical principles that guide health care

ethics consultations. Then, it correlates the implications of this chapter’s definition of the

Principle of Double Effect with the similar Principle of Cooperation.

CHAPTER FOUR – HEALTH CARE ETHICS CONSULTATIONS AND COOPERATION

Chapters five and six of this dissertation apply the normative theory discussed in chapters

two and three. This chapter provides a procedural bridge between the normative and applied

chapters. The discussion concerning health care ethics consultations explains the procedure or

process of decision making that connects theory to application. Although normative, given its

link to the Principle of Double Effect, the Principle of Cooperation analogously applies theory to

practice, providing an opportunity for organizations with conflicting missions to work together.

4A. Health Care Ethics Consultations

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This section evaluates the ethical method that guides health care ethics consultations.

i. Health Care Ethics Consultations

In accord with the American Society for Bioethics and Humanities132 and the Veterans

Health Administration,133 this subsection delineates health care ethics consultations that are case

based and non-case based. American Society for Bioethics and Humanities advocates a

facilitation approach to health care ethics consultations, since it empowers people to act on well-

articulated values.134 The size and nature of the health care ethics consultations depends on

various factors that I further articulate here.135

a. Proficiencies

American Society for Bioethics and Humanities and the Veterans Health Administration

provide proficiencies, which I enunciate here.136 These consist of knowledge, skills, and

attributes.137

b. Veterans Health Administration

This subsubsection first elucidates practical skills for leading health care ethics

consultations according to the American Society for Bioethics and Humanities.138 Next, it

explains the Veterans Health Administration approach for leading ethics consultations.139 I use

Albert R. Jonsen et al.’s Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical

Medicine to illuminate the Veterans Health Administration’s approach.140 The next subsection

explores the moral method of principlism that is foundational for health care ethics consultations

and its implications for Catholic health care.

ii. Principles and Topics for Health Care Ethics Consultations

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This subsection uses Tom L. Beauchamp and James F. Childress’s book Principles of

Biomedical Ethics141 and Jonsen et al.’s above mentioned text to explicate the four foundational

principles of health care ethics: autonomy, beneficence, non-maleficence, and justice.

a. Autonomy

For Beauchamp et al., autonomy consists of liberty and agency.142 I discuss three

concepts that depend on autonomy: competence, informed consent, and confidentiality.143

b. Non-Maleficence and Beneficence

Beauchamp et al., offer four norms that proceed from the two principles of non-

maleficence—do no harm—corresponds to beneficence—act helpfully, which I elucidate in this

subsection.144 Questions relating to quality of life, associated with non-maleficence, sometimes

lead to support for euthanasia. Following May, I explain the anthropology that underlies such

reasoning145 and defend the Congregation for the Doctrine of the Faith’s prohibition against

euthanasia.146

c. Justice

In this subsection, I discuss four rules that Beauchamp et al. correlates with beneficence;

which inexorably relates to justice.147 Next, I elucidate ten questions pertaining to justice.148

Having discussed the correlation between principles of health care ethics and the moral method

of Catholic health care ethics, the following section discusses the principle of cooperation, which

helps ethicists in establishing health care alliances.

4B. Principle of Cooperation

This section explicates the role of the Principle of Cooperation for Catholic health care

ethics.

i. Principle of Cooperation

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a. Cooperation and Double Effect

Ethicists often highlight the similarities between the Principle of Double Effect and the

Principle of Cooperation.149 Traditional formulations of the Principle of Double Effect have four

or five conditions that correspond to similar conditions in the Principle of Cooperation.150

Beginning with Alphonsus Liguori’s articulation, this section outlines the parallels between the

two principles.151 Just as one’s understanding of the Natural Law and the Object of the Act

influence one’s construct of the Principle of Double Effect, so they affect how one uses the

Principle of Cooperation.

ii. Cooperation and Sterilization

a. Sterilization

In the face of pressure to perform procedures such as sterilizations and abortions, which

the Church argues violates exceptionless moral norms,152 that is, an immoral Object of the Act,

they use the Principle of Cooperation to delineate degrees of cooperation.153 This subsection

traces this history of the Church’s use of the Principle of Cooperation to address cooperation

with institutions that perform sterilizations.

b. The United States Bishops’ and Cooperation

This subsection explores the development of United States bishops’ use of the Principle

of Cooperation, in particular, in the various editions of the Ethical and Religious Directives for

Catholic Health Care Services.154 In particular, I use Kevin O’Rourke’s insightful article to shed

light on the changes that occur in the Ethical and Religious Directives.155

c. The Object of the Cooperator

O’Rourke contends that the Congregation for the Doctrine of the Faith finds fault with

the United States bishops’ formulation of Cooperation.156 I contend that this is because they fail

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to maintain the distinction between the Object of the Act of the cooperator and that of the

principal agent. Peter J. Cataldo in “Models of Health Care Collaboration” offers four

characteristics for licit collaboration between Catholic and non-Catholic health care entities,

which I also elucidate.157

d) The United States 2018 Articulation of Cooperation

This subsubsection discusses the changes to the Unites States Bishops’ sixth edition of

the Ethical and Religious Directives in which they articulate a less consequentialist version of

Cooperation.158 The following subsection demonstrates that a consequentialist definition of the

Object of the Act makes it difficult to maintain the difference between the Object of the

cooperator and that of the principal agent. Moreover, the Principle of Appropriation further

clarifies this difference.

iii. Contemporary Contributions to Cooperation

a. Rejecting the ‘No Difference Argument’

Christopher Kutz, in Complicity: Ethics and Law for a Collective Age demonstrates how

consequentialists’ emphasis on outcome results in problematic dilemmas,159 which Luke

Gormally calls the “‘no difference’ argument.”160 This subsection reveals the connection this has

to the Principle of Cooperation.

b. M. Cathleen Kaveny’s Appropriation of Evil

In “Appropriation of Evil: Cooperation’s Mirror Image,” M. Cathleen Kaveny argues for

a mirror principle to the Principle of Cooperation, appropriation of evil, what I call the Principle

of Appropriation.161 This subsection unveils the connection between the two principles.

c. Double Effect and Appropriation

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Just as a tenuous parallel exists between the Principle of Double Effect and the Principle

of Cooperation, so one exists between the Principle of Double Effect and the Principle of

Appropriation.162 This subsection highlights the connection between the two.

d. Appropriation and Fetal Tissue Remains of Elective Abortion

The United States Bishops forbid material cooperation in abortion.163 In accord with

Kaveny’s contention, I demonstrate that the Principle of Appropriation proscribes appropriation

of aborted fetuses for research.164 Having discussed health care ethics consultations and the

Principle of Cooperation, the next chapter analyzes two other applied topics: oophorectomies and

emergency contraception.

CHAPTER FIVE – OOPHORECTOMIES AND EMERGENCY CONTRACEPTION

This chapter uses Natural Law, the Object of the Act and the Principle of Double Effect

to justify procedures that physically-defined are sterilizing and contraceptive, respectively.

5A. Risk Reducing Bilateral Salpingo-oophorectomies

This section applies the above-mentioned moral method to a prophylactic procedure to

prevent cancer in women that foreseeably renders them sterile.

i. Clinical Explanation

a. Discovering BRCA1 and BRCA2

Both BRCA1 and BRCA2 are tumor suppressor genes, some mutations of which

significantly increase one’s risk for developing breast, ovarian, or prostate cancer.165 This

subsection explores the milestones in research that lead to the discovery of these genes,

especially highlighting the work of Mary-Claire King.166

b. Cancer Inhibition

23

Especially using Kiyotsugu Yoshida and Yoshio Miki review article, “Role of BRCA1

and BRCA2 as Regulators of DNA Repair, Transcription, and Cell Cycle in Response to DNA

Damage,” I elaborate on the respective roles that BRCA1 and BRCA2 play in DNA repair,

transcriptional response to DNA damage and cell cycle check pointing.167

c. Prophylactic Treatments

55 to 65 percent of women with a deleterious BRCA1 mutation and 45 percent of women

with a harmful BRCA2 mutation develop breast cancer by the age of 70,168 39 percent of women

who inherit the BRCA1 mutation and 11 to 17 percent of women who inherit the BRCA2

mutation develop ovarian cancer by the age of 70.169 This subsection discusses the risks and

benefits of risk-reducing bilateral mastectomies and risk-reducing bilateral salpingo-

oophorectomies—the removal of the ovaries and Fallopian tubes.170 Having an accurate

understanding of the physical circumstances that concern this ethical decision, the discussion

focuses on the moral method, especially focusing on the Principle of Double Effect and the

Object of the Act.

ii. Double-Effect Reasoning

a. Totality

Despite the Church’s teaching against sterilization,171 this subsection demonstrates that

the Principle of Totality, which Aquinas first articulates in the Summa Theologica,172 and Pius

XII further develops,173 justifies the use of bilateral salpingo-oophorectomies for BRCA1 and 2

mutation carriers.

b. Double-Effect Reasoning

This subsection discusses Aquinas’s use of Double-Effect Reasoning in the Summa

Theologica,174 with particular focus on the broad meaning of intention that Finnis attributes to

24

his articulation.175 In addition, this subsection further elucidates a non-consequentialist

understanding of praeter intentionem for the Principle of Double Effect.176

c. Object of the Act

With a clear understanding of the distinction between the proximate end and the ulterior

end, I delineate the precise Object of the Act of using bilateral salpingo-oophorectomies for

BRCA mutation carriers. In particular, I emphasize the importance of maintaining the distinction

between the genus moris and the genus naturae, which is important because the latter does not

differ for an act of sterilization. Keeping the Object of the Act in the genus moris enables one to

differentiate the foreseen physical act which sterilizes from the intentional moral act that

prevents cancer. The following subsection raises other ethical issues that concern this topic.

iii. Health Care Ethics Consultations

a. Genetic Testing

Antonella Surbone, in “Social and Ethical Implications of BRCA Testing,” defines

genetic testing as “any analysis to detect genotypes, genetic mutations or chromosomal changes,

not including analysis of proteins or metabolites directly related to a manifest disease,” which

can lead to genetic exceptionalism, that is, treating patients with genetic disorders differently

than patients with other diseases.177 This subsection highlights the complexity of identifying

mutations, but also the implications of those mutations for patients.

b. Genetic Discrimination

Some women are reluctant to get genetic testing, not only because of the ambiguity

regarding results, but also because of fear of discrimination by insurance companies or health

care providers.178 This subsection discusses this dilemma in greater detail including the

implications of the 2008 Genetic Information Non-discrimination Act.179

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c. Confidentiality

In the United States, the Health Insurance Portability and Accountability Act of 1996

delimits confidentiality in healthcare.180 This subsection weighs the principles of confidentiality

against that of non-maleficence, especially concerning implications for family members that may

share genetic similarities.181 This subsection highlights ethical concerns that genetically-based

prophylactic procedures raise. The following subsection demonstrates the difference between

contraception and this risk reducing procedure.

iv. Catholic Health Care Policy

a. Prohibiting Sterilization

Although bilateral salpingo-oophorectomies for BRCA mutation carriers renders patients

sterile, the Object of the Act and the purpose are distinctly different from a contraceptive choice.

In accord with Rhonheimer’s definition of contraception,182 this subsection defines the Object

the Act of using bilateral salpingo-oophorectomies for BRCA mutation carriers as unique.

b. Non-BRCA Mutation Carriers

Although some ethicists advocate for bilateral salpingo-oophorectomies for non-BRCA

mutation carriers,183 I concur with the National Catholic Bioethics Center that the situation does

not warrant such practice,184 since this is not medically indicated.185 The prophylactic procedure

discussed in this chapter needs recourse to the Principle of Double Effect, because it must justify

the negative effect of sterilization; however, the following section discusses the use of

emergency contraception to prevent conception after sexual assault. A non-consequentialist

definition of the Object of the Act does not need further recourse to the Principle of Double

Effect.

5B. Emergency Contraceptive for Victims of Sexual Assault

26

The United States Conference of Catholic Bishops, in the Ethical and Religious

Directives assert that women have the right to defend themselves from conception in cases of

sexual assault.186 Because of the Church’s strict prohibition of abortion,187 which begins from the

moment of fertilization, the United States Bishops insists that the method must not remove,

destroy, or interfere with a conceptus.188

i. Clinical Analysis

a. Menstrual-Ovulatory Cycle

Contraceptives interfere with the menstrual-ovulatory cycle, thereby preventing

conception from occurring. This subsection explores the complex physiology of this cycle to

better understand the impact that contraceptives have on it. In particular, it follows the

articulation that Marc A. Fritz and Leon Speroff provide in Clinical Gynecologic Endocrinology

and Infertility, 8th edition.189

b. Physiology of Contraceptives

This subsection explicates the mechanism of action for commonly prescribed emergency

contraceptives, including copper intrauterine device, oral contraceptive pills combining estrogen

and progestin, ulipristal acetate, and progestin-only levonorgestrel.190 In particular, it highlights

controversy over the precise mechanism of action for levonorgestrel and its ethical

implications.191

ii. Principle of Double Effect

a. Object of the Act

This subsection defines the object of the act from a non-consequentialist perspective as

the proximate end, formulated by practical reason, thus of the genus moris, which the will

chooses (electio). This subsection delves deeply into the development of Aquinas’s

27

understanding regarding the role of the will in action, especially as it relates to intending

(intentio) and choosing.192

b. Nominalism, Manualism, and Proportionalism

This subsection reveals the impact that William of Ockham’s nominalism has on

manualism and proportionalism. In particular, it highlights the extrinsic nature of morality for

them.193

c. The Object: Contraception and Self-Defense

In accord with Rhonheimer’s non-consequentialist definition of the Object of the Act of

contraception,194 this subsection defines the use of emergency contraception as an act of self-

defense, which he articulates in Ethics of Procreation.195

d. Genus Moris

A consequentialist articulation of the object of the act, which conflates the genus moris

with the genus naturae gives the impression that one must use the Principle of Double Effect to

justify emergency contraception to defend against sexual assault. However, as I demonstrate in

this subsection, a non-consequentialist description of the object of the act precludes the necessity

of recourse to the Principle of Double Effect. The following chapter discusses two other topics

that ethicists use the Principle of Double Effect to justify.

CHAPTER SIX – SEX REASSIGNMENT SURGERY AND CONTRACEPTION

This chapter discusses the application of the Principle of Double Effect to two procedures

that render the patient sterile or infertile. In both cases the intention is not to sterilize; however,

this constitutes an unintended, yet foreseen consequence.

6A. Sex Reassignment Surgery for Gender Dysphoria

28

Some ethicists argue that the Principle of Double Effect and the Principle of Totality and

Integrity justify the use of sex reassignment surgery in patients diagnosed with gender

dysphoria.196 In accord with Church teaching, I argue against gender ideology and sex

reassignment therapies.197

i. Sex, Gender, and Gender Dysphoria

This first subsection uses contemporary medical literature to define sex, gender, gender

dysphoria, and sex reassignment therapies.

a. Defining Sex

Defining sex biologically as male or female is not as easy as it may at first appear. In

accord with the Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition, I analyze the

physiological criteria that define sex, including: genetic, gonadal, ductal, and phenotypic or

genital. 198 In addition, I explicate the variety of intersex conditions.199

b. Defining Gender

In this subsection, I enunciate the definition of gender.200 In addition, I discuss the social

constructionist origins of gender ideology, first attributable to Simon de Bouvoir,201 Ann

Oakley,202 Suzaane J. Kessler and Wendy McKenna,203 Gayle Rubin204 and Judith Butler.205

c. Gender Dysphoria

Here, I reveal the evolution of the concept of gender dysphoria, especially as the

Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition 206 and Diagnostic and

Statistical Manual of Mental Disorders, 5th Edition207 articulate it.

d. Sex Reassignment Therapies

Some advocate for sex reassignment therapies to address gender dysphoria. This

subsection briefly expounds on these treatment options.208 The definitions in this subsection

29

contrasts with the medical, philosophical, and theological positions of Catholic health care that

the following subsection explains.

ii. Objections to Sex Reassignment Therapies

United States Conference of Catholic Bishops’ Committee on Doctrine objects to sex

reassignment therapies on three grounds that I explicate further in this section: medical,

philosophical, and theological.209

a. Medical

Lawrence S. Mayer and Paul R. McHugh in “Gender Identity” examine scientific

research and find little to no evidence that medical procedures to change gender have any

psychological benefit.210 They contest the plasticity of gender that social constructionists

advocate. At the same time, they counter contradictory arguments that suggest gender is

biological. Carl Elliott in “A New Way to Be Mad,” finds similarities between body dysmorphic

disorder and gender dysphoria.211

b. Philosophical

In this subsection, I attribute the ideology of gender to three philosophical trends that I

expound: anthropological dualism, physicalistic determinism, and existential voluntarism.

Anthropological dualism I connect with Rene Descartes’ “Cogito, ergo sum.”212 Physicalistic

determinism I attribute to British Empiricism.213 Existential voluntarism I link to Scotus,214

Schopenhauer,215 and Nietzsche.216

c. Theological

Contrary to Enlightenment philosophy, Christian anthropology presumes ontological and

epistemic realism. This subsection articulates Christian anthropology with the presumption that

the human person is a substantial unity of body and soul.217 At the same time, it avoids

30

essentialism, which contends that sexual difference abides in the soul.218 The illumination of

Catholic medicine, philosophy, and theology informs its objection to the use of the Principle of

Totality or the Principle of Double Effect to justify sex reassignment therapies.

iii. Totality and Double Effect

a. The Principle of Totality and Integrity

Becket Gremmels argues in “Sex Reassignment Surgery and the Catholic Moral

Tradition: Insight from Pope Pius XII on the Principle of Totality,” that one struggling with

gender dysphoria may meet the three criteria for the Principle of Totality and Integrity that Pius

XII proposes to justify sex reassignment surgery. 219 In this subsection, I elucidate Pius XII’s

version of the Principle of Totality and Integrity,220 and contend with John Brehany that Totality

does not justify sex reassignment surgery.221

b. Principle of Double Effect

Carol Bayley, in “Transgender Persons and Catholic Healthcare,” argues that the

Principle of Double Effect justifies the use of sex reassignment surgery in persons with gender

dysphoria.222 After articulating the Object of the Act of sex reassignment surgery for gender

dysphoria I demonstrate how it is contrary to Catholic anthropology. It is not merely because sex

reassignment surgery renders the person sterile that Catholic ethicists object to its use, but

because it contradicts the Christian understanding of the sexual human person. The following

section discusses the use of another physically contraceptive procedure.

6B. Non-Contraceptive Benefits of Contraceptives

This section analyzes the ethical use of physically contraceptive methods for non-



31

a. Intrauterine Devices as a Contraceptive

This subsubsection begins by providing the historical development of intrauterine

devices,223 including stem pessaries, metallic rings,224 copper intrauterine devices,225 and the

levonorgestrel-releasing intrauterine system, marketed as Mirena® and manufactured by

Schering-Oy.226

b. Long-Acting Contraceptives

There are two unique long-acting contraceptives available for market in the United

States: implants and depot-medroxyprogesterone (Depo-Provera).227 In this subsubsection, I

discuss the history and contraceptive mechanism of these two contraceptives.

c. Non-Contraceptive Benefits of Contraceptives

In this subsubsection, I discuss the non-contraceptive side effects of both intrauterine

devices and long-acting contraceptives. In particular, I focus on their use to treat

endometriosis228 and abnormal uterine bleeding.229 Having an awareness of the physical

circumstances of the act, the next subsection explores the Moral Object of the Act of

contraception.

ii. Object

a. Contraception, Casti Cannubii and the Manualist

This subsubsection briefly outlines the historical development of the Church’s precarious

relationship with contraception.230 In particular, it demonstrates the physicalistic definition of the

Object of the Act according to Jean Pierre Gury,231 which influences the rejection of

contraception in Pius XI Casti Cannubii.232

b. Proportionalistic Reformation of the Moral Object

32

Here I demonstrate the methodological continuity between the manualists and the

proportionalists in such authors as Louis Janssens233 and Peter Knauer.234 More precisely, their

physical definition of the Object of the Act.

c. Keeping the Object of the Act in the Genus Naturae

In this subsubsection, I demonstrate how the action theory of Finnis235 and

Rhonheimer,236 true to Aquinas, keeps the Object of the Act in the genus moris, which is not

derivable from the genus naturae, thereby avoiding the Naturalistic Fallacy. This is contrary not

only to the action theory of the proportionalists, but Ralph McInerny as well.237

d. The Object of Contraception

In accord with Aquinas, Rhonheimer contends that Paul VI presumes that the Object of

the Act of contraception is in the genus moris.238 At the same time, insofar as it constitutes an

intrinsically evil act, it violates the norm of Natural Law, the Inseparability Principle.239 Situating

his definition of the Object of the Act of contraception in the context of virtue, Rhonheimer

describes it as a circumvention of chastity.240

e. The Object of Using Contraceptives for Non-Contraceptive Benefits

Since the Object of the Act exists on the moral order, not the physical order, one must

take the first-person perspective to determine what the person chooses in using a contraceptive

method. It is possible to formulate a practical syllogism that includes the choice to use a

contraceptive for non-contraceptive benefits.241 Although using contraceptives for non-

contraceptive benefits does not constitute an immoral Object of the Act, it does have at least one

evil consequence—infertility—which necessitates recourse to the Principle of Double Effect.

iii. Principle of Double Effect

a. Thomistic Formulation of Double-Effect Reasoning

33

This subsubsection articulates a non-consequentialist formulation of the Principle of

Double Effect.242 Even if one cannot rule the use of contraceptives for non-contraceptive

benefits, it may still be possible to rule out its use based on the disproportionate evil associated

with such a choice.

b. Intention

The first-person perspective of intention gives clarity not only to the Object of the Act,

but also the ulterior end, that is, the reason why one chooses a particular act.243 This section

highlights the importance of not only having an ethically sound intention concerning the

proximate end of the act, but also concerning the ulterior end.

c. Proportionality and Abortifacient Risk

Grisez weighs the non-contraceptive benefits of contraceptives against the injustice of

abortifacient activity consequent to an embryo should breakthrough ovulation and conception

occur.244 Although some authors conclude that levonorgestrel-releasing intrauterine systems

definitely do not have abortifacient properties,245 Edward Furton demonstrates that this debate

remains open.246 Thus, Grisez concludes that one must have a very serious reason to choose a

contraceptive for non-contraceptive benefits.247 A contraceptive that acts as an abortifacient is

likely disproportionate to the benefit, however, one that does not act as an abortifacient is

proportionate. The two preceding chapters apply the aforementioned moral method for Catholic

health care ethics.

CHAPTER SEVEN – CONCLUSION

This chapter is a brief summary of the implications of the abovementioned theory and

application.

34

1 Thomas Aquinas, The Summa Theologica, (Chicago: Benzinger Brothers, 1947),

http://dhspriory.org/thomas/summa/index.html, I-II, q. 94. 2 John Paul II, Veritatis Splendor, August 6, 1993, http://w2.vatican.va/content/john-paul-

ii/en/encyclicals/documents/hf_jp-ii_enc_06081993_veritatis-splendor.html, 79-83. 3 Aquinas, Summa Theologica, II-II, q. 64, a. 7. 4 John Paul II, Veritatis Splendor, 79-83. 5 United States Conference of Catholic Bishops (USCCB), Ethical and Religious Directives for

Catholic Health Care Services, 6th ed. (Washington D.C.: USCCB, 2018). 6 Aquinas, Summa Theologica, II-II, q. 90-4. 7 Martin Rhonheimer, Natural Law and Practical Reason: A Thomistic View of Moral Autonomy,

translated by Gerald Malsbary, (New York City: Fordham, 2000). 8 Rhonheimer, Natural Law and Practical Reason, 63. 9 Rhonheimer, Natural Law and Practical Reason, 63. 10 Aquinas, Summa Theologica, I-II, q. 91, a. 2, r. 11 Aquinas, Summa Theologica, I-II, q. 90, a. 2, r. 12 John Finnis, Natural Law and Natural Rights, 2nd edition, (Oxford: Oxford, 2011), 398-403. 13 Aquinas, Summa Theologica, I-II, q. 94, a. 2, answer. 14 R. A. Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, (The

Hague: Martinus Nijhoff, 1966), 28ff. 15 Kevin L. Flannery, Acts Amid Precepts: The Aristotelian Logical Structure of Thomas

Aquinas’s Moral Theory, (Washington D. C.: Catholic University of America, 2001), 41ff. 16 Germain Grisez, “The First Principles of Practical Reason: A Commentary on the Summa

theologiae, 1-2, Question 94, Article 2,” Natural Law Forum 10 (1965): 174. 17 Finnis, Natural Laws and Natural Rights, 378-88. 18 Martin Rhonheimer, The Perspective of Morality: Philosophical Foundations of Thomistic

Virtue Ethics, (Washington D. C.: Catholic University of America, 2011), 95-101. 19 Rhonheimer, The Perspective of Morality, 146, 162. 20 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 44;

Aquinas, Summa Theologica, I, q. 59, a. 1. 21 Rhonheimer, The Perspective of Morality, 65-8. 22 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 47. 23 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 47ff. 24 Finnis, Natural Law and Natural Rights, 86-92. 25 David Hume, A Treatise of Human Nature, (Oxford: Clarendon Press, 1896),

https://people.rit.edu/wlrgsh/HumeTreatise.pdf, book III, part I, section I, pp. 245. 26 Rhonheimer, Natural Law and Practical Reason, 43; G. E. Moore, Principia Ethica, ed.

Thomas Baldwin, (Cambridge: Cambridge University, 1993). 27 John Finnis, Fundamentals of Ethics, (Washington D. C.: Georgetown, 1983), 15; Aristotle,

Nicomachean Ethics, 1097b24-1098a20 in Thomas Aquinas, “Lecture 10: Definition of

Happiness,” in Commentary on the Nicomachean Ethics translated by C. I. Litzinger (Chicago:

Henry Regnery Company, 1964), http://dhspriory.org/thomas/Ethics1.htm#10. 28 Finnis, Fundamentals of Ethics, 16. 29 Ralph McInerny, Aquinas on Human Action: A Theory of Practice, (Washington D. C.:

Catholic University of America, 2012), 184-92.

http://dhspriory.org/thomas/summa/index.html

http://w2.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_06081993_veritatis-splendor.html


https://people.rit.edu/wlrgsh/HumeTreatise.pdf

http://dhspriory.org/thomas/Ethics1.htm#10

35

30 Martin Rhonheimer, The Perspective of Morality, 271-2, footnote 28; Martin Rhonheimer,

Praktische Vernunft und Vernunftigkeit der Praxis: Handlungstheorie bei Thomas von Aquin in

Ihrer Entstehung aus dem Problemkontext der Aristotelischen Ethik, (Berlin: Academie Verlag,

1994), 53-9. 31 Heinrich Albert Rommen, Die ewige Wiederkehr des Naturrechts, (Munchen: Kosel, 1947),

185. 32 Joseph Pieper, Living the Truth: The Truth of All Things and Reality and the Good, (San

Francisco: Ignatius, 1989), 161-2. 33 McInerny, Aquinas on Human Action, 191-2; Ralph McInerny, Ethica Thomistica: The Moral

Philosophy of Thomas Aquinas, revised edition, (Washington D.C.: Catholic University of

America, 1997); “The Principles of Natural Law,” American Journal of Jurisprudence, 25

(1980): 1-15. 34 Steven J. Jensen, Good and Evil Actions: A Journey through Saint Thomas Aquinas,

(Washington D. C.: Catholic University of America, 2010), 225-78; Steven J. Jensen, Knowing

the Natural Law: From Precepts and Inclinations to Deriving Oughts, (Washington D.C.:

Catholic University of America, 2015). 35 Francis Russell Hittinger, A Critique of the New Natural Law Theory, (Notre Dame, IN:

University of Notre Dame Press, 1987). 36 Steven A. Long, The Teleological Grammar of the Moral Act, 2nd Edition, (Ave Maria, FL:

Sapientia Press, 2015). 37 Rhonheimer, Natural Law and Practical Reason, 18-9, 48. 38 Peter Knauer, “The Hermeneutic Function of the Principle of Double Effect,” (1967), Natural

Law Forum, Paper 127. http://scholarship.law.nd_naturallaw_forum/127. 39 Josef Fuchs, Natural Law: A Theological Investigation, trans. Helmut Reckter, and John

Dowling (New York City: Sheed and Ward, 1965); Josef Fuchs, “The Absoluteness of Moral

Terms,” in Readings in Moral Theology No. 1: Moral Norms and Catholic Tradition, edited by

Charles E. Curran and Richard A. McCormick (New York City: Paulist Press, 1979), 94-137. 40 Louis Janssens, “Ontic Evil and Moral Evil,” in Proportionalism and the Natural Law

Tradition, by Christopher Kaczor, (Milwaukee, WI: Marquette University Press, 2000), 60-99. 41 Bruno Schuller, “Direct Killing/Indirect Killing,” in Proportionalism and the Natural Law

Tradition, by Christopher Kaczor, (Milwaukee, WI: Marquette University Press, 2000), 148-65. 42 Richard McCormick, “Ambiguity in Moral Choice,” in Proportionalism and the Natural Law

Tradition, by Christopher Kaczor, (Milwaukee, WI: Marquette University Press, 2000), 166-214. 43 Martin Rhonheimer, “The Cognitive Structure of the Natural Law and the Truth of

Subjectivity,” in The Perspective of the Acting Person: Essays in the Renewal of Thomistic

Moral Philosophy, Edited by William F. Murphy Jr. (Washington D.C.: Catholic University of

America, 2008), 158-94. 44 Jean Porter, “Review of Natural Law and Practical Reason by Martin Rhonheimer”

Theological Studies 62, no. 4 (2001): 851-53. 45 Martin Rhonheimer, “The Moral Significance of Pre-Rational Nature in Aquinas: a Reply to

Jean Porter (and Stanley Hauerwas),” in The Perspective of the Acting Person: Essays in the

Renewal of Thomistic Moral Philosophy, Edited by William F. Murphy Jr. (Washington D.C.:

Catholic University of America, 2008), 129-57. 46 John Paul II, Veritatis Splendor, 12, 42. 47 Paul VI, Humanae Vitae, July 25, 1968, http://w2.vatican.va/content/paul-

vi/en/encyclicals/documents/hf_p-vi_enc_25071968_humanae-vitae.html, 12.

http://scholarship.law.nd_naturallaw_forum/127

http://w2.vatican.va/content/paul-vi/en/encyclicals/documents/hf_p-vi_enc_25071968_humanae-vitae.html


36

48 Martin Rhonheimer, Ethics of Procreation and the Defense of Human Life: Contraception,

Artificial Fertilization and Abortion, Ed. By William F. Murphy, Jr. (Washington D. C.: Catholic

University of America Press, 2010). 49 Paul VI, Humanae Vitae, 16, 21. 50 Rhonheimer, Ethics of Procreation, 90-102. 51 John Paul II, Man and Woman He Created Them: A Theology of the Body, trans. Michael

Waldstein, (Boston, MA: Pauline, 2006). 52 Servais Pinckaers, “Historical Perspective on Intrinsically Evil Acts,” in The Pinckaers

Reader: Renewing Thomistic Moral Theology, ed. John Berkman et al. (Washington D. C.:

Catholic University Press, 2005), 185-235. 53 John Finnis, Aquinas: Moral, Political and Legal Theory (Founders of Modern Political and

Social Thought), (Oxford: Oxford, 1998), 62-71. 54 Finnis, Aquinas, 65. 55 Rhonheimer, The Perspective of Morality, 116; see also Martin Rhonheimer, Natural Law and

Practical Reason: A Thomistic View of Moral Autonomy, translated by Gerald Malsbary, (New

York City: Fordham, 2000), 24ff; Aquinas, Summa Theologiae, I, q. 79, a. 11. 56 Joseph Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, (Oxford:

Oxford Theological Monographs, 2006)47-51. 57 Sousa-Lara, “Aquinas on Interior and Exterior Acts: Clarifying a Key Aspect of His Action

Theory,” 277ff. 58 Martin Rhonheimer, “Norm-Ethics, Moral Rationality, and the Virtues: What’s Wrong with

Consequentialism?” in The Perspective of the Acting Person: Essays in the Renewal of Thomistic

Moral Philosophy, edited by William F. Murphy Jr. (Washington D. C.: Catholic University of

America, 2008), 20. 59 Finnis, Aquinas, 24. 60 Finnis, Fundamentals of Ethics, 4. 61 Servais Pinckaers, The Sources of Christian Ethics, 3rd edition, translated by Mary Thomas

Noble, (Washington D. C.: Catholic University of America Press, 1995), 254-79. 62 Peter Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 133. 63 Rhonheimer, The Perspective of Morality, 398. 64 Finnis, Fundamentals of Ethics, 118. 65 Martin Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a Central

Teaching of Veritatis Splendor,” in The Perspective of the Acting Person: Essays in the Renewal

of Thomistic Moral Philosophy, edited by William F. Murphy Jr. (Washington D. C.: Catholic

University of America, 2008), 46. 66 Finnis, Fundamentals of Ethics, 8. 67 Finnis, Fundamentals of Ethics, 109ff; Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral

Viewpoint: Clarifying a Central Teaching of Veritatis Splendor,” 66ff. 68 John Paul II, Veritatis Splendor. 69 John Paul II, Veritatis Splendor, 65-83. 70 Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a Central

Teaching of Veritatis Splendor,” 48-9; John Paul II, Veritatis Splendor, 79. 71 John T. Noonan, Jr., Contraception: A History of Its Treatment by the Catholic Theologians

and Canonists, enlarged edition (Cambridge, MA: Harvard University Press, 1986), 397ff. 72 Pius XI, Casti Cannubii, (December 31, 1930), https://w2.vatican.va/content/pius-

xi/en/encyclicals/documents/hf_p-xi_enc_19301231_casti-connubii.pdf, 53-7

https://w2.vatican.va/content/pius-xi/en/encyclicals/documents/hf_p-xi_enc_19301231_casti-connubii.pdf


37

73 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 157-8. 74 Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a Central

Teaching of Veritatis Splendor,” 48. 75 Rhonheimer, Ethics of Procreation, 83. 76 Rhonheimer, Ethics of Procreation, 99ff. 77 Aquinas, Summa Theologica, II-II, q. 64, a. 7. 78 Augustine, “On Free Choice of the Will,” in On the Free Choice of the Will, On Grace, and

Free Choice, and Other Writings, ed. & trans. Peter King (Cambridge: Cambridge University

Press, 2010), 11; Aquinas, Summa Theologica, II-II, q. 64, a. 7, reply 1. 79 T. A. Cavanaugh, Double-Effect Reasoning: Doing Good and Avoiding Evil, (Oxford: Oxford,

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Journal, 18, no. 2 (2011): 418-53. 80 Aquinas, Summa Theologica, II-II, q. 43, a. 4. 81 Aquinas, Summa Theologica, II-II, q. 169, a. 2. 82 Antoninus, Summa Theologica (Graz: Akademische Druck, 1959), vol. ii, t. iv, c. v, vii, 595. 83 Joseph T. Mangan, “An Historical Analysis of the Principle of Double Effect,” Theological

Studies 10, no. 1, (1949): 41-61. 84 Thomas Cajetan, Commentario a “Summa Theologiae,” in Sancti Thomae Aquinatis Opera

Omnia, Leonine ed. (Rome: S. C. de Propaganda Fide, 1882-),

http://archive.org/stream/operaomniaiussui09thom#page/74/mode/2up. 85 Finnis, Aquinas, 63-4; Vitoria in John P. Doyle, Reflections on Homicide and Commentary on

Summa theologiae IIa-IIae Q. 64: Thomas Aquinas, (Milwaukee: Marquette University, 1997),

195. 86 Francisco Suarez, Censuris in Communi in Opera Omnia Vol. 23 (Paris: Vives, 1867), 426. 87 J. Ghoos, “L’Act a Double Effet Ètude de Théologie Positive,” Ephemerides Theologicae

Lovanienses, 27, (1951): 32. 88Jean Pierre Gury, Compendium Theologiae Moralis, Vol. 1, 17th ed. (Romae: Typis Civilitatis

Catholicae, 1866). https://archive.org/details/compendiumtheo01gury. 89 Christopher Kaczor, “Double-Effect Reasoning from Jean Pierre Gury to Peter Knauer,”

Theological Studies 59, no. 2 (1998): 311. 90 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 132-62. 91 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 135. 92 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 137. 93 John Paul II, Veritatis Splendor, August 6, 1993, http://w2.vatican.va/content/john-paul-

ii/en/encyclicals/documents/hf_jp-ii_enc_06081993_veritatis-splendor.html, 75. 94 John Finnis, Germain Grisez, and Joseph Boyle, "'Direct' and 'Indirect': A Reply to Critics of

Our Action Theory," The Thomist 65, no. 1 (2001): 1-44. 95 Finnis et al., “‘Direct’ and ‘Indirect,’” 10. 96 Finnis, Aquinas, 63-4; Aquinas, Thomas Aquinas, On Evil, Q. 2, a. 2, ad 8 trans. Richard

Regan, ed. Brian Davies, (Oxford: Oxford, 2003), 99. 97 Finnis et al., “‘Direct’ and ‘Indirect,’” 14; John Paul II, Veritatis Splendor, 78. 98 Augustine, “Contra mendacium (Against Lying),” in Nicene and Post-Nicene Fathers, vol. 3,

ed. Philip Schaff & trans. H. Browne. (Buffalo, NY: Christian Literature Publishing Co., 1887).

http://www.newadvent.org/fathers/1313.htm. 99 John Finnis, Moral Absolutes: Tradition, Revision, and Truth, (Washington D. C.: Catholic

University of America Press, 1991), 65-7.



38

100 Finnis et al., “‘Direct’ and ‘Indirect,’” 21-7. 101 Finnis et al., “‘Direct’ and ‘Indirect,’” 23. 102 Finnis et al., “‘Direct’ and ‘Indirect,’” 26-7. 103 Finnis et al., “‘Direct’ and ‘Indirect,’” 28; Kevin L. Flannery, “What Is Included in a Means

to an End?” Gregorianum 74, no. 3 (1993): 510ff. 104 Jean Porter, “‘Direct’ and ‘Indirect’ in Grisez’s Moral Theory,” Theological Studies 57, no. 4

(1996): 612; Finnis et al., “‘Direct’ and ‘Indirect,’” 31ff. 105 Cavanaugh, Double-Effect Reasoning, 69-70. 106 Cavanaugh, Double-Effect Reasoning, 68. 107 Duarte Sousa-Lara, “Aquinas on Interior and Exterior Acts: Clarifying a Key Aspect of His

Action Theory,” Josephinum Journal of Theology 15, no. 2 (2008): 277-316. 108 Cavanaugh, Double-Effect Reasoning, 73ff. 109 Cavanaugh, Double-Effect Reasoning, 85. 110 James Sterba, “Reconciling Pacifists and Just War Theorists,” Social Theory and Practice 18,

no. 1 (1992): 26. 111 G. E. M. Anscombe, Intention (Ithaca, NY: Cornell University Press, 1957), 13-20. 112 Cavanaugh, Double-Effect Reasoning, 102. 113 Congregation for the Doctrine of the Faith (CDF), Declaration on Euthanasia, May 5, 1980,

http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_1980050

5_euthanasia_en.html. 114 CDF, Declaration on Euthanasia, chapter 3; United States Catholic Bishops Conference

(USCCB), Ethical and Religious Directives for Catholic Health Care Services (ERDs), 6th ed.

(Washington D. C.: USCCB, 2018), pp. 21-2, #61. 115 Committee on National Guideline for Palliative Sedation, Guidelines for Palliative Sedation,

(Utrecht, Netherlands: Royal Dutch Medical Association, 2009), 66. 116 Joseph M. Boyle, Jr., “On Killing and Letting Die,” New Scholasticism, 51 (1977): 433-52. 117 Michael Tooley, “A Defense of Abortion and Infanticide,” in The Problem of Abortion, ed.

Joel Feinberg (Belmont, CA: Wadsworth Publishing Company, 1973), 84-5. 118 Boyle, “On Killing and Letting Die,” 449. 119 Cavanaugh, Double-Effect Reasoning, 110. 120 John Paul II, Evangelium Vitae, March 25, 1995, http://w2.vatican.va/content/john-paul-

ii/en/encyclicals/documents/hf_jp-ii_enc_25031995_evangelium-vitae.html, 62. 121 Pope Pius XII, “Address to the Biomedical Association of St. Luke,” November 12, 1944, in

Discorsi e Radiomessagi di Sua Santità Pio XII (Vatican City: Libreria Editrice Vaticana, 1945),

6 (1944-1945), p. 191; see also USCCB, ERD, pp. 19, #47; William May, Catholic Bioethics and

the Gift of Human Life, 3rd ed. (Huntington, IN: Our Sunday Visitor, 2013), 263ff. 122 Germain Grisez, Living a Christian Life, (Chicago: Franciscan Herald Press, 1993), 502. 123 Joseph M. Boyle, Jr., “Double Effect and a Certain Type of Embryotomy,” Irish Theological

Quarterly, 44, no. 4 (1977): 303-318. 124 H. L. A. Hart, “Intention and Punishment,” in Punishment and Responsibility, (Oxford:

Oxford, 1968), 123-4. 125 Cavanaugh, Double-Effect Reasoning, 69-70; R. A. Duff, “Intentionally Killing the

Innocent,” Analysis 34, no. 1 (1973): 17. 126 Cavanaugh, Double-Effect Reasoning, 69-70, 90ff; 112-3. 127 James F. Childress, “Just-War Theories: The Bases, Interrelations, Priorities, and Functions of

Their Criteria,” Theological Studies 39 no. 3 (1978): 427-45.

http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19800505_euthanasia_en.html


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39

128 John Finnis, Germain Grisez, Joseph Boyle, Nuclear Deterrence, Morality and Realism,

(Oxford: Oxford, 1987). 129 Finnis et al., Nuclear Deterrence, Morality and Realism, 317-8. 130 Cavanaugh, Double-Effect Reasoning, 114-7. 131 Cavanaugh, Double-Effect Reasoning, 116-7. 132 American Society for Bioethics and Humanities (ASBH), Core Competencies for Healthcare

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1. 134 ASBH, Core Competencies, 6-7. 135 ASBH, Core Competencies, 19-20 and VA, Ethics Consultation, 3-5. 136 ASBH, Core Competencies, 22-33; VA, Ethics Consultation, 5-10. 137 ASBH, Core Competencies, 22-33; VA, Ethics Consultation, 5-10. 138 ASBH, Core Competencies, 23-4. 139 VA, Ethics Consultation, 19. 140 Albert R. Jonsen, Mark Siegler, and William J. Winslade, Clinical Ethics: A Practical

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York: Oxford University Press, 2013). 142 Beauchamp et al., Principles of Biomedical Ethics, 102. 143 Jonsen et al., Clinical Ethics, 55-107. 144 Beauchamp, Principles of Biomedical Ethics, 152. 145 May, Catholic Bioethics and the Gift of Human Life, 262-73. 146 CDF, Declaration on Euthanasia; USCCB, ERDs, pp. 20ff. 147 Beauchamp, Principles of Biomedical Ethics, 204. 148 Jonsen, Clinical Ethics, 168. 149 Gerard Magill, “Complicity of Catholic Healthcare with Immoral Laws,” in Contemporary

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Switzerland: Springer, 2016), 710-9. NCBC Ethicists, “Cooperating with Non-Catholic

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Furton et al., (Philadelphia, PA: National Catholic Bioethics Center, 2009), 268. 150 Edward J. Furton and Albert S. Moraczewski, “Double Effect,” in in Catholic Health Care

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National Catholic Bioethics Center, 2009), 23-6; Orville N. Griese, Catholic Identity in Health

Care: Principles and Practice, (Braintree, MA: The Pope John Center, 1987), 246-299. 151 Alphonsus Liguori, Moral Theology: Vol. 1 Books I-III, trans. Ryan Grant, (Post Falls, ID:

Mediatrix Press, 2015), Vol. 1, Book III, trac. III, cap. 2, Dub. V, art. III, n. 63. For the Latin

version see: S. Alphonsi M. de Ligorio, Theologia Moralis: Vol. 1, (Turin, IT: Ex Typis

Hyacinthi Marietti, 1879) pp. 253-254. 152 John Paul II, Evangelium Vitae, 62, 91; John Paul II, Veritatis Splendor, 80; Pius XII,

“Address to the Associations of the Large Families,” Acta Apostolicae Sedis 43 (1951): 859

http://www.vatican.va/archive/aas/documents/AAS-43-1951-ocr.pdf.

http://www.vatican.va/archive/aas/documents/AAS-43-1951-ocr.pdf

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153 Sacred Congregation for the Doctrine of the Faith (CDF), Responses to Questions Concerning

Sterilization in Catholic Hospitals, March 13, 1975,


3_quaecumque-sterilizatio_en.html; National Conference of Catholic Bishops (NCCB),

“Commentary on the Reply of the Sacred Congregation for the Doctrine of the Faith to National

Conference of Catholic Bishops on Sterilization in Catholic Hospitals,” September 15, 1977,

reprinted in Griese, Catholic Identity in Health Care, 422-425. 154 NCCB, Ethical and Religious Directives for Catholic Health Care Services, 3rd edition

(Washington, D. C.: United States Catholic Conference, 1995), 29; USCCB, “Ethical and

Religious Directives for Catholic Health Care Services,” 4th edition, (Washington D. C.: United

States Conference of Catholic Bishops (USCCB), 2001), 36; USCCB, “Ethical and Religious

Directives for Catholic Health Care Services,” 5th edition, (Washington D. C.: USCCB, 2009);

USCCB, ERDs, 6th ed. 155 Kevin D. O’Rourke et al., “A Brief History: A Summary of the Development of the Ethical

and Religious Directives for Catholic Health Care Services,” Health Progress 82, no. 6 (2001):

18-21. 156 Kevin D. O’Rourke, “A Brief History,” 20-21. 157 Peter J. Cataldo, “Models of Health Care Collaboration,” in Catholic Health Care Ethics: A

Manual for Practitioners, 2nd Ed., edited by Edward J. Furton et al., (Philadelphia: The National

Catholic Bioethics Center, 2009), 271-3. 158 USCCB, ERDs, 6th ed., pp. 23-6. 159 Christopher Kutz, Complicity: Ethics and Law for a Collective Age, (Cambridge: Cambridge

University Press, 2000), 124ff. 160 Luke Gormally, “Why Not Dirty Your Hands? Or: on the Supposed Rightness of

(Sometimes) Intentionally Cooperating in Wrongdoing,” in Cooperation, Complicity and

Conscience: Problems in Healthcare, Science, Law and Public Policy, edited by Helen Watt,

(London: The Linacre Centre, 2005), 15, 12-26. 161 M. Cathleen Kaveny, “Appropriation of Evil: Cooperation’s Mirror Image,” Theological

Studies 61, no. 2 (2000): 280-313. 162 Edward J. Furton and Albert S. Moraczewski, “Double Effect,” in in Catholic Health Care

Ethics: A Manual for Practitioners, 2nd ed. Edited by Edward Furton et al., (Philadelphia, PA:

National Catholic Bioethics Center, 2009), 23-6; Kaveny, “Appropriation of Evil: Cooperation’s

Mirror Image,” 280-313. 163 USCCB, ERDs, 45. 164 Kaveny, “Appropriation of Evil,” 310. 165 Kiyotsugu Yoshida and Yoshio Miki, “Role of BRCA 1 and BRCA2 as Regulators of DNA

Repair, Transcription, and Cell Cycle in Response to DNA Damage,” Cancer Science 95, no. 11

(2004): 866-71. National Cancer Institute, “BRCA1 and BRCA2: Cancer Risk and Genetic

Testing,” April 1, 2015, https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-

fact-sheet#q1. 166 Jillian H. Hurst, “Pioneering Geneticist Mary-Claire King Receives the 2014

Lasker~Koshland Special Achievement Award in Medical Science,” The Journal of Clinical

Investigation 124, no. 10 (2014): 4148-51; Joi L. Morris, Ora K. Gordon, Selma R. Schimmel,

Positive Results: Making the Best Decisions When You’re at High Risk for Breast or Ovarian

Cancer, (Amherst, NY: Prometheus, 2010), 39-50. 167 Yoshida et al., “Role of BRCA1 and BRCA2,” 866-71.

http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19750313_quaecumque-sterilizatio_en.html


41

168 National Cancer Institute, “BRCA1 and BRCA2: Cancer Risk and Genetic Testing,” April 1,

2015, https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet#q2; see

also National Cancer Institute, “SEER Cancer Statistics Review,” 1975-2011, Updated

December 17, 2014, http://seer.cancer.gov/csr/1975_2011/. 169 National Cancer Institute, “BRCA1 and BRCA2: Cancer Risk and Genetic Testing,” April 1,

2015, https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet#q2. 170 J. Kotsopoulos, et al., “Bilateral Oophorectomy and Breast Cancer Risk in BRCA1 and

BRCA2 Mutation Carriers,” Journal of the National Cancer Institute 109, no. 1 (1 January

2017): https://doi.org/10.1093/jnci/djw177. 171 USCCB, ERDs, 53. 172 Aquinas, Summa Theologica, II-II, q. 65, a. 1. 173 Pius XII, “Address to the First International Congress on the Histopathology of the Nervous

System,” Sept. 14, 1952, https://w2.vatican.va/content/pius-

xii/fr/speeches/1952/documents/hf_p-xii_spe_19520914_istopatologia.html. Pius XII, “Discours

Du Pape Pie XII Aux Participants au XXVIe congrès organisé par la société Italienne

D’Urologie,” October 8, 1953, https://w2.vatican.va/content/pius-

xii/fr/speeches/1953/documents/hf_p-xii_spe_19531008_congresso-urologia.html. 174 Aquinas, Summa Theologica, II-II, q. 64, a. 7. 175 Finnis, Aquinas, 64. 176 Sousa-Lara, “Per Se and Praeter Intentionem in Aquinas,” 418-53. 177 Anotonella Surbone, “Social and Ethical Implications of BRCA Testing,” Annals of

Oncology, 22, Supplement no. 1 (2011): i61. (i60-i66) 178 Surbone, “Social and Ethical Implications of BRCA Testing,” i61. Emily A. Peterson et al.,

“Health Insurance and Discrimination Concerns and BRCA1/2 Testing in a Clinic Population,”

Cancer, Epidemiology, Biomarkers and Prevention 11, no. 1 (2002): 85. 179 110th Congress, “The Genetic Nondiscrimination Act of 2008 (GINA),” Public Law 110-233,

Approved May 21, 2008 https://www.gpo.gov/fdsys/pkg/PLAW-110publ233/pdf/PLAW-

110publ233.pdf. 180 Jonsen et al., Clinical Ethics, 181. 181 Jonsen et al., Clinical Ethics, 180. 182 Rhonheimer, Ethics of Procreation, 100. 183 Becket Gremmels et al., “Opportunistic Salpingectomy to Reduce the Risk of Ovarian

Cancer,” National Catholic Bioethics Quarterly 16, no. 1 (2016): 99-131. 184 Ethicists of The National Catholic Bioethics Center, “Statement of The National Catholic

Bioethics Center on Salpingectomy to Reduce Cancer Risk,” June 7, 2016,

https://www.ncbcenter.org/resources/news/opportunistic-salpingectomy-reduce-risk-ovarian-

cancer/. 185 Lynn C. Hartmann and Noralane M. Lindor, “The Role of Risk-Reducing Surgery in

Hereditary Breast and Ovarian Cancer,” The New England Journal of Medicine 374, no. 5

(2016): 454-68. 186 USCCB, ERDs, pp. 15, dir. 36. 187 John Paul II, Evangelium Vitae, (March 25, 1995), http://w2.vatican.va/content/john-paul-

ii/en/encyclicals/documents/hf_jp-ii_enc_25031995_evangelium-vitae.html, 58. 188 USCCB, ERDs, 36. 189 Marc A. Fritz and Leon Speroff, in Clinical Gynecologic Endocrinology and Infertility, 8th

ed., (New York City, NY: Lippincott Williams and Wilkins, 2011).

http://seer.cancer.gov/csr/1975_2011/

https://doi.org/10.1093/jnci/djw177

https://w2.vatican.va/content/pius-xii/fr/speeches/1952/documents/hf_p-xii_spe_19520914_istopatologia.html


https://w2.vatican.va/content/pius-xii/fr/speeches/1953/documents/hf_p-xii_spe_19531008_congresso-urologia.html


https://www.gpo.gov/fdsys/pkg/PLAW-110publ233/pdf/PLAW-110publ233.pdf


https://www.ncbcenter.org/resources/news/opportunistic-salpingectomy-reduce-risk-ovarian-cancer/




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190 James Trussell et al., “Emergency Contraception: A Last Chance to Prevent Unintended

Pregnancy,” Office of Population Research Princeton University, (August 2018),

https://ec.princeton.edu/questions/ec-review.pdf, 2ff. 191 Kathleen Mary Raviele, “Levonorgestrel in Cases of Rape: How Does It Work?” The Linacre

Quarterly 81, no. 2 (2014): 117-129; Marie T. Hilliard, “Moral Certitude and Emergency

Contraception,” Catholic Health Care Ethics: A Manual for Practitioners, 2nd ed., ed. Edward J.

Furton et al. (Philadelphia: National Catholic Bioethics Center, 2009), 153-61. 192 Thomas Aquinas, Scriptum super libros Sententiarum magistri Petri Lombardi episcopi

Parisiensis, Vol. 2, ed. P. Mandonnet (Parisiis: Sumptibus P. Lethielleux, 1929),

http://www.corpusthomisticum.org/snp2035.html, lib. II, d. 40, q. 1, a. 2; Finnis, Moral

Absolutes, 66; Aquinas, On Evil, trans. Richard Regan and ed. Brian Davies, (Oxford: Oxford,

2003), q. 2, a. 4, ad. 9, pp. 108. 193 Thomas Petri, Aquinas and the Theology of the Body: The Thomistic Foundation of John Paul

II’s Anthropology, (Washington D. C.: Catholic University of America Press, 2016), 41-2; from

John A. Gallagher, Time Past, Time Future: An Historical Study of Catholic Moral Theology

(New York: Paulist Press, 1990), 76; John A. McHugh and Charles J. Callan, Moral Theology: A

Complete Course Based on St. Thomas Aquinas and the Best Modern Authorities (New York:

Joseph F. Wagner, 1929), 1:23. 194 Rhonheimer, Ethics of Procreation, 71ff. 195 Rhonheimer, Ethics of Procreation, 133ff. 196 Carol Bayley, “Transgender Persons and Catholic Healthcare,” Health Care Ethics USA: A

Quarterly Resource for the Catholic Health Ministry 24, no. 1 (2016): 1-5; Becket Gremmels,

“Sex Reassignment Surgery and the Catholic Moral Tradition: Insight from Pope Pius XII on the

Principle of Totality,” Health Care Ethics USA: A Resource for the Catholic Health Ministry,

24.1 (January, 2016), 6-10. 197 Pope Francis, Apostolic Exhortation Amoris Laetitia, March 19, 2016,

https://w2.vatican.va/content/dam/francesco/pdf/apost_exhortations/documents/papa-

francesco_esortazione-ap_20160319_amoris-laetitia_en.pdf, no. 56. 198 American Psychiatric Association, “Gender Dysphoria,” Diagnostic and Statistical Manual of

Mental Disorders, Fifth Edition [hereafter DSM-V], (Arlington, VA: American Psychiatric

Publishing, 2013), 451. 199 Kumar, Vinay et al., Robbins and Cotran Pathological Basis of Disease, 8th Edition, Kindle

Edition, (Philadelphia, PA: Saunders Elsevier, 2010), Kindle location 7833-5. 200 APA, DSM-V, 451ff. 201 Simon de Beauvoir, The Second Sex (New York: Vintage, 2011), 283. 202 Ann Oakley, Sex, Gender and Society (London: Maurice Temple Smith, 1972). 203 Suzanne J. Kessler and Wendy McKenna, Gender: An Ethnomethodological Approach (New

York: John Wiley and Sons, 1978). 204 Gayle Rubin, “The Traffic in Women: Notes on the ‘Political Economy’ of Sex,” in Toward

an Anthropology of Women, ed. Rayna R. Reiter (New York: Monthly Review Press, 1975), 157-

210. 205 Judith Butler, Gender Trouble: Feminism and the Subversion of Identity (London: Routledge,

1990). 206 APA, “Gender Identity Disorder,” Diagnostic and Statistical Manual of Mental Disorders,

Fourth Edition [hereafter DSM-IV], (Washington D.C.: American Psychiatric Association,

1994), 532-8.

https://ec.princeton.edu/questions/ec-review.pdf

http://www.corpusthomisticum.org/snp2035.html

https://w2.vatican.va/content/dam/francesco/pdf/apost_exhortations/documents/papa-francesco_esortazione-ap_20160319_amoris-laetitia_en.pdf


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207 APA, “Gender Dysphoria,” in DSM-V, 451-9. 208 Francis Duval Smith, “Perioperative Care of the Transgender Patient,” Association of

Perioperative of Registered Nurse Journal 103, no. 2 (2016): 152-63. 209 Allen Vigneron and Robert McManus, “Memorandum from the USCCB Committee on

Doctrine Concerning Sex Reassignment,” December 22, 2016. 210 Lawrence S. Mayer and Paul R. McHugh, “Gender Identity,” The New Atlantis: A Journal of

Technology and Society no. 50 (Fall 2016): 86-143. 211 Carl Elliott, “A New Way to Be Mad,” The Atlantic Monthly 286, no. 6 (2000):

https://www.theatlantic.com/magazine/archive/2000/12/a-new-way-to-be-mad/304671/. 212 Rene Descartes, Meditations on First Philosophy: With Selections from the Objections and

Replies, 2nd edition, ed. John Cottingham (Cambridge, UK: Cambridge University, 2017), 78. 213 Francis Bacon, “Introduction,” in The New Organon, ed. Lisa Jardine et al., (Cambridge:

Cambridge University Press, 2000). 214 Duns Scotus, Contingency and Freedom: Lectura I 39, ed. Antonie Vos (Boston: Kluwer

Academic, 1994). 215 Arthur Schopenhauer, On the Will in Nature: An Account of the Corroborations Received by

the Author’s Philosophy Since Its First Appearance from the Empirical Sciences, Translated by

Madame Karl Hillebrand, ed. Julius Frauenstadt (London, 1907). 216 Friedrich Nietzsche, The Will to Power, (New York: Penguin, 2017). 217 John Paul II, Veritatis Splendor, n. 48; Rhonheimer, The Perspective of Morality, 186. 218 John S. Grabowski, “Male and Female: Equality, Difference, Dignity,” Sex and Virtue: An

Introduction to Sexual Ethics, (Washington, D.C.: Catholic University Press, 2003), 96-126. 219 Becket Gremmels, “Sex Reassignment Surgery and the Catholic Moral Tradition: Insight

from Pope Pius XII on the Principle of Totality,” Health Care Ethics USA: A Resource for the

Catholic Health Ministry 24, no. 1 (2016): 6-10. 220 Pope Pius XII, “Address to the Participants of the 26th Congress of the International Society

of Urology,” (October 8, 1953), Acta Apostolicae Sedis 45 (1953): 674.

http://www.vatican.va/archive/aas/documents/AAS-45-1953-ocr.pdf. 221 John F. Brehany, “Pope Pius XII and Justifications for Sex Reassignment Surgery,” Health

Care Ethics USA: A Quarterly Resource for the Catholic Health Ministry 24, no. 4 (2016): 18-

21. 222 Carol Bayley, “Transgender Persons and Catholic Healthcare,” Health Care Ethics USA: A

Quarterly Resource for the Catholic Health Ministry 24, no. 1 (2016): 1-5. 223 Fritz and Speroff, Clinical Gynecologic Endocrinology and Infertility, 1095. 224 Lazar Margulies, “History of Intrauterine Devices,” in Bulletin of the New York Academy of

Medicine 51, no. 5 (1975): 662-3. 225 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1100. 226 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1100. 227 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1059. 228 William Green, Contraceptive Risk: The FDA, Depo-Provera, and the Politics of

Experimental Medicine (New York: New York University Press, 2017), 348; Mosby’s Medical

Dictionary, 7th ed. (Saint Louis, MO: Mosby, Elsevier, 2006), 44-5. 229 Fritz and Speroff, Clinical Gynecologic Endocrinology, 614-5. 230 Noonan Contraception: A History of Its Treatment by the Catholic Theologians and

Canonists. 231 Gury, Compendium Theologiae Moralis.

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232 Pius XI, Casti Cannubii. 233 Louis Janssens, “Ontic Evil and Moral Evil,” in Proportionalism: For and Against ed.

Christopher Kazcor (Milwaukee: Marquette University Press, 1999), 100-147. 234 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 138ff. 235 Finnis, Fundamentals of Ethics, 1-25; Finnis, Natural Law and Natural Rights, 36-42. 236 Rhonheimer, Natural Law and Practical Reason, 87ff; Rhonheimer, The Perspective of

Morality, 268; Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a

Central Teaching of Veritatis Splendor,” 44. 237 McInerny, Aquinas on Human Action, 191. 238 Rhonheimer, Ethics of Procreation and the Defense of Human Life, 42. 239 Paul VI, Humanae Vitae, 12. 240 Rhonheimer, Ethics of Procreation and the Defense of Human Life, 100. 241 Rhonheimer, The Perspective of Morality, 117ff. 242 Edward J. Furton et al.,“Double Effect,” 24. 243 John Paul II, Veritatis Splendor, 78; Rhonheimer, “The Perspective of the Acting Person and

the Nature of Practical Reason: The ‘Object of the Human Act’ in Thomistic Anthropology of

Action,” in The Perspective of the Acting Person: Essays in the Renewal of Thomistic Moral

Philosophy, ed. William F. Murphy, Jr. (Washington D.C.: Catholic University Press, 2008),

195ff. 244 Grisez, Difficult Moral Questions, 310-11. 245 Ron Hamel, “Thinking Ethically about Emergency Contraception: Critical Judgments Require

Adequate and Accurate Information,” in Health Progress 91, no. 1 (2010): 62-7. 246 Edward J. Furton, Selective Citations, The National Catholic Bioethics Center 10, no. 1

(2010): 39-41. 247 Grisez, Difficult Moral Questions, 311.

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CHAPTER TWO – NATURAL LAW AND THE MORAL OBJECT

This chapter analyzes the concepts of Natural Law and the Moral Object of the Act that

Aquinas provides a comprehensive and systematic formulation of in his Summa Theologica.

Each section focuses on the scholarship of two contemporary ethicists—John Finnis and Martin

Rhonheimer.

2A: Natural Law

Thomas Aquinas articulates his understanding of Natural Law in the context of his

discussion of law itself, which he identifies as a measure and rule of reason.1 Unlike the laws of

nature, which constitute a passive participation in the eternal law of God, Natural Law properly

speaking involves an active participation of the human person in formulating norms according to

practical reason. Since the human person formulates the dictates of Natural Law, one must

adequately account for the distinct aspects of human nature, without over or underemphasizing

the physical or spiritual dimension. Thus, an adequate account avoids the pitfalls of either

physicalism or spiritualism.

This section articulates Finnis and Rhonheimer’s interpretation of Aquinas’s Natural Law

avoiding the abovementioned pitfalls. The first subsection describes the various components of

Natural Law. The second addresses the Naturalistic Fallacy, which presumes that the genus

moris derives from the genus naturae. The third subsection highlights the uniquely personal

dimension of Natural Law, without falling into spiritualism. Finally, the last subsection

illustrates the contribution that such a deep understanding of Natural Law makes to the

controversial prohibition of contraception.

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i. Natural Law

For Rhonheimer, it is essential to maintain the distinction between the concrete working

of practical reason and one’s reflection upon it, which constitutes moral philosophy.2 Natural

Law does not first consist of normative statements that one discovers and then applies to one’s

life.3 Rather, first, on the level of action, one follows precepts in accord with or conceived of by

practical reason.4 Afterwards, or even in the midst of the whole complex process of acting

through practical reasoning, one may reflect upon this and formulate so-called ought statements.5

The reflection on the process of practical reasoning is not practical in nature itself, but theoretical

or speculative.6 At the same time, one may apply the product of one’s theoretical reflection—

which Rhonheimer identifies with the activity of moral philosophy—to practical decision

making.7 In this sense, the prescriptive formulations of moral philosophy become practical

insofar as they guide one’s conscience in practical matters.8

a. Law

Aquinas discusses Natural Law in the context of law.9 Law relates to the dictates of

reason.10 In fact, laws are the measure and rule of action.11 Insofar as the word law originates

from ligare, which means to bind, it conveys the notion of compelling action.12 In other words,

laws govern action. Aquinas relates this concept of reason to human nature, insisting that it

directs one to his or her end or ends.13 Rhonheimer, following Aquinas, understands law to be

the ordering of reason to action.14 Moreover, Aquinas understands law to be a proposition

(propositio), not however in the theoretical sense, but in the logical sense insofar as it constitutes

a judgment, rather than a statement, therefore, leading to a command or precept (praeceptum).15

In addition, law is not merely a judgment, but also constitutes a dictate of reason (dictamen

rationis).16 Ultimately, for Rhonheimer, the precept of reason is an act of the will expressed not

47

in word, but action.17 Only in reflection on practical reason in act is one able to formulate

theoretically a normative statement in words.18 For Rhonheimer, it is only with this distinction

between theoretical and practical in mind that one can understand properly Aquinas’s statement:

“the Natural Law is something constituted by reason, just as the propositio is a work of the

reason.”19 With this important distinction in mind, one avoids the tendency toward spiritualistic

dualism or the Naturalistic Fallacy.20

Aquinas distinguishes between law that is essential and law that is by participation.21

Essential law constitutes reason alone, while law by participation is that which the law measures

and rules.22 Put another way, law may be understood from two perspectives: the one ruling and

the one whom the law measures and rules.23 Law is a work of reason, so strictly speaking,

wherever reason does not exist law does not exist, except by similarity.24 Therefore, the law of

reason acts upon irrational beings—inanimate and animate—insofar as behavior is in accord with

reason.25 In this sense, they participate in the law.

Having established that law is an ordinance of reason, Aquinas further relates it to the

common good.26 Just as every part relates to the whole in a body, so all the laws relate to the

common good.27 For Aquinas, the common good is the common end of humanity, which is

eternal happiness.28 In addition, legitimate authority must promulgate law.29 Legitimate authority

constitutes one that has the common good of all in mind, whether a single person or a

conglomerate of leaders.30 Authority must promulgate, that is, make the law known, otherwise it

has no binding force.31

b. Eternal Law and Natural Law

Natural Law is the eternal law of God written on the heart of each human person.32

Insofar as legitimate authority promulgates law, God, as the provident ruler of the universe

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governs through the divine reason.33 The eternal, divine law is not distinct from God, because it

has no other end than God.34 Insofar as all things have their origin in God, they participate in the

eternal law of God.35 In other words, all creatures receive the eternal law insofar as the divine

reason is a measure and rule for them.36 Humans, however, participate in the divine law in an

even more excellent way insofar as they have a share in the providential role of God.37 The

divine law not only measures and rules people like it does for all other creatures, but human

persons also have a role in measuring and ruling.

Finnis explicates Aquinas’s understanding of participatio in his Natural Law and Natural

Rights. 38 Finnis explains that Aquinas means two things: one causality and similarity.39

Something causes a similar quality in one being when it has that quality in a more excellent and

less dependent way.40 To illustrate, Finnis explains that humans have intelligence that is far

inferior to what may be understood as a more superior and perfect intelligence in the separate

intellect of God.41 As light illuminates the act of seeing, so the divine intellect illuminates the

human intellect in understanding.42 As such, the divine law does not merely measure and rule

humans as it does irrational creatures, but just as God measures and rules creatures according to

the divine law, so humans in a less perfect way measure and rule nature according to Natural

Law, which constitutes a quality of similarity to the divine law and caused by it.43

c. Self-Evidence of Practical Reason

The first principle of practical reason is like the first principle of metaphysics insofar as it

is self-evident truth.44 The statement itself suffices to demonstrate that it is true.45 R. A.

Armstrong in Primary and Secondary Precepts in Thomistic Natural Law Teaching identifies

what Aquinas means by self-evident.46 First, Armstrong outlines Aquinas’s argument in the

49

Commentary on the Sentences.47 The self-evident knowledge constitutes a substratum of

knowledge for all subsequent knowledge.48

In Acts Amid Precepts, Kevin L. Flannery highlights a parallel between the ordering of

theoretical and practical knowledge in Aquinas.49 Both begin with apprehension: in theoretical

knowing, the person apprehends being, while in practical knowing one apprehends good.50

Aquinas holds that regarding self-evident knowledge a habitus abides within the person.51 For

speculative knowing, Aquinas calls this intellectus principiorum, while for practical knowing he

calls this synderesis.52 For habitus, Armstrong uses the English word “capacity,” rather than skill

or habit, because humans have this ability in virtue of their nature.53

While Aquinas insists that these principles or precepts—practical principles for

Flannery—are self-evident, he does not believe that they are innate, in the sense that one can

know them without sensation or memory.54 To the contrary, one must have both in order to

ascertain these principles or precepts.55 In De Veritate, Aquinas, using an argument by reductio

ad absurdum, insists that some principles must be permanent and unchanging otherwise nothing

could be known certainly.56 Moreover, Aquinas insists that there can be no err regarding

synderesis.57

Armstrong indicates that the self-evidence of the first precepts of Natural Law are

analogous to the self-evidence of first principles of demonstration in speculative knowing, which

implies some degree of difference.58 Aquinas highlights this difference in the Prima Secundae

where he indicates that something may be self-evident in two ways: one, in itself and two, in

relation to us.59 Armstrong and Flannery find the examples illustrative of the difference.60 What

can be known in relation to us (per se quoad nos) constitutes an analytic proposition insofar as

the predicate is contained in the subject.61 Put another way, so long as one understands the terms,

50

the truth of the statement is undeniably true. For example, the statement: “every whole is greater

than its parts,” is knowable by all and constitutes an analytic statement known per se quoad

nos.62

Germain Grisez in “The First Principles of Practical Reason: A Commentary on the

Summa theologiae, 1-2, Question 94, Article 2,” insists that the dichotomous distinction between

analytic and synthetic originating with Kant have no meaning for Aquinas.63 Rather, Aquinas

understands the subject and predicate as complementary elements of unified knowledge of a

single knowable reality.64 Put another way, the intelligibility of the predicate belongs to that of

the subject.65 Grisez understands intelligibility to be all that is included in a word used

correctly.66 Suffice it to say that for Aquinas, self-evident principles are not mere tautologies,

that is, restatements of what is already given.67

Unlike the first set of self-evident principles that are knowable and undeniable to all so

long as one understands the definition of the terms, the second set of self-evident principles are

knowable only to a few—self-evident in itself (per se secundum se).68 In this class of self-evident

principles, the terms are more complex, but so long as one understands the terms, their truth also

becomes self-evident. To illustrate, Aquinas uses the example of “man is a rational animal.”69

Not everyone knows the truth of the proposition, because not everyone knows that the very

meaning of man entails rational being, however, if one does know the definition of man, one

knows the truth of the proposition.70

The principle of non-contradiction and the first principle of Natural Law are

foundational, but not in the sense that one may deduce more particular principles or precepts

from them as though they were general premises.71 Rather, both constitute directive principles

insofar as one must formulate more particular principles and precepts in accord with them.72

51

Finnis relates the concept of the self-evidence of principles or precepts of Natural Law to

the rationality of the notion that any state of affairs may exist without further explanation.73

Contrary to rationalists of the late seventeenth and eighteenth centuries, Finnis insists that it is

possible for a state of affairs to exist that has no further explanation for its existence outside of

itself.74 This he identifies as an uncaused cause.75 More precisely, it is not to say that this entity

has no explanation, but that its explanation is itself.76

For Finnis the self-evidence of practical principles means that they are indemonstrable,

and un-inferable.77 The principles of practical reasoning do not stand in need of demonstration.78

Moreover, their validity is not a matter of convention or inferring from observation; rather, it is

objective.79 While it is possible to deny them, it is not possible to be reasonable and deny them.80

Contrary to the modern criteria, feelings of certitude do not validate these truths.81 Although

understanding a principle of practical reason is not like understanding a principle of logic or

mathematics, it is no less true.82

d. Happiness, Natural Inclinations, and Reason

In The Perspective of Morality: Philosophical Foundations of Thomistic Virtue Ethics,

Rhonheimer highlights the difference between an authentic eudemonistic ethic and one that only

seems oriented toward happiness, but really constitutes hedonism.83 Both ethical theorists argue

that happiness is the end or goal of action; however, hedonism not only defines happiness more

basely as a state of contentment, but also understands this as the motive for action.84 Rhonheimer

recalls Augustine’s warning not to follow God for a reward, because God is the reward.85

Rhonheimer is most critical of Kant who ultimately advocates for hedonism, understanding God

as a divine giver of pleasure, but not in this world; therefore, he evacuates all happiness as a

motive for action in this life basing all morality on duty.86 While one may understand happiness

52

as the ultimate end of action, this never constitutes the motive for concrete acting.87 Rather, the

good, which practical reason formulates as good to be done, motivates concrete action.88 It is

only in this sense that one may say that the will strives for happiness.89

For Rhonheimer, practical reason not only constitutes striving for happiness, but also “is

the reasoning that cognitively directs intentional action.”90 Put another way, practical reasoning

concerns the person’s intending of means and ends in action.91 Rhonheimer asserts that action is

a phenomenon of appetition.92 Individuals act because they are seeking or striving for a good.93

Moreover these inclinations toward the good correspond to one’s substantial form.94 The

substantial form of human beings is a rational soul; therefore, human appetition or striving

corresponds to the rational soul.95 For humans the soul consists of the two faculties of the

intellect and will. Accordingly, Rhonheimer explains that willing is an appetition guided by

reason.96

For Aristotle, happiness, as the ultimate goal, constitutes what one rationally wills for its

own sake.97 This end does not take the form of a goal for the sake of which, but a goal through

which.98 In other words, it is an activity that is unique to rational humans.99 This activity is also

the activity, which the virtuous person delights in the most.100 Aristotle identifies this with life

according to the intellect; at the highest level a life of contemplation; and at the next level a life

lived according to virtue, according to reason.101

Aquinas discusses natural inclinations in relationship to the classes of forms: 1) purely

natural appetites constituting inanimate beings such as plants; 2) sensitive appetites

corresponding to animate beings such as animals; and 3) rational appetites, such as humans.102

Moreover, each class of beings corresponds with a type of apprehension or knowledge of the

good. Beings with natural appetites merely tend toward the good with no apprehension of it

53

whatsoever.103 Beings with sensitive appetites apprehend the good only in particular things, but

not in a general sense.104 Finally, rational beings such as humans apprehend the good not only in

particular things, but also in a general sense, as in universals.105 Moreover, the rational

apprehension of the good is intentional.106

To each of these classes corresponds a degree of necessity regarding action. Inanimate

beings follow natural inclinations of necessity.107 Animate beings follow natural inclinations

when they perceive objects of desire as useful.108 And rational beings only desire the good in

general by necessity, but not with necessity any particular good, enabling one to freely choose a

particular good among options.109

The good to which natural inclinations tend corresponds to the end of the being in

question.110 Aquinas adapts Aristotle’s ‘ergon argument’ to make his point that the good for

each being corresponds to the substantial form of the being in question.111 The ‘ergon argument,’

which I discuss in greater detail in the following subsection, determines that the primary function

or activity of humans consists in the use of reason.112 Rhonheimer recalls that action is an agent

of appetition or striving for an object that is good.113

Reason formulates every human act, regardless of the origin of the desire—whether

natural, sensitive, or rational.114 Germain Grisez understands Aquinas’s explanation for the

diversity of Natural Law precepts to be precisely due to “the different inclinations objects,

viewed by reason as ends for rationally guided efforts.”115 While inclinations, which originate

from nature play an important role as raw datum, they themselves do not constitute the Natural

Law.116 This corresponds with the dictum that laws of nature do not constitute Natural Law.117

Grisez explains that the tendencies of natural inclinations provide reason with the beginnings of

proposed ends.118 The precepts that conform inclinations in action constitute the Natural Law.119

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Just as it is impossible for reason to err regarding synderesis, so it is impossible for

reason to err regarding its judgment of the good.120 Saying that reason does not err, does not

mean that people do not make mistakes, but that mistakes are not attributable to failure of the

intellect’s perception of good, which subsequently measures action.121 In the De Anima, Aristotle

holds that since err is not attributable to the intellect with regard to reason, it must reside in

appetition or imagination.122 In addition, false opinions, emotions or passions, and the will may

disturb reason.123 Sin occurs when these other factors inhibit reason’s measure of good and bad

in action.124 Put another way, one sins when the lower, nonrational appetitions dominate the

appetition of reason.125 Ultimately, this is because the freedom of reason “guarantees the an

encounter with the good for man qua man.”126

As a faculty, Rhonheimer explains that the will, not already rational by itself, pursues

what the judgment of reason presents to it.127 Contrary to Kant’s formulation of the will, it is not

pure spontaneity; rather, reason thoroughly determines it.128 Insofar as reason is able to reflect

upon its own judgments, thereby becoming the object of an act of judgment, it is free.129 It can

have multiple conceptions of the good.130 This Rhonheimer identifies as freedom of

specification, which constitutes a freedom of the will due to reason.131

However, the will may also be free in execution; that is, choosing or not choosing means

that are in concert with one’s goal or intention.132 Freedom of execution is the source of freedom

of choice.133 If one does not want to do something, it does not happen.134 Ultimately, reason

alone does not suffice as a motivating principle for action; the will can pursue other motivating

factors, such as feelings, or pure self-willing.135

e. Principles of Natural Law and Basic Human Goods

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Each principle of Natural Law corresponds to the natural inclinations in humans, which

corresponds to all three of the above-mentioned classes of inclinations.136 While the principles of

Natural Law are not the inclinations themselves, they are nonetheless “an ordering of the reason

in relation to or in the natural inclinations,” taking the form of a practical judgment ‘p is

good.’137 Finnis indicates that the principles of Natural Law are not moral judgments, but the

substratum for moral judgments.138 Moreover, Natural Law concerns the acts of practical

understanding in which one grasps the basic values of human existence.139

Finnis understands the good not as a desirable objective, but as a form of good with an

indefinite number of means or occasions for one to participate in or realize, which he uses value

to identify.140 As such, unless one engages in reflection on the presuppositions of one’s practical

reasoning, one is not likely to formulate these principles in one’s arguments concerning

particular goods.141 Again, the self-evidence of these principles means not only that they are

indemonstrably true, but also that they stand in no need of justification.142 These principles are

not derivable or inferable.143

Armstrong relates the principles of practical reason to human inclinations,144 while Finnis

relates it to basic human values.145 To the first natural human inclination is that of self-

preservation, which Armstrong formulates as: although a hierarchy of life exists, one ought to

respect and preserve human life and where possible other life as well.146 This, Aquinas argues is

self-evident in itself, but not to all.147 Finnis correlates the principle of self-preservation with the

basic human value of life.148

The second basic human inclination, shared by other animals is the inclination to sexual

union and the rearing of offspring.149 Armstrong following Maritain, insists that certain

limitations must exist for sexual union, considering how special a place it has in engendering

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children.150 In addition, the family group ought to comply with a particular pattern.151 Finnis

relates this principle to life also.152 At the same time, he recognizes that the education and rearing

of children includes other basic human values, such as sociability and truth.153

The third basic human inclination corresponds with rational nature.154 This, according to

Aquinas, involves the inclination for relationship with God and to live in society.155 Insofar as

humans need assistance from other people to exist, the principle to live in society following

certain rules and prohibitions is self-evident.156 For Finnis, this corresponds to the basic human

value of knowledge.157 In so far as this inclination extends to sociability and religion, it

corresponds to these goods as well.158 In addition, the rational inclination relates to the basic

human values of play, practical reasonableness, and the aesthetic experience.159

Having introduced the concept of Natural Law, the following subsection highlights the

importance of avoiding the critical error of the Naturalistic Fallacy.

ii. Naturalistic Fallacy and Natural Law

The concept of the Naturalistic Fallacy originates with G. E. Moore in Principia Ethica,

in which he argues that the moral good is not merely a conglomeration of physical goods.160 He

builds on the concept from David Hume that an ‘ought statement’ never derives from an ‘is

statement.’161 Unfortunately, Hume throws the baby out with the bath water, further insisting that

morality has nothing to do with reason; instead, insisting that it depends on moral sense or

feeling.162 While both Rhonheimer and Finnis concur with Hume that ‘ought statements’ do not

derive from ‘is statements,’ they do not agree that this means that ethics is unreasonable.163 In

fact, this merely demonstrates the underivability of ethics from metaphysics.

a. Ergon Argument

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In Fundamentals of Ethics, John Finnis argues that Aristotle and Aquinas would agree

with his thesis that reasoning concerning human goods is primarily practical, not theoretical.164

He offers four reasons why they are often misunderstood as proposing that practical knowledge

is derivative of theoretical.165 One, Aristotle seeks a holistic explanation of biology with

cosmology.166 Two, Aquinas utilizes analogies between different natures to elucidate

concepts.167 Three, interpreters of Aristotle and Aquinas often over-simplify concepts in an effort

to systematize.168 Four, Finnis takes issue with Aristotle’s so-called ‘ergon argument,’ which

translates as function or activity that is proper to humans.169

In the first book of the Nicomachean Ethics Aristotle argues that the unique function of

humans is the activity of the soul in accord with reason, therefore, a good person acts in accord

with reason.170 Aristotle argues that just as with a flute player or sculptor the good resides with

the function, so the good of humans must reside in their function.171 Of course, humans share

several functions with other organisms, such as, growth and sensation; however, the function that

typifies human beings must be unique to them.172 For Aristotle, a rational principle characterizes

human activity.173 In particular, it constitutes a function of the soul. Above all, for Aristotle, what

sets humanity apart is its activity in conformity with reason.

Finnis insists that since this argument is theoretical, not practical in nature it contributes

nothing substantial to Aristotle’s ethics.174 Moreover, because of this, Finnis argues that it is not

only uncharacteristic of Aristotle, but does not properly belong to his ethics.175 Furthermore, it

contributes to the mistaken notion that ethics derives from physics and metaphysics.176 Once

again, Finnis holds that practical knowledge does not derive from theoretical knowledge.177

Insofar as the genus moris and the genus naturae differ, one’s grasp of the good in practical

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reasoning—constitutive of the genus moris—does not depend on or derive from the genus

naturae.

Ralph McInerny178 and Rhonheimer179 both take issue with Finnis’s dismissal of

Aristotle’s function argument. McInerny disagrees with Finnis’s argument that practical

knowledge is radically independent of theoretical knowledge.180 He reasons that since there is

one intellect that knows both speculatively and practically (by extension)—knowing being

speculatively before knowing the good practically—practical knowing depends on speculative

knowing.181 Indeed, for him, practical knowing constitutes the knowing of a good being.182 In

other words, for one to judge that ‘X is good for me,’ one must know what X is.183 Consequently,

for McInerny, practical knowledge does derive from speculative knowledge.184

Rhonheimer agrees with McInerny that Finnis should not discount the significance of

Aristotle’s ‘ergon argument’ for ethics, but he does not think that this is because practical

knowledge derives from speculative knowledge.185 For Rhonheimer, McInerny fails to

distinguish between the initial grasp of first principles and the subsequent reflection upon action,

which is substantially speculative.186 For Rhonheimer this is the content of moral philosophy,

which gives rise to normative statements.187

For Rhonheimer, it is essential to maintain the distinction between theoretical knowledge

and practical knowledge, because their founding principles are unique.188 The object of practical

knowledge is the good and constitutes the Natural Law.189 However, one’s reflection upon the

act of practical reasoning is descriptive, also called theoretical. It is only in the latter that one

discovers the Natural Law, which Rhonheimer identifies as moral philosophy.190 It is precisely

by reflecting on the practical knowing that one derives normative statements or commands.191

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Although this appears to contradict what Rhonheimer says above, namely that ‘ought

statements’ do not derive from ‘is statements’; it does not, because for Rhonheimer, one is

observing human reason in action.192 In other words, moral philosophy is not merely a social

science experiment or survey, but reflection on how the human person uses reason to act. Since

one does not merely observe how one acts, but maintains the connection to practical reason, the

commands that one formulates remain constitutive to practical reasoning.193

Finnis and McInerny presume that the ‘ergon argument’ attempts to justify the foundation

of practical reasoning through speculative knowledge. Consequently, Finnis rejects the argument

altogether,194 while McInerny subscribes to it as a confirmation of his presumption that practical

knowledge does derive from speculative knowledge.195 While Rhonheimer agrees with McInerny

that Finnis should not reject the ‘ergon argument’ altogether, he does not agree with McInerny’s

interpretation and conclusion.196 Rhonheimer understands McInerny to be rejecting a red herring

insofar as McInerny creates or presumes a dilemma that does not really exist.197

In Praktische Vernunft und Vernunftigkeit der Praxis: Handlungstheorie bei Thomas von

Aquin in Ihrer Entstehung aus dem Problemkontext der Aristotelischen Ethik, Rhonheimer

explains that Finnis fails to see that the ‘ergon argument’ relates to ethical reflection, not

practical reasoning.198 Therefore, while the argument does nothing for the foundation of practical

reasoning, it is indispensable for a metaphysical-anthropological interpretation and justification

of the normative function of practical reason.199 Rhonheimer not only rejects McInerny’s

conclusion that practical knowledge derives from speculative knowledge, he also insists that

practical knowledge plays an essential role in elucidating human nature; in fact, one that cannot

be merely chalked up to ethical reflection, that is speculative.200

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b. Essentialist Understanding of Morality

Rhonheimer rejects what he calls an essentialist understanding of morality, of which

Heinrich Rommen,201 Joseph Pieper,202 Ralph McInerny,203 Steven Jensen,204 R. Hittinger,205 and

Steven A. Long206 are leading proponents.207 Such proponents conflate metaphysics with

morality insofar as they insist that actions perfect being.208 Although ethicists often attribute this

to Aquinas, Rhonheimer insists that this is not what Aquinas proposes.209 Above all, for

Rhonheimer, such a theory poses an epistemic contradiction: it is impossible to know what to do

until one has perfected one’s being through action.210

Essentialists fail to recognize an important distinction in Aquinas between moral being

(esse morale) and essential being (esse essentiale), which he discusses in De Veritate.211 For

Aquinas moral goodness constitutes the perfection of moral being, not essential being.212

Aquinas insists that creatures cannot fail to be good with regard to essential goodness, but when

it comes to accidental goodness, it may or may not be good, by participation.213 Being is good in

its essence insofar as it exists.214 However, with the exception of God, who is good in the

absolute sense, creatures are morally good insofar as they participate in goodness in an

accidental sense, that is, insofar as this goodness is super-added to the essential goodness of the

individual.215 Put another way, creatures are morally good in relation to the one who is goodness

itself, that is, God.216 Rhonheimer asserts that any attempt to ground morality in natural teleology

is caught in a vicious circle.217

Essentialism relates to another misconception held by proportionalists that moral evil

merely constitutes the causing of physical evil.218 This is the position held by proportionalists

such as Peter Knauer,219 Josef Fuchs,220 Louis Janssens,221 Bruno Schuller,222 and Richard

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McCormick.223 Janssens, for instance, in “Ontic Evil and Moral Evil,” maintains that one

commits moral evil whenever one causes ontic evil in the world.224 Following this understanding

of moral evil, both Knauer and Janssens evacuate the Moral Object of its intentional content and

reduce it to the material component of action.225

Therefore, in one sense, proportionalists make the same mistake of essentialists, insofar

as they constitute moral evil as the causing of physical evil. Once again, they fail to maintain the

important distinction between orders of the genus naturae versus the genus moris. For the

proportionalists, however, the moral is not merely derivative of the ontological, but

constitutively the same. Ironically, this relative equivocation gives rise to a radical dualism that

centers on the person. Since the Moral Object is materially constituted, morality centers on the

intention as ends, without regard for the intentional content of the Moral Object. Moreover, as

the next subsection highlights, proportionalist morality is eventistic, rather than personalistic,

focusing more on consequences than the deliberate will.

iii. Natural Law and the Perspective of the Acting Person

a. The Primacy of the First-Person Perspective

In “The Cognitive Structure of the Natural Law and the Truth of Subjectivity,”

Rhonheimer explains the dualistic fallacy as a deficient understanding of the Natural Law that

presumes a dichotomy between the natural order (objective) and reason (subjective).226

Accordingly, the Natural Law consists of a pre-packaged normative statement in nature, which

the soul simply identifies.227 Put another way, the Natural Law simply consists of a law of nature

that one identifies. In contrast, Rhonheimer insists that Natural Law is primarily subjective since

it originates within the person and constitutes the openness of the subject to true moral

goodness.228 The whole process whereby one knows the good—to be pursued—and evil—to be

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avoided—itself constitutes practical reason and is part of human nature. As such, it is impossible

to know human nature before one knows the good through practical reason, which is a

constitutive part of human nature itself. Consequently, for Rhonheimer, ethics and the Natural

Law do not begin with human nature; rather, one knows human nature insofar as one knows the

good through practical reason.229

One advantage to establishing the Natural Law on human nature is that it provides an

objective foundation that does not vacillate, as a subjective foundation seems to do, at least from

a modern perspective.230 Both Pope Leo XIII and Pope John Paul II avoid this whimsical basis

by connecting it to God through the eternal law.231 Insofar as God creates rational beings and

implants the light of reason within their heart, the Natural Law is the eternal law that guides

humans to their ends, formulated by human reason.232 Not only is the Natural Law a reflection of

the divine law, but also human autonomy is a participation in the divine autonomy, which

Rhonheimer calls theonomy: “participation and self-possession of the eternal law.”233 For

Rhonheimer, the participatory nature of the Natural Law in the eternal law may provide

motivation for following its dictates, especially in difficult circumstances.234 Insofar as the

eternal law is immutable, the Natural Law’s connection to the former provides an unequivocal

foundation, and though subjective it remains unwavering.

Much criticism against Rhonheimer centers on the role of inclinations in relationship to

human reason. In fact, critics often accuse him of connecting reason too closely to

inclinations,235 falling victim of physicalism or so disjoining reason from the inclinations that he

commits spiritualism.236 Jean Porter accuses Rhonheimer of the latter critique in “Review of

Natural Law and Practical Reason by Martin Rhonheimer,”237 to which Rhonheimer responds in

“The Moral Significance of Pre-Rational Nature in Aquinas: a Reply to Jean Porter (and Stanley

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Hauerwas).”238 Essentially, Rhonheimer avoids both physicalism and spiritualism by rooting the

acts of practical reason in the person as a substantial unity of body and soul rather than in either

the body or the soul.239

Rhonheimer rejects the notion that human persons are embodied souls, because such

terminology implies a Cartesian dualism—the soul, equivalent to the person being trapped in the

body.240 Instead, Rhonheimer reaffirms Boethius’s definition of the human person as a rational

animal.241 Accordingly, the body contributes natural inclinations with proper goods and ends like

its irrational counterparts. Moreover, these inclinations too participate in and reflect the eternal

law, but in a passive, rather than active way.242 Natural inclinations follow an order determined

by nature with proper operations and goals.243 Natural law presupposes that natural inclinations

follow the natural order.244 The natural inclinations become properly human through the

regulation of practical reason, which takes a uniquely active role in ordering goods and ends in

accord with the eternal law.245

Rhonheimer highlights three important points that Aquinas makes regarding the Natural

Law.246 First, as a work of practical reason, Natural Law does not derive from speculative

reason, which, as in the first principle of practical reason, the underivability of the practical

copulas of—prosecutio or fugo—from the theoretical copulas—is or is not—demonstrates.247

Second, the person, using the intellect in extension, spontaneously understands the ends and

goods of natural inclinations, and according to practical reason formulates practical precepts,

which constitute Natural Law.248 Third, insofar as the human person as a substantial unity of

body and soul regulates these goods and ends of natural inclinations, they constitute Natural

Law.249

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Rhonheimer avoids the pitfalls of physicalism or spiritualism by placing the role of active

agent not in the faculties of the soul or the body, but the human person, who constitutes a

substantial unity of both. The human person utilizes the unique components of his or her one

nature—body and soul—to formulate the Natural Law.

b. First-Person Perspective of Natural Law in Veritatis Splendor

John Paul II, following Aquinas, understands the Natural Law to be a divine light of

reason, which God imprints on humanity in creation.250 This reason, which promulgates the

Natural Law, is not merely part of irrational nature, but distinctly part of human nature.251

Humans do not merely read off the divine law immanently written on the human heart; rather,

they have an active participation in the ordering function of the divine reason.252 In other words,

God does not formulate and promulgate it, but human reason does.253 God does not externally

impose the Natural Law; rather, insofar as humans use reason to formulate the dictates of reason,

it is uniquely autonomous and internal.254 Humans, created in the image of God, are uniquely

free and rational, which enables them to discern between good and evil.255

At the same time that both Rhonheimer and John Paul II emphasize the role of human

reason in formulating and promulgating Natural Law, they also hold that individuals do not do so

with absolute freedom.256 John Paul II, in accord with Leo XIII, understands the Natural Law to

be a mirror of a higher divine reason.257 Again, the Natural Law is the divine law implanted

within rational beings inclining them to right action.258 Of course, people remain free to conform

themselves to this law or not. Because it originates with the divine, Rhonheimer understands

human autonomy to be a participated theonomy; formulating Natural Law according to human

reason that God infuses.259

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John Paul II rejects dualistic understandings of the human person including both

spiritualism and physicalism that emphasize the spiritual or corporal aspect of humanity over the

other, respectively.260 The previous subsection demonstrates how important it is to avoid a

naturalistic understanding of Natural Law and the human person. In “The Moral Signficance of

Pre-Rational Nature in Aquinas: A Reply to Jean Porter (and Stanley Hauerwas),” Rhonheimer

not only explicitly denies that his theory is spiritualistic, but also shows the defects of such a

theory.261 For John Paul II, humans are by nature body and soul.262 The soul constitutes the

source of unity as the human form, but it is not exclusively the human person.263 Nor is the body

raw matter for the soul to form.264 Rhonheimer insists that one’s corporality ought not to oppose

one’s rational will as though the former is nature and the latter reason, rather, human nature

constitutes a substantial unity of being that is both body and soul.265

Thus human morality pertains to both the bodily and spiritual dimensions of the human

person.266 Rhonheimer illustrates using the marital act.267 The body provides sexual attraction

between the sexes that serves procreation, which human reason naturally receives.268 The light of

reason reveals the marital act as love and communion between two persons making a gift of self

to the other for transmission of life.269

Insofar as the human person is a substantial unity of body and soul, both contribute to

human morality.270 The body contributes natural inclinations that the soul regulates using human

reason.271 Of course, the soul contributes inclinations to the good as well.272 To the extent that

reason regulates these inclinations—of the body or the soul—they constitute Natural Law.273

Since the intellect, a faculty of the soul formulates these dictates of reason, an outside observer

cannot see this; rather, one must have the perspective of the person.274 Rhonheimer reminds the

reader that the formulation of Natural Law is properly a reflexive act of the soul.275 Therefore,

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following Lehu and John Paul II, Rhonheimer insists that one does not know Natural Law

through human nature, but one does come to know human nature through the Natural Law.276

The next subsection demonstrates the value of a personalistic conception of Natural Law.

iv. Contraception and Natural Law

The search for an explanation for the immorality of contraception in the twentieth century

is a catalyst for a deeper understanding of the Natural Law. The material and superficial rejection

of contraception on the basis that condoms—and other contraceptives—physically interrupt the

natural process of the marital act, thereby preventing the possibility of conception does not

account for anovulants as contraception.277 Put another way, the physical act of preventing

conception does not provide sufficient grounds for deriving a proscription against the act of

contraception. Pope Paul VI’s bases his prohibition of contraception on two important principles:

1) The Inseparability Principle and 2) responsible parenthood. Before articulating how

Rhonheimer explains the role of Natural Law that avoids both physicalism and spiritualism, I

highlight an important distinction between contraception and licit birth control.278

In Humanae Vitae, Paul VI prohibits “any action which either before, at the moment of,

or after sexual intercourse, is specifically intended to prevent procreation—whether as an end or

as a means.”279 This exclusion does not make any specific reference to the method, but rather to

intention. Rhonheimer rejects the terminological distinction between artificial contraception and

so-called natural methods of contraception, because Paul VI declares contraception immoral,

that is, the intention of preventing conception.280 This does not mean that he rejects responsible

parenthood, which sometimes involves couples abstaining from the marital act as a means of

avoiding pregnancy. To the contrary, as the following demonstrates, both Paul VI and

Rhonheimer, assert that periodic continence, unlike contraception, respects and maintains the

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inseparability of the procreative and unitive significance of the marital act, and provides a means

for growth in chastity.281

a. Inseparability Principle

To understand the immorality of contraception, one must understand the good and end

that it contradicts. In particular, Rhonheimer connects it to the precept of Natural Law relating to

the marital act.282 For the sake of analysis he distinguishes between the spiritual and bodily

contributions to human nature, beginning with the bodily, natural inclination common to other

animals for male and female to join for the transmission of life.283 The connection of the soul to

the human person—substantial unity—raises the physical act of copulation arising from the

natural inclination to a new level when reason regulates it and it occurs between husband and

wife, which Rhonheimer identifies as married love.284 He insists that one resist the temptation to

neglect the role of the body, since doing so implies an anthropology that incarnates the soul

within the body as though the two are different natures.285 This is spiritualism, which neglects

the contribution that natural, bodily inclinations, ordered by nature, have for morality.286

The Church distinguishes between two goods of marriage: the unitive and procreative.287

The unitive significance includes the fidelity to total self-giving manifest in conjugal love.288 The

procreative significance, which invariably connects with the unitive significance, manifest in the

conjugal act, reflects one’s openness to fecundity.289 As such, the object of marital act includes

both significances. Rhonheimer identifies it as the loving bodily union of husband and wife,

which necessarily includes its procreative character.290 The inseparable connection between the

unitive and procreative significance of the marital act, which Paul VI highlights in Humanae

Vitae constitutes the Inseparability Principle.291

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Paul VI holds that each and every conjugal embrace must remain open to both

significances.292 Rhonheimer distinguishes between function and meaning insisting that although

one may not be functionally able to reproduce because of sterility or periodic incontinence, one

ought nonetheless be open in meaning or, better said, in will to fruitfulness.293 In Man and

Woman He Created Them, John Paul II argues that the body speaks a language in truth that is

reread each time a couple engages in the conjugal act.294 The truth spoken by the body in the

conjugal act refers to its innermost structure, which includes the inseparable connection between

the unitive and procreative meanings.295 Rhonheimer insists that referral to the inseparability

principle is not sufficient to explain why each and every marital embrace must remain open to

procreation, because it does not include the object of contraception.296 To explain, Rhonheimer

has recourse to the virtue of chastity, which the Moral Object of contraception contradicts.297

b. Responsible Parenthood and Chastity

Reason makes the inclination toward bodily union in the marital act human.298 Insofar as

it constitutes an act touched by reason, it is a truly personal act. Reason is the measure and rule

of the natural inclination to husband and wife joining in the marital embrace, which makes the

act both human and personal.299 Rhonheimer identifies the ordering of reason with responsible

parenthood, which he relates to both the virtue of justice and chastity.300 In particular, he focuses

on the role that chastity, as an ordering virtue of sexual inclinations, plays for responsible

parenthood.301 Following Paul VI in Humanae Vitae,302 Rhonheimer argues that responsible

parenthood necessitates periodic continence, which provides married couples means of growth in

chastity, that is, the integration of sexual drives to the order of personal love.303 Contraception

not only denies the procreative significance of the marital act, thereby denying its unitive

significance, because of the Inseparability Principle, but it also robs the couple of a means to

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growth in chastity, since it enables them to engage in the marital act without regard for the

procreative consequences.304 Without the rational ordering that responsible parenthood places on

sexual drives, the marital act loses its connection to what makes it an authentically human act of

love oriented to one’s spouse.305 Consequently, contraception disrupts both the procreative and

unitive significance of the marital act. This also accords with John Paul II’s interpretation.306

Rhonheimer’s articulation of contraception eschews physicalism and spiritualism

defining it as a vice that counters chastity. He shows that the natural, bodily inclination to sexual

union contributes to morality and that practical reason regulates sexual desire with an orientation

to responsible parenthood, that invariably relates to personal love, which a proper ordering of

desire presumes.

This section demonstrates that an accurate account of Natural Law includes an adequate

understanding of anthropology that avoids the pitfalls of physicalism and spiritualism, which

ethicists that derive Natural Law from the physical order cannot avoid. The next section analyzes

the related concept of the Moral Object of the Act.

2B. Moral Object

John Paul II, in Veritatis Splendor, rejects the teleological interpretation of action of

consequentialism and proportionalism, while reaffirming the longstanding concept of the Moral

Object attributable to Thomas Aquinas.307 Not excluding the role that intention—as ulterior

end—and circumstances play in determining the morality of human acts, John Paul II maintains

the primary and fundamental role that the Moral Object as rationally chosen by a deliberate will

plays in determining the morality of human acts.308 John Paul II also retains the existence of

intrinsically evil acts, a concept that teleological theorists eliminate.309 His defense of the Moral

Object and intrinsically evil acts sparks renewed interest in Aquinas’s understanding of action.310

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In this section, I explicate the object of the act in the context of Aquinas’s complex virtue

theory concerning action. Then, I demonstrate the erroneous understanding of the Moral Object

of the manualists and proportionalists. One implication of the Naturalistic Fallacy is that one

considers morality from the third-person perspective, rather than a first-person perspective. The

third subsection not only illustrates the deficiency of the third-person perspective, but elucidates

John Paul II’s restoration of the first-person perspective regarding the object in Veritatis

Splendor. The final subsection addresses the topic of contraception that is a sticking point for the

controversy regarding the Moral Object and intrinsically evil acts.

i. Aquinas’s Action Theory

In the following, I articulate Aquinas’s understanding of the Moral Object. First, I situate

his discussion in the context of the debate on the role of intentions in relationship to action

according to Peter Abelard and Peter Lombard. Then, I follow John Finnis’s interpretation of

Aquinas’s meticulous situating of intention within the person.311

a. Intrinsically Evil Acts

Servais Pinckaers, in “A Historical Perspective on Intrinsically Evil Acts,” articulates

Aquinas’s development of Peter Abelard and Peter Lombard’s use of intention vis-à-vis

intrinsically evil acts.312 Although intrinsece malum does not appear in expression before the

sixteenth century, the concept of deeds being evil in themselves originates in Scripture and

Augustine explicates it in his De mendacio and Contra mendacium ad consentium.313 Against the

legalism of his day that focuses merely on the external act or the desires to commit sin, Abelard

attempts a retrieval of Augustine’s morality rooted in reason and will.314 Abelard places the

source of evil solely in the intention of the agent; that is, his or her voluntary consent to a desire

or action.315 In other words, for Abelard, the evil of an action is neither in the desire to commit

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an evil act, nor in the performance of it, rather, it resides in the agent’s intention. Pinckaers

indicates that the main thrust of Abelard’s theory is positive, to reposition the focus of morality

on intention and consent, however, the downside is that it eliminates any consideration of

external action and desire for morality.316 Although this does not seem to be Abelard’s intention,

his theory, in principle, excludes the possibility of intrinsically evil acts.317

In distinction 40 of the second book of his Sentences, Peter Lombard addresses the

question of intention and its relationship to external acts.318 First, he restates Abelard’s position

that external works are neither good nor evil except insofar as an agent intents them as such.319

Then, Lombard presents the counter-position that some works are good or evil regardless of the

intention of the agent.320 Lombard offers a via media following Augustine’s direction in Contra

mendacium ad consentium.321 Augustine holds that some acts are good or evil depending on their

causa or reason, for instance a couple engaging in the marital act to conceive children, or to give

food to the poor.322 So long as one does these acts for a good reason, they are good; however,

should one do them for a bad reason, they are bad. For example, it is not good to give to the poor

in order to look good; this is vanity.323 However, for Augustine, some acts are evil in themselves:

theft, fornication, and blasphemy; and one may never do these even for a good reason.324 To

illustrate, Augustine forbids one to steal from the rich to feed the poor.325

b. Intention to Action

Arguably no one reflects deeper on the inner workings of the person concerning action

than Aquinas.326 Finnis indicates that many philosophers and theologians misunderstand his

action theory, which in turn, leads to erroneous implications.327 In Aquinas: Moral, Political and

Legal Theory (Founders of Modern Political and Social Thought), Finnis meticulously follows

Aquinas’s articulation of his action theory from the internal perspective, which comes from

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questions 11-20 of the Prima Secundae of the Summa Theologica.328 Understanding Aquinas’s

action theory is essential to understanding the Moral Object.

Just like the Church Fathers, Aquinas reorients ethics from a legalistic reduction of

external acts to its original purpose: virtue and beatitude.329 Moreover, like Abelard and

Lombard, intention has a central role. Intentions concern the movement of the will to ends.330 To

be sure, many ends may motivate or move people to act, but Aquinas denies any infinite

regresses, 331 insisting instead that the ultimate end for humanity is beatitude or contemplation of

the Divine Essence. 332 Regarding ends, Aquinas distinguishes between the order of intention and

the order of execution.333 What is first in the order of intention is last in the order of execution.334

Thus, some end inclines the will to execute action. The end begins by motivating to action and

concludes in execution. To illustrate, the experience of hunger and the past experience of

satisfaction by eating, may motivate one to eat this cantaloupe here and now. On the order of

intention, the satiation by eating constitutes an end. On the order of execution, the satiation of

one’s hunger by eating a cantaloupe constitutes the end, and the final achievement—fruitio.335

Aquinas’s action theory concerns all the intervening steps beginning with an end on the order of

intention and concluding with an action on the order of execution.

According to Finnis, for Aquinas, intention (intentio) and choice (electio) are the central

acts of the will.336 Properly speaking, choice concerns means for accomplishing ends, while

intention concerns ends.337 For example, if one intends to stay warm during the winter, one must

heat the house and different means exist by which one may choose to achieve the end of heating

one’s house: burning wood, electricity, or gas. The ability to conceive of means to achieve one’s

end is practical understanding (intellectus practicus).338 The ability to relate various benefits to

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each other and make a judgment about the value of one over another is practical reason (ratio

practica).339 Therefore, practical decision-making involves the will and intellect.

Rhonheimer understands Aquinas to assert that the intellect, which ordinarily acts

theoretically, perceiving and judging the world according to the speculative order of knowing,

acts in extension (extensio) during practical reasoning.340 One way of distinguishing theoretical

from practical is by the type of syllogism or mode of reasoning that one uses. Theoretical

syllogisms only lead to theoretical conclusions that do not entail action.341 For instance, one may

conclude that since one cat has four legs, all cats have four legs. Practical syllogisms, on the

other hand, consist of practical premises that give rise to conclusions of action.342 For

Rhonheimer, the practical syllogism is thinking that involves doing.343 For example, staying

warm constitutes a necessity for life; therefore, one must choose some means for achieving the

end of heating one’s house during the winter.

Finnis identifies choice as the central event for action, but several internal processes

involving both the intellect and the will lead up to and follow choice.344 Although each of these

functions may belong to a particular faculty of the soul—intellect or will—ultimately, it is the

person who acts.345 Thinking about the interesting proposals that the intellect offers is

deliberation.346 Sometimes this involves taking counsel (consilium) with oneself or others.347

After deliberating and taking counsel, one may determine that one option stands out as

better than the rest.348 In this case, one reaches a consensus and although assent belongs properly

to the intellect, Finnis says that one assents to the only eligible action.349 Put another way, since

one does not prefer one truly eligible option to another, one simply assents rather than

chooses.350 Aquinas also calls the assent of the will a sentence (sententia) or judgment

(iudicium).351 If, however, one concludes the process of thinking with several viable options,

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then one must make a final judgment (iudicum electionis) that does properly constitute a

choice.352

One commits to a final judgment as an action by the will choosing it.353 But choice is not

enough for action; one must actually command (imperium) the act, using (usus) one’s bodily

powers to physically actualize it.354 Finally, in the intellect one knows that the act is complete

(cogitio finis in actu) and through the will one experiences satisfaction in it (fruitio).355

c. External Act: Materia Circa Quam and Proximate End

For Aquinas, actions receive their species from ends.356 Joseph Pilsner holds that Aquinas

uses the relationship between form and matter in a substantial being to illustrate the analogous

relationship that ends have for action.357 This is particularly true because human actions cannot

exist without an end.358 Therefore, just as form gives shape to substantial beings, so ends give

form to action.359 Pilsner following Aquinas holds that acts of the will, itself a type of motion,

like all motions, are specified by their end.360 Distinct from natural motions, so-called active

principles do not determine the species of human acts.361 This is because humans are free, that is,

not limited by instinct.362 To illustrate, eyes can only see color by means of light; they cannot

hear or taste or feel, as such. Therefore, the active principle of seeing limits the function of eyes.

In contrast to humans, active principles limit animals to particular physical behaviors in response

to stimuli; however, because humans have a will and an intellect, they have a freedom regarding

decisions and actions that do not characterize other animals.

Pilsner identifies three distinct meanings for object in Aquinas. First, object consists of

that to which an action relates.363 This is what Rhonheimer calls the res aliena.364 Ralph

McInerny offers a more sophisticated definition: “that which the agent sets out to do, to effect,”

that is, the act itself.365 According to Pilsner and Rhonheimer, this limited understanding of

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object does not constitute the meaning of the Moral Object for Aquinas.366 Second, object means

a certain formal aspect that specifies a related action, habit or power.367 This notion of object has

reference to qualities and the senses, which Aquinas discusses in his Commentary on Aristotle’s

De Anima.368 Just as formal aspects of being correspond to the different senses, so formal aspects

of the good rationally composed by the intellect attract human agents through the will.369

Therefore, in this sense, the ratio constitutes the formal aspect of the object of human action.

Finally, but most importantly, the object constitutes the proximate end of action, as opposed to

the remote end.370 Working together, one may say that the remote end orders the specific act.

For example, one may steal—an evil proximate end—for the purpose of giving money to the

poor—a good remote end.371 However, for the act to be good, both the proximate end and the

remote end must be good.372 Both ends relate to intention, but the proximate end constitutes the

Moral Object, since it specifies the act, while the remote end acts as a circumstance of the act.373

In article 18 of the Prima Secundae of the Summa Theologica, Aquinas addresses the

sources of good or evil in action.374 He maintains that the goodness of an act depends on three

distinct sources: Moral Object, end, and circumstance.375 To demonstrate how the Moral Object

and the end affect the will, Aquinas uses the dichotomous terms of matter and form—analogous

to the hylomorphic sense376— in relationship to external and internal acts, and materia ex qua

and materia circa quam.377 The Moral Object determines the species of an act just as form

determines the species of natural things.378 The end configures the Moral Object, impacting the

species as well.379 However, John Abraham Makdisi indicates that the end does not replace the

Moral Object.380 The Moral Object is not the matter ‘of which’ (a thing is made) (materia ex

qua), but the matter ‘about which’ (something is done) (materia circa quam) giving act its

species like a form.381 In human acts, the intellect predicates good and evil Moral Objects in

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reference to reason.382 Good Moral Objects conform to practical reason because they have

suitable matter (materia debita) and evil Moral Objects do not conform to reason since they have

unsuitable matter (materia indebita).383

Aquinas insists that one consider the species of an act formally with regard to the end—

the object of the internal act—and materially with regard to the object of the external act—that

which is brought to bear.384 Regarding how ends impact species of acts, Aquinas makes an

important distinction between external (exterior) and internal (interior) acts of the will, each

having their own proper object: that which is brought to bear and the end, respectively.385 For

Sousa-Lara, internal acts pertain to intention and ends, while external acts concern the

choice/command and the Moral Object.386 This accords with Makdisi who indicates that the

interior act is the very act of willing, while the exterior act is a voluntary act that the will

commands.387 The end is formal because the agent chooses the Moral Object to attain it.

To illustrate, Aquinas says that he who steals that he may commit adultery is more an

adulterer than a thief.388 The object of the interior act of the will, also the remote end, is adultery,

which causes the agent to choose the Moral Object of theft. The end formally configures the

species of the act of theft, which constitutes his means for achieving the end of adultery.

The Moral Object may be indifferent, but the end must be morally good.389 Driving a car

is indifferent, but doing it to rob a bank is evil, while doing it to go to church is good. In action,

there is always an end (finis operantis) with a rational good (ratio boni) that the will intends,

otherwise nothing attracts the will to move.390 Therefore, it is possible to consider the morality of

the object of the internal act of the will, that is, the object of intention (end), separately from the

object of the external act of the will, which is the object of the choice (Moral Object).391

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Concerning the description of the order of practical reason from the subsection above,

intention is formal to choice, just as choice is formal to command.392 In his On Evil, Aquinas

asserts that exterior acts are part of the moral genus only insofar as they are voluntary, that is,

proceeding from the will.393 By separating content of the exterior act from its voluntariness, one

is left with the so-called materia ex qua of the human act.394 The will commands the materia ex

qua of the external act through the other faculties, constituting merely the act’s material

dimension.395 The choice is formal to the will’s command of the materia ex qua of the exterior

act.396 Moreover, insofar as the exterior act—materia ex qua—is devoid of voluntariness, it

receives its moral character solely from the choice.397

In addition to speaking about the interior and exterior acts, one may speak of their

respective objects as well. The will intends the object of the internal act of the will—the end,

while it chooses the object of the external act of the will, and as the previous paragraph

demonstrates, the former configures the latter like form to matter.398 Sousa-Lara understands

Aquinas to equate the object of the external act with the materia circa quam, the Moral Object,

and the proximate end.399 Aquinas identifies the object of the internal act with the remote end.400

Rhonheimer notes the confusion that identifying the object of the external act with the Moral

Object presents.401 He indicates that the object of the external act “is the external act as a good

understood and ordered by reason.”402 More precisely, the object of the exterior act is the matter

and circumstances understood and ordered by reason, which present it to the will as good.403

Therefore, Rhonheimer, following Aquinas, asserts that the Moral Object is the exterior act.404

Rhonheimer is not considering the external act as prescinded from its voluntariness, that is,

materia ex qua, but configured by reason materia circa quam.405 On the order of intention, the

external act is the Moral Object insofar as the intellect forms it and presents it as a proposal for

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action to the will.406 Moreover, the Moral Object has the character of an end insofar as intention

focuses on it.407 Thus it is also the proximate end. Since the interior act of the will is the very act

of willing,408 it is possible for Rhonheimer to call the Moral Object the object of the interior act

of the will.409 The intelligible proposal to take what does not belong to oneself—to steal—

constitutes the means by which the adulterer accomplishes his end. In its voluntariness, that is,

insofar as the will intends it as a choice, it constitutes an end, specifically a proximate end,

chosen as configured by and for an ulterior end—adultery.410 On the order of execution, the will

forms the goodness of the external act, which possesses a moral quality to the extent that one

wills it.411

Sousa-Lara notes that while Rhonheimer insists on introducing a new term to explain the

intelligible content of the external act—what he calls basic intentional content—the necessity for

this disappears if one understands the external act as both the object of choice (Moral Object)

and that which one commands.412 On the order of intention, reason configures the external act

and presents it to the will as a proposal, in which case it is materia circa quam, and the Moral

Object. On the order of execution, the will chooses and commands the external act. On the

order of intention, the moral goodness of the act comes from reason, whereas on the order of

execution, it comes from the will.413 As the will chooses and commands the external act, in the

interior act of the will, the will intends the ends.414

Having analyzed the concept of the Moral Object in the context of Aquinas’s action

theory, the following subsection highlight the importance of maintaining the unique origin of the

Moral Object in the moral order.

ii. Naturalistic Fallacy

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a. Genus Moris Versus Genus Naturae

Finnis notes that Aquinas presents in his prologue to his commentary on Aristotle’s

Politics four distinct orders that correspond to four distinct sciences.415 First, there is the natural

order that corresponds to the natural sciences, math and metaphysics.416 Second, the order of the

mind pertains to the science of logic.417 Third, the order of deliberating, choosing and acting

pertains to the science of moral philosophy.418 Finally, a multitude of practical arts corresponds

to an order that humans impose on external matter.419 The latter two categories constitute two

distinct parts of the practical philosophy.420 Many interpreters of Aquinas mistakenly believe that

moral laws derive from laws of nature.421

In point of fact, however, Finnis insists that misappropriating human actions as any of the

other three categories leads to its misunderstanding.422 Rhonheimer holds that the fundamental

error of consequentialism is that it reduces morality to poiesis, technical decision making.423 In

consequentialism, rather than answering what the right choices one should be doing, one uses

reason to bring about through action as a cause the best possible consequences. Finnis says that

this amounts to reducing a question of doing to one of making.424 In this sense, the concern of the

consequentialist is bringing about states of affairs through action.425 Consequentialism derails

moral decision making from its primary focus of freely choosing good act.426 Instead, human

action focuses on how to create the best outcome by action.427 The right action for choice is

relative. There is little concern about the goodness of the will regarding choices.

Finnis acknowledges that one may approach ethics from a speculative or theoretical

perspective; that is, one may analyze how one comes to know practical truths, discuss and relate

these to other truths, but ethics is primarily about practical truth.428 Ethics is practical not merely

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because it is the study of human praxis, but because it concerns one’s acting on real and true

goods.429 The Naturalistic Fallacy holds that the practicality of ethics derives from the physical;

contending that the genus moris derives from the genus naturae.430 Rhonheimer calls this error

physicalism or naturalism.431 It presumes that Natural Law and laws of nature are the same.432 It

constitutes the primary error of manualists and the teleological theorists who oppose them.433 For

Rhonheimer, they mistakenly believe that one discovers moral truths; when reason constitutes

them as acts of practical understanding.434

b. Manualism and Proportionalism

In The Sources of Christian Ethics, Servais Pinckaers describes the characteristics of

manualism.435 The modern period of moral theology begins with the nominalism of Ockham,

which focuses morality on obligation and the ideal law.436 A chasm develops between theology

and pastoral concerns, which necessitates the development of manuals to guide parochial priests

in confession.437 This corresponds with the counter-reformation and the formation of seminaries

as institutions for preparing priests to minister in an increasingly pluralistic world.438 Under the

influence of the Jesuits, the focus of moral theology becomes increasing pragmatic. They

eliminate speculative content, such as the final end of man and grace altogether, emphasizing the

commandments, sacraments, canonical censures and penalties, and states of life.439 The manuals

use cases that illustrate concretely how to apply the commandments and moral obligations. The

entire attention of morality theology focuses on individual cases of conscience.440

The manuals generally have four different categories: human or free action, law,

conscience and sin.441 Freedom is freedom of indifference with voluntaristic overtones that

contrast with the limits of the law.442 In this sense, law does not incorporate one’s natural

inclinations or direct one toward beatitude; rather, it simply constitutes an externally imposed

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mandate.443 The law becomes an external imposition that obliges, but as G. E. M. Anscombe

indicates in Intention, ought is a late addition to the practical syllogism.444 Casuistically, the

conscience represents the person’s use of freedom of indifference to conform external acts to

externally imposed laws.445 One sins when one fails to use one’s freedom to adequately apply

laws in concrete action.446

Just as Abelard and Lombard respond to contemporary legalism, proportionalists such as

Peter Knauer,447 Josef Fuchs,448 Louis Janssens,449 Bruno Schuller,450 and Richard McCormick451

respond to the legalism of the manualist tradition. However, as Rhonheimer indicates, their

rejection of manual legalism, rooted in physicalism, amounts to letting the Naturalistic Fallacy in

through the back door.452 To illustrate, one need look no further than the first article that

introduces the term proportionalism, that is, Peter Knauer’s “The Hermeneutic Function of the

Principle of Double Effect,” where he says that moral evil consists in nothing more than causing

physical evil.453 Using the Principle of Double Effect, Knauer argues that so long as a

commensurate reason exists one may do any action.454 So long as the ends justify the means, one

may commit any finis operis, which he identifies as the Moral Object.455 In fact, if the ends are

satisfactory, then the commensurate reason changes the finis operis from a direct causing of evil

to an indirect causing of evil.456 This is exactly what Richard McCormick means by the

expanded notion of the object.457

Louis Janssens, in “Ontic Evil and Moral Evil,” reduces moral evil to intending ontic

evils, that is, physical evil.458 He reduces the means (Moral Object) to the material component of

the act.459 In Thomistic terms, he reduces the Moral Object to the external act prescinded from its

voluntariness, that is, materia ex qua.460 Consequently, Janssens falls victim to the same flaw

that Rhonheimer accuses Josef Fuch of: reducing acts to pure events or behavior.461 According to

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Rhonheimer, proportionalists reduce acting to intending failing to realize that acts themselves

have intentional content.462 In other words, action for proportionalists involves causing the

purely physical act or event for an end, which constitutes a state of affairs.463 For this reason,

opponents accuse proportionalists of being consequentialists.

The main problem with the proportionalists’ approach to theology is that it evacuates

reason from the intentional content of the Moral Object.464 Moreover, by making the genus moris

derivative of the genus naturae, it establishes a dualism.465 Rhonheimer contends that the proper

good (bona propria) toward which the natural inclinations tend are of the genus naturae, but not

pre-moral in the sense that they are indifferent to the genus moris.466 Rather, for Rhonheimer,

natural, human inclinations are always subject to the influence of practical reason insofar as this

is a constitutive component of the human person.467 Once again, Rhonheimer affirms that for

Aquinas, the Moral Object is not a matter out of which (materia ex qua), but a matter concerning

which (materia circa quam).468 The Moral Object is the external act formed by reason and

chosen by the will.469

An important implication of not deriving the genus moris from the genus naturae is that

the Moral Object can only be known from the first-person perspective, which the next subsection

discusses.

iii: Moral Object and the Perspective of the Acting Person

Manualism is casuistic, using cases to teach. Unfortunately, the perspective of the acting

person, which John Paul II reaffirms as of primary importance for moral theology, is lost.470 In

fact, one can only know the Moral Object from the first-person perspective.471 This subsection

addresses the deficiency of the third-person perspective of morality of the manualists and

teleological theorists. First, following Finnis and Rhonheimer, I show how the naturalistic fallacy

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reduces action and choice to events, devoid of intentional content. Second, I articulate Finnis’s

demonstration of the irrationality of a proportionalist utilizing the Socratic Principle. Finally, I

summarize John Paul II’s personalistic perspective to morality, which avoids the relativistic

pitfalls of proportionalism.

a. Avoiding Eventism

As morality during the manualist era focuses more on obligation, so theologians

increasingly define the object of the act in terms of the genus naturae. As the above

demonstrates, this corresponds to a dualism that renders action indifferent to natural inclination.

At the same time, as Rhonheimer points out, it makes objects of the genus moris derivative of the

genus naturae, which constitutes the Naturalistic Fallacy.472 Ultimately, this culminates in the

proportionalists equating the object with causing evil in the world, without commensurate

reason.473 Consequently, human acts are nothing more than events that give rise to states of

affairs.474 Finnis indicates that the proportionalists attempt to guide choice by assessing states of

affairs from a so-called objective standpoint; as such, they are guilty of eventism.475 Ultimately,

this renders choice insignificant, since it can only be known from the first-person perspective.476

In fact, a consequence of an eventistic perspective for morality is that it reduces the

Moral Object to intention.477 According to an eventistic approach all acts in themselves lack

moral content. The only thing that morally specifies them is their reason for acting, that is, the

end or intention.478 Rhonheimer explains that the act of killing another person, according to an

eventistic perspective, lacks moral content, except for the intention or end that one has in view of

killing the person.479 Thus, if the commensurate reason suffices, one may kill another person.

For Rhonheimer, what is missing in this assessment is the intentional content that exists

in doing an act, prior to any consideration of the end, that is, why or for what purpose one is

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doing this act.480 The intelligible content of ‘the what one is doing’ constitutes the Moral Object.

This explains what one is choosing in doing a particular act. For example, in the act of killing

another person, one is setting oneself against the other’s life—a fundamental good of that

person.481 The act of killing another is, therefore, not inherently morally neutral as an earthquake,

but intentionally and morally charged, even before one considers the ulterior end of action.482

Moreover, one can only know the Moral Object from the perspective of the acting person. Only

the acting person knows if she intends to kill the other person or is practicing self-defense.

Similarly, the outside observer cannot tell if a man and a woman copulating are committing

adultery or engaging in the marital act.

b. The Socratic Principle

Finnis and Rhonheimer reject the third-person perspective of morality because it does not

pass the test of the Socratic Principle.483 The Socratic Principle, which hold that it is better to

suffer wrong than to do it originates with Democritus.484 The Pauline Principle, ‘evil may not be

done for the sake of good,’ is a corollary.485 Kant’s categorical imperative that ends do not justify

the means also derives from this.486 The author of the Gospel of John also raises this question by

placing it into the mouth of Caiaphas: “Is it not better that one innocent person be put to death

than that the whole people perish?”487 For both John and Paul, the answer is clearly no.488 For

Rhonheimer and Finnis, proportionalists clearly teach that one may indeed do evil that good may

result, so long as the ends justify the means.489

For Finnis the biggest difference between a proportionalists and a non-proportionalist is

that the right choice resides in the outcome of action.490 Finnis illustrates the irrationality of

proportionalism by demonstrating a contradiction that all eventistic ethics are subject to. Finnis

offers two apparently similar propositions:

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(1) It is true that every person x that x should act on the principle that ‘I ought not to do V.’

(2) It is true of every person x that x not doing V is a proportionately better state of affairs

than x doing V.491

Finnis reformulates (1) to include the Socratic Principle: “(1a) It is true of every person x that x

should act on the principle that ‘I ought to suffer wrong rather than do wrong.”492 Consequently,

“(2a) It is true of every person x that x suffering wrong is a proportionately better state of affairs

than x doing wrong.”493 However, Finnis demonstrates that (2a) contains a contradiction insofar

as it implies that “(2b) It is true of any person x, y, z that x suffering wrong from y is a better state

of affairs than x doing wrong to z.”494 In addition, one can derive: “(2c) a suffering wrong from b

is a better state of affairs than a doing wrong to b” and “(2d) b suffering wrong from a is a better

state of affairs than b doing wrong to a.”495 These radical contradictions are possible in an

eventistic ethic because the acting subject disappears.496

Rhonheimer explains that the implication of the Socratic Principle is that one cannot

simply compare two separate individuals to determine which action is correct.497 Sometimes the

right action is to abstain from acting. To illustrate, Rhonheimer uses the extreme example of the

French Nazi collaborator Paul Touvier who claims that he killed seven innocent people to rescue

93 innocent people.498 According to Rhonheimer and Finnis, nothing—no matter how good the

ends—justifies one willing the death of innocent people. Another example includes the scenario

of an assailant coercing a hostage to kill another hostage, lest the attacker kill all the hostages. In

an eventistic ethic one simply weighs the consequences, without any consideration of the

morality of choosing the death of an innocent person. For a non-proportionalist, it is better to

suffer the evil of another person’s decision, than to commit evil so as to prevent it. Of course,

this example has the mistaken logic that one person’s decision to abstain from an evil act causes

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an even greater evil state of affairs. In fact, the assailant freely chooses to murder the innocent

hostages. The hostage does not commit a greater evil, by failing to commit an evil that

purportedly rescues others from death. After all, there is nothing that prevents the assailant from

violating his word and killing the other hostages anyway.

c. Personalism in Veritatis Splendor

In Veritatis Splendor, John Paul II affirms the traditional personalistic perspective of

morality that characterizes authentic Thomistic moral theology.499 This is not to say that he

embraces a relativistic approach to morality, which he clearly rejects.500 Nor does it mean

denying its objective and universal application.501 It is, however, to say that the Natural Law,

which governs morality, is not extrinsic to the human person, but constitutive of it.502 In other

words, God does not arbitrarily dictate commands that have nothing to do with the human

condition. Rather, the Natural Law, reflective of the eternal and divine law, abides in the human

person through creation.503 It is precisely its connection to the eternal and divine that renders it

universal.504

In action, the Natural Law manifests itself as practical reason, which guides, but does not

determine the truly autonomous person in moral decision making.505 John Paul II avoids the

trappings of reducing moral decision making to biological processes; rather, he insists that

humans are truly free, though not in an absolute sense that treats human nature as raw datum.506

Thus, he avoids the trappings of dualism that reduces the human person to either the bodily or

spiritual component.507 Rather, the human person constitutes a unity of both body and soul,

reducible to neither.508 By rooting morality in the human person, John Paul II, not only avoids

conflicts between nature and freedom, which a dualistic understanding of human nature lends

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itself to, he also further establishes its universal and immutable character.509 This is what

provides the foundation for moral norms that transcend culture or time.510

For John Paul II, the voice of reason speaks within the depth of one’s heart on practical

matters through one’s conscience.511 While norms both negative and positive may be universal

and immutable, the human person must still apply these in concrete actions.512 In this regard, the

personal perspective for morality is invaluable and primary, not because one decides what is

good to do in an absolute sense, but because one appropriates the truth in action by means of

one’s conscience.513 Therefore, the conscience stands as a witness to the law and constitutes a

dialogue between the person and God.514

In opposition to proportionalists and teleological theorists, in general, John Paul II both

rejects the fundamental option and reaffirms the existence of intrinsically evil acts, which

meeting the appropriate criteria constitute mortal sin.515 John Paul II concurs that one may

fundamentally orient one’s life toward God, but this does not mean that one’s concrete actions do

not matter, nor that they have little to no impact on one’s commitment to God.516 It is precisely

through one’s acts that one reveals one’s commitment.517 Separating concrete acts from one’s

fundamental orientation represents a dualism rooted in human nature.518 Therefore, following the

longstanding teaching of the Church, John Paul II reaffirms that mortal sin is possible, when

one’s act constitutes grave matter; one has full knowledge, and gives deliberate consent of the

will.519 Indeed, for John Paul II, an appropriate teleology regarding morality understands the

human person as attaining one’s ultimate end through concrete acts.520

Ultimately, John Paul II takes issue with teleological theorists—consequentialists and

proportionalists—for their rejection of the traditional understanding of the Moral Object.521 The

next subsection illustrates how proportionalists conceive of the Moral Object as intention.522 As

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Rhonheimer illustrates in the above subsection, proportionalists evacuate the Moral Object of its

own intentional content.523 They make the Moral Object equivalent to intention—hence the

identification as teleologists—while Thomists, such as Finnis, Rhonheimer, and John Paul II

defend a notion of the Moral Object as having an intentional content of its own.524 John Paul II

retains the traditional distinction regarding the three sources of morality—Moral Object,

intention, and circumstances—of which Moral Object is primary.525

John Paul II defines the Moral Object as that which the will deliberately and rationally

chooses.526 The human person, through a deliberate act of the will, chooses a rationally

configured type of behavior.527 The person constitutes the active agent; as such, one can only

know the Moral Object from the perspective of the acting human person.528 The intellect

rationally configures it, which the will deliberately intends, bestowing moral content upon the

so-called behavior.529 Insofar as certain types of rationally configured behavior conform or fail to

conform to the suppositum of human nature, that is, truly lead to one’s ultimate end—good or

evil—intrinsically evil acts do exist.530 As such, each particular human act—freely and

deliberately chosen—not only builds character—either contributing to growth in virtue or vice—

but also draws the acting human person closer to one’s ultimate end. Moreover, the primacy of

the Moral Object means that no intention or circumstance can change the Moral Object, making

an intrinsically evil act good.531

In reaffirming the primacy of the Moral Object, John Paul II also demonstrates the

importance of returning to the perspective of the acting human person when evaluating action. At

the same time, he rejects any tendency to relativize morality, by rooting the Natural Law in the

divine law, which God bestows on humanity in creation. Moreover, he understands the human

person as a composite that avoids the dualistic trappings of teleological theories. Above all, he

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re-establishes the primary role of the Moral Object for morality. Insofar as this constitutes a

rationally configured type of behavior, which the will deliberately chooses, it manifests itself in

particular acts that have teleological import regarding an one’s ultimate end.

Having demonstrated the importance of the first-person perspective for Moral Object, the

next subsection identifies the Moral Object of contraception.

iv. Object of Contraception

The meaning of the Moral Object centers on the debate as to whether or not contraception

is an intrinsically evil act. John Paul II reorients the understanding and significance of the Moral

Object as the deliberate act of the will in Veritatis Splendor.532 Before this encyclical,

theologians arrive at differing conclusions based on their divergent understandings of the Moral

Object. The following subsection considers the perspectives of the manualists, proportionalists

and virtue ethicists, especially Rhonheimer concerning the topic of contraception.

a. Manualism

John T. Noonan Jr. in Contraception: A History of Its Treatment by the Catholic

Theologians and Canonists traces the historical approach of theologians throughout the centuries

of the Church regarding their treatment of the pastoral issue of contraception.533 As Pinckaers

indicates, the manuals are tools for pastoral formation of priests in seminary.534 Consequently,

the focus is physical and external. Regarding the variety of manual authors, Noonan follows the

perspective of four: John Gury’s Compendium of Moral Theology,535 Thomas Gousset’s

Justification de la theologie morale de St. Alphonse de Liguori,536 John Baptist Bouvier’s

Dissertation on the Sixth Commandment of the Decalogue and Supplement to the Treatise on

Marriage,537 and Francis P. Kenrick’s Theologia moralis.538

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Noonan indicates that manual authors eliminate recourse to Augustine in favor of the

more tolerant Liguori to extinguish the Jansenist influence.539 They equate contraception with

Onanism or coitus interruptus, that is, the act of withdrawing the penis and ejaculating

extravaginally.540 Rome’s approach to contraception in the nineteenth century is surprisingly

tolerant, encouraging priests “not to destroy the good faith without any fruit for souls,” that is,

not to mention the issue if it is not brought up, but to speak the truth if nonetheless pressed.541

Equating contraception with Onanism makes it odious and ugly, and a quick, yet superficial

rejection.542 Of the four manuals that Noonan analyzes, only Bouvier’s has an argument against

contraception that does not merely constitute a rejection of Onanism.543 Although he argues that

contraception violates the primary end of marriage, procreation, he nonetheless contends that the

punishment is due to its equivalence with Onanism.544

As the birth control movement spreads in the Western world during the late nineteenth

and early twentieth century, the need for a more sophisticated, if not nuanced approach to the

onslaught becomes apparent. Short and sweet arguments with recourse to Old Testament

retributive justice—divine or not—no longer suffice. For this reason, Pope Pius XI writes Casti

Cannubii, an encyclical that addresses the nature of marriage and modern threats to it.545 Pius XI

after articulating the three ends of marriage according to Augustine, condemns the practice of

frustrating the marital act to avoid having children, but nonetheless intending to gratify desires

without the so-called consequent burden of having children.546 He unequivocally condemns as

unnatural, intrinsically vicious, and gravely evil any contraceptive act, which is disruptive of the

primary end of the marital act of begetting children.547 He admits of no exception to this rule, the

violation of which constitutes an intrinsically evil act.548

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b. Proportionalism

Proportionalists offer a nuanced approach to contraception, one that allows for exceptions

to the exceptionless. Knauer’s argument, which has recourse to the Principle of Double Effect,

rejects too narrow an understanding of Pius XI’s pronouncement in Casti Cannubii, which he

perceives as ambiguous.549 It is ambiguous for Knauer because it does not specify whether one’s

intention to physically interfere with the fertility of the procreative act is psychological or

moral.550 He indicates that the purely physical evil of losing procreative power does not

constitute a moral evil, without further content, in particular, intention in the moral sense.551

Recall that Knauer’s definition of moral evil constitutes the causing of a physical evil

without a commensurate reason.552 He insists that without intentional content in the moral sense,

the act of preventing pregnancy does not yet constitute the Moral Object; therefore, it is

impossible to make a moral assessment of it.553 It must have a commensurate reason.554 Insofar

as one can use periodic continence for an evil end of preventing children, Knauer sees no

difference between using periodic continence or contraception either for good or immoral

reasons.555 For Knauer, if periodic continence is not realistic for preventing pregnancy, where a

couple ought not to get pregnant, for a commensurate reason, such as, a lack of resources for

fulfilling the responsibilities of parenthood in education and rearing, then a couple may use

contraception.556 Moreover, if utilizing contraception, instead of periodic continence, improves

the love between the couple, then they ought to use it.557

c. Rhonheimer

In 1968, Paul VI publishes Humanae Vitae, reaffirming the Church’s condemnation of

contraception.558 Paul VI bases his rejection of contraception on the Inseparability Principle,

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which constitutes the notion that the procreative and unitive dimension of the marital act are

inseparable.559 One cannot have one without the other; if one denies or violates the procreative

dimension of the marital act, then one also denies or violates the unitive dimension.560 Insofar as

contraception interrupts the procreative significance of the marital act, it also interrupts the

unitive significance.561 Moreover, Paul VI rejects any argument that attempts to justify the use of

contraception based on either its means or end, reaffirming the truth of the Socratic Principle: “it

is never lawful, even for the gravest reasons, to do evil that good may come of it.”562

Rhonheimer argues that the Moral Object of the contraceptive act violates chastity,

rooted in the Inseparability Principle.563 He bases his argument in anthropology, that is, human

nature.564 Human acts are always of a human person, which constitutes both a body and spirit.565

Rhonheimer rejects any dualistic anthropology that separates acts of the body from the soul.566

Dualists usually equate the soul with the person and relegate the body to mechanistic

determinism.567 For Rhonheimer, freedom is a constitutive part of the human act of love, which

the marital act speaks as the language of the body.568

Rhonheimer defends Paul VI’s teaching on the Inseparability Principle, making an

important distinction between meaning and function.569 To say that every instance of the marital

act must have the procreative and unitive meaning, or the procreative to have the unitive and visa

versa, is not to say that each and every act must be functionally procreative, that is giving rise to

conception.570 For this reason, a couple practicing periodic continence respects and maintains the

openness to the procreative meaning, even if they know or expect the act not to functionally lead

to conception. The same may be said of a couple that is unable to conceive because of age or

sterility. Rhonheimer accuses Noonan of misunderstanding this conceptual distinction, which

leads Noonan to make room for exceptions.571

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For Rhonheimer, the Moral Object concerns choices pertaining to action, which the will

deliberately chooses.572 In particular, the Moral Object constitutes what one does in an

intentional sense.573 For this reason, Rhonheimer, following Aquinas, understands the Moral

Object to be formae a ratione conceptae—a form of a rational concept, that is, a proposal that

the intellect forms according to reason and presents to the will as a choice.574 Therefore, for

Rhonheimer the description with intentional content, that is, the Moral Object of the marital act

is: for a married couple to give themselves with their whole spiritual, affective, emotional, and

sexual being to loving union, which physically manifests itself in copulation.575 Intentionally,

this includes openness to the meaning, not necessarily, function of procreation.576 Moreover,

conceptually, the ends of marriage are unique to the Moral Object of the conjugal act. However,

in the object of the marital act, the aspect of loving union is the fundamental aspect, which

implies the procreative meaning, not in a secondary way, but as inseparably connected.577

For Rhonheimer, recourse to the Inseparability Principle does not suffice to answer why

one may not utilize contraception in a particular instance, if as the proportionalists say one is

fundamentally open to life.578 To explain why each and every instantiation of the marital act

must be open to the procreative meaning, Rhonheimer correlates responsible parenthood to

chastity, that is, the virtuous integration of sexual drives into the dominion of reason and will.579

This is not a matter of repelling or suppressing sensual appetites, rather it means impressing or

modifying them with the seal of reason.580 For Rhonheimer, responsible parents practicing

periodic continence to avoid conception do not just commit an act of omission by avoiding

sexual intercourse during fertile times, but commit a deliberate human act; and therefore, bodily

and sexual act of loving union that is open to procreation.581 Though their act of refrain does not

entail sexual intercourse, it nonetheless is sexual and a personal expression of mutual love.

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In contrast to periodic continence, contraception enables a couple to avoid pregnancy

without modifying sexual behavior.582 More precisely, contraception constitutes choosing an act

that impedes the possible procreative consequences of the sexual act.583 For Rhonheimer,

contraceptive acts are immoral not merely because they physically impede the possibility of

procreation, but because they render “needless a specific sexual behavior informed by

procreative responsibility.”584 Moreover, it constitutes a choice against chastity, insofar as they

are no longer procreative and need to be under the domain of reason and the will.585 Therefore,

the Moral Object of contraception constitutes a vice against the virtue of chastity.586

Having demonstrated the impact that a personalistic conception of both the Natural Law

and the Moral Object have for the Catholic Church’s official teaching against contraception, the

following chapter connects this chapter’s insights on the Moral Object to the Principle of Double

Effect.

1 Thomas Aquinas, The Summa Theologica, (Chicago: Benzinger Brothers, 1947),

http://dhspriory.org/thomas/summa/index.html, I-II, q. 90, a. 1. 2 Martin Rhonheimer, Natural Law and Practical Reason: A Thomistic View of Moral Autonomy,

trans. Gerald Malsbary, (New York City: Fordham, 2000), 58-61. 3 Rhonheimer, Natural Law and Practical Reason, 61. 4 Rhonheimer, Natural Law and Practical Reason, 61. 5 Rhonheimer, Natural Law and Practical Reason, 59. 6 Rhonheimer, Natural Law and Practical Reason, 58-61. 7 Rhonheimer, Natural Law and Practical Reason, 58-61. 8 Rhonheimer, Natural Law and Practical Reason, 60-1. 9 Aquinas, Summa Theologica, I-II, q. 90-94. 10 Aquinas, Summa Theologica, I-II, q. 90, a. 1, r. 11 Aquinas, Summa Theologica, I-II, q. 90, a. 1, r. 12 Aquinas, Summa Theologica, I-II, q. 90, a. 1, r. 13 Aquinas, Summa Theologica, I-II, q. 90, a. 1, r.; Aquinas, Summa Theologica, I-II, q. 1, a. 1, r. 14 Rhonheimer, Natural Law and Practical Reason; Aquinas, Summa Theologica, I-II, q. 90, a. 4,

ad. 2. 15 Rhonheimer, Natural Law and Practical Reason, 62. 16 Rhonheimer, Natural Law and Practical Reason, 62; Aquinas, Summa Theologica, I-II, q. 92,

a. 1. 17 Rhonheimer, Natural Law and Practical Reason, 63.


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18 Rhonheimer, Natural Law and Practical Reason, 63. 19 Rhonheimer, Natural Law and Practical Reason, 63; Aquinas, Summa Theologica, I-II, q. 94,

a. 1. 20 Rhonheimer, Natural Law and Practical Reason, 64. 21 Aquinas, Summa Theologica, I-II, q. 90, a. 1, r. 22 Aquinas, Summa Theologica, I-II, q. 90, a. 1, reply 1. 23 Aquinas, Summa Theologica, I-II, q. 90, a. 1, reply 1; q. 91, a. 2, r. 24 Rhonheimer, Natural Law and Practical Reason, 61; Aquinas, Summa Theologica, I-II, q. 94,

a. 1; I-II, q. 91, a. 2, ad 2. 25 Rhonheimer, Natural Law and Practical Reason, 61; Aquinas, Summa Theologica, I-II, q. 91,

a. 2, ad. 2. 26 Aquinas, Summa Theologica, I-II, q. 90, a. 2, r. 27 Aquinas, Summa Theologica, I-II, q. 90, a. 2, r. 28 Aquinas, Summa Theologica, I-II, q. 90, a. 2, r, reply 2. 29 Aquinas, Summa Theologica, I-II, q. 90, a. 3-4. 30 Aquinas, Summa Theologica, I-II, q. 90, a. 3, r. 31 Aquinas, Summa Theologica, I-II, q. 90, a. 4, r. 32 Aquinas, Summa Theologica, I-II, q. 91, a. 2, r. 33 Aquinas, Summa Theologica, I-II, q. 91, a. 1, r. 34 Aquinas, Summa Theologica, I-II, q. 91, a. 1, reply 3. 35 Aquinas, Summa Theologica, I-II, q. 91, a. 1, reply 1. 36 Aquinas, Summa Theologica, I-II, q. 90, a. 2, r. 37 Aquinas, Summa Theologica, I-II, q. 90, a. 2, r. 38 John Finnis, Natural Law and Natural Rights, 2nd edition, (Oxford: Oxford, 2011), 398-403. 39 Finnis, Natural Law and Natural Rights, 399. 40 Finnis, Natural Law and Natural Rights, 399. 41 Finnis, Natural Law and Natural Rights, 400; Aquinas, Summa Theologica, I, q. 79, a. 4c. 42 Finnis, Natural Law and Natural Rights, 400; Thomas Aquinas, Summa Contra Gentiles,

trans. Vernon J. Bourke, (New York: Hanover House, 1956), Book III, q. 53.

https://dhspriory.org/thomas/ContraGentiles3a.htm#53 43 Finnis, Natural Law and Natural Rights, 398-403. 44 Aquinas, Summa Theologica, I-II, q. 94, a. 2, answer. 45 Germain Grisez, The Way of the Lord Jesus: Christian Moral Principles, Vol. 1, (Chicago:

Franciscan Herald Press, 1983), available online http://twotlj.org/G-1-7-C.html, Ch. 7, Q. C, 4. 46 R. A. Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, (The

Hague: Martinus Nijhoff, 1966), 28ff. 47 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 28. 48 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 28-9. 49 Kevin L. Flannery, Acts Amid Precepts: The Aristotelian Logical Structure of Thomas

Aquinas’s Moral Theory, (Washington D. C.: Catholic University of America, 2001), 41ff. 50 Flannery, Acts Amid Precepts, 39-42. 51 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 28-30. 52 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 29. 53 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 29-30. 54 See also Finnis, Natural Laws and Natural Rights, 32, footnote 27, 34, 65, 77, 401, footnote

80; Rhonheimer, The Perspective of Morality, 116.

https://dhspriory.org/thomas/ContraGentiles3a.htm#53

http://twotlj.org/G-1-7-C.html

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55 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 30; Finnis,

Natural Laws and Natural Rights, 32, footnote 27; Aquinas, Summa Theologica, I-II, q. 94, a. 2c,

q. 66, a. 5 and 4, I, q. 79, a. 2c; Aquinas, De Veritate, q. 16, a. 1c. 56 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 32; Thomas

Aquinas, Questiones Disputatae de Veritate: Questions 10-20, trans. James V. McGlynn,

(Chicago: Henry Regnery Company, 1952), http://dhspriory.org/thomas/QDdeVer16.htm, q. 16,

a. 2. 57 Aquinas, De Veritate, q. 16, a. 2, reply. 58 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 35. 59 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 35;

Aquinas, Summa Theologica, I-II, q. 94, a. 2. 60 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 35;

Flannery, Acts Amid Precepts, 31ff. 61 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 35. 62 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 35. 63 Germain Grisez, “The First Principles of Practical Reason: A Commentary on the Summa

theologiae, 1-2, Question 94, Article 2,” Natural Law Forum 10 (1965): 173 (168-201) 64 Grisez, “The First Principles of Practical Reason,” 173. 65 Grisez, “The First Principles of Practical Reason,” 174. 66 Grisez, “The First Principles of Practical Reason,” 174. 67 Grisez, “The First Principles of Practical Reason,” 174. 68 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 36. 69 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 37;

Aquinas, Summa Theologica, I-II, q. 94, a. 2, r. 70 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 37. 71 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 39. 72 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 40. 73 Finnis, Natural Laws and Natural Rights, 378-88. 74 Finnis, Natural Laws and Natural Rights, 384. 75 Finnis, Natural Laws and Natural Rights, 386-7. 76 Finnis, Natural Laws and Natural Rights, 387. 77 Finnis, Natural Law and Natural Rights, 70. 78 Finnis, Natural Law and Natural Rights, 69. 79 Finnis, Natural Law and Natural Rights, 69. 80 Finnis, Natural Law and Natural Rights, 69. 81 Finnis, Natural Law and Natural Rights, 69. 82 Finnis, Natural Law and Natural Rights, 71-2. 83 Martin Rhonheimer, The Perspective of Morality: Philosophical Foundations of Thomistic

Virtue Ethics, (Washington D. C.: Catholic University of America, 2011), 95-101. 84 Rhonheimer, The Perspective of Morality, 95-7. 85 Rhonheimer, The Perspective of Morality, 100; Augustine, Commentary on the Gospel of

John, 3.20. 86 Rhonheimer, The Perspective of Morality, 100. 87 Rhonheimer, The Perspective of Morality, 99. 88 Rhonheimer, The Perspective of Morality, 99. 89 Rhonheimer, The Perspective of Morality, 99.

97

90 Rhonheimer, The Perspective of Morality, 115. 91 Rhonheimer, The Perspective of Morality, 101-115. 92 Rhonheimer, The Perspective of Morality, 162. 93 Rhonheimer, The Perspective of Morality, 162. 94 Rhonheimer, The Perspective of Morality, 146; Aquinas, Summa Theologica, q. 18, a. 5; q. 71,

a. 2. 95 Rhonheimer, The Perspective of Morality, 146; Aquinas, Summa Theologica, q. 18, a. 5; q. 71,

a. 2. 96 Rhonheimer, The Perspective of Morality, 68. 97 Rhonheimer, The Perspective of Morality, 65. 98 Rhonheimer, The Perspective of Morality, 65-68. 99 Rhonheimer, The Perspective of Morality, 67-8. 100 Rhonheimer, The Perspective of Morality, 73. 101 Rhonheimer, The Perspective of Morality, 73-4; Aristotle, “Nicomacean Ethics,” in The

Complete Works of Aristotle, Volume 1: The Revised Oxford Translation, ed. Jonathan Barnes,

trans. W. D. Ross, revised by J. O. Urmson (Princeton: Princeton, 1984), Book 10. 102 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 44;

Aquinas, Summa Theologica, I, q. 59, a. 1. 103 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 44;

Aquinas, Summa Theologica, I, q. 59, a. 1. 104 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 45;

Aquinas, Summa Theologica, I, q. 59, a. 1. 105 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 44-5;

Aquinas, Summa Theologica, I, q. 59, a. 1, reply 1. 106 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 44. 107 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 44. 108 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 45. 109 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 45;

Aquinas, De Veritate, q. 25, a. 1. 110 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 46;

Aquinas, De Veritate, q. 22, a. 1-2. 111 Rhonheimer, The Perspective of Morality, 146; following Aquinas, Summa Theologica, I-II,

q. 18, a. 5; q. 71, a. 2. 112 Aristotle, “Nicomachean Ethics,” 1735. 113 Rhonheimer, The Perspective of Morality, 162. 114 Rhonheimer, The Perspective of Morality, 163; Aquinas, Summa Theologica, I-II, q. 59, a. 4. 115 Grisez, “The First Principle of Practical Reason,” 171. 116 Grisez, “The First Principles of Practical Reason,” 181. 117 Grisez, “The First Principles of Practical Reason,” 181; Martin Rhonheimer, “Practical

Reason and the ‘Naturally Rational’: On the Doctrine of the Natural Law as a Principle of Praxis

in Thomas Aquinas,” in The Perspective of the Acting Person: Essays in the Renewal of

Thomistic Moral Philosophy, ed. William F. Murphy, Jr. (Washington D.C.: Catholic University

of America, 2009), 95. (95-128) 118 Grisez, “The First Principles of Practical Reason,” 181. 119 Grisez, “The First Principles of Practical Reason,” 181. 120 Rhonheimer, The Perspective of Morality, 164.

98

121 Rhonheimer, The Perspective of Morality, 164-6. 122 Rhonheimer, The Perspective of Morality, 165; Aristotle, De Anima, 10 (433a27-28). 123 Rhonheimer, The Perspective of Morality, 168. 124 Rhonheimer, The Perspective of Morality, 166. 125 Rhonheimer, The Perspective of Morality, 167. 126 Rhonheimer, The Perspective of Morality, 167. 127 Rhonheimer, The Perspective of Morality, 175. 128 Rhonheimer, The Perspective of Morality, 175. 129 Rhonheimer, The Perspective of Morality, 176; Aquinas, De Veritate, q. 24, a. 2. 130 Rhonheimer, The Perspective of Morality, 175. 131 Rhonheimer, The Perspective of Morality, 177. 132 Rhonheimer, The Perspective of Morality, 178. 133 Rhonheimer, The Perspective of Morality, 178. 134 Rhonheimer, The Perspective of Morality, 178. 135 Rhonheimer, The Perspective of Morality, 178. 136 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 47. 137 Rhonheimer, The Perspective of Morality, 279. 138 Finnis, Natural Law and Natural Rights, 59. 139 Finnis, Natural Law and Natural Rights, 59. 140 Finnis, Natural Law and Natural Rights, 61. 141 Finnis, Natural Law and Natural Rights, 61, 63-4. 142 Finnis, Natural Law and Natural Rights, 69. 143 Finnis, Natural Law and Natural Rights, 70. 144 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 47ff. 145 Finnis, Natural Law and Natural Rights, 86-92. 146 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 48. 147 Aquinas, Summa Theologica, I-II, q. 94, a. 2 148 Finnis, Natural Law and Natural Rights, 86-7. 149 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 48. 150 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 49-50. 151 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 50. 152 Finnis, Natural Law and Natural Rights, 86-7. 153 Finnis, Natural Law and Natural Rights, 87. 154 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 49. 155 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 49;

Aquinas, Summa Theologica, I-II, q. 94, a. 2. 156 Armstrong, Primary and Secondary Precepts in Thomistic Natural Law Teaching, 50. 157 Finnis, Natural Law and Natural Rights, 87, 59-80. 158 Finnis, Natural Law and Natural Rights, 87-9. 159 Finnis, Natural Law and Natural Rights, 87-9. 160 Rhonheimer, Natural Law and Practical Reason, 43; G. E. Moore, Principia Ethica, ed.

Thomas Baldwin, (Cambridge: Cambridge University, 1993). 161 David Hume, A Treatise of Human Nature, (Oxford: Clarendon Press, 1896),

https://people.rit.edu/wlrgsh/HumeTreatise.pdf, book III, part I, section I, pp. 245. 162 Hume, A Treatise of Human Nature, book III, part I, section I-II, pp. 245.


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163 Finnis, Natural Law and Natural Rights, 37; Rhonheimer, Natural Law and Practical Reason,

43-44. 164 John Finnis, Fundamentals of Ethics, (Washington D. C.: Georgetown, 1983), 12. 165 Finnis, Fundamentals of Ethics, 12. 166 Finnis, Fundamentals of Ethics, 12. 167 Finnis, Fundamentals of Ethics, 12. 168 Finnis, Fundamentals of Ethics, 12-13. 169 Finnis, Fundamentals of Ethics, 15; Aristotle, Nicomachean Ethics, 1097b24-1098a20 in

Thomas Aquinas, “Lecture 10: Definition of Happiness,” in Commentary on the Nicomachean

Ethics trans. C. I. Litzinger (Chicago: Henry Regnery Company, 1964),

http://dhspriory.org/thomas/Ethics1.htm#10. 170 Aristotle, “Nicomachean Ethics,” 1097b24-1098a 20, pp. 1735. 171 Aristotle, “Nicomachean Ethics,” 1735. 172 Aristotle, “Nicomachean Ethics,” 1735. 173 Aristotle, “Nicomachean Ethics,” 1735. 174 Finnis, Fundamentals of Ethics, 16. 175 Finnis, Fundamentals of Ethics, 13ff. 176 Finnis, Fundamentals of Ethics, 13ff; Henry Veatch, Aristotle: A Contemporary Appreciation

(Bloomington, IN: Indiana University Press, 1974. 177 Finnis, Fundamentals of Ethics, 10ff. 178 Ralph McInerny, Aquinas on Human Action: A Theory of Practice, (Washington D. C.:

Catholic University of America, 2012), 184-92. 179 Martin Rhonheimer, The Perspective of Morality, 271-2, footnote 28; Martin Rhonheimer,

Praktische Vernunft und Vernunftigkeit der Praxis: Handlungstheorie bei Thomas von Aquin in

Ihrer Entstehung aus dem Problemkontext der Aristotelischen Ethik, (Berlin: Academie Verlag,

1994), 53-9. 180 McInerny, Aquinas on Human Action, 190-1. 181 McInerny, Aquinas on Human Action, 191. 182 McInerny, Aquinas on Human Action, 191. 183 McInerny, Aquinas on Human Action, 192. 184 McInerny, Aquinas on Human Action, 192. 185 Rhonheimer, The Perspective of Morality, 271-2, footnote 28. 186 Rhonheimer, The Perspective of Morality, 271. 187 Rhonheimer, Natural Law and Practical Reason, 58-61. 188 Rhonheimer, The Perspective of Morality, 271-2. 189 Rhonheimer, Natural Law and Practical Reason, 58. 190 Rhonheimer, Natural Law and Practical Reason, 58. 191 Rhonheimer, Natural Law and Practical Reason, 59. 192 Rhonheimer, Natural Law and Practical Reason, 60-1. 193 Rhonheimer, Natural Law and Practical Reason, 60. 194 Finnis, Fundamentals of Ethics, 10ff. 195 McInerny, Aquinas on Human Action, 192. 196 Rhonheimer, The Perspective of Morality, 271-2, footnote 28. 197 Rhonheimer, The Perspective of Morality, 272. 198 Rhonheimer, Praktische Vernunft und Vernunftigkeit der Praxis, 53-9.


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199 Rhonheimer, Praktische Vernunft und Vernunftigkeit der Praxis, 59; “Das ergon-argument

hat weder fur die praktische Erkenntnis noch fur den Beginn der ethischen Reflexion

grundlegende Bedeutung. Es ist aber unerlaßlich fur eine metaphysisch-anthropologische

Deutung und Rechtfertigung der normativen Funktion der praktischen Vernunft sowie fur eine

Beweisfuhrung, worin denn nun das Gluck - d. h. die eigentliche „Trefflichkeit" oder Tugend -

des Menschen bestehe.” 200 Rhonheimer, The Perspective of Morality, 272. 201 Heinrich Albert Rommen, Die ewige Wiederkehr des Naturrechts, (Munchen: Kosel, 1947),

185. 202 Joseph Pieper, Living the Truth: The Truth of All Things and Reality and the Good, (San

Francisco: Ignatius, 1989), 161-2. 203 McInerny, Aquinas on Human Action, 191-2; Ethica Thomistica: The Moral Philosophy of

Thomas Aquinas, revised edition, (Washington D.C.: Catholic University of America, 1997);

“The Principles of Natural Law,” American Journal of Jurisprudence, 25 (1980): 1-15. 204 Steven J. Jensen, Good and Evil Actions: A Journey through Saint Thomas Aquinas,

(Washington D. C.: Catholic University of America, 2010), 225-78; Knowing the Natural Law:

From Precepts and Inclinations to Deriving Oughts, (Washington D.C.: Catholic University of

America, 2015). 205 Francis Russell Hittinger, A Critique of the New Natural Law Theory, (Notre Dame, IN:

University of Notre Dame Press, 1987). 206 Steven A. Long, The Teleological Grammar of the Moral Act, 2nd Edition, (Ave Maria, FL:

Sapientia Press, 2015). 207 Rhonheimer, Natural Law and Practical Reason, 18-9, 48. 208 Rhonheimer, Natural Law and Practical Reason, 19. 209 Rhonheimer, Natural Law and Practical Reason, 19. 210 Rhonheimer, Natural Law and Practical Reason, 19-20. 211 Rhonheimer, Natural Law and Practical Reason, 20; Rhonheimer, The Perspective of

Morality, 270; Thomas Aquinas, De Veritate Questions 21-29, (Chicago: Henry Regnery

Company, 1954), http://dhspriory.org/thomas/QDdeVer.htm, Q. 21, a. 5. 212 Rhonheimer, Natural Law and Practical Reason, 20; 213 Aquinas, De Veritate, Q. 21, a. 5, answer 1. 214 Aquinas, De Veritate, Q. 21, a. 5, reply. 215 Aquinas, De Veritate, Q. 21, a. 5, answer 1; Rhonheimer, Natural Law and Practical Reason,

21; Rhonheimer, The Perspective of Morality, 270. 216 Aquinas, De Veritate, Q. 21, a. 5, answer 1. 217 Rhonheimer, The Perspective of Morality, 270. 218 Rhonheimer, The Perspective of Morality, 127. 219 Peter Knauer, “The Hermeneutic Function of the Principle of Double Effect,” Natural Law

Forum, Paper 127. http://scholarship.law.nd_naturallaw_forum/127. 220 Josef Fuchs, Natural Law: A Theological Investigation, trans. Helmut Reckter and John

Dowling (New York City: Sheed and Ward, 1965); Josef Fuchs, “The Absoluteness of Moral

Terms,” in Readings in Moral Theology No. 1: Moral Norms and Catholic Tradition, ed. Charles

E. Curran and Richard A. McCormick (New York City: Paulist Press, 1979), 94-137. 221 Louis Janssens, “Ontic Evil and Moral Evil,” in Proportionalism and the Natural Law

Tradition, by Christopher Kaczor, (Milwaukee, WI: Marquette University Press, 2000), 60-99.

http://dhspriory.org/thomas/QDdeVer.htm


101

222 Bruno Schuller, “Direct Killing/Indirect Killing,” in Proportionalism and the Natural Law

Tradition, by Christopher Kaczor, (Milwaukee, WI: Marquette University Press, 2000), 148-65. 223 Richard McCormick, “Ambiguity in Moral Choice,” in Proportionalism and the Natural Law

Tradition, by Christopher Kaczor, (Milwaukee, WI: Marquette University Press, 2000), 166-214. 224 Janssens, “Ontic Evil and Moral Evil,” 124. 225 Janssens, “Ontic Evil and Moral Evil,” 136; Knauer, “The Hermeneutic Function of the

Principle of Double Effect,” 141. 226 Martin Rhonheimer, “The Cognitive Structure of the Natural Law and the Truth of

Subjectivity,” in The Perspective of the Acting Person: Essays in the Renewal of Thomistic

Moral Philosophy, ed. William F. Murphy Jr. (Washington D.C.: Catholic University of

America, 2008), 159. 227 Rhonheimer, “The Cognitive Structure of the Natural Law,” 159. 228 Rhonheimer, “The Cognitive Structure of the Natural Law,” 159-60. 229 Rhonheimer, “The Cognitive Structure of the Natural Law,” 162. 230 Rhonheimer, “The Cognitive Structure of the Natural Law,” 160-1. 231 Leo XIII, Libertas Praestantissimum, June 20, 1888, http://w2.vatican.va/content/leo-

xiii/en/encyclicals/documents/hf_l-xiii_enc_20061888_libertas.html, 8; John Paul II, Veritatis

Splendor, August 6, 1993,

http://w2.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-

ii_enc_06081993_veritatis-splendor.html, 44; Rhonheimer, “The Cognitive Structure of the

Natural Law,” 166-7. 232 Rhonheimer, “The Cognitive Structure of the Natural Law,” 167. 233 Rhonheimer, “The Cognitive Structure of the Natural Law,” 167-8. 234 Rhonheimer, “The Cognitive Structure of the Natural Law,” 169. 235 See Rhonheimer, “The ‘Naturally Rational,’” 98, footnote 11 lists critics who accuse him of

such faults. 236 Rhonheimer, “The ‘Naturally Rational,’” 98 (the essence of the second objection). 237 Jean Porter, “Review of Natural Law and Practical Reason by Martin Rhonheimer”

Theological Studies 62, no. 4 (2001): 851-53. 238 Martin Rhonheimer, “The Moral Significance of Pre-Rational Nature in Aquinas: a Reply to

Jean Porter (and Stanley Hauerwas),” in The Perspective of the Acting Person: Essays in the

Renewal of Thomistic Moral Philosophy, ed. William F. Murphy Jr. (Washington D.C.: Catholic

University of America, 2008), 129-57. 239 Rhonheimer, “The Cognitive Structure of the Natural Law,” 172ff. 240 Rhonheimer, “The Cognitive Structure of the Natural Law,” 173. 241 Rhonheimer, “The Cognitive Structure of the Natural Law,” 173; Rhonheimer, Natural Law

and Practical Reason, 97. 242 Rhonheimer, “The Cognitive Structure of the Natural Law,” 174, footnote 48; Aquinas,

Summa Theologica, I-II, q. 91, a. 2. 243 Rhonheimer, Natural Law and Practical Reason, 108. 244 Rhonheimer, Natural Law and Practical Reason, 109. 245 Rhonheimer, “The Cognitive Structure of the Natural Law,” 174; Aquinas, Summa

Theologica, I-II, q. 94, a. 2. 246 Rhonheimer, “The Cognitive Structure of the Natural Law,” 175ff; Aquinas, Summa

Theologica, I-II, q. 94, a. 2. 247 Rhonheimer, “The Cognitive Structure of the Natural Law,” 175-6.

http://w2.vatican.va/content/leo-xiii/en/encyclicals/documents/hf_l-xiii_enc_20061888_libertas.html




102

248 Rhonheimer, “The Cognitive Structure of the Natural Law,” 177-8. 249 Rhonheimer, “The Cognitive Structure of the Natural Law,” 179-81. 250 John Paul II, Veritatis Splendor, 12, 42. 251 John Paul II, Veritatis Splendor, 42. 252 Martin Rhonheimer, Ethics of Procreation and the Defense of Human Life: Contraception,

Artificial Fertilization and Abortion, ed. William F. Murphy, Jr. (Washington D. C.: Catholic

University of America Press, 2010), 3. 253 Rhonheimer, Ethics of Procreation, 4 footnote 6. 254 Rhonheimer, Ethics of Procreation, 5. 255 Rhonheimer, Ethics of Procreation, 4. 256 Rhonheimer, Ethics of Procreation, 6-7; John Paul II, Veritatis Splendor, 44. 257 Rhonheimer, Ethics of Procreation, 6; John Paul II, Veritatis Splendor, 44; Leo XIII, Libertas

Praestantissimum, 8. 258 Rhonheimer, Ethics of Procreation, 6; John Paul II, Veritatis Splendor, 44. 259 Rhonheimer, Ethics of Procreation, 6; John Paul II, Veritatis Splendor, 41. 260 John Paul II, Veritatis Splendor, 47-50. 261 Rhonheimer, “The Moral Significance of Pre-Rational Nature in Aquinas: a Reply to Jean

Porter (and Stanley Hauerwas),” 140ff. 262 Rhonheimer, Ethics of Procreation, 7; John Paul II, Veritatis Splendor, 48. 263 Rhonheimer, Ethics of Procreation, 7; John Paul II, Veritatis Splendor, 48. 264 John Paul II, Veritatis Splendor, 48. 265 Rhonheimer, Ethics of Procreation, 7-8. 266 Rhonheimer, Ethics of Procreation, 8. 267 Rhonheimer, Ethics of Procreation, 8-9; Rhonheimer, Natural Law and Practical Reason,

96ff. 268 Rhonheimer, Ethics of Procreation, 9. 269 Rhonheimer, Ethics of Procreation, 9. 270 Rhonheimer, “The Moral Significance of Pre-Rational Nature in Aquinas,” 129-57. 271 Rhonheimer, Ethics of Procreation, 15; Aquinas, Summa Theologica, I-II, q. 94, a. 2, ad. 2. 272 Aquinas, Summa Theologica, I, Q. 80, a. 1. 273 Rhonheimer, Ethics of Procreation, 15; Aquinas, Summa Theologica, I-II, q. 94, a. 2, ad. 2. 274 Rhonheimer, Ethics of Procreation, 14. 275 Rhonheimer, Ethics of Procreation, 14. 276 Rhonheimer, Ethics of Procreation, 13; L. Lehu, La Raison, regle de la moralita d’apres

Saint Thomas, (Paris: J. Gabalda et Fils, 1930). 277 John Paul II, Veritatis Splendor, 47. 278 Rhonheimer, Ethics of Procreation, 46. 279 Paul VI, Humanae Vitae, July 25, 1968, http://w2.vatican.va/content/paul-

vi/en/encyclicals/documents/hf_p-vi_enc_25071968_humanae-vitae.html, 14. 280 Rhonheimer, Ethics of Procreation, 46. 281 Paul VI, Humanae Vitae, 16. 282 Rhonheimer, Natural Law and Practical Reason, 94-145; Rhonheimer, Ethics of Procreation,

1-132. 283 Rhonheimer, Natural Law and Practical Reason, 94-7. 284 Rhonheimer, Natural Law and Practical Reason, 97-8. 285 Rhonheimer, Natural Law and Practical Reason, 98; Rhonheimer, Ethics of Procreation, 72.



103

286 Rhonheimer, Natural Law and Practical Reason, 102. 287 Catechism of the Catholic Church, 2nd edition, (Citta del Vaticano: Liberia Editrice Vaticana,

1997), pp. 410-413, #1643-54. 288 CCC, 1644-6, John Paul II, Familiaris Consortio, November 22, 1981,

http://w2.vatican.va/content/john-paul-ii/en/apost_exhortations/documents/hf_jp-

ii_exh_19811122_familiaris-consortio.html, 19. 289 CCC, 1652-4. 290 Rhonheimer, Natural Law and Practical Reason, 100. 291 Paul VI, Humanae Vitae, 12; Rhonheimer, Ethics of Procreation, 78ff. 292 Paul VI, Humanae Vitae, 11-12. 293 Rhonheimer, Natural Law and Practical Reason, 100-101; Rhonheimer, Ethics of

Procreation, 78-81. 294 John Paul II, Man and Woman He Created Them: A Theology of the Body, trans. Michael

Waldstein, (Boston, MA: Pauline, 2006), 118. 295 John Paul II, Man and Woman He Created Them, 118. 296 Rhonheimer, Ethics of Procreation, 88-90. 297 Rhonheimer, Ethics of Procreation, 90ff. 298 Rhonheimer, Natural Law and Practical Reason, 102. 299 Rhonheimer, Natural Law and Practical Reason, 111. 300 Rhonheimer, Natural Law and Practical Reason, 112. 301 Rhonheimer, Natural Law and Practical Reason, 113ff; Rhonheimer, Ethics of Procreation,

90ff. 302 Paul VI, Humanae Vitae, 16. 303 Rhonheimer, Ethics of Procreation, 90-102. 304 Rhonheimer, Ethics of Procreation, 71-132. 305 Rhonheimer, Ethics of Procreation, 124-5. 306 John Paul II, Man and Woman He Created Them, 124ff. 307 John Paul II, Veritatis Splendor, 71. 308 John Paul II, Veritatis Splendor, 78. 309 John Paul II, Veritatis Splendor, 79ff. 310 Romanus Cessario, Introduction to Moral Theology, (Washington D. C.: Catholic University

of America, 2001); Romanus Cessario et al., Ressourcement Thomism: Sacred Doctrine, the

Sacraments, and the Moral Life: Essays in Honor of Romanus Cessario, O. P., (Washington D.

C.: Catholic University of America, 2010); John Finnis, Aquinas: Moral, Political and Legal

Theory (Founders of Modern Political and Social Thought), Oxford: Oxford, 1998); Kevin L.

Flannery, Acts Amid Precepts: The Aristotelian Logical Structure of Thomas Aquinas’s Moral

Theory, (Washington D. C.: Catholic University Press, 2001); Steven A. Long, The Teleological

Grammar of the Moral Act, 2nd ed. (Naples, FL: Sapientia Press, 2015); Ralph McInerny, Ethica

Thomistica: The Moral Philosophy of Thomas Aquinas, revised edition, (Washington D. C.:

Catholic University of America, 1997; Joseph Pilsner, The Specification of Human Actions in

Saint Thomas Aquinas, (Oxford: Oxford Theological Monographs, 2006); Servais Pinckaers, The

Pinckaers Reader: Renewing Thomistic Moral Theology, ed. John Berkman and Craig Steven

Titus, (Washington D. C.: Catholic University Press, 2005); Martin Rhonheimer, The

Perspective of Morality: Philosophical Foundations of Thomistic Virtue Ethics, (Washingtion D.

C.: Catholic University of America, 2011. 311 Finnis, Aquinas, 62ff.

http://w2.vatican.va/content/john-paul-ii/en/apost_exhortations/documents/hf_jp-ii_exh_19811122_familiaris-consortio.html


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312 Servais Pinckaers, “Historical Perspective on Intrinsically Evil Acts,” in The Pinckaers

Reader: Renewing Thomistic Moral Theology, ed. John Berkman et al. (Washington D. C.:

Catholic University Press, 2005), 185-235. 313 Pinckaers, “Historical Perspective on Intrinsically Evil Acts,” 186, 193. Augustine, “De

mendacio (On Lying),” in Nicene and Post-Nicene Fathers, First Series, Vol. 3 ed. Philip Scaff,

trans. H. Browne, (Buffalo, NY: Christian Literature Publishing Co., 1887)

http://www.newadvent.org/fathers/1312.htm; see also Augustine, “Contra mendacium ad

consensium, (To Consensus, Against Lying),” in Nicene and Post-Nicene Fathers, First Series,

Vol. 3 ed. By Philip Scaff, trans. H. Browne, (Buffalo, NY: Christian Literature Publishing Co.,

1887), http://www.newadvent.org/fathers/1313.htm. 314 Pinckaers, “Historical Perspective on Intrinsically Evil Acts,” 195. 315 Pinckaers, “Historical Perspective on Intrinsically Evil Acts,” 194; Peter Abelard, Ethical

Writings: His Ethics or “Know Yourself” and His Dialogue between a Philosopher, a Jew, and a

Christian, trans. Paul Vincent Spade (Indianapolis: Hackett, 1995), 10-11. 316 Pinckaers, “Historical Perspective on Intrinsically Evil Acts,” 196. 317 Pinckaers, “Historical Perspective on Intrinsically Evil Acts,” 195-6. 318 Pinckaers, “Historical Perspective on Intrinsically Evil Acts,” 198; see Peter Lombard,

Sentences, in Sententiae in IV Libris Distinctae, 3rd edition (Romae: Grottaferrata, 1971)

distinctio 40, cap. 1, pp. 556-61.

https://archive.org/stream/PeterLombardSentencesEditioCriticaVols12/Peter-Lombard-

Sentences-editio-critica-vols-1-2#page/n281/mode/2up 319 Pinckaers, “Historical Perspective on Intrinsically Evil Acts,” 198; Lombard, Sentences, II, D.

40, C. 1, 557. 320 Pinckaers, “Historical Perspective on Intrinsically Evil Acts,” 198; Lombard, Sentences, II, D.

40, C. 1, 6, pp. 558. 321 Pinckaers, “Historical Perspective on Intrinsically Evil Acts,” 198; Pinckaers says that

Lombard quotes Augustine’s De mendacio, in fact Lombard quotes Augustine’s Contra

mendacium ad consentium; see Lombard, Sentences, II, d. 40, c. 1, 7, pp. 258-9; Augustine,

“Contra mendacium ad consentium,” in Collectio selecta SS. Ecclesiae Patrum 133: Patres quint

Ecclesiae Saeculi S. Augustinus Vol. 26, (Parisiis: Apud Parent-Desbarres, 1835), book 1, cap.

18, pp. 487-9, https://archive.org/details/operaomniaaccura26auguuoft; see also Augustine, To

Consensus, Against Lying, 18. 322 Pinckaers, “Historical Perspective on Intrinsically Evil Acts,” 198-9; Augustine, To

Consensus, Against Lying, 18. 323 Augustine, To Consensus, Against Lying, 18. 324 Augustine, To Consensus, Against Lying, 18. 325 Augustine, To Consensus, Against Lying, 18. 326 Pinckaers, “Historical Perspective on Intrinsically Evil Acts,” 199ff; Finnis, Aquinas, 62. 327 Finnis, Aquinas, 62. 328 Finnis, Aquinas, 62-71. 329 Pinckaers, “Historical Perspective on Intrinsically Evil Acts,” 207-8; Aquinas, Summa

Theologica, I-II, q. 1-3. 330 Aquinas, Summa Theologica, I-II, q. 12. 331Aquinas, Summa Theologica, I-II, q. 1, a. 4, c. 332 Aquinas, Summa Theologica, I-II, q. 3, a. 8, c. “Final and perfect happiness can consists in

nothing else than the vision of the Divine Essence.”

http://www.newadvent.org/fathers/1312.htm


105

333 Aquinas, Summa Theologica, I-II, q. 1, a. 4, c. 334 Aquinas, Summa Theologica, I-II, q. 1, a. 4, c. 335 Finnis, Aquinas, 68. 336 Finnis, Aquinas, 65. 337 Finnis, Aquinas, 63-4; Aquinas, Summa Theologica, I-II, q. 13, a. 3, q. 12, a. 2. 338 Finnis, Aquinas, 65. 339 Finnis, Aquinas, 65. 340 Rhonheimer, The Perspective of Morality, 116; see also Martin Rhonheimer, Natural Law

and Practical Reason: A Thomistic View of Moral Autonomy, trans. Gerald Malsbary, (New

York City: Fordham, 2000), 24ff; Aquinas, Summa Theologica, I, q. 79, a. 11. 341 Rhonheimer, The Perspective of Morality, 117. 342 Rhonheimer, The Perspective of Morality, 117. 343 Rhonheimer, The Perspective of Morality, 118. 344 Finnis, Aquinas, 63. 345 Finnis, Aquinas, 65. 346 Finnis, Aquinas, 66; see Aquinas, Summa Theologica, I-II, q. 14, a. 4. 347 Finnis, Aquinas, 66; see Aquinas, Summa Theologica, I-II, q. 14. 348 Finnis, Aquinas, 66; see Aquinas, Summa Theologica, I-II, q. 15. 349 Finnis, Aquinas, 66; Aquinas, Summa Theoologiae, I-II, q. 15, a. 3, ad. 3. 350 Finnis, Aquinas, 66. 351 Finnis, Aquinas, 67. 352 Finnis, Aquinas, 67, endnote j on 96; Aquinas, Commentary on the Sentences, d. 24, q. I a. 3

ad. 5, q. 2 a. 3 ad. 4; Aquinas, De Veritate, q. 16 a. I ad. 15, q. 17 a. I ad. 4 and ad. 17. 353 Finnis, Aquinas, 67; see Aquinas, Summa Theologica, I-II, q. 13. 354 Finnis, Aquinas, 67-8; see Aquinas, Summa Theologica, I-II, q. 16-17. 355 Finnis, Aquinas, 68; see Aquinas, Summa Theologica, I-II, q. 11. 356 Aquinas, Summa Theologica, I-II, q. 1, a. 3, c; Pilsner, The Specification of Human Actions in

Saint Thomas Aquinas, 47. 357 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 47-51. 358 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 50-1; Aquinas, Summa

Theologica, I-II, q. 1. a. 2. 359 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 51. 360 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 52; Aquinas,

Commentary on the Sentences, lib. II, d. 38, q. 1, a. 5, sc. 1. 361 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 54. 362 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 54; Aquinas, Summa

Theologica, I-II, q. 6, a. 6. 363 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 72-90. 364 Martin Rhonheimer, “The Perspective of the Acting Person and the Nature of Practical

Reason: The ‘Object of the Human Act,’ in Thomistic Anthropology of Action,” in The

Perspective of the Acting Person: Essays in the Renewal of Thomistic Moral Philosophy, ed.

William F. Murphy Jr. (Washington D. C.: Catholic University of America, 2008), 198. 365 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 77; Ralph McInerny,

Aquinas on Human Action: A Theory of Practice, (Washington D. C.: Catholic University of

America Press, 1992), 77.

106

366 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 78; Rhonheimer, “The

Perspective of the Acting Person and the Nature of Practical Reason: The ‘Object of the Human

Act,’” in Thomistic Anthropology of Action,” 200; see also Martin Rhonheimer, Ethics of

Procreation and the Defense of Human Life: Contraception, Artificial Fertilization, and

Abortion, ed. William F. Murphy Jr. (Washington D. C.: Catholic University of America, 2010),

80. 367 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 72, 91-133. 368 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 91-133. 369 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 105; Thomas Aquinas,

On Evil, trans. Richard Regan and ed. Brian Davies (Oxford: Oxford, 2003), q. 2, a. 4. Cor. 370 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 72, 133-40. 371 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 134. 372 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 136. 373 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 135. 374 Aquinas, Summa Theologica, I-II, q. 18. 375 Aquinas, Summa Theologica, I-II, q. 18, a. 2-4. 376 Pilsner, The Specification of Human Actions in Saint Thomas Aquinas, 49. 377 Aquinas, Summa Theologica, I-II, q. 18, a. 6, q. 18, a. 2, ad. 2. 378 Aquinas, Summa Theologica, I-II, q. 18, a. 2, r. 379 Aquinas, Summa Theologica, I-II, q. 18, a. 6. 380 John Abraham Makdisi, “The Object of the Moral Act: Understanding St. Thomas Aquinas

Through the Work of Steven Long and Martin Rhonheimer,” (PhD diss., Catholic University of

America, 2017), 108. 381 Aquinas, Summa Theologica, I-II, q. 18, a. 2, ad. 2. 382 Aquinas, Summa Theologica, I-II, q. 18, a. 5, answer. 383 Aquinas, Summa Theologica, I-II, q. 18, a. 5, answer; see also Duarte Sousa-Lara, “Aquinas

on the Object of the Human Act: A Reading in Light of the Texts and Commentators,”

Josephinum Journal of Theology 15, no. 2 (2008): (243-276). 384 Aquinas, Summa Theologica, I-II, q. 18, a. 6; see also Aquinas, On Evil, q. 7, a. 3, c; Sousa-

Lara, “Aquinas on Interior and Exterior Acts,” 283. 385 Aquinas, Summa Theologica, I-II, q. 18, a. 6. 386 Duarte Sousa-Lara, “Aquinas on Interior and Exterior Acts: Clarifying a Key Aspect of His

Action Theory,” Josephinum Journal of Theology 15, no. 2, (2008): 277ff. 387 Makdisi, “The Object of the Moral Act: Understanding St. Thomas Aquinas Through the

Work of Steven Long and Martin Rhonheimer,” 95. 388 Aquinas, Summa Theologica, I-II, q. 18, a. 6. 389 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 307. 390 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 307. 391 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 306. 392 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 280. 393 Aquinas, On Evil, q. 2, a. 2, ad. 13, pp. 100. 394 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 278. 395 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 280; see also Aquinas, On Evil, q. 2, a.

2, ad 5. 396 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 279; see Aquinas, On Evil, q. 2, a. 2, ad

5.

107

397 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 281-2, Aquinas, Commentary on the

Sentences, lib. 2, d. 40, q. 1, a. 3, c. 398 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 283. 399 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 284. 400 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 284. 401 Rhonheimer, “The Perspective of the Acting Person and the Nature of Practical Reason: The

‘Object of the Human Act,’” 210. 402 Rhonheimer, “The Perspective of the Acting Person and the Nature of Practical Reason: The



‘Object of the Human Act,’” 202. Aquinas, Summa Theologica, I-II, q. 20, a. 1, ad. 1. 405 Rhonheimer, “The Perspective of the Acting Person and the Nature of Practical Reason: The

‘Object of the Human Act,’” 210. 406 Rhonheimer, Natural Law and Practical Reason, 92; Aquinas, Summa Theologica, I-II, q. 20,

a. 1, ad. 1. 407 Duarte Sousa-Lara, “‘Materia ex qua’ and ‘Materia circa quam’ Aquinas,” trans. Joseph T.

Papa and William F. Murphy, from A especificacao moral dos actos humanos segundo sao

Tomas de Aquino, (Rome: Edizioni Universita Santa Croce, 2008)

http://www.eticaepolitica.net/eticafondamentale/dsl_materia_ex_qua_materia_circa_quam.pdf,

pp. 1; see also Aquinas, Summa Theologica, I-II, q. 73, a. 3, ad. 1. 408 Makdisi, “The Object of the Moral Act: Understanding St. Thomas Aquinas Through the

Work of Steven Long and Martin Rhonheimer,” 95. 409 Rhonheimer, “The Perspective of the Acting Person and the Nature of Practical Reason: The


‘Object of the Human Act,’” 202-4. 411 Rhonheimer, Natural Law and Practical Reason, 91. 412 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 316. 413 Rhonheimer, Natural Law and Practical Reason, 92. 414 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 278ff. 415 Finnis, Aquinas, 21; Thomas Aquinas, Sententia Libri Politicorum: Commentary on

Aristotle’s Politics, trans. Ernest L. Fortin and Peter D. O’Neill from the Spiazzi 1951 ed.

www.dhspriory.org/thomas/Politics.htm (accessed April 3, 2018) prologue, 1-8. 416 Finnis, Aquinas, 21. 417 Finnis, Aquinas, 21. 418 Finnis, Aquinas, 21. 419 Finnis, Aquinas, 21; Aquinas, Commentary on Aristotle’s Politics, Prologue, 6. 420 Finnis, Aquinas, 23. 421 John Finnis, Natural Law and Natural Rights, 2nd Ed. (Oxford: Oxford, 2011), 44. 422 Finnis, Aquinas, 22. 423 Martin Rhonheimer, “Norm-Ethics, Moral Rationality, and the Virtues: What’s Wrong with

Consequentialism?” in The Perspective of the Acting Person: Essays in the Renewal of Thomistic

Moral Philosophy, ed. William F. Murphy Jr. (Washington D. C.: Catholic University of

America, 2008), 20.

http://www.eticaepolitica.net/eticafondamentale/dsl_materia_ex_qua_materia_circa_quam.pdf

http://www.dhspriory.org/thomas/Politics.htm

108

424 Finnis, Aquinas, 24. 425 Rhonheimer, “Norm-Ethics, Moral Rationality, and the Virtues: What’s Wrong with

Consequentialism?,” 20. 426 Rhonheimer, “Norm-Ethics, Moral Rationality, and the Virtues: What’s Wrong with

Consequentialism?,” 20. 427 Rhonheimer, “Norm-Ethics, Moral Rationality, and the Virtues: What’s Wrong with

Consequentialism?,” 20; Finnis, Aquinas, 22. 428 Finnis, Fundamentals of Ethics, 1-3. 429 Finnis, Fundamentals of Ethics, 3. 430 Finnis, Fundamentals of Ethics, 4; 431 Rhonheimer, Natural Law and Practical Reason, 5. 432 Rhonheimer, Natural Law and Practical Reason, xv. 433 Rhonheimer, Natural Law and Practical Reason, 5. 434 Rhonheimer, Natural Law and Practical Reason, 5. 435 Servais Pinckaers, The Sources of Christian Ethics, 3rd edition, trans. Mary Thomas Noble,

(Washington D. C.: Catholic University of America Press, 1995), 254-79. 436 Pinckaers, The Sources of Christian Ethics, 254-6. 437 Pinckaers, The Sources of Christian Ethics, 257. 438 Pinckaers, The Sources of Christian Ethics, 259-60. 439 Pinckaers, The Sources of Christian Ethics, 260-1. 440 Pinckaers, The Sources of Christian Ethics, 266. 441 Pinckaers, The Sources of Christian Ethics, 267. 442 Pinckaers, The Sources of Christian Ethics, 268-9. 443 Pinckaers, The Sources of Christian Ethics, 269-70. 444 G. E. M. Anscombe, Intention, (Cambridge, MA: Harvard University Press, 2000), 78. 445 Pinckaers, The Sources of Christian Ethics, 270-2. 446 Pinckaers, The Sources of Christian Ethics, 270. 447 Peter Knauer, “The Hermeneutic Function of the Principle of Double Effect,” Natural Law

Forum, Paper 127. http://scholarship.law.nd_naturallaw_forum/127. 448 Fuchs, Natural Law: A Theological Investigation; Fuchs, “The Absoluteness of Moral

Terms,” 94-137. 449 Janssens, “Ontic Evil and Moral Evil,” 60-99. 450 Schuller, “Direct Killing/Indirect Killing,” 148-65. 451 McCormick, “Ambiguity in Moral Choice,” 166-214. 452 Rhonheimer, Natural Law and Practical Reason, 6. 453 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 133. 454 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 141. 455 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 141. 456 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 141. 457 Rhonheimer, Martin Rhonheimer, “Intentional Actions and the Meaning of the Object: A

Reply to McCormick,” in The Perspective of the Acting Person: Essays in the Renewal of

Thomistic Moral Philosophy, ed. William F. Murphy Jr. (Washington D. C.: Catholic University

of America, 2008), 78-85. 458 Louis Janssens, “Ontic Evil and Moral Evil,” 136. 459 Louis Janssens, “Ontic Evil and Moral Evil,” 136. 460 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 278ff.


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461 Rhonheimer, “Intentional Actions and the Meaning of the Object: A Reply to McCormick,”

75; Fuchs, “The Absoluteness of Moral Terms,” 119. 462 Rhonheimer, “Intentional Actions and the Meaning of the Object: A Reply to McCormick,”

77. 463 Rhonheimer, “Intentional Actions and the Meaning of the Object: A Reply to McCormick,”

77. 464 Rhonheimer, Natural Law and Practical Reason, 88. 465 Rhonheimer, Natural Law and Practical Reason, 88. 466 Rhonheimer, Natural Law and Practical Reason, 87. 467 Rhonheimer, Natural Law and Practical Reason, 89-90. 468 Rhonheimer, Natural Law and Practical Reason, 89-90. 469 Rhonheimer, Natural Law and Practical Reason, 91. 470 John Paul II, Veritatis Splendor, 78. 471 Finnis, Fundamentals of Ethics, 138. 472 Rhonheimer, Natural Law and Practical Reason, 5-7, 87-90. 473 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 141. 474 Martin Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a Central


of Thomistic Moral Philosophy, ed. William F. Murphy Jr. (Washington D. C.: Catholic

University of America, 2008), 45ff. 475 Finnis, Fundamentals of Ethics, 118. 476 Finnis, Fundamentals of Ethics, 136-8. 477 Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a Central

Teaching of Veritatis Splendor,” 46. 478 “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a Central Teaching of Veritatis

Splendor,” 46. 479 “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a Central Teaching of Veritatis




Splendor,” 46. 483 Finnis, Fundamentals of Ethics, 109ff; Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral

Viewpoint: Clarifying a Central Teaching of Veritatis Splendor,” 66ff. 484 Finnis, Fundamentals of Ethics, 109. 485 Finnis, Fundamentals of Ethics, 109; referring to Romans 3:8 and 6:1, 15. 486 Finnis, Fundamentals of Ethics, 109. 487 Finnis, Fundamentals of Ethics, 110; John 11:50; 18:14. 488 Finnis, Fundamentals of Ethics, 110. 489 Finnis, Fundamentals of Ethics, 112; Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral

Viewpoint: Clarifying a Central Teaching of Veritatis Splendor,” 66ff. 490 Finnis, Fundamentals of Ethics, 113. 491 Finnis, Fundamentals of Ethics, 114. 492 Finnis, Fundamentals of Ethics, 114.

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493 Finnis, Fundamentals of Ethics, 114. 494 Finnis, Fundamentals of Ethics, 115. 495 Finnis, Fundamentals of Ethics, 115. 496 Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a Central

Teaching of Veritatis Splendor,” 65. 497 Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a Central

Teaching of Veritatis Splendor,” 66. 498 Rhonheimer, The Perspective of Morality, 390. 499 John Paul II, Veritatis Splendor, 36. 500 John Paul II, Veritatis Splendor, 1, 33, 40. 501 John Paul II, Veritatis Splendor, 53. 502 John Paul II, Veritatis Splendor, 38. 503 John Paul II, Veritatis Splendor, 40. 504 John Paul II, Veritatis Splendor, 43. 505 John Paul II, Veritatis Splendor, 40. 506 John Paul II, Veritatis Splendor, 47-8. 507 John Paul II, Veritatis Splendor, 48-50. 508 John Paul II, Veritatis Splendor, 50. 509 John Paul II, Veritatis Splendor, 51. 510 John Paul II, Veritatis Splendor, 51-3. 511 John Paul II, Veritatis Splendor, 54. 512 John Paul II, Veritatis Splendor, 55. 513 John Paul II, Veritatis Splendor, 56. 514 John Paul II, Veritatis Splendor, 58. 515 John Paul II, Veritatis Splendor, 65-83. 516 John Paul II, Veritatis Splendor, 65. 517 John Paul II, Veritatis Splendor, 67. 518 John Paul II, Veritatis Splendor, 67. 519 John Paul II, Veritatis Splendor, 70. 520 John Paul II, Veritatis Splendor, 75. 521 John Paul II, Veritatis Splendor, 71-83. 522 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 159. 523 “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a Central Teaching of Veritatis

Splendor,” 46. 524 Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a Central

Teaching of Veritatis Splendor,” 46; John Paul II, Veritatis Splendor, 74, 76. 525 John Paul II, Veritatis Splendor, 74. 526 John Paul II, Veritatis Splendor, 78. 527 John Paul II, Veritatis Splendor, 78. 528 John Paul II, Veritatis Splendor, 78. 529529 Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a Central

Teaching of Veritatis Splendor,” 39ff. 530 Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a Central

Teaching of Veritatis Splendor,” 48-9; John Paul II, Veritatis Splendor, 79. 531 John Paul II, Veritatis Splendor, 82. 532 John Paul II, Veritatis Splendor, 78.

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533 John T. Noonan, Jr., Contraception: A History of Its Treatment by the Catholic Theologians

and Canonists, enlarged edition (Cambridge, MA: Harvard University Press, 1986). 534 Pinckaers, The Sources of Christian Ethics, 254. 535 Jean Pierre Gury, Compendium theologiae moralis, Vol. 1, 17th ed. (Romae: Typis Civilitatis

Catholicae, 1866). https://archive.org/details/compendiumtheo01gury 536 Thomas Gousset, Justification de la théologie morale du B. A.-M. de Ligorio (Besançon,

1832). 537 John Baptist Bouvier, Dissertatio in sextum decalogi praeceptum et supplementum ad

tractatum de matrimonio, 18th ed. (Paris, N. D.). 538 Francis P. Kenrick, Theologia Moralis, (Philadelphia: Eugenium Cummiskey, 1841). 539 Noonan, Contraception, 397. 540 Noonan, Contraception, 397. 541 Noonan, Contraception, 402; following Bouvier’s, Dissertatio, 2.1.3.4. 542 Noonan, Contraception, 405. 543 Noonan, Contraception, 405; Bouvier’s, Dissertatio, 2.1.3.4. 544 Noonan, Contraception, 405; Bouvier’s, Dissertatio, 2.1.3.4. 545 Pius XI, Casti Cannubii, (December 31, 1930), https://w2.vatican.va/content/pius-

xi/en/encyclicals/documents/hf_p-xi_enc_19301231_casti-connubii.pdf, 53-7 546 Pius XI, Casti Cannubii, 53. 547 Pius XI, Casti Cannubii, 54, 55. 548 Pius XI, Casti Cannubii, 54, 61. 549 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 157-8. 550 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 157-8. 551 Pius XI, Casti Cannubii, 158. 552 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 159. 553 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 159. 554 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 159. 555 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 160-1. 556 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 161. 557 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 161. 558 Paul VI, Humanae Vitae. 559 Paul VI, Humanae Vitae, 12. 560 Paul VI, Humanae Vitae, 12. 561 Paul VI, Humanae Vitae, 14. 562 Paul VI, Humanae Vitae, 14. 563 Martin Rhonheimer, Ethics of Procreation, 71ff. 564 Rhonheimer, Ethics of Procreation, 71. 565 Rhonheimer, Ethics of Procreation, 72. 566 Rhonheimer, Ethics of Procreation, 73. 567 Rhonheimer, Ethics of Procreation, 73-4. 568 Rhonheimer, Ethics of Procreation, 73-4. 569 Rhonheimer, Ethics of Procreation, 78-81. 570 Rhonheimer, Ethics of Procreation, 80. 571 Rhonheimer, Ethics of Procreation, 78; Noonan, Contraception, 550ff. 572 Rhonheimer, Ethics of Procreation, 81; recall John Paul II, Veritatis Splendor, 78. 573 Rhonheimer, Ethics of Procreation, 82.



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574 Rhonheimer, Ethics of Procreation, 81-2; Following Aquinas, Summa Theologica, I-II, q. 18,

a. 10. 575 Rhonheimer, Ethics of Procreation, 83. 576 Rhonheimer, Ethics of Procreation, 83. 577 Rhonheimer, Ethics of Procreation, 87. 578 Rhonheimer, Ethics of Procreation, 88-9. 579 Rhonheimer, Ethics of Procreation, 92. 580 Rhonheimer, Ethics of Procreation, 93-4. 581 Rhonheimer, Ethics of Procreation, 96-7. 582 Rhonheimer, Ethics of Procreation, 99. 583 Rhonheimer, Ethics of Procreation, 99. 584 Rhonheimer, Ethics of Procreation, 100. 585 Rhonheimer, Ethics of Procreation, 100-1. 586 Rhonheimer, Ethics of Procreation, 101-3.

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CHAPTER THREE – PRINCIPLE OF DOUBLE EFFECT

In light of the preceding chapter’s insights on the Natural Law and the Moral Object, this

chapter analyzes the Principle of Double Effect. The first section traces the Double-Effect

Reasoning from Thomas Aquinas to Peter Knauer. The second section contrasts a teleological

construct of Double Effect with non-consequentialist versions.

3A. Double Effect from Aquinas to Knauer

i. Aquinas and Double Effect Reasoning

Aquinas uses Double-Effect Reasoning in two places in the Summa Theologica.1 First, he

explains killing in self-defense.2 Second, he shows how one may unintentionally scandalize

others by alluring dress or spiritual acts.3 In the following, I elucidate several criteria that derive

from Aquinas’s Double-Effect Reasoning.

In the first objection to article seven, Aquinas quotes Augustine’s objection to killing

another, even in self-defense, except for a soldier or official exercising public office.4 The

objector implies that one may only kill if one exercises public authority. The following objection

and the response both qualify the meaning of Augustine’s statement. Moreover, the proper

meaning of intention gives further weight to Aquinas’s explanation.

Intention has several means for Aquinas. Understanding his parsing of the terms in the

explanation of human action clarifies his use of it in the context of Double-Effect Reasoning. In

the Prima Secundae of the Summa Theologiae, he distinguishes between intending a remote end

(finis operantis) versus choosing a proximate end (finis proximus or finis operis).5 The proximate

end is the Moral Object, while the remote end is the reason one does an act.

In agreement with Augustine, Aquinas objects to civilians intending to kill a person either

as a means or an end. One may not intend to kill another even in self-defense. This is because he

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objects to doing evil for a good result. This constitutes at least two criteria in the Principle of

Double Effect. One, the Moral Object of the act must be morally good or neutral. Two, one must

not intend any evil effects.

Aquinas uses praeter intentionem to explain the unintended consequences of an act.6

Returning to his answer on killing in self-defense, he says that an act may have more than one

effect not all of which one intends.7 Moreover, actions get their species from intention, not from

what is beside (praeter intentionem) intention, which is accidental.8 Praeter intentionem is a

multivalent concept that has several meanings in Aquinas’s corpus. Duarte Sousa-Lara elucidates

three ways Aquinas uses praeter intentionem, which I explicate in the following.9

First, regarding moral actions and intention, he insists that the agent never intends evil

per se, but praeter intentionem or per accidens. Whenever one commits sin, one chooses a good

with a privation. The will intends the good per se, but the privation accompanies the good,

praeter intentionem. Aquinas uses the example of one eating unto death as an analogy for one

who sins intending a good with an associated evil. Just as the diner chooses, and therefore,

intends the good pleasure associated with eating, not the premature death due to poor health, so

he chooses and intends some good in the sin, not the evil.10 The premature death and damage due

to sin are praeter intentionem. It is only in this sense that one chooses to sin.

Second, praeter intentionem refers to an unforeseen effect or a causally chance

occurrence. Intelligible agents choose what they apprehend. If one errs in apprehension, then one

errs in choosing and intending. For example, if one chooses to drink fruit punch, but instead

drinks poison, the evil of consuming poison is not chosen per se, since it is outside of both one’s

apprehension and intention. The consumption of poison is praeter intentionem. Nonetheless, the

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evil consequences of consuming poison ensue. The agent did not foresee this. Here, praeter

intentionem refers to an accidental event in that it is both unforeseen and occurs by chance.

Third, praeter intentionem, refers to the foreseeable, yet unintended effects of actions.

This concerns Double-Effect Reasoning. More specifically, it concerns intention’s moral

specification of the act. An act receives its species precisely from what the agent intends, not

from its effects.11 As it pertains to Double-Effect Reasoning and self-defense, one may intend to

preserve one’s life; however, one’s action may kill the assailant. Insofar as one does not intend

the latter, it is beside (praeter intentionem) the Moral Object.

In addition to the negative effect being praeter intentionem, Aquinas also insists that the

act of self-defense must be proportionate to the attack.12 By proportionate, Aquinas does not

mean that the ends must justify the means. He is not saying, weighing all possible outcomes, if

the remote end is good enough, one may have a proximate end that is immoral. For instance, in a

hypothetical scenario where a captor threatens to kill five hostages, if one does not kill one

person in exchange for the five, one may not licitly acquiesce. No matter how many people may

be saved—five or a hundred—or how menacing the foe one may not justifiably commit an

intrinsically disordered act. No positive outcome can ever justify one intending an intrinsically

evil act. For Aquinas, proportionality does not mean a change in intention or the Moral Object.

Indirectly, however, the amount of force one uses in self-defense reflects intention, and

therefore, the Moral Object. In this regard, proportionality is a litmus test for Aquinas. For him,

if one uses more force than necessary, this indicates that one’s intention is not one of self-

defense, but murder. The proportionality criterion necessitates that the defender not use more

force than necessary to resist the assailant’s attack. If an assailant attacks with a pillow, it is not

proportionate to resist with a gun.

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Aquinas, following Jerome’s interpretation of Matthew 15:12, asserts that one commits

scandal when one’s actions or words cause another’s spiritual downfall.13 He distinguishes

between active and passive scandal.14 Active scandal occurs in the one who commits a sin that

leads another into sin. Passive scandal occurs in the one led into sin. Ordinarily, active scandal

leads to passive scandal, but one may resist the temptation to scandal, thereby not sinning. In

such a case, active scandal exists without passive scandal. It is also possible to have passive

scandal without active scandal, such as when one’s good deeds are the occasion for another’s

sin.15 For instance, one moved to envy by another’s charity, is an occasion of passive scandal

without active scandal.

Aquinas divides active scandal into two types: direct and accidental.16 Direct active

scandal occurs when one intentionally leads another into sin by one’s sinful actions. Accidental

active scandal occurs when one’s sinful actions unintentionally leads another into sin. In this

accidental case, the scandal is beside the sinful act. In the following article, Aquinas further

clarifies that one may commit active scandal by “doing something that has the appearance of

evil.”17

Aquinas uses Double-Effect Reasoning again in his discussion about women wearing

adorning dress. He acknowledges that women’s dress lead some men to lust; however, he allows

women to adorn themselves if they intend to please their husbands.18 He says “those women who

have no husband nor wish to have one, or who are in a state of life inconsistent with marriage,”

sin if they intend to insight lust in another by their dress.19 Intention is central.

Having elucidated Aquinas’s version of Double-Effect Reasoning, the following

subsection traces its development in his successors.

ii. Antoninus to Gury

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Double-Effect Reasoning evolves through the centuries in articulation and prominence.

Ironically, as it becomes more prominent, it also diverges more from the principles that

undergird it. As the role of the Moral Object diminishes, a causal system replaces it. The focus

shifts from choosing proximate ends to causing effects. This subsection follows the

chronological development of these trends in the following: Antoninus, Cajetan, Vitoria, Suarez,

John of Saint Thomas, and Domingo of Saint Teresa.

According to T. A. Cavanaugh, Antoninus is the first to advance Aquinas’s use of Double

Effect.20 In his Summa theologica moralis, Antoninus returns to scandal and alluring dress.21

Antoninus makes explicit Aquinas’s implicit use of Double Effect to justify women wearing

alluring dress to please their husbands, but unintentionally scandalizing others.22 For Cavanaugh,

Antoninus does with Aquinas’s discussion of revealing dress, what Aquinas does with

Augustine’s killing by self-defense.23 Just as Aquinas permits killing by self-defense under the

umbrella of Double Effect, so Antoninus permits alluring dress, even if it scandalizes another, so

long as she only intends to please her husband or to follow the custom of her status or country.24

Scandal and alluring dress is a hallmark example for discussions on Double-Effect Reasoning.

Another Dominican, Tommaso de Vio Gaetani (Cajetan) writes a comprehensive and

influential commentary on Aquinas’s Summa Theologica in the sixteenth century.25 Joseph T.

Mangan, in “An Historical Analysis of the Principle of Double Effect,” says that for the first 200

years after Aquinas, no significant development occurs for Double-Effect Reasoning until

Cajetan’s commentary on the Summa Theologica.26 Cajetan interprets Aquinas’s Double-Effect

Reasoning in line with contemporary formulations of the Principle of Double Effect.27 Mangan

interprets Cajetan’s understanding of both the means (finis proximus) and the remote end (finis

operantis) to simultaneously fall under one intention.28 But he distinguishes the end from the

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necessary effects of the end. While the end falls under the intention, its effects do not. For killing

in self-defense, the death of the assailant proceeds from the defensive act necessarily as an effect

but does not fall under intention either as a means or an end.29

Cajetan maintains the distinction in Aquinas between one who intends to kill to save

one’s life and one who intends self-defense but kills. An important development, however, is the

awareness of the necessary, causal relationship between the act of self-defense and the death of

the assailant. In I-II, q. 20, a. 5, Aquinas argues that foreseen consequences do increase the

goodness or badness of an act.30 Thus one might conclude that it is only when consequences are

not foreseen that one may refer to them as praeter intentionem.31 Cajetan contests this view in

his commentary.32 He has no qualms about knowing or foreseeing the death of the attacker in

self-defense. This does not change the scope of intention over the Moral Object. For Cajetan,

even though one may know that the act of self-defense is fatal, one may still not intend to kill,

either as a means or an end.

Next, Cajetan broadens the application of Double Effect to include not only self-defense,

but also defense of temporal possessions and spiritual welfare.33 Just as one has a right to self-

defense, so one has a right to defend necessities of life, if no other means exist. Again, the act is

one of defense, with the effect of the death of a thief. Moreover, if one can defend physical life

and property (to the death), then it is all the more important to defend one’s spiritual vitality

(even to death), especially in light of eternal implications.

Cajetan also argues that a judge—personally knowing a man to be innocent—ought to

condemn him to death, if the public evidence convicts him.34Aquinas argues that a judge, acting

as a public person may only use the knowledge available to her as a public person.35 She does

not intend to kill, but acting in the confines of the office, she sentences him to death.

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Cajetan’s monumental commentary on Aquinas’s Summa Theologica transfers the

hermeneutic of theology from commentary on Peter Lombard’s Sentences to Aquinas’s Summa

Theologica.36 The Dominican, Francisco de Vitoria, follows Cajetan’s lead as department chair

of theology at the University of Salamanca. With regard to foreknowledge of the death of an

assailant, Vitoria applies a distinction between choosing and intending to Double Effect, which

Aquinas and Cajetan avoid. Mangan emphasizes the importance of a correct understanding of

intention for a proper interpretation of Aquinas’s Double Effect.37 He argues that his Jesuit

counterpart, Vincente M. Alonso, limits the scope of intention solely to the reach of the remote

end, whereas Aquinas utilizes a broader sense for intention that includes the proximate end as

well.38 John Finnis, in Aquinas: Moral, Political and Legal Theory, highlights the difference

between the narrow and broad sense of intention.39 Generally speaking, the object of choice

corresponds to the means, while the object of intention corresponds to the remote end, but for II -

II, q. 64, a. 7, Aquinas uses the broader sense of intention.40 In the footnote, Finnis points the

reader to Aquinas’s De Malo to illustrate this broader sense of intention, which Aquinas applies

to Double-Effect Reasoning.41 In De Malo, Aquinas offers a hypothetical scenario of one

choosing to steal from the rich to give to the poor.42 He argues that while the person may intend

good, he wills evil. Thus, he concludes, “if we should understand the will by intention, so that we

call the whole, both the end intended and the deed willed, the intention, the intention also will be

evil.”43 For this reason, Aquinas specifically denies one the possibility of intending to kill

another, even for the purpose of self-defense.

Since Vitoria maintains the distinction between choice and intention, he argues that one

may will to kill an attacker in self-defense, but one may not intend to kill him as an end for one’s

action.44 Analogously Vitoria uses the example of a sick man amputating his arm to save his life.

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The man intends to save his life choosing to amputate his arm as a means to good health.45 The

analogy, however, does not hold, because amputating one’s arm is a neutral act. Choosing to kill

another, either as a means or an end is not neutral, but intrinsically immoral. Aquinas’s broader

sense of intention that includes both the means and the end precludes Vitoria’s move to justify

the means by the ends. What exempts the death of an assailant from moral guilt is that it is

beyond the scope of the intention and will altogether, which is precisely what praeter

intentionem means.

Twenty years after Vitoria’s death in 1546, Francisco Suarez begins studies in theology at

the University of Salamanca. Whereas Vitoria neglects the morality of the proximate end for

sake of the ultimate end, permitting one to choose to kill an assailant, Suarez eliminates

discussion of the proximate end altogether. In addition, he introduces vocabulary that opens the

door further to causal morality. Sousa-Lara translates Suarez’s words.46 Suarez concedes that if

one kills another unintentionally, then one is not guilty of per se direct, voluntary homicide,

which means the act is not voluntary in the absolute sense.47 However, as to the cause-effect

relationship, that is, insofar as it is known that one’s action causes the death of another, Suarez

asserts that it is indirectly voluntary, which remains true even if the effect follows per se from

the cause.48 Where the death is accidental, in that it is not foreseen, he argues that it is not

voluntary.

Suarez’s use of ‘indirect voluntary’ is not consistent with Aquinas, who uses indirect

voluntary to describe willing by omission.49 For instance, if one willfully chooses not to save a

person’s life when it is within one’s power to do so, then one kills by omission. The inactive

willing is what Aquinas means by indirect voluntary, but this is not what Suarez means. In fact,

Suarez and other commentators develop Aquinas’s notion of indirect willing to include positive

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acts as well as acts of omission. Afterwards, they apply indirect willing to cases of Double

Effect, with the implication that indirect willing is synonymous with praeter intentionem.

In Aquinas, indirect voluntary connotes culpability, since it is by means of the will

choosing not to act that one commits a sin. However, Suarez and others remove culpability, but

maintain an extrinsic connection to the will. What he says regarding the unintended killing of

another in self-defense illustrates this point: “It is confirmed, on the other hand, that it is

voluntary only in its cause, it is only indirectly voluntary, even if the effect follows necessarily

(per se) from that cause.”50 For Aquinas, however, so long as the will connects with the act,

culpability abides. Praeter intentionem means that the will in no way intends or chooses the evil

effect; thus removing moral culpability.

In addition to substituting indirect voluntary for praeter intentionem and maintaining a

connection of the will to the effect, Suarez also eliminates discussion of the proximate end.

Without any consideration for the proximate end, the first-person perspective of choice that

constitutes an action as voluntary, is lost. The movement of the will as intention and choice give

an external act its moral character. The movement of the will is by definition an internal act,

which can only be known from within the person. By eliminating consideration of the proximate

end, Suarez pushes morality outside the soul into the natural sphere. Consequently, acts are

merely causes chosen for their effects.

According to Aquinas, one may consider one act in two ways: the natural order and the

moral order. Insofar as an act causes an effect that has a corresponding order or disorder in the

natural order it is good or evil on that level. However, for an act to be evil on the moral level, one

must will it as such.51 Recall the above example of unknowingly, and unwillingly consuming

poison. An evil on the natural order occurs, but since one does not will it, it is not a moral evil.

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Recall from the previous chapter that Aquinas considers two movements of the will:

intending and choosing. By intending, the will has as its object an end. Intention guides

choosing. By choosing, the will selects a particular Moral Object, and then commands a specific

external act. Rationally ordered to its end, the will commands external acts by means of the

choice. The object of the choice is the proximate end that intention and the remote end formally

configure, as form to matter in such a way that the will commits one act through intention and

choice.

By way of example, if one kills an assailant, as an outside observer, one does not

necessarily know the agent’s intention. The external act of self-defense in its purely natural

sense—materia ex qua—may look no different than one choosing to kill the assailant. Only the

perspective of the acting person reveals the will. By means of self-revelation, various scenarios

may arise. One, it may become apparent that the agent fully intends to kill the assailant,

regardless of self-defense. Two, the agent may intend to kill the agent, as a means to self-

defense, something which Vitoria and many other commentators have no problem with, but that

Aquinas detests as immoral. Three, the agent may intend to protect one’s self using proportionate

means, that one may or may not foresee leading to the death of the assailant. The first example

differs from the latter two in that the proximate end is murder, not self-defense. Without an

appreciation for the proximate end, the difference between scenarios two and three obfuscates.

Only the first-person perspective reveals the proximate end.

J. Ghoos, in “L’Act a Double Effet Ètude de Théologie Positive,” insists that John of

Saint Thomas (John Poinsot) is the first to put the full version of Double Effect into written form

in his treatise on the fundamentals of moral theology, published posthumously in 1645.52

Cavanaugh speculates that Suarez had little influence on Poinsot.53 Poinsot restricts morality to

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the realm of freedom, both of which he limits to the internal act of intention that he defines as an

act of the will.54 Unlike Aquinas, however, he argues that external acts have no intrinsic

freedom, since the will does not govern them.55 As such, external acts are also devoid of intrinsic

moral quality, but only have it by analogy, in virtue of intention.56 With so much focus on

intention, which includes the ultimate end, morality becomes more about causing acts for their

effects. Ghoos illustrates this inclination by explicating the inchoate criteria of Double Effect in

Poinsot’s writing. First, one must not intend the harmful consequences.57 Two, the bad effect

cannot be the proper effect of the intentional object.58 Three, the good effect must offset the

negative.59 As with Suarez, Poinsot has no account for the distinction between the proximate and

remote end. Acts are about causing effects. Like his predecessors, he applies Double Effect to

new and old examples: a butcher selling meat to a Jew who uses it for idolatrous worship; a

priest who distributes communion to one having made a sacrilegious confession; and killing in

self-defense.60

Mangan, argues that Domingo de Saint Teresa writes the most important articulation of

the Principle of Double Effect in his Treatise on Sin in the 1647 Carmelite publication of Cursus

Theologicus.61 The Salmanticenses use four criteria of Double Effect to justify situations of illicit

sensual pleasure.62 Domingo maintains the causal language dividing the principles between

causes per se and causes per accidens. The first assertion prohibits causes per se that have only

unlawful effects or bring about good effects only as a consequence of the unlawful effect.63 The

second assertion permits causes per se that have an evil effect, if and only if, the good effect is

either simultaneous to or precedes the evil effect.64 Third, there must be a proportionately good

reason for performing the act that cannot otherwise be avoided and one must not be able to

prevent the evil effect.65 Finally, they advise one to weigh the act in relationship to the virtues

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that it opposes.66 Not all virtues oblige in the same way. If act conforms to a virtue higher than

the evil effect it opposes, one may commit it.

Aquinas’s successors broaden the application of Double Effect; eliminate the distinction

between the proximate and remote end; and externalize moral deliberation. The following

subsection examines a manualist’s construct of the Principle of Double Effect.

iii. Jean Pierre Gury

Mangan argues that Jean Pierre Gury is the first to articulate the Principle of Double

Effect as a theory applicable to the rest of moral theology in his Compendium theologiae

moralis.67 Christopher Kaczor, in “Double Effect Reasoning from Jean Pierre to Peter Knauer,”

indicates that many consider Gury to be the leading casuist of the 19th century.68 Because of his

important role in Catholic moral theology, and his development of the Principle of Double

Effect, this subsection explicates his version. In particular, it highlights the implications of

Gury’s cause-effect morality in contrasts to Aquinas’s intention-focused morality. Gury

publishes the first of 17 editions in his lifetime of the Compendium in 1850.69 I use the 17th

edition since it presumably represents his most mature formulation.70

In the first tractatus, De Actibus Humanis, Gury discusses human acts and willing. Here,

he explicates the Principle of Double Effect in number nine of chapter 2.71 First, recalling

Aquinas’s Summa II-II, q. 64, a. 7, he argues that it is morally permissible for there to be a

situation where two effects follow immediately from a good or indifferent cause, one good and

the other truly bad, if there is a grave reason, and the end of the agent is honorable.72 Unlike

Aquinas, but very much like his causal predecessors, Gury identifies human acts as posited or

actualized causes.73 This concise statement says a lot in just a few words. First, if one concedes

that positing causes is at least analogous to intending ends, then like Aquinas, Gury argues that

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some causes are good or indifferent in themselves—and conversely, some are intrinsically evil—

independent of the end of the agent. Given the complexity of the world, he, like Aquinas

recognizes that multiple effects may proceed from any given cause (or act), some good and some

bad. Third, not all of these are intended equally. Indeed, for Aquinas, some may not be intended

at all. Fourth, the immediate following of the effects indicates that the good and bad effects are

causally independent. In other words, the bad effect does not cause the good effect. Fifth, he

holds that a grave reason must proportionately justify positing the cause in light of the evil effect.

Put another way, the good effect needs to outweigh the bad effect. Finally, he insists that the

agent must not intend the bad, but the good effect.

Similar to an argument reductio ad absurdum, Gury logically reasons that the above

statement must be true, otherwise one would be sinning by: one, intending the bad effect; two, by

positing the cause itself; or three, by foreseeing the evil effect.74 Regardless of how good the end

is for which one acts, the act would be unlawful simply because of the evil effect. Two,

regardless of the intrinsic moral quality of the act, the evil effect means that one sins simply by

positing it. Three, if one foresees that an evil effect will occur, then the act is definitely sinful.

All of these absurd conclusions are true if the criteria of the Principle of Double Effect are not

true. Therefore, in order to avoid this absurd reduction to sin, they must be true.

Notice that the above conditions essentially reduce morality to a form of

consequentialism. Cconsequentialist ethical theories run aground of rendering all of the above

conditions true. If one only considers consequences, then only effects matter. Such ethical

theories externalize acts rooting moral quality in consequences. If an action leads to a negative

consequence, then it is sinful and ought not to be done. This is truer if one foresees evil effect.

The only thing that saves a consequentialist theory from absurdity is the criteria of

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proportionality that capriciously weighs effects against effects. This is the basis of Gury’s fourth

criterion.

Gury explains why each of the absurd conclusions is false in the first of two etenim. One,

since the end is good, it is not on account of it that the act is unlawful.75 Two, since the cause is

good or indifferent, positing it does not render the act unlawful.76 Gury relies on more than

effects to justify his ethical theory. Three, foreseeing the evil effect does not render it immoral,

because it is at least offset by the good.77 Mangan, following the fifth German edition translates

this as “not on account of the foreseeing of the evil effect, because in the hypothesis the evil

effect is not intended but merely permitted.”78 Apparently, later editors alter this third criterion

according to a distinction between permitting evil versus intending evil. Permitting still has a

connotation of willing. Aquinas’s praeter intentionem is completely separate from the will,

thereby exonerating the agent of any culpability. Fourth, where the bad does not overpower the

good, one has a right to obtain a good end from the honorable cause.79 In summary, he insists

that all four of the above conditions of Double Effect must hold: 1) the end of the agent must be

honorable; 2) the cause of the effects must be good or at least indifferent; 3) the evil effect must

not be the means to the good effect; and 4) there must be a proportionately serious reason for

positing the cause that does not contradict an obligation of virtue such as justice or charity.80

Finally, in the second entenim, Gury explains each of the four conditions in greater detail.

First, the end of the agent must be good; one must not intend the bad effect, otherwise one sins.81

As with Vitoria and Suarez, the broader sense of intention, that includes the proximate end, is

lost. The proximate end is entirely assumed into the remote end.

Second, Gury insists that the cause must be good or at least indifferent, that is as an act it

must not oppose any law.82 Obviously, if the cause is evil in itself, the action is imputable to the

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agent as a fault.83 Again, the concept of the will choosing a Moral Object (proximate end) is lost.

Gury replaces this with the positing of external causes. The causes externally imposed laws.

There is no sense that the will chooses rationally ordered object of the moral order; rather, one

posits a cause in natural order. While intrinsically evil acts may exist, they exist externally to the

soul. Understood as causes, acts follow laws on the natural order discoverable through trial and

error. Constituting moral theology externally, he lays the foundation for teleological ethical

theories.

Third, the bad effect must not be the means to the good effect, since this is causing an

evil effect for the sake of a good effect.84 For Gury, actions involve causing effects. Sometimes

effects cause other effects. As such, one must not cause an evil effect for the good effect that

results. Gury’s causal expression fails to encapsulate Aquinas’s prohibition of choosing evil

means for a good end. This is because, for Aquinas, the Moral Object is not merely an external

effect, but an object of the moral order that the will deliberately chooses.

Fourth, Gury argues that the positive effects must proportionately outweigh the negative

to justify actuating the cause.85 Kaczor astutely notes that for Aquinas the law of proportion

regarding Double Effect weighs the act in relationship to the end, while Gury weighs effects to

effects.86 Recall that for killing in self-defense, the question is about the means chosen to repel

an attacker. If the attacker is using deadly force, then one may justifiably choose deadly means

for self-defense; not, however, to justify choosing the evil of murdering an assailant. According

to Gury, the implication is that so long as the good effect (staying alive) outweighs the negative

effect (death of the assailant), one may justifiably kill the attacker.

Gury’s formulation of the Principle of Double Effect is the culmination of his

predecessors’ casuistic and causal morality. Like Suarez, he abandons the distinction between the

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proximate ends and ultimate end. His construct maintains the cause-effect terminology of

Domingo de St. Teresa. Since willing is about positing causes, he inadvertently equals laws of

morality with laws of nature and shifts the focus of moral decision making to the perspective of

the outside observer. Finally, his understanding of proportionality, which constitutes the

weighing of effects paves the way for Peter Knauer’s proportionalism, which the following

subsection discusses.

iv. Peter Knauer

Peter Knauer, in “The Hermeneutic Function of the Principle of Double Effect,” says that

the Principle of Double Effect is not only an important principle for morality, but also the most

fundamental of all the principles of moral theology.87 His paper is groundbreaking because it

represents the inauguration of proportionalism, an important movement in moral theology that

peaks in the late twentieth century under the advocacy of the American theologian Richard

McCormick, before Pope John Paul II condemns it in Veritatis Splendor.88 This subsection

elucidates Knauer’s articulation of Double Effect and its subsequent role in proportionalism.

Knauer argues that the ‘simply good’ or a physical goodness desirable in itself is

precisely what is morally good too.89 He holds that the will intends the ‘simply good,’ distinct

from any evil.90 Obviously, evil constitutes part of reality, but one does not will evil directly, but

only in association with some good.91 Like his predecessors, he explains human action in terms

of cause and effect. Similar to Gury, he also uses the concept of permitting evil effects. Since

actions cause good or evil, Double Effect aids one in justifying the causing of evil effects.

Knauer, attempting to avoid modernist tendencies of relativism that subjective arbitration

risks, attributes an objective morality to Aquinas. He sees a direct correlation between what one

intends and the external world in which acts produce effects. For this reason, he argues that the

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Moral Object (proximate end) is ‘the end of the work’ (finis operis), also the effect of the act in

the world.92 Knauer equates the effect with the Moral Object.93

Knauer realizes that for an action to be moral there must be some connection between it

and the will or intention, otherwise one simply identifies the effect with the external, physical

act.94 Intention morally qualifies act. But it must be objectively grounded; so, he roots the good

(or evil) of an intention in the physical, external world. He says, “all physical evils which are not

justified, and which arise in pursuit of a value, are in the moral sense eo ipso morally intended

and belong to the finis operis itself.” In other words, the will intends physical evil in the world.

Knauer maintains this position, not only to objectively ground morality, but also because

he believes that a consistent reading of Aquinas demands it. He refers the reader to I-II, q. 1, a. 3

and to I-II, q. 18. 95 In I-II, q. 1, a. 3, Aquinas says that acts receive their species from their end.96

He further indicates that only acts proceeding from a deliberate will are human.97 In addition, the

object of the will is the good and the end, but the end is the principle of human acts.98

In the answer, Aquinas does not explicitly specify the nature of the end. Since the

discussion of passions and heat immediately precedes his discussion of human acts, it is

understandable how one could interpret ends physically. But Aquinas, referring the reader to the

first article, clearly distinguishes purely physical, involuntary acts from distinctly human acts

that proceed from the deliberate will.99 If this is not enough, he eliminates further confusion in

his response to the second objection, when he says, “the end, insofar as it pre-exists in the

intention, pertains to the will.”100 That is, the ends of human acts originate in the will. Therefore,

the disorder of an intrinsically evil act corresponds more to a privation in the deliberate act of the

will, than any evil effect in the world. Basing morality in the subject person does not detract

from the objectivity of Aquinas’s ethical theory, since he roots it both in Natural Law and the

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human person. It does, however, mean that the moral order is not the same as, nor derivative of

the natural order.

Regarding the role of the remote end (finis operantis), Knauer insists that it too must not

merely be in the will, but must correspond to the external end.101 What has been said above in

this subsection regarding ends of the will and the broad sense of intention in response to Vitoria

in the second subsection, suffices to clarify that moral ends are not derivative of the natural

order, but the moral order. Moreover, moral ends do not depend so much on their external effects

as the orientation of the will.

Because of the strong correlation between the effects of an act and the intention of the

will, Knauer equates the proportion of the intention of the act to the end in Aquinas to the

contemporary formulation of commensurate reason.102 Since Knauer equates the object of

intention with effects, he like Gury considers the criterion of proportion to be about the weighing

of effects, not the proportioning of intention to a remote end, as a good rationally ordered by the

intellect and intended by the will. Knauer asserts “that an evil effect is not ‘directly intended’

only if there is a ‘commensurate reason’ for the act.”103 Put another way, one may cause an evil

effect if there is a commensurate reason.104

Knauer links his distinction between direct and indirect to three other aspects of

traditional moral theology: 1) formal and material cooperation in evil; 2) intrinsic and extrinsic

acts; and 3) negative and affirmative laws. He argues that once one applies the Principle of

Double Effect to the formal and material cooperation in evil the distinction between the two

becomes the same as direct and indirect, respectively.105 While formal cooperation in evil always

constitutes a direct willing of evil, where commensurate reason abides material cooperation in

evil constitutes indirect willing of evil.106

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Knauer makes a distinction between intrinsically evil acts and extrinsically evil acts. He

claims that intrinsically evil acts are always forbidden, while he permits extrinsically evil acts

where there is commensurate reason.107 By intrinsically evil acts, Knauer does not mean the

same thing as Aquinas. For Aquinas, intrinsically evil reflects a disorder in the will’s intending

of a proximate end that can never be rationally ordered to the good. For Knauer, the only

difference between the two is that an intrinsically evil act constitutes an extrinsically evil act

without a commensurate reason.108 With the application of Double Effect or commensurate

reason, the distinction between the two reduces to the difference between direct and indirect

causing of effects.

Finally, Knauer argues that the difference between a negative law and an affirmative law

consists in its obligation to the agent. He insists that negative laws are always obligatory, no

matter what, whereas, affirmative laws are obligatory, unless one has a commensurate reason not

to obey them.109 Relating these to causality, he asserts whenever one violates a negative law, one

directly causes evil, which is always prohibited.110 However, one may licitly violate the

affirmative law causing evil indirectly, if one has a commensurate reason.111 Regarding natural

law, he argues that the only unchanging norm is the obligation “to seek the best possible

solutions in their total existential entirety.”112 This clearly links Natural Law and morality to the

natural order through effects.

Ultimately, for Knauer, the Principle of Double Effect “means that to cause or permit an

evil without commensurate reason is a morally bad act.”113 Without a commensurate reason, the

evil is no longer accidental to the intention of the person, but becomes the Moral Object.114

Whenever a commensurate reason exists, it occupies the place of the Moral Object and alone

determines the moral quality of the act.115 To illustrate he argues that when killing in self-

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defense, the commensurate reason constitutes self-defense. Knauer insists that a commensurate

reason is not just any reason whatsoever, but must outweigh the evil in exchange for the good in

such a way that it is not contrary to nature.116 Whenever one wills evil directly, that is without a

commensurate reason, one intents something in such a way that it cannot be achieved according

to nature. This is precisely what constitutes sin as being contrary to nature. In other words, one

permits or causes a physical evil, without a commensurate reason.

Several things are apparent from the above discussion regarding Double Effect and

commensurate reason. According to Knauer, moral quality derives from the natural order as an

effect, which constitutes the Moral Object. Furthermore, whenever a commensurate reason

exists, evil is accidental or caused indirectly, which is what he means by praeter intentionem.

This is contrary to Aquinas’s understanding of praeter intentionem that means outside the will

altogether. For Aquinas, one does not will the evil at all, either directly or indirectly.

By rooting moral quality exclusively in the end, either as effect or commensurate reason, he

affirms that ends do justify means. This is the hallmark of proportionalism. So long as one has a

sufficient reason, one may use any means to achieve one’s end. Indeed, he rejects ethical theories

that render an act evil merely because of means.117 If the means are not good enough, it is simply

because one does not have a commensurate reason.118 With sufficient commensurate reason, one

can justify the causing of virtually any evil. For this reason, proportionalists, like Knauer deny

Aquinas’s version of intrinsically evil acts.

In summary, like his predecessors, Knauer maintains the external orientation of the action

with a focus on direct and indirect causing/permitting of effects. Moreover, to maintain

objectivity, he grounds morality in the natural order. He dissolves the distinction between the

proximate and the remote end with his proportionality criterion that justifies the any means for a

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good end. The following section contrasts the proportionalist’s version of the Principle of Double

Effect with that of non-consequentialists.

3B. Contemporary Formulations of the Principle of Double Effect

In Veritatis Splendor, Pope John Paul II rejects components of teleological ethical

theories including proportionalism.119 This section explores contemporary formulations and

applications of Double Effect by several authors. First, it explicates John Finnis, Germain Grisez

and Joseph Boyle’s use of Double Effect in defense of craniotomy in “‘Direct’ and ‘Indirect’: A

Reply to Critics of our Action Theory.”120 Second, it highlights the distinction between intending

and foreseeing, which T. A. Cavanaugh, following G. E. M. Anscombe argues is a difference

between practical and speculative knowledge, respectively.121 Third, it explores several practical

applications including: euthanasia/terminal sedation, terror bombing/tactical bombing, and

craniotomy/hysterectomy.

i. Finnis, Grisez and Boyle: Defending Craniotomy

Finnis et al., in “‘Direct’ and ‘indirect’: a Reply to Critics of Our Action Theory,” offer

eight cases that illustrate the intuitive veracity of their action theory, which incorporates the

perspective of the acting person, in common language.122 Next, they offer a proper account for

the role of intention with regard to the perspective of the acting person.123 Finally, they

demonstrate how this perspective may justify a physician performing a craniotomy.124

a. Eight Cases that Illustrate Intention

Finnis et al. use eight cases to show that intention, and therefore, the perspective of the

acting human person is important for moral determination.125 The first case consists of a boy who

decides to forgo his lunch, choosing instead, to buy a toy airplane with his lunch money.126 This

first case demonstrates that action consists of a choice for a particular proposal among several

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options.127 Here, the boy, both intends to carry out the chosen proposal, and to attain the purpose

of the act.128 By choosing to the buy the airplane instead of lunch, he experiences hunger.129 But

he does not intend the hunger; rather, he tolerates it as an unintended side effect.130 This shows

that actions often have unintended consequences.131

In the second case, a patient succumbs to a rare, but fatal side effect of his blood pressure

medication.132 This illustrates that one does not necessarily intend bad side effects, even when

one foresees and causes them through one’s actions.133 In the third case, a man chooses to drive

home drunk, rather than to take a cab or stay at his friend’s house; consequently, he hits and kills

a bystander.134 This demonstrates that even though one may not intend negative side effects, one

can still be morally responsible for them.135 The fourth case, a stuttering witness testifying on

behalf of a defendant, demonstrates that one’s behavior in acting may constitute a side effect

preceding both one’s intended action and purpose.136

The fifth example, a farmer castrating bulls to fatten them up, shows that observable

context is not enough to determine what a person is actually intending to do.137 As an outside

observer, one may conclude that the farmer is sterilizing the bulls for the purpose of making

them infertile. Only the perspective of the acting person determines whether a consequence

constitutes a side effect or the purpose for one’s action.138 The sixth case, upsetting the minority

by commending an unpopular outgoing president, shows that even when one’s behavior

constitutes the choosing, doing and purpose of an act, there may be side effects distinct from

it.139

The seventh example consists of a company director choosing when to halt production to

retool, based on both a slight financial gain and the ability to undermine unionization.140 This

shows that foreseen effects may not be the reason one chooses, even when doing so looks no

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different from the outside.141 Finally, the eighth case is a spy who kills his beloved guest for the

purpose of silencing her.142 Although the spy kills the guest for the purpose of silencing her, this

ulterior motive does not detract from the fact that he intends and chooses to kill her. This

highlights the important perspective of the acting person, which indicates what the person

intends by an action.143

Finnis et al. conclude that the above examples demonstrate the important role of intention

from the first-person perspective. Moreover, although the emphasis in ethics and law denigrates

its significances as of late, it remains, as it has throughout history, an important component for

moral decision-making.144 Unfortunately, Bentham’s utilitarianism conflates what one foresees

with what one intends.145 Finnis et al. refer the reader to contemporary jurisprudence that

maintains a distinction between intended and unintended actions.146 That is not the same as

saying that there are no consequences for one’s actions, if the consequences are not intended.

The third case of the drunk driver killing a pedestrian proves this.147

b. Perspective of the Acting Person

Finnis et al. demonstrate the importance of the perspective of the acting human person for

an adequate account of Aquinas’s action theory that also conforms to John Paul II’s critique of

proportionalism and defense of the Moral Object in Veritatis Splendor.148 Following the

perspective of the manualists and Enlightenment philosophers, proportionalists continue to focus

on the third-person perspective regarding morality.149 As the above cases demonstrate, the

observer’s perspective does not adequately account for intention, especially regarding the Moral

Object. In the previous section, I highlight a distinction between the broad and narrow sense for

intention that Finnis elucidates in his reading of Aquinas’s De Malo.150 The broad sense of

intention includes both the proximate end and the ultimate end; however, more narrowly

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understood, it constitutes only the ultimate end.151 Much confusion arises from the failure to

distinguish between the broad and narrow understanding of intention. Finnis et al. indicate that in

Veritatis Splendor, John Paul II uses the term intention in the narrow sense.152

In the broad sense of the interpretation, intention is important insofar as the Moral Object

constitutes the willing or intending of a means for an end. The Moral Object that one wills is

what the person chooses through a deliberate will.153 Only the perspective of the acting person

enables one to identify the Moral Object, which is the primary determinant of an acts morality.154

Actions that have a Moral Object contrary to the good constitute intrinsically evil acts or

exceptionless, non-tautological negative norms.155

Finnis, in Moral Absolutes: Tradition, Revision, and Truth explains Aquinas’s defense of

exceptionless moral norms.156 Augustine, in Contra mendacium argues that there are at least two

exceptionless moral norms: lying about the faith—even to catch heretics—and adultery.157 In

response to this, Peter Abelard argues that the moral quality of an act depends entirely on

intention.158 Perhaps inadvertently, readers accuse him of denying the existence of intrinsically

evil acts.159 For instance, Peter Lombard, in his Sentences argues that certain acts are wrong in

themselves (mala in se) precisely because they do not depend on the purpose, will, intention or

motivation of the acting person.160 In his commentary on the Sentences, Aquinas argues that

intrinsically evil acts are wrong precisely because of the acting person’s will, intention and

purpose.161 Even if the intentions and circumstances are good, the object can be wrong insofar as

the will’s choosing of it is wrong.162 For instance, lying to catch a thief is wrong because one

cannot deliberately will or choose to lie in a good way.

Intention, understood in the broad sense, includes both, the choosing of a Moral Object

(proximate end), and the intending of an end (remote end); the difference being one of proximity

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to the acting agent.163 Insofar as one chooses a particular action for a given end, the former

constitutes the proximate end, while the latter is the ulterior (or remote) end.164 Although there

may be no chronological distinction between an agent’s choosing a proximate end and intending

an ulterior end, the former has greater proximity to the agent, insofar as the will deliberately

chooses that action.165 In this sense, the proximate end acts as a means to the ulterior end.166 If

the proximate end violates an exceptionless moral norm, then it’s object is immoral and ought

not to be done. Moreover, the quality of the ulterior end or circumstances cannot change this.

c. Debunking Unsound Arguments against Craniotomies

Having established the use of intention according to their action theory, Finnis et al.

utilize it to debunk so-called unsound arguments against craniotomies.167 In particular, they

reject the cause-effect approach to morality that presumes a third-person perspective.168 To this

end, they reject seven traditional arguments against craniotomies.169 First, they rebuff the

argument that a craniotomy just is killing a baby, precisely because this presumes an outsider’s

perspective, constitutive of the cause-effect approach to morality.170 Such an argument presumes

that the species of the act consists of the natural order; however, Aquinas specifically places the

character of the moral act in the moral order.171 Second, they reject any claim that “since the

procedure alone does not help the mother, it may not be done,” since such an assertion, once

again, restricts morality to the physical domain.172 Third, the physical dissimilarity to removing a

gravid uterus is not enough to constitute an ethical difference.173 Alternatively, the physical

similarity to partial-birth abortion, does not render the proposal the same.174 The permissibility of

an alternate procedure that squeezes the skull without crushing it, points to the fact that the

physical act alone does not characterize the object.175 While alternatives, allowing the mother

and child both to die and the death of the child through craniotomy are repugnant; Finnis et al.

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argue that the exceptionless moral norm prohibiting the killing of the innocent does not exclude

craniotomies.176

Finally, Finnis et al. assert that just because a procedure cannot be safely taught or done

does not mean that it is immoral.177 For clarity, however, they accept the Church’s teaching

against the direct killing of the unborn.178 They argue, however, that a craniotomy does not

constitute direct killing.179 Moreover, one may assert that craniotomies are immoral, but they

insist, not because it constitutes direct killing.180

d. Defending Craniotomies

Next, Finnis et al. rebut an argument which Kevin F. Flannery makes asserting two

physical differences between a hysterectomy of a pregnant woman with uterine cancer versus a

craniotomy.181 First, the physician performs the hysterectomy on the woman, and the craniotomy

on the child.182 Second, descriptively, the hysterectomy does not necessitate the death of the

child according to its definition, while the craniotomy does. To the first objection, Finnis et al.

argue that direct physical action does not entail direct killing of the innocent, as countless

examples indicate.183 For instance, in self-defense, the defendant may kill the assailant using

direct physical means, but this does not equate to direct killing of the innocent as the adopted

moral proposal. Regarding the second, they insist that what counts for moral analysis is content

of the proposal the agent actually adopts, not what an outside observer may ascribe to it.184

Accordingly, they assert that their description of a craniotomy does not include killing a baby.185

In “Natural Law mens rea versus the Benthamite Tradition,” Flannery says that

performing a hysterectomy on a pregnant woman’s cancerous womb needlessly early changes

the act to direct killing.186 Finnis et al., however, insist that although failing to wait a few weeks

to save the baby constitutes an injustice to the baby and homicide, it does not then become direct

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killing.187 Similarly, a bomber proposing to explode an aircraft in flight to collect insurance on

the aircraft kills the passengers only indirectly.188 They contend that asserting that neither case

constitutes direct killing does not detract from the grave moral wrongness of the acts.189

Finnis et al. refute the allegation that their moral theory depends on the criterion of the

indivisibility of performance, which Jean Porter concludes is of central importance for them in

“‘Direct’ and ‘Indirect’ in Grisez’s Moral Theory.”190 Recalling the rebuttal to the second

illusory argument in section III—crushing the skull alone does not suffice, but that removal of

the body must follow—they reiterate the insignificance of the inseparability of the primitive or

physical act.191 Again, what matters for the moral determination of the act is what one actually

proposes as a means to one’s end, not what one could propose.192 Porter argues that the weakness

of their action theory is the inability to actually know what the agent is, in fact, choosing.193

Indeed, such a weakness, she argues, enables one to substitute motives after the fact.194 For

Finnis et al., the apparent lack of objective from the third-person perspective, does not equate to

an actual lack of objectivity.195 Regardless of what may be ascribed by one’s self or an outside

observer after the fact, the means chosen at the time of deliberation objectively are what they are;

and the conscience of the agent testifies to this.196 Moreover, in contrast to what Porter infers on

Grisez, namely that the intention be understood psychologically and logically, they assert that

both are irrelevant since the object chosen constitutes a proposition rationally configured to some

intended good end.197 While emotions motivate, they do not constitute what one actually does,

which is a product of practical reason.198

Using the example of killing in self-defense and euthanasia, Porter reveals her inability to

distinguish between the intended end and the accepted side effects.199 Indeed, the statement

regarding self-defense, “attempt to kill again,” and the example of a physician’s botched attempt

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to euthanize a patient, indicate that the respective agents actually chose an immoral means from

the beginning, namely to kill.200 What makes killing in self-defense permissible is precisely the

agent’s intent not to kill, but defend one’s self, even if one foresees the death of the agent.

Likewise, intention distinguishes euthanasia from sedation to relieve pain that expedites the

dying process. In both cases, death constitutes an unintended side effect, not the end for one’s

action.

Finnis et al., utilizing an action theory based on perspective of the acting person, defend

their view that the object of the act in performing a craniotomy does not constitute direct killing,

but the reducing the dimensions of the cranium, of the child, which indirectly or unintentionally

leads to the death of the child. They contend that their opponents’ failure to grasp the soundness

of their argument constitutes an inability to understand the complexity of their theory. Two

errors stand out, one, they reduce the means to the external, physical act alone, or two, they fail

to differentiate the object from the unintended side effects. The following explores the intended

versus the foreseen in greater deal from the perspective of T. A. Cavanaugh.

ii. A Thomistic Response to Finnis, Grisez, and Boyle

T. A. Cavanaugh in, Double-Effect Reasoning: Doing Good and Avoiding Evil, addresses

Finnis et al.’s perspective on craniotomies.201 Essentially, Cavanaugh argues that their inability

to arrive at the conclusion that craniotomies constitute direct killing amounts to relegating the

moral realm to the conceptual realm to such a degree that not only is each person’s moral

deliberation incommunicable, but a disconnect exists between the mind and the external

world.202 Cavanaugh asserts that they fall victim to H. L. A. Hart’s critique of rendering what

constitutes a contingent connection merely conceptual.203 In his discussion regarding self-

defense, Aquinas says, “An act may be rendered unlawful, if it be out of proportion to the

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end.”204 By implication, if the means chosen is not proportionate to the end, one may correctly

conclude that the Moral Object is immoral. For instance, if one intentionally uses more force

than necessary to repulse an assailant’s attack, this may indicate a Moral Object of murder, not

self-defense. Moreover, it is not necessary to conclude this merely from the first-person

perspective. In other words, a third-person perspective on action does say something about an

agent’s intention.

Finnis et al., utilizing the writings of John Paul II, argue against using the third-person

perspective to determine another’s intention: “the truth about what is intended and being done is

available, primarily if not exclusively to the acting person in that acting.”205 Ostensibly this is

because it caves to the teleological tendencies that John Paul II condemns.206 Such a subjectively

grounded method risks relativism. While it may be true that what one actually deliberates,

chooses and carries out in choice is known primarily, if not exclusively by the acting person, if

one cannot communicate this in words or behavior, then nothing prevents one from covering

one’s actions with lies. Cavanaugh indicates that language constitutes one means of

communicating intention, but the body, in its behavior does so too.207 For instance, regarding

adultery, John Paul II in Man and Woman He Created Them: A Theology of the Body says, “The

body tells the truth through faithfulness and conjugal love, and, when it commits ‘adultery’ it

tells a lie, it commits falsehood.”208 Not with standing differences, confusion and ambiguity in

language and behavior, an objective truth, whether of the moral order or the natural order is

certainly communicable.

The dilemma seems to abide between the role of the Moral Object and its relation the

exterior act. Duarte Sousa-Lara discusses the relationship between the interior (internal) act and

the exterior (external) act in relationship to the proximate end in “Aquinas on Interior and

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Exterior Acts: Clarifying a Key Aspect of His Action Theory.”209 Following Aquinas’s

articulation of exterior acts in De Malo, Sousa-Lara indicates, “exterior acts belong to the genus

moris [Moral order] only insofar as they are voluntary.”210 Conceptually, one may abstract the

voluntariness from the exterior act, which constitutes the materia ex qua, also called the material

element of the human act or the primitive act.211 Alternatively, the materia circa quam is the

proximate end (Moral Object) and the object of choice.212 Sousa-Lara, following Martin

Rhonheimer and Finnis et al., argues that the materia circa quam, links the soul of the act

(proximate end) to the body of the act (materia ex qua).213 Moreover, in this regard, the materia

circa quam already has a formal element, a rational good able to move the will.214

Manualists, proportionalists and many Thomists interpret exterior acts merely as the

physical acts commanded by the will.215 Such an interpretation renders the exterior act devoid of

rational configuration to the good, in which case the connection between the physical act in

natural order and the moral act in the moral order is tenuous at best. The third-person

perspective, being speculative in nature, only reveals the natural order. For this reason, many

Thomists insist that one needs more than a third-person perspective to determine intention.

Sousa-Lara takes Aquinas to relate the interior act with intention and the remote end.216 In

addition, the exterior act refers to the choice, the proximate end, and the commanded act.217

Thus, a connection occurs between the natural and moral order in the exterior act.

For intrinsically evil acts, Aquinas insists that an inappropriate or unsuitable matter

abides, which the will chooses.218 This matter is the Moral Object, suitable or unsuitable in

relationship to reason219 and the human person.220 Insofar as the will deliberately chooses the

inappropriate matter, a disorder abides within the will itself.221 The will externalizes the

disordered choice by commanding the act. Again, insofar as the external act is voluntary, it

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retains its connection to the moral order.222 As a commanded act, the exterior act manifests in the

natural order. Thus, a connection abides between the practical and ontological. In “‘Materia ex

qua’ and ‘Materia circa quam’ in Aquinas,” Sousa-Lara indicates that the physical act limits the

range of possible Moral Objects.223 For example, there are only three possible Moral objects for

coitus: marital love, fornication, or adultery. While an outsider’s perspective can limit the

options, only the first-person perspective indicates which Moral Object one chooses.

Practical reason does not formulate the Moral Object in a conceptual vacuum. John

Abraham Makdisi in his dissertation, “The Object of the Moral Act: Understanding St. Thomas

Aquinas Through the Work of Steven Long and Martin Rhonheimer,” following Aquinas shows

how circumstances on the natural order can impact the moral order.224 As the third criteria for

determining the morality of an act,225 circumstances are of the natural order that add to or detract

from the morality of an act only accidentally, but do not change the Moral Object.226 However, if

one chooses that which is a circumstance in another act as the reason for acting, then it

determines the Moral Object.227 For example, if one chooses lethal means to rebuff a non-lethal

attack, then the Moral Object is not self-defense, but murder. In addition, if a couple engaging in

the sexual act are not married in natural order, then the act cannot be one of marital love. So long

as both freely choose it, the Moral Object must be either fornication or adultery.

That the natural order limits the range of possible Moral Objects does not detract from

the primacy of the first-person perspective in morality.228 Indeed, the above demonstrates the

unique importance this plays for Thomistic action theory. It does; however, mean that since some

external behaviors correspond with certain intentions, one may attain a closer awareness, even if

not perfect, about what the acting agent intends. Though he does not word it in such terms,

Cavanaugh rightly demonstrates that the conceptual disconnect between the practical choice and

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the contingent physical behavior of crushing a child’s skull in a craniotomy clearly and

unambiguously manifests a direct intent to kill.229 As a subsection demonstrates below, while

one may make a conceptual distinction between crushing the skull of a child and killing it, the

effect so intimately connects with the act it is a constitutive part of the intent, not a foreseen

effect.230 The following subsection differentiates terminology for the Principle of Double Effect.

iii. Intended and Foreseen in T. A. Cavanaugh

This subsection elucidates Cavanaugh’s distinction between intending and foreseeing.

a. Double-Effect Terminology

In Double-Effect Reasoning: Doing Good and Avoiding Evil, Cavanaugh argues for the

distinction between intended and foreseen, as opposed to alternative formulations: intended/side

effect, direct/indirect, or intended/unintended.231 Cavanaugh dislikes the use of side effect

because it implies that it has no ethical significance.232 Moreover, he asserts that proponents

often insinuate that bad side effects are less bad, and therefore, permissible to allow.233 This is

precisely what foreseen avoids.234

In addition, the direct/indirect distinction is ambiguous and leads to confusion.235 The

confusion arises because one may use direct or indirect in reference to intention or cause, which

mean very different things.236 For instance, in self-defense, one may use force, that directly

causes harm to one’s assailant, but one does not intend it directly, but indirectly. In contrast, one

may directly intend to harm another through an action that only does so causally indirectly.

Cavanaugh insists that permitting, allowing and accepting do not suffice to describe the

foreseen, yet unintended.237 Once again, it fails to capture the distinction between intending and

causing. For instance, in passive euthanasia, one intentionally omits action, causally permitting,

allowing, and accepting the patient to succumb to the dying process to relieve suffering.238

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Causally, the agent does nothing, allowing, permitting, accepting, the process of dying to

proceed unhindered. However, intentionally, the agent intends for the patient to die.

Cavanaugh dislikes the intended/unintended distinction as well, because as Finnis

indicates unintentional implies accidental or lack of foresight.239 Logically, unintended is not

necessarily the contrary of intended insofar as it may mean both intending-not-to-x and not-

intending-to-x.240 Only the latter is the contrary to intending.241 Ultimately, Cavanaugh

concludes that an important distinction for Double Effect is intended/foreseen, where the latter is

not intended.

b. Intention/Foreseen Distinction

Cavanaugh argues that certain actions inexorably have a malevolent intention attached to

them: euthanasia, terror bombing, and craniotomy.242 One cannot commit these actions without

intending harm. At the same time, this does not mean that agents cannot intend harm by actions

that do not necessarily have evil intentions linked to them, such as, terminal sedation, tactical

bombing and hysterectomies.243 Put another way, one cannot choose euthanasia, terror bombing

or a craniotomy as a means to an end without intending harm. Though malicious intent is not

inexorably linked to terminal sedation, tactical bombing and hysterectomies, one may

nonetheless intend harm choosing them as a means to an end—good or bad.

Cavanaugh asserts, with G. E. M. Anscombe that changing the direction of intention does

not thereby render one’s act devoid of intention.244 In other words, one cannot simply redirect

one’s intention in such a way that one’s act is not intentional. Moreover, one cannot add

secondary intentions to cover for primary intentions.245 According to Cavanaugh, such an

approach to foreseen effects is a non-starter.246

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Cavanaugh demonstrates the deficiency of the counter-factual test that Charles Fried

offers.247 Fried asserts that one may determine whether one intends the bad effect, by answering

the question: would one commence without the foreseen negative effect?248 According to Fried, a

negative response indicates that the agent intends the evil, while a positive answer indicates one

does not intend the malevolent effect.249 Following James Sterba, such a test does not suffice to

conclude that the agent does not maliciously intend the foreseen means.250 To establish intent,

Sterba recommends asking if the foreseen bad effects help to explain why one chose a particular

action.251 If the answer is yes, then one may tie it to intention.252

Next, Cavanaugh addresses closeness and conceptual necessity to determine if an effect

constitutes intention or foreseen effect.253 According to Cavanaugh, certain actions have a

conceptual necessity attached to them.254 For example, it is impossible to conceive of

assassinating someone without killing.255 Intending to assassinate conceptually necessitates

intending to kill.256 Likewise, for Cavanaugh, intending to perform a craniotomy inexorably

entails killing a child, even if one can conceptually distinguish the act of crushing the skull and

the child dying.257 Accordingly, Cavanaugh asserts, “if one’s intent conceptually includes the

effect, then one intends that effect.”258

Next, Cavanaugh defines the nature of intention and distinguishes it from foreseen

effects.259 To begin with, he observes that intentions concern that which is desirable.260

Unfortunately, desirable has several references, including reason and feelings.261 Regarding

intention, desirable concerns that which one determines to be rationally good to effect,

something that may be affectively undesirable.262 As such, it is clear that intention is different

from emotional feelings.

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For Cavanaugh, intention also has a volitional content oriented to achieving a particular

good in action.263 More than simply wanting or desiring a good, one wills to act according to

plan by intending.264 In fact, what distinguishes wanting from intending is the plan for action.265

To achieve one’s goal, one both intends the end in sight and the means to achieving the end.266 In

contrast, foresight lacks the volitional content of intention; rather, it consists of an awareness of

causal relations.267 Knowing causal relations does not amount to having a plan of action and

acting accordingly. When one acts with foresight, however, it does reveal one’s intention.268

Deliberation is the process whereby one formulates an intentional plan of action.269 To

intend is for an agent to tend toward some end, the intervening space of which constitutes the

means.270 It is precisely through deliberation that reason discovers means to achieving ends.271 In

deliberation, the end answers the question why and the means answer the question how.272

Committing one’s plan to action, Cavanaugh logically induces that one may say “end x by means

y.”273 An important distinction between intention and foresight is that the former causes

deliberation, while latter does not.274

It is important for Cavanaugh to avoid any consequentialist tendency, which reduces

means to causes and ends to effects. The difference between means/ends and causes/effects is

that means relate to ends as through an agent’s deliberation.275 An agent deliberates over possible

causes to achieve specific effects and insofar as the agent intends causes for effects they are

means for ends.276 As an example, a cue ball may hit an eight ball into a corner pocket, such that

an observer says that the cue ball causes the eight ball to going into the pocket. But a qualitative

difference occurs when an agent intentionally hits the cue ball so that this constitutes a means to

attaining the end of putting the eight ball in the corner pocket.277

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Recall that for Aquinas there are four irreducible orders—order of nature, logical order,

moral order, and practical arts—that correspond to four irreducible sciences—natural sciences

(math and metaphysics), logic, morality, and technical sciences.278 Following Anscombe’s lead,

Cavanaugh highlights the epistemic difference between intention and foreseen effects that

corresponds to the difference in orders.279 Intention corresponds to practical knowledge;

therefore, it consists of knowing by doing without observation; while foreseeing effects

corresponds to speculative knowledge—knowing by observing.280 As such, both have different

directions of fit.281 Foreseen effects, insofar as they constitute speculative knowledge are true

insofar as what one knows corresponds to the truth that is.282 Intentions, on the other hand, are

true when one’s execution of action achieves its end.283 Therefore, intentions give rise to actions,

while foreseen effects correspond to events or happenings.284 Moreover, since foresight

constitutes a different order from intention, it does not define one’s act or inform one’s behavior,

as the latter does.285

While intent may at times be difficult to observe, different intentions give rise to different

behaviors that although subtle and sometimes ambiguous, are nonetheless often discernible.286

Cavanaugh illustrates by showing how different intentions inform the same behavior, with

differences, as for example, blinking to send a message looks quite different from blinking to

remove an irritant from one’s eye.287

To eliminate confusion and correct error, Cavanaugh advocates for the adoption the

intention/foreseen distinction in Double Effect. The above demonstrates that this lexicon offers

several advantages for highlighting important distinctions between what one intends and the

foreseen effects. The next subsections apply this distinction to three contrasting topics:

euthanasia/terminal sedation; craniotomy/hysterectomy; and terror/tactical bombing.288

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iv. Euthanasia Versus Terminal Sedation

This subsection discusses the distinction between euthanasia and terminal sedation.

a. The Catholic Church: Euthanasia and Terminal Sedation

In the Declaration on Euthanasia, the Congregation for the Doctrine of the Faith defines

euthanasia as “an action or omission which of itself or by intention causes death, in order that all

suffering may in this way be eliminated.”289 Intention plays a vital role in determining whether

an act constitutes euthanasia. In Catholic Bioethics and the Gift of Human Life, William May

highlight a distinction between active and passive euthanasia that relates to intention.290 Active

euthanasia constitutes an act of commission whereas passive euthanasia is an act of omission,

both for the end of eliminating suffering by killing.291 He further delineates, taking into account

the will of the patient: voluntary—the patient agrees, non-voluntary—the patient is unaware and

involuntary—the patient refuses.292 Few question the immorality of nonvoluntary or involuntary

euthanasia, since it violates the patient’s autonomy; however, voluntary active or passive are

finding increasing acceptance among ethicists.293

Pope John Paul II, in Evangelium Vitae, contends that insofar as euthanasia entails the

intentionally terminating human life, it violates the exceptionless moral norm to respect the

inviolable dignity of the human person.294 At the same time, this does not mean that physicians

may not use treatments at their disposal to relieve pain and as an unintended, yet foreseen effect

expedites the dying process by depressing respiratory function.295 Moreover, while one is obliged

to accept proportionate or ordinary treatment, one may refuse disproportionate or extraordinary

treatment.296 Since the treatments and methods chosen to euthanize—actively or passively—or to

relieve pain are often identical, the first-person perspective is crucial for determining intent.

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Many physicians contend that continuous, deep sedation, when done properly, does not

shorten a patient’s life.297 If true, this renders obsolete recourse to the Principle of Double Effect

to justify the unintended, but foreseen expedited death of the patient. However, insofar as the

Church encourages patients to maintain consciousness to prepare themselves for death as they

near the end of life, the Principle of Double Effect justifies sedation for patients experiencing

intense pain or anxiety.298 Thus, even if painkillers do not hasten death, ethicists rely on Double

Effect to vindicate rendering a patient unconscious at the end of life.299

b. Joseph Boyle: Euthanasia and Terminal Sedation

In “On Killing and Letting Die,” Joseph M. Boyle, Jr. formulates an argument defending

the moral distinction between killing and letting die.300 First, he indicates that it is possible to

wrongly let someone die.301 He holds that such an act of omission is just as morally

reprehensible as killing a person by commission.302 He acknowledges that not all cases of letting

die are morally wrong.303 However, he insists that “most cases of killing—and all case of directly

killing the innocent—are morally wrong.”304 If the abovementioned premises are true, then two

converse conclusions are true: 1) not all cases of deciding to let someone die simply constitutes

the application of the judgment that it is wrong to kill; 2) the moral decision to kill someone is

not merely the application of the decision that it would be wrong to let this person die.305 Boyle

highlights that for traditional ethics the proscription for killing the innocent includes killing via

euthanasia, because the patient is innocent in the relevant sense, that is, innocent as non-

combatants in war.306 Moreover, killing in euthanasia constitutes direct killing, rather than

indirect killing—a foreseen, yet unintended effect of an action—since one intends the death of

the patient, usually as a means to bring about an end to suffering.307 In active euthanasia, the

patient’s death constitutes the means for ending pain.308

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Boyle raises an objection that opponents such as James Rachels often level against the

moral significance thesis, namely, that it is sometimes worse to let someone die, than to relieve

their suffering quickly by killing them.309 To illustrate, Rachels argues that parents who let their

Down syndrome child die by starvation, neglecting to repair an intestinal blockage, should have

simply acknowledged their intention—not to raise a child with Down syndrome—and killed the

child via active euthanasia to forgo the painful death of starvation.310 Boyle indicates that

Rachels’ inference does not justify his wholesale rejection of the thesis, but merely shows that

one can abuse it.311 Indeed, as Boyle illustrates there are many cases where one determines that

treatment is futile or burdensome, and therefore, one ceases treatment, allowing the patient to

die, but this does not necessarily mean that one intends the death of the patient, as one clearly

does in active and passive euthanasia.312

The moral significance of the distinction between passive euthanasia and allowing one to

die, without necessarily intending death, depends on two assumptions: 1) that there is a

difference between what one intends and what one foresees, but does not intend as a side effect;

and 2) that this distinction has moral significance.313 Boyle demonstrates that Rachels’s rejection

of a distinction between euthanasia and letting die, presumes falsely that all decisions for the

latter entails a decision to end the patient’s suffering by death, which is patently not true.314

Others such as Michael Tooley315 contest the moral significance thesis with the so-called moral

symmetry principle, which asserts that there is no moral difference between killing and letting

die, but is only supportable by example.316

Michael Tooley offers two examples in which one intends the death of the other, but the

physical difference consists in Jones letting Smith die by a bomb (by not warning him), as

opposed to Jones killing Smith by shooting him.317 Daniel Dinello counters using an example of

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two patients desperately in need of the other’s organ to survive: Jones needs a heart transplant or

will die in two hours and Smith needs a kidney transplant or will die in four hours—each are the

only possible donor candidate for the other.318 Boyle indicates that this counterexample does not

suffice to disprove the symmetry principle, because there may indeed be a difference of

intention.319 Clearly it is wrong to kill Smith, but this does not entail the decision to will Jones’s

death.320 As such, the symmetry principle still remains valid for some cases, but this does not

invalidate Boyle’s thesis.321 In turn, Boyle concludes that while there are certainly cases where

one may intend another’s death by letting her die, this does not constitute a logical necessity,

since it is possible to allow her to die without intending her death.

In the abovementioned paper, Boyle demonstrates that a physician’s intention may not

always include the death of the patient, but when it comes to terminal sedation, intent—an

important factor for resolving legal disputes—is precisely what one must prove. In “Medical

Ethics and Double Effect: The Case of Terminal Sedation,” Joseph Boyle argues that the

Principle of Double Effect is transferable to medical ethics.322 In particular, by analyzing

documentation and dosage, Boyle argues one can determine the physician’s intention.323

Following Aquinas and Gury, Boyle articulates the four criteria of Double Effect.324 First, the act

in question must be good or indifferent, which he indicates prescribing and administering

analgesics to be.325 Second, the bad effect must not be the cause of the good.326 Again, in this

case, the bad effect—the death of the patient—is not necessarily the cause of relieving the

patient’s pain. Third, the bad effect must not be intended.327 Fourth, Boyle highlights the

condition of proportionality, which necessitates a grave enough reason to justify the accepted,

yet unintended effects.328

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c. Intention/Foreseen Distinction: Euthanasia and Terminal Sedation

Using the intention/foreseen distinction, Cavanaugh explains the difference between

voluntary active euthanasia and terminal sedation.329 In the case of euthanasia, the physician

deliberates over how to achieve the intended end of ceasing the patient’s pain and concludes that

killing the patient is a good solution.330 Consequently, the physician deliberates further about

how to terminate the patient’s life.331 Arriving at a practical action, the physician administers a

lethal dose of a drug.332 Since the physician intends to end the patient’s pain by means of death,

pain relief alone does not qualify as success; the patient must die.333 In the case of terminal

sedation, having the goal of ending the patient’s pain, the physician deliberates that a barbiturate

drip is the best solution, even though he foresees this causing a premature death.334 Unlike in the

case of euthanasia, the foresight that the barbiturate-drip causes death, does not invoke further

deliberation in the physician about utilizing it for that purpose.335 Put more simply, the foresight

does not provoke further deliberation, whereas the intent to kill does; which stands out as a

defining difference between foresight and intent.336 Moreover, regarding terminal sedation,

although the physician expects the patient to die using the barbiturate-drip, if death does not

ensue, he does not fail in achieving his goal.337 Failure occurs if the barbiturate-drip does not

relieve the patient’s pain.338 Thus, Cavanaugh concludes that the distinction between euthanasia

and terminal sedation contrasts as “necessarily-intended-death versus foreseen-not-necessarily-

intended-death.”339

v. Hysterectomy Versus Craniotomy

This subsection explicates the distinction between a hysterectomy and a craniotomy.

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a. Direct Killing in Abortion

In Evangelium Vitae, Pope John Paul II points to the Didache as testimony for the

Church’s unbroken teaching against direct abortion: “you shall not put a child to death by

abortion nor kill it once it is born.”340 Direct abortion occurs whenever one wills the death of the

unborn child either as a means or an end to one’s action.341 He recapitulates what the

Congregation for the Doctrine of the Faith articulates as the Magisterial Teaching of the Church

that this prohibition against killing begins at the moment of conception, which corresponds to the

inviolable dignity of the human person.342 The Church does not prohibit indirect abortion for

proportionate reasons.343 Indirect abortion means that one does not will the death of the child.344

The classic scenario is a woman with a gravid (pregnant), cancerous uterus who undergoes a

hysterectomy to save the mother’s life.345 The foreseen, yet unintended effect is the death of the

child.

b. Defending Craniotomies

As the above demonstrates, Finnis et al. argue that the same line of reasoning justifies

craniotomies, since for them it is nothing more than cutting the cranium.346 Germain Grisez

defends craniotomies in Living a Christian Life.347 First, he insists that four criteria must exist: 1)

some pathology threatens both mother and child; 2) it is not safe to wait; 3) there is no way to

save the child; 4) the procedure that saves the mother’s life results in the child’s death.348 In

“Double Effect and a Certain Type of Embryotomy,” Joseph M. Boyle argues in favor of

craniotomy, under the circumstances given by Grisez, rejecting the traditional belief that it

constitutes direct killing.349 Boyle understands direct killing “as that killing in which the

resulting death either is intended or is immediate or is the effect of a cause which may not

morally be posited.”350 Boyle defends H. L. A. Hart’s assertion that the craniotomy is not direct

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killing, holding that it is no different than the indirect killing that occurs when removing a

gravid, cancerous uterus via hysterectomy.351 Hart insists that in both cases the fetus’s body must

be removed from the woman’s body.352 In fact, however, for the hysterectomy the body of the

fetus does not pose the threat, so properly speaking, this is not what the surgeon removes; rather,

she removes the uterus that carries the child. Even if the woman were not pregnant, the physician

must remove the cancerous uterus. In the case necessitating a craniotomy, however, the condition

of the child being stuck constitutes the pathology.

Following Hart, Boyle insists that if there is no conceptual connection between a side

effect and what one intends in action then the side effect is outside of one’s intention—praeter

intentionem.353 Boyle argues that since the craniotomy has no conceptual connection to the death

of the child,354 it does not constitute direct killing.355 Rather, he argues that the conceptual

content of a craniotomy is merely the altering of the dimensions of the fetus’s skull.356 Boyle

continues the argument asserting that the fetus’s death is neither the means nor the end of saving

the mother’s life, for which the physician performs a craniotomy.357

Cavanaugh indicates that common language points to an awareness of a correspondence

between the conceptual and causal.358 For Cavanaugh, Finnis et al. so narrowly define

craniotomy that it conceptually excludes the death of the child.359 As such, their conceptual

definition excludes what is causally necessary to craniotomy, the death of the child.360 In fact, the

causal necessity is so strong; it is virtually impossible to conceive of even the possibility of a

craniotomy that does not also entail the death of the child.361 Moreover, R. A. Duff argues that

this connection is so strong that it is even logically impossible to define craniotomy without

including the death of the child.362 Duff offers two examples which he proposes are analogous to

saying that a craniotomy does not logically entail the death of the fetus: 1) a man decapitating his

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wife to see her surprise in the morning; and 2) a man intentionally colliding his car with a police

officer’s, but only intending to knock him off, but not cause injury.363 Boyle rejects the first,

insisting that the stated claim cannot possibly be the intention of one’s act.364 The second he

rejects because he argues that a stunt man may indeed intend such a consequence without

injury.365 Just because Duff’s two examples do not hold up to Boyle’s criticism does not suffice

to negate his argument altogether.366 The fact that one cannot conceive of a child surviving a

craniotomy suffices to prove Duff’s point.

c. Craniotomies and Hysterectomies

As Cavanaugh indicates, the procedure of crushing the skull, by its definition entails the

death of the child, and therefore, one cannot practically distinguish killing the child from a

craniotomy.367 He utilizes the intention/foreseen distinction to shed further light on this

situation.368 In both cases, the physician desires to save the mother’s life, which leads to further

deliberation about means.369 In the case of the gravid, cancerous uterus, he concludes that its

removal is the only viable solution.370 The death of the child is foreseen as causally necessary,

but the success of the procedure does not depend on this.371 Moreover, the definition of the

procedure does not depend on the death of the child; it is possible to perform a hysterectomy on a

woman who is not pregnant.372

In the case of the craniotomy, however, the physician after deliberation concludes that

intentionally crushing the baby’s skull and extracting its body from the birth canal is the means

to saving the mother’s life.373 In a craniotomy, she is not using forceps to maneuver the child’s

head and body through the cervix, in which case one may argue that the intention is to remove

the child’s head and body from the cervix without necessarily killing the child.374 Rather, she is

cutting the skull, and removing the brains, essentially beheading the child, which by definition

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not only causes the death of the child, but also intends it.375 Therefore, Finnis et al.’s objection to

the fifth argument against craniotomies, namely that it is never done to help the child, does not

hold.376 Most importantly, however, Cavanaugh argues that the craniotomy is direct killing, since

the intentional content necessitates the removal of the contents of the child’s head, which

inexorably links to the child’s death.377 While she succeeds in saving the mother’s life, should

the child somehow survive the procedure, she has not succeeded in doing a craniotomy.378 The

next subsection considers the difference between terror bombing and tactical bombing.

vi. Terror Bombing Versus Tactical Bombing

This subsection highlights the distinction between terror bombing and tactical bombing.

a. Traditional Just War Theory

The American Civil War constitutes the most devastating war on United States’ soil and

the tactic of “Total War” not only represents a fundamental change in approach, but also shapes

the nature of war for the twentieth century and beyond. William Tecumseh Sherman’s

unforgettable words, “war is cruelty” and his further argument that the “crueler it is, the sooner it

will be over” seems to resonate with many theorists.379 As oxymoronic as it may seem,

philosophical tradition does advocate for rules of war and just war theory. While Augustine first

gives voice to just war, it is Aquinas that articulates its conditions.380 Today, just war theorists

often distinguish between jus ad bellum and jus in bello; that is, just reasons to go to war and just

action in war, respectively.381 In general, the latter qualifies questions pertaining to bombing.

James F. Childress, in “Just-War Theories: The Bases, Interrelations, Priorities, and

Functions of Their Criteria,” says that the primary goal of war is not to kill or injure, but to

incapacitate the enemy’s ability to wage war, which informs the rules in war.382 This constitutes

an exceptionless moral norm of war that for Childress provides a foundation for the criteria of

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justice in war: 1) enemies that surrender deserve protection and medical care; 2) one ought not to

target non-combatants; 3) one should use proportionate force; and 4) avoiding weapons or

practices that inflict unnecessary suffering.383 Childress further indicates that should one foresee

that an attack poses a risk to civilians, due proportion ought to inform one’s decision making.384

These criteria alone should discourage any legitimate military authority from utilizing terror

bombing.

b. Just War, Terrorism, and Nuclear Deterrence

In 1987, Finnis et al., in Nuclear Deterrence, Morality and Realism, reject the use of

nuclear weapons as a deterrent, calling for an immediate abandonment of this policy by Western

governments, in spite of the fact that the Soviet Union would likely not reciprocate.385 They base

this decision on the threat that it poses to the human lives of the Soviet Union.386 Their line of

reasoning stands on appreciation for the basic human goods, of which human life—not only the

condition for realizing other human goods—is itself.387 Finnis et al. formulate the first principle

of morality in terms that integrate both human goods and the first principle of natural law: one

ought to choose and will acts in favor of human good and avoid those that are not.388 This gives

rise to the universal Golden Rule: treat others, as one would like to be treated. 389 The

Democritean Principle is another intermediate principle: “do not do evil that good may come.”390

After affirming that human life is not only the means to enjoy other basic human goods,

but a basic human good itself, Finnis et al. use the three abovementioned principles to defend

their thesis that “it is always wrong to choose to kill a human being.”391 Although their theory

restricts violence greatly, they do not advocate pacifism.392 They permit the killing of the non-

innocent in just wars, but only as a means to defend or halt serious attacks that cannot be

otherwise stopped.393 One’s use of force in war is justified, if and only if, one chooses it to

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defend or stop the unjust enemy’s aggression, but not if one intends to kill the enemy.394

Consequently, they reject wars of aggression for any reason altogether.395

Finnis et al. argue that killing an offender out of retribution or retaliation consists of

choosing a bad means for a good end.396 Although one may accidentally kill innocent people in

combat, it is never morally permissible to kill the innocent intentionally.397 Therefore, since the

use of nuclear weapons in the context of deterrence entails retaliatory action and the intentional

murder of innocent non-combatants, it constitutes an intrinsically evil act.398 Moreover, since

keeping nuclear weapons, as a deterrent is only effective if one is actually willing to use them,

this act also constitutes an intrinsically evil act.399 Furthermore, recalling the Socratic Principle,

that “it is better to suffer wrong than to do it,”400 Finnis et al. advise all Western nations to

immediately disarm their nuclear weapons, for the welfare of the citizens of the Soviet Union.401

In “Catholic Teaching on War and Peace: Its Application to American Foreign Policy

after 9/11,” Joseph Boyle revisits the topic of nuclear deterrence, arguing that it constitutes a

form of terrorism.402 In an earlier paper, “Just War Doctrine and Military Response to

Terrorism,” however, Boyle maintains a distinct difference between terrorism and deterrence.403

Terrorism consists in the use of violent actions for the purpose of influencing decision-making in

its survivors.404 By definition, deterrence entails the threat of either just or unjust response to

criminal acts, and therefore, does not necessarily exclude the threat of using terrorism.405 For

instance, Boyle argues that nuclear deterrence during the Cold War constitutes the threat of

terrorism.406 In the later paper, however, Boyle conflates the two acts, deterrence and terrorism,

insisting that nuclear deterrence constitutes a form of terrorism, not merely an act of terrorism.407

Boyle’s conflation of the two distinct acts is another instance of failing to see how the

physical act itself influences and contributes to the definition of the act. It is one thing for one to

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threaten terrorism in an act of deterrence, but quite another for one to actually commit a violent

act of terrorism.408 Boyle is correct in asserting that nuclear deterrence constitutes the threat of

terrorism, but not in saying that the act of deterrence itself is terrorism.409 Certainly an analogy

exists insofar as the threat of terrorism attempts to persuade, but a true difference abides between

a threat and a violent act, which terrorism by definition entails.

c. Terror Bombing and Tactical Bombing

Cavanaugh uses the intention/foreseen distinction to further highlight the immorality of

terror bombing in contrast to discriminate tactical bombing.410 In both cases, the agent desires

victory, but uses different means to achieve this end.411 The terror bomber, by definition intends

harm to non-combatants, maiming, or killing in an attempt to demoralize the enemy.412 While the

ultimate end is victory, the terror bomber seeks to achieve this end by means of killing or

maiming non-combatants.413 Such behavior necessarily coincides with the terror bomber’s

intention. If one achieves victory without killing or maiming non-combatants, one has attained

one’s ultimate goal, but failed to achieve one’s proximate means.414 Not only does terror

bombing violate the exceptionless norm to not intentionally kill, but it violates at least three of

the abovementioned criteria, possibly excepting only the norm to do no harm to surrendering

combatants.

In contrast to terror bombing, tactical bombing entails the intent of destroying an enemy’s

ability to wage war by attacking installations of war.415 The tactical bomber foresees that

bombing a combatants’ installation causally necessitates the death of enemy combatants and

even non-combatants.416 While the tactical bomber is aware of this, it does not determine the

outcome of deliberation.417 Moreover, since the death of the non-combatants does not constitute

the intention of one’s action, it also does not define success.418 In other words, if no non-

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combatants die in the bombing of military installations, the tactical bomber may still claim

success, so long as it damages the installations.419 So long as the tactical bomber uses due

proportion in determining which targets to hit in relationship to potential harm to non-

combatants, he or she does not violate any of the abovementioned criteria.

The three contrasting cases above distinguish between intrinsically evil acts and those

that have causally foreseen effects, but do not violate exceptionless moral norms.420 In each case,

Cavanaugh demonstrates that where one violates an exceptionless moral norm the harm not only

constitutes a causally necessary effect, but the agent also intends it as a means to one’s end. As a

volitional act, one must do more than answer “would one pursue the action were the evil not

brought about?”; but “is one successful in accomplishing the intended act without the harm being

done?”421 In each of the cases that violate an exceptionless moral norm the answer is negative,

while in the permissible cases, the answer is positive. In other words, doing the harm in the

permissible cases does not define the act, whereas in the impermissible cases it does.

The first subsection of this section presents Finnis et al.’s argument in favor of

craniotomies arguing that from the perspective of the acting person they do not constitute

intentional killing.422 Next, based on the work of Sousa-Lara’s understanding of the external act

constituting the choice and the commanded physical act, I argue that a certain degree of

predictability regarding primitive physical acts enables one to observe and determine moral

intention with a limited degree of potential.423 Cavanaugh’s distinction between intended means

and foreseen effects not only provides an adequate terminology, but also enables one to

sufficiently distinguish acts that violate exceptionless moral norms from those that Double-Effect

Reasoning justifies.424 The three subsequent subsections present the Church’s traditional

teaching regarding three different ethical dilemmas including: euthanasia/terminal sedation,

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craniotomies/hysterectomies, and terror bombing/tactical bombing. In addition, these respective

subsections account for Finnis et al.’s perspective on the aforementioned topics. Finally, the

three contrasting examples illustrate the veracity of Cavanaugh’s theory.425

The following chapter applies the theory of this and the preceding chapter first to health

care ethics consultations, and then, to the Principle of Cooperation.

1 The phrase Double-Effect Reasoning comes from T. A. Cavanaugh, Double-Effect Reasoning:

Doing Good and Avoiding Evil, (Oxford: Oxford, 2007). 2 Thomas Aquinas, Summa Theologica, (Chicago: Benzinger Brothers, 1947),

http://dhspriory.org/thomas/summa/index.html, II-II q.64 a.7 3 Aquinas, Summa Theologica, II-II q.43 a.1 and 4 and II-II q.169 a.2 4 Aquinas, Summa Theologica, II-II, q.64 a.7 obj.1 5 Aquinas, Summa Theologica, I-II q.12 a.4 6 Augustine, On the Freedom of the Will, Trans. Anna S Benjamin et al, (Englewood Cliffs, NJ:

Prentice Hall, 1964), Book 1, V, pp. 12; Aquinas, Summa Theologica, II-II, q. 64, a. 7, objection

1 and 2, reply 1. 7 Aquinas, Summa Theologica, II-II, q.64 a.7 8 Aquinas, Summa Theologica, II-II, q.64 a.7 9 Duarte Sousa-Lara, “Per Se and Praeter Intentionem in Aquinas,” Josephinum Journal, 18, no.

2 (2011): 418-53. 10 Thomas Aquinas, Scriptum super sententiis Magistri Petri Lombardi. “S. Tommaso d’ Aquino

Commento alle Sentenze di Pietro Lombardo.” Vol. 1-10. Edizioni Studio Dominicano, Bologna

1999-2002. http://www.corpusthomisticum.org/snp2000.html.

lib. 2, d. 35, q. 1, a. 5, ad 4; http://www.corpusthomisticum.org/snp2035.html 11 Aquinas, Summa Theologiae, II-II, q. 64, a. 7. c. 12 Aquinas, Summa Theologiae, II-II, q. 64, a. 7. c. 13 Aquinas, Summa Theologiae, II-II, q. 43, a. 1, sed contra. 14 Aquinas, Summa Theologiae, II-II, q. 43, a. 1, reply to obj. 4. 15 Aquinas, Summa Theologiae, II-II, q. 43, a. 2, c. 16 Aquinas, Summa Theologiae, II-II, q. 43, a. 3, c. 17 Aquinas, Summa Theologiae, II-II, q. 43, a. 4, c. 18 Aquinas, Summa Theologiae, II-II, q. 169, a. 2, answer. 19 Aquinas, Summa Theologiae, II-II, q. 169, a. 2, answer. 20 T. A. Cavanaugh, Double-Effect Reasoning, 15-17. 21 Antoninus, Summa Theologica (Graz: Akademische Druck, 1959), vol. ii, t. iv, c. v, vii, 595. 22 Cavanaugh, Double-Effect Reasoning, 16. 23 Cavanaugh, Double-Effect Reasoning, 16. 24 Cavanaugh, Double-Effect Reasoning, 16-19. 25 Thomas Cajetan, Commentario a “Summa Theologiae,” in Sancti Thomae Aquinatis Opera

Omnia, Leonine ed. (Rome: S. C. de Propaganda Fide, 1882-).

http://archive.org/stream/operaomniaiussui09thom#page/74/mode/2up


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26 Joseph T. Mangan, “An Historical Analysis of the Principle of Double Effect,” Theological

Studies 10, no. 1, (1949): 52. 27 Joseph T. Mangan, “An Historical Analysis,” 52. 28 Joseph T. Mangan, “An Historical Analysis,” 52. 29 Joseph T. Mangan, “An Historical Analysis,” 52. 30 Aquinas, Summa Theologiae, I-II, q. 20, a. 5, answer. 31 Aquinas, Summa Theologiae, I-II, q. 20, a. 5, answer. 32 Thomas Cajetan, Commentario a “Summa Theologiae,” I-II, q. 20, a. 5, in Sancti Thomae

Aquinatis Opera Omnia, Leonine ed. Vol. 6 (Rome: S. C. de Propaganda Fide, 1891), 162.

https://archive.org/stream/operaomniaiussui06thom#page/162/mode/2up 33 Thomas Cajetan, Commentario a “Summa Theologiae.” Sancti Thomae Aquinatis

Vol. 9, Opera omnia, Leonine ed. (Romae: S. C. de Propaganda Fide, 1897), pp. 74.

http://archive.org/stream/operaomniaiussui09thom#page/74/mode/2up 34 Thomas Cajetan, Commentario a “Summa Theologiae,” II-II, q. 67, a. 2, pp. 100.

http://archive.org/stream/operaomniaiussui09thom#page/100/mode/2up 35 Aquinas, Summa Theologiae, II-II, q. 67, a. 2, answer. 36 T. A. Cavanaugh, Double-Effect Reasoning, 18-9 37 Joseph T. Mangan, “An Historical Analysis of the Principle of Double Effect,” 44 38 Joseph T. Mangan, “An Historical Analysis of the Principle of Double Effect,” 47 39 John Finnis, Aquinas: Moral, Political and Legal Theory (Founders of Modern Political and

Social Thought), (Oxford: Oxford, 1998), 63-4. 40 John Finnis, Aquinas, 63-4. 41 John Finnis, Aquinas, 64, footnote 17. 42 Thomas Aquinas, On Evil, trans. Richard Regan, ed. Brian Davies, (Oxford: Oxford, 2003), Q.

2, a. 2, ad 8, pp. 99. 43 Aquinas, On Evil, Q. 2, a. 2, ad. 8, 100. 44 Vitoria, Reflections on Homicide and Commentary on Summa theologiae IIa-IIae Q. 64:

Thomas Aquinas, ed. John P. Doyle (Milwaukee: Marquette University, 1997), 195. 45 Vitoria, Reflections on Homicide, 195. 46 Sousa-Lara, “Per Se and Praeter Intentionem in Aquinas,” 433-5 47 Francisco Suarez, Censuris in Communi in Opera Omnia, Vol. 23 (Paris: Vives, 1867), 426;

trans. Sousa-Lara, “Per Se and Praeter Intentionem in Aquinas,” 433. 48 Suarez, Censuris in communi in Opera omnia, 426; trans. Sousa-Lara, “Per Se and Praeter

Intentionem in Aquinas,” 433. 49 Aquinas, Summa Theologica, I-II, q. 6, a. 3. 50 Suarez, Censuris in communi in Opera omnia, 426; trans. Sousa-Lara, “Per Se and Praeter

Intentionem in Aquinas,” 433. 51 Aquinas, Super Sent., lib. 2, d. 40, q. 1, a. 1, c 52 J. Ghoos, “L’Act a Double Effet Ètude de Théologie Positive,” Ephemerides Theologicae

Lovanienses, 27, (1951): 32. 53 Cavanaugh, Double-Effect Reasoning, 20. 54 J. Ghoos, “L’Act a Double Effet,” 48. 55 J. Ghoos, “L’Act a Double Effet,” 48-9. 56 J. Ghoos, “L’Act a Double Effet,” 49.

http://archive.org/stream/operaomniaiussui09thom#page/74/mode/2up

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57 J. Ghoos, “L’Act a Double Effet,” 50. “l’agent ne peut d’aucune façon vouloir la

conséquence néfaste: celle-ci doit être exclue de l’objet de l’acte intérieur d’intention, en

d’autres mots: elle doit être praeter intentionem (élément subjectif).” 58 J. Ghoos, “L’Act a Double Effet,” 50. “cette conséquence néfaste ne peut pas être l’effet

propre de l’objet intentionné, mais elle doit découler d’une façon purement accidentelle {per

accidens ), c'est-à-dire: elle doit être l’effet propre d’une autre cause que celle directement

intentionnée (élément objectif).” 59 J. Ghoos, “L’Act a Double Effet,” 50. “la valeur de l’effet bon doit compenser les

conséquences néfastes ; cette proportionnalité est réglée par la hiérarchie des vertus.” 60 J. Ghoos, “L’Act a Double Effet,” 51. 61 Joseph T. Mangan, “An Historical Analysis of the Principles of Double Effect,” 56. 62 Joseph T. Mangan, “An Historical Analysis of the Principles of Double Effect,” 56. 63 Salmanticenses, Cursus Theologicus, t. 7, tr.13, disp. 10, dub. 6, no. 214-47 quoted in Joseph

T. Mangan, “An Historical Analysis of the Principles of Double Effect,” 57. 64 Salmanticenses, Cursus Theologicus, t. 7, tr.13, disp. 10, dub. 6, no. 214-47 quoted in Joseph



T. Mangan, “An Historical Analysis of the Principles of Double Effect,” 57-8. 67 Joseph T. Mangan, “An Historical Analysis of the Principles of Double Effect,” 59. 68 Christopher Kaczor, “Double-Effect Reasoning from Jean Pierre Gury to Peter Knauer,”

Theological Studies 59, no. 2 (1998): 300. 69 Joseph T. Mangan, “An Historical Analysis of the Principles of Double Effect,” 59. 70 Jean Pierre Gury, Compendium theologiae moralis, 17th ed., Vol. 1, (Romae: Typis Civilitatis

Catholicae, 1866), https://archive.org/details/compendiumtheo01gury. 71 Gury, Compendium Theologiae Moralis, c. 2, no. 9, pp. 9-10. 72 Gury, Compendium Theologiae Moralis, c. 2, no. 9, pp. 9. “Licet ponere causam bonam aut

indifferentem ex qua immediate sequitur duplex effectus, unus bonus, alter vero malus, si adsit

causa gravis, et finis agentis sit honestus.” 73 Kaczor, “Double-Effect Reasoning,” 308. 74 Gury, Compendium Theologiae Moralis, c. 2, no. 9, pp. 9. “Ratio huius principia est, quia, si

id non liceret, agens peccaret, vel ex intentione pravi effectus, vel ex positione causae, vel ex

praevisione effectus mali.” 75 Gury, Compendium Theologiae Moralis, c. 2, no. 9, pp. 9. Hoc illicitum esse non potest

ratione finis, quipped qui supponitur honestus, 76 Gury, Compendium Theologiae Moralis, c. 2, no. 9, pp. 9. “Neque ratione appositionis

causae, siquidem supponitur bona, vel saltem indifferens.” 77 Gury, Compendium Theologiae Moralis, c. 2, no. 9, pp. 9. “Neque ex praevisione pravi

effectus, nam, in hypothesi, malus effectus saltem per bonum compensatur.” 78 Joseph T. Mangan, “An Historical Analysis of the Principles of Double Effect,” 60 quoting

Jean Pierre Gury, Compendium theologiae moralis, (5th German Edition), (Ratisbonae Typis et

sumptibus Georgii Josephi Manz, 1874), c. 2, no. 9. 79 Gury, Compendium Theologiae Moralis, c. 2, no. 9, pp. 9-10. “Porro quisque ius habet ad

bonum finem obtinendum ex causa honesta, ubi malo bonum non superatur.”

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80 Gury, Compendium Theologiae Moralis, c. 2, no. 9, pp. 10. “Quatuor autem conditions in hoc

principio enuntiatae omnino requiruntur, scilicet: ut honestus sit finis agentis, ut causa sit bona,

vel saltem indifferens, ut effectus bonus sit immediatus, et adsit ratio gravis ponendi causam, nec

teneatur agens ex iustitia, aut ex officio, aut ex caritate eam omittere.” 81 Gury, Compendium Theologiae Moralis, c. 2, no. 9, pp. 10. “Requiritur finis bonus, idest

agens malum effectum intendere non debet, quia secus quid inordinatum intenderet, et proinde

peccaret. Ergo in pravo effectu nullo modo sibi complacere debet.” 82 Gury, Compendium Theologiae Moralis, c. 2, no. 9, pp. 10. “Requiritur causa bona, vel saltem

indifferens, scilicet ut actus nulli legi opponatur.” 83 Gury, Compendium Theologiae Moralis, c. 2, no. 9, pp. 10. “Ratio evidens est. Etenim, si

causa in se mala foret, per se reatum induceret.” 84 Gury, Compendium Theologiae Moralis, c. 2, no. 9, pp. 10. 85 Gury, Compendium Theologiae Moralis, c. 2, no. 9, pp. 10. 86 Kaczor, “Double-Effect Reasoning,” 311. 87 Peter Knauer, “The Hermeneutic Function of the Principle of Double Effect,” Natural Law

Forum, Paper 127. http://scholarship.law.nd_naturallaw_forum/127. 132. 88 John Paul II, Veritatis Splendor, August 6, 1993, http://w2.vatican.va/content/john-paul-

ii/en/encyclicals/documents/hf_jp-ii_enc_06081993_veritatis-splendor.html, 75. 89 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 133. 90 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 133. 91 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 133. 92 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 135. 93 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 134-5. 94 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 135. 95 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 135. 96 Aquinas, Summa Theologiae, I-II, q. 1, a. 3. 97 Aquinas, Summa Theologiae, I-II, q. 1, a. 3. 98 Aquinas, Summa Theologiae, I-II, q. 1, a. 3. 99 Aquinas, Summa Theologiae, I-II, q. 1, a. 3. 100 Aquinas, Summa Theologiae, I-II, q. 1, a. 3, response 2, “ad secundum dicendum quod finis

secundum quod est prior in intentione, ut dictum est, secundum hoc pertinent ad voluntatem.” 101 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 135. 102 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 136. 103 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 137. 104 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 137. 105 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 137-8. 106 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 138 107 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 138. 108 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 138. 109 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 139 110 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 140. 111 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 140. 112 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 140 113 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 140-1 114 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 141 115 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 141




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116 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 142-3. 117 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 148. 118 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 148. 119 John Paul II, Veritatis Splendor, 78-9. 120 John Finnis, Germain Grisez, and Joseph Boyle, "'Direct' and 'Indirect': A Reply to Critics of

Our Action Theory," The Thomist 65, no. 1 (2001): 1-44. 121 Cavanaugh, Double-Effect Reasoning. 122 Finnis et al., “‘Direct’ and ‘Indirect,’” 3-8. 123 Finnis et al., “‘Direct’ and ‘Indirect,’” 12-19. 124 Finnis et al., “‘Direct’ and ‘Indirect,’” 19ff. 125 Finnis et al., “‘Direct’ and ‘Indirect,’” 3-8. 126 Finnis et al., “‘Direct’ and ‘Indirect,’” 3-4. 127 Finnis et al., “‘Direct’ and ‘Indirect,’” 7. 128 Finnis et al., “‘Direct’ and ‘Indirect,’” 7. 129 Finnis et al., “‘Direct’ and ‘Indirect,’” 3-4. 130 Finnis et al., “‘Direct’ and ‘Indirect,’” 3-4, 7. 131 Finnis et al., “‘Direct’ and ‘Indirect,’” 7. 132 Finnis et al., “‘Direct’ and ‘Indirect,’” 4. 133 Finnis et al., “‘Direct’ and ‘Indirect,’” 7. 134 Finnis et al., “‘Direct’ and ‘Indirect,’” 4. 135 Finnis et al., “‘Direct’ and ‘Indirect,’” 7. 136 Finnis et al., “‘Direct’ and ‘Indirect,’” 4, 7. 137 Finnis et al., “‘Direct’ and ‘Indirect,’” 5, 7. 138 Finnis et al., “‘Direct’ and ‘Indirect,’” 7. 139 Finnis et al., “‘Direct’ and ‘Indirect,’” 7-8. 140 Finnis et al., “‘Direct’ and ‘Indirect,’” 5-6. 141 Finnis et al., “‘Direct’ and ‘Indirect,’” 8. 142 Finnis et al., “‘Direct’ and ‘Indirect,’” 6. 143 Finnis et al., “‘Direct’ and ‘Indirect,’” 8. 144 Finnis et al., “‘Direct’ and ‘Indirect,’” 9-10. 145 Finnis et al., “‘Direct’ and ‘Indirect,’” 10. 146 Finnis et al., “‘Direct’ and ‘Indirect,’” 11. 147 Finnis et al., “‘Direct’ and ‘Indirect,’” 11. 148 Finnis et al., “‘Direct’ and ‘Indirect,’” 12. 149 Finnis et al., “‘Direct’ and ‘Indirect,’” 12. 150 Finnis, Aquinas, 64, footnote 17; Aquinas, On Evil, Q. 2, a. 2, ad 8, pp. 99. 151 Finnis et al., “‘Direct’ and ‘Indirect,’” 17. 152 Finnis et al., “‘Direct’ and ‘Indirect,’” 17. 153 John Paul II, Veritatis Splendor, 78. 154 Finnis et al., “‘Direct’ and ‘Indirect,’” 14; John Paul II, Veritatis Splendor, 78. 155 Finnis et al., “‘Direct’ and ‘Indirect,’” 15; John Paul II, Veritatis Splendor, 79. 156 John Finnis, Moral Absolutes: Tradition, Revision, and Truth, (Washington D. C.: CUA

Press, 1991), 65-7. 157 Finnis, Moral Absolutes, 64-5; Augustine, “Contra mendacium (Against Lying),” in Nicene

and Post-Nicene Fathers, vol. 3, ed. Philip Schaff & trans. H. Browne. (Buffalo, NY: Christian

Literature Publishing Co., 1887). http://www.newadvent.org/fathers/1313.htm.

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158 Finnis, Moral Absolutes, 65; Finnis et al, “‘Direct’ and ‘Indirect,’” 15. 159 Finnis, Moral Absolutes, 65; Finnis et al, “‘Direct’ and ‘Indirect,’” 15. 160 Finnis, Moral Absolutes, 65-6; Finnis et al, “‘Direct’ and ‘Indirect,’” 16; Peter Lombard, 2

Libri quatuor sententiarum, d. 40. 161 Aquinas, Scriptum Super Sententiis, lib. 2, d. 40, q. 1, a. 2, c and ad 2-3,

http://www.corpusthomisticum.org/snp2035.html; see also Aquinas, De Malo (On Evil), q. 2, a.

2, ad. 8; Finnis, Moral Absolutes, 66; Finnis et al., “‘Direct’ and ‘Indirect,’” 16. 162 Finnis et al., “‘Direct’ and ‘Indirect,’” 16. 163 Finnis et al., “‘Direct’ and ‘Indirect,’” 17. 164 Finnis et al., “‘Direct’ and ‘Indirect,’” 17; Finnis, Aquinas, 64. 165 Finnis, Aquinas, 64; John Paul II, Veritatis Splendor, 78. 166 Finnis, Aquinas, 64. 167 Finnis et al., “‘Direct’ and ‘Indirect,’” 22. 168 Finnis et al., “‘Direct’ and ‘Indirect,’” 22. 169 Finnis et al., “‘Direct’ and ‘Indirect,’” 21-2. 170 Finnis et al., “‘Direct’ and ‘Indirect,’” 21-3. 171 Finnis et al., “‘Direct’ and ‘Indirect,’” 23. 172 Finnis et al., “‘Direct’ and ‘Indirect,’” 23-4. 173 Finnis et al., “‘Direct’ and ‘Indirect,’” 24. 174 Finnis et al., “‘Direct’ and ‘Indirect,’” 24-5. 175 Finnis et al., “‘Direct’ and ‘Indirect,’” 25. 176 Finnis et al., “‘Direct’ and ‘Indirect,’” 25-6. 177 Finnis et al., “‘Direct’ and ‘Indirect,’” 26-7. 178 Finnis et al., “‘Direct’ and ‘Indirect,’” 27. 179 Finnis et al., “‘Direct’ and ‘Indirect,’” 27. 180 Finnis et al., “‘Direct’ and ‘Indirect,’” 27, footnote 42. 181 Finnis et al., “‘Direct’ and ‘Indirect,’” 28; see Kevin L. Flannery, “What Is Included in a

Means to an End?” Gregorianum 74, no. 3 (1993): 510ff. 182 Finnis et al., “‘Direct’ and ‘Indirect,’” 28. 183 Finnis et al., “‘Direct’ and ‘Indirect,’” 28. 184 Finnis et al., “‘Direct’ and ‘Indirect,’” 29. 185 Finnis et al., “‘Direct’ and ‘Indirect,’” 29. 186 Finnis et al., “‘Direct’ and ‘Indirect,’” 30; see Kevin L. Flannery, “Natural Law mens rea

versus the Benthamite Tradition,” American Journal of Jurisprudence 40 (1995): 395. 187 Finnis et al., “‘Direct’ and ‘Indirect,’” 30. 188 Finnis et al., “‘Direct’ and ‘Indirect,’” 30. 189 Finnis et al., “‘Direct’ and ‘Indirect,’” 30-1. 190 Finnis et al., “‘Direct’ and ‘Indirect,’” 31; see Jean Porter, “‘Direct’ and ‘Indirect’ in Grisez’s

Moral Theory,” Theological Studies 57, no. 4 (1996): 612. 191 Finnis et al., “‘Direct’ and ‘Indirect,’” 32. 192 Finnis et al., “‘Direct’ and ‘Indirect,’” 41. 193 Finnis et al., “‘Direct’ and ‘Indirect,’” 33-4. 194 Finnis et al., “‘Direct’ and ‘Indirect,’” 23-4; Porter, “‘Direct’ and ‘Indirect’ in Grisez’s Moral

Theory,” 620. 195 Finnis et al., “‘Direct’ and ‘Indirect,’” 34. 196 Finnis et al., “‘Direct’ and ‘Indirect,’” 34-6.


168

197 Finnis et al., “‘Direct’ and ‘Indirect,’” 36-8; see Porter, “‘Direct’ and ‘Indirect’ in Grisez’s

Moral Theory,” 623. 198 Finnis et al, “‘Direct’ and ‘Indirect,’” 37. 199 Finnis et al, “‘Direct’ and ‘Indirect,’” 38-9. Porter, “‘Direct’ and ‘Indirect’ in Grisez’s Moral

Theory,” 624-5. 200 Finnis et al., “‘Direct’ and ‘Indirect,’” 38-9; Porter, “‘Direct’ and ‘Indirect’ in Grisez’s Moral

Theory,” 624-5. 201 Cavanaugh, Double-Effect Reasoning, 66ff. 202 Cavanaugh, Double-Effect Reasoning, 69-72. 203 Cavanaugh, Double-Effect Reasoning, 69-70. 204 Aquinas, Summa Theologica, II-II, q. 64, a. 7, c. “Potest tamen aliquis actus ex bona

intentione proveniens illicitus redid si non sit proportionatus fini.” 205 Finnis et al., “‘Direct’ and ‘Indirect,’” 34. 206 John Paul II, Veritatis Splendor, 78-9. 207 Cavanaugh, Double-Effect Reasoning, 68. 208 John Paul II, Man and Woman He Created Them: A Theology of the Body, trans. Michael

Waldstein, (Boston, MA: Pauline, 2006), 104th General Audience 12 January 1983, para. 8. 209 Duarte Sousa-Lara, “Aquinas on Interior and Exterior Acts: Clarifying a Key Aspect of His

Action Theory,” Josephinum Journal of Theology 15, no. 2 (2008): 277-316. 210 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 278; quoting De Malo, q. 2, a. 2, ad 13. 211 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 278. 212 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 278, footnote five. 213 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 279, footnote 5. 214 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 279, footnote 5. 215 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 315. 216 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 314. 217 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 314. 218 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 285; see Aquinas, Summa Theologiae,

I-II, q. 20, a. 1, c. 219 Aquinas, Summa Theologica, I-II, q. 18, a. 5. 220 Aquinas, Summa Theologica, I-II, q. 54, a. 3. 221 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 285. 222 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 278. 223 Duarte Sousa-Lara, “‘Materia ex qua’ and ‘Materia circa quam’ in Aquinas,” (2008)

http://www.eticaepolitica.net/eticafondamentale/dsl_materia_ex_qua_materia_circa_quam.pdf,

10. 224 John Abraham Makdisi, “The Object of the Moral Act: Understanding St. Thomas Aquinas

Through the Work of Steven Long and Martin Rhonheimer,” (PhD diss., Catholic University of

America, 2017), 99-101; Aquinas, Summa Theologica, I-II, q. 18, a. 5, ad. 4. 225 Aquinas, Summa Theologica, I-II, q. 18, a. 2-4. 226 Aquinas, Summa Theologica, I-II, q. 7, a. 1. 227 Aquinas, Summa Theologica, I-II, q. 18, a. 10. 228 Finnis et al., “‘Direct’ and ‘Indirect,’” 12ff. 229 Cavanaugh, Double-Effect Reasoning, 69-70, 90. 230 Cavanaugh, Double-Effect Reasoning, 90. 231 Cavanaugh, Double-Effect Reasoning, 73ff.


169

232 Cavanaugh, Double-Effect Reasoning, 75. 233 Cavanaugh, Double-Effect Reasoning, 75. 234 Cavanaugh, Double-Effect Reasoning, 75. 235 Cavanaugh, Double-Effect Reasoning, 75-6. 236 Cavanaugh, Double-Effect Reasoning, 76. 237 Cavanaugh, Double-Effect Reasoning, 78. 238 Cavanaugh, Double-Effect Reasoning, 79. 239 Cavanaugh, Double-Effect Reasoning, 80-1 following John Finnis “Intention and Side-

Effects,” in Liability and Responsibility, ed. R. Frey and C. Morris, (Cambridge: Cambridge

University Press, 1991), 32– 64. 240 Cavanaugh, Double-Effect Reasoning, 81. 241 Cavanaugh, Double-Effect Reasoning, 81. 242 Cavanaugh, Double-Effect Reasoning, 85. 243 Cavanaugh, Double-Effect Reasoning, 84-5. 244 Cavanaugh, Double-Effect Reasoning, 86-7. 245 Cavanaugh, Double-Effect Reasoning, 86-7. 246 Cavanaugh, Double-Effect Reasoning, 87. 247 Cavanaugh, Double-Effect Reasoning, 87ff. 248 Cavanaugh, Double-Effect Reasoning, 87. 249 Cavanaugh, Double-Effect Reasoning, 87, see Charles Fried, Right and Wrong, (Cambridge,

MA: Harvard University Press, 1978), 23. 250 Cavanaugh, Double-Effect Reasoning, 88; see James Sterba, “Reconciling Pacifists and Just

War Theorists,” Social Theory and Practice 18, no. 1 (1992): 25. 251 Cavanaugh, Double-Effect Reasoning, 89; see Sterba, “Reconciling Pacifists and Just War

Theorists,” 26. 252 Cavanaugh, Double-Effect Reasoning, 89. 253 Cavanaugh, Double-Effect Reasoning, 90. 254 Cavanaugh, Double-Effect Reasoning, 90. 255 Cavanaugh, Double-Effect Reasoning, 90. 256 Cavanaugh, Double-Effect Reasoning, 90. 257 Cavanaugh, Double-Effect Reasoning, 90. 258 Cavanaugh, Double-Effect Reasoning, 90. 259 Cavanaugh, Double-Effect Reasoning, 91. 260 Cavanaugh, Double-Effect Reasoning, 91-2. 261 Cavanaugh, Double-Effect Reasoning, 92. 262 Cavanaugh, Double-Effect Reasoning, 92. 263 Cavanaugh, Double-Effect Reasoning, 93. 264 Cavanaugh, Double-Effect Reasoning, 93. 265 Cavanaugh, Double-Effect Reasoning, 93-4. 266 Cavanaugh, Double-Effect Reasoning, 94-5. 267 Cavanaugh, Double-Effect Reasoning, 95. 268 Cavanaugh, Double-Effect Reasoning, 97. 269 Cavanaugh, Double-Effect Reasoning, 97. 270 Cavanaugh, Double-Effect Reasoning, 97-8. 271 Cavanaugh, Double-Effect Reasoning, 98. 272 Cavanaugh, Double-Effect Reasoning, 98.

170

273 Cavanaugh, Double-Effect Reasoning, 99. 274 Cavanaugh, Double-Effect Reasoning, 99-100. 275 Cavanaugh, Double-Effect Reasoning, 100. 276 Cavanaugh, Double-Effect Reasoning, 100. 277 Cavanaugh, Double-Effect Reasoning, 100. 278 Finnis, Aquinas, 21. 279 Cavanaugh, Double-Effect Reasoning, 101-2; see G. E. M. Anscombe, Intention (Ithaca, NY:

Cornell University Press, 1957), 13-20. 280 Cavanaugh, Double-Effect Reasoning, 102. 281 Cavanaugh, Double-Effect Reasoning, 104. 282 Cavanaugh, Double-Effect Reasoning, 104. 283 Cavanaugh, Double-Effect Reasoning, 104. 284 Cavanaugh, Double-Effect Reasoning, 105. 285 Cavanaugh, Double-Effect Reasoning, 105. 286 Cavanaugh, Double-Effect Reasoning, 105. 287 Cavanaugh, Double-Effect Reasoning, 105. 288 Cavanaugh, Double-Effect Reasoning, 108. 289 Congregation for the Doctrine of the Faith (CDF), Declaration on Euthanasia, May 5, 1980,


5_euthanasia_en.html. 290 William May, Catholic Bioethics and the Gift of Human Life, 3rd ed. (Huntington, IN: Our

Sunday Visitor, 2013), 254. 291 May, Catholic Bioethics, 254. 292 May, Catholic Bioethics, 254. 293 Albert R. Jonsen, Mark Siegler, and William J. Winslade, Clinical Ethics: A Practical

Approach to Ethical Decisions in Clinical Medicine, 8th ed. (New York: McGraw Hill, 2015),

153. 294 John Paul II, Evangelium Vitae, 25 March 1995, http://w2.vatican.va/content/john-paul-

ii/en/encyclicals/documents/hf_jp-ii_enc_25031995_evangelium-vitae.html, 57, 64-7. 295 United States Catholic Bishops Conference (USCCB), Ethical and Religious Directives for

Catholic Health Care Services (ERDs), 6th ed. (Washington D. C.: USCCB, 2018), pp. 21-2,

#61; CDF, Declaration on Euthanasia, ch. 3; John Paul II, Evangelium Vitae, 65. 296 USCCB, ERDs, pp. 31, #56, #57. 297 Committee on National Guideline for Palliative Sedation, Guidelines for Palliative Sedation,

(Utrecht, Netherlands: Royal Dutch Medical Association, 2009), 66. 298 USCCB, ERD, 55; CDF, Declaration on Euthanasia, ch. 3. 299 CDF, Declaration on Euthanasia, ch. 3. 300 Joseph M. Boyle, Jr., “On Killing and Letting Die,” New Scholasticism, 51 (1977): 433-52. 301 Boyle, “On Killing and Letting Die,” 435. 302 Boyle, “On Killing and Letting Die,” 435. 303 Boyle, “On Killing and Letting Die,” 435. 304 Boyle, “On Killing and Letting Die,” 435. 305 Boyle, “On Killing and Letting Die,” 435. 306 Boyle, “On Killing and Letting Die,” 435. 307 Boyle, “On Killing and Letting Die,” 436. 308 Boyle, “On Killing and Letting Die,” 436.





171

309 Boyle, “On Killing and Letting Die,” 437-8. 310 Boyle, “On Killing and Letting Die,” 438; see James Rachels, “Active and Passive

Euthanasia,” The New England Journal of Medicine 292, no. 1(1975): 78-80. 311 Boyle, “On Killing and Letting Die,” 438. 312 Boyle, “On Killing and Letting Die,” 439. 313 Boyle, “On Killing and Letting Die,” 440. 314 Boyle, “On Killing and Letting Die,” 442-5. 315 Michael Tooley, “A Defense of Abortion and Infanticide,” in The Problem of Abortion, ed.

Joel Feinberg (Belmont, CA: Wadsworth Publishing Company, 1973), 84-5. 316 Boyle, “On Killing and Letting Die,” 449. 317 Boyle, “On Killing and Letting Die,” 449; see also Tooley, “A Defense of Abortion and

Infanticide,” 85. 318 Boyle, “On Killing and Letting Die,” 450; Daniel Dinello, “On Killing and Letting Die,”

Analysis, 31, no. 3 (1971): 84-5. 319 Boyle, “On Killing and Letting Die, 450ff. 320 Boyle, “On Killing and Letting Die, 451. 321 Boyle, “On Killing and Letting Die, 451. 322 Joseph Boyle, “Medical Ethics and Double Effect: The Case of Terminal Sedation,”

Theoretical Medicine and Bioethics 25, no. 1 (2004): 51-60. 323 Boyle, “Medical Ethics and Double Effect,” 51-2. 324 Boyle, “Medical Ethics and Double Effect,” 52-55. 325 Boyle, “Medical Ethics and Double Effect,” 54. 326 Boyle, “Medical Ethics and Double Effect,” 53. 327 Boyle, “Medical Ethics and Double Effect,” 53. 328 Boyle, “Medical Ethics and Double Effect,” 55. 329 Cavanaugh, Double-Effect Reasoning, 108. 330 Cavanaugh, Double-Effect Reasoning, 108. 331 Cavanaugh, Double-Effect Reasoning, 108. 332 Cavanaugh, Double-Effect Reasoning, 109. 333 Cavanaugh, Double-Effect Reasoning, 109. 334 Cavanaugh, Double-Effect Reasoning, 110. 335 Cavanaugh, Double-Effect Reasoning, 110. 336 Cavanaugh, Double-Effect Reasoning, 110. 337 Cavanaugh, Double-Effect Reasoning, 110. 338 Cavanaugh, Double-Effect Reasoning, 110. 339 Cavanaugh, Double-Effect Reasoning, 111. 340 John Paul II, Evangelium Vitae, 54 quoting Didache, I, 1; II, 1-2; V, 1 and 3: Patres

Apostolici, ed. F.X. Funk, I, 2-3, 6-9, 14-17; cf. Letter of Pseudo-Barnabas, XIX, 5:loc. cit., 90-

93. 341 May, Catholic Bioethics, 163. 342 John Paul II, Evangelium Vitae, 53; CDF, Donum Vitae, 22 February 1987,


2_respect-for-human-life_en.html [accessed 1 November 2017], ch. 5. 343 Pope Pius XII, “Address to the Biomedical Association of St. Luke,” November 12, 1944, in

Discorsi e Radiomessagi di Sua Santità Pio XII (Vatican City: Libreria Editrice Vaticana, 1945),

6 (1944-1945), p. 191; see also USCCB, ERD, pp. 19, #47.

http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html

http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html

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344 May, Catholic Bioethics, 163. 345 May, Catholic Bioethics, 164. 346 Finnis et al, “‘Direct’ and ‘Indirect,’” 21ff. 347 Germain Grisez, Living a Christian Life, (Chicago: Franciscan Herald Press, 1993), 502. 348 Grisez, Living a Christian Life, 502. 349 Joseph M. Boyle, Jr., “Double Effect and a Certain Type of Embryotomy,” Irish Theological

Quarterly, 44, no. 4 (1977): 303-318. 350 Boyle, “Double Effect and a Certain Type of Embryotomy,” 305. 351 Boyle, “Double Effect and a Certain Type of Embryotomy,” 306-8. 352 H. L. A. Hart, “Intention and Punishment,” in Punishment and Responsibility, (Oxford:

Oxford, 1968), 123-4. 353 Boyle, “Double Effect and a Certain Type of Embryotomy,” 306. 354 Boyle, “Double Effect and a Certain Type of Embryotomy,” 308. 355 Boyle, “Double Effect and a Certain Type of Embryotomy,” 306. 356 Boyle, “Double Effect and a Certain Type of Embryotomy,” 309. 357 Boyle, “Double Effect and a Certain Type of Embryotomy,” 306, 309. 358 Cavanaugh, Double-Effect Reasoning, 69. 359 Cavanaugh, Double-Effect Reasoning, 69-70. 360 Cavanaugh, Double-Effect Reasoning, 70. 361 Cavanaugh, Double-Effect Reasoning, 69. 362 Boyle, “Double Effect and a Certain Type of Embryotomy,” 308; R. A. Duff, “Intentionally

Killing the Innocent,” Analysis 34, no. 1 (1973): 17. 363 Boyle, “Double Effect and a Certain Type of Embryotomy,” 308; Duff, “Intentionally Killing

the Innocent,” 17. 364 Boyle, “Double Effect and a Certain Type of Embryotomy,” 308-9. 365 Boyle, “Double Effect and a Certain Type of Embryotomy,” 309. 366 Boyle, “Double Effect and a Certain Type of Embryotomy,” 309. 367 Cavanaugh, Double-Effect Reasoning, 69-70, 90ff. 368 Cavanaugh, Double-Effect Reasoning, 112. 369 Cavanaugh, Double-Effect Reasoning, 112. 370 Cavanaugh, Double-Effect Reasoning, 113. 371 Cavanaugh, Double-Effect Reasoning, 113. 372 Cavanaugh, Double-Effect Reasoning, 114 373 Cavanaugh, Double-Effect Reasoning, 112. 374 Cavanaugh, Double-Effect Reasoning, 112. 375 Cavanaugh, Double-Effect Reasoning, 112. 376 Finnis et al, “‘Direct’ and ‘Indirect,’” 22, 25. 377 Cavanaugh, Double-Effect Reasoning, 112. 378 Cavanaugh, Double-Effect Reasoning, 113. 379 William Tecumseh Sherman, Fateful Lightning: A New History of the Civil War and

Reconstruction, Allen C. Guezlo, (Oxford: Oxford University Press, 2012), 439. 380 Augustine, City of God, in Saint Augustin’s: City of God and Christian Doctrine, in Nicene

and Post-Nicene Fathers, Series 1, Vol. 2, ed. Philip Schaff and trans. Marcus Dods, (Edinburgh:

WM.B. Eerdmans Publishing Company, 1886),

https://www.ccel.org/ccel/schaff/npnf102.iv.XIX.7.html [accessed on 2 November 2017];

Aquinas, Summa Theologiae, II-II, q. 40, a. 1.

https://www.ccel.org/ccel/schaff/npnf102.iv.XIX.7.html

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381 James F. Childress, “Just-War Theories: The Bases, Interrelations, Priorities, and Functions of

Their Criteria,” Theological Studies 39 no. 3 (1978): 428. 382 Childress, “Just-War Theory,” 440. 383 Childress, “Just-War Theory,” 440-1. 384 Childress, “Just-War Theory,” 441. 385 John Finnis, Germain Grisez, Joseph Boyle, Nuclear Deterrence, Morality and Realism,

(Oxford: Oxford, 1987), 328. 386 Finnis et al., Nuclear Deterrence, 329. 387 Finnis et al., Nuclear Deterrence, 283, 300. 388 Finnis et al., Nuclear Deterrence, 283. 389 Finnis et al., Nuclear Deterrence, 284. 390 Finnis et al., Nuclear Deterrence, 287; see John Finnis, Fundamentals of Ethics,

(Georgetown: Georgetown University Press, 1983), 109ff. 391 Finnis et al., Nuclear Deterrence, 310. 392 Finnis et al., Nuclear Deterrence, 315. 393 Finnis et al., Nuclear Deterrence, 315-6. 394 Finnis et al., Nuclear Deterrence, 315. 395 Finnis et al., Nuclear Deterrence, 315. 396 Finnis et al., Nuclear Deterrence, 316. 397 Finnis et al., Nuclear Deterrence, 318. 398 Finnis et al., Nuclear Deterrence, 317-8. 399 Finnis et al., Nuclear Deterrence, 324. 400 John Finnis, Moral Absolutes, 47. 401 Finnis et al, Nuclear Deterrence, 328. 402 Joseph M. Boyle, “The Catholic Teaching on War and Peace: Its Application to American

Foreign Policy after 9/11,” University of Saint Thomas 3, no. 2 (2005): 256. 403 Joseph M. Boyle, “Symposium: Responding to Terrorism: Just War Doctrine and Military

Response to Terrorism,” The Journal of Political Philosophy 11 no. 2 (2003): 153-70. 404 Boyle, “Just War Doctrine,” 156. 405 Boyle, “Just War Doctrine,” 156. 406 Boyle, “Just War Doctrine,” 156. 407 Boyle, “The Catholic Teaching on War and Peace,” 256. 408 Boyle, “Just War Doctrine,” 156. 409 Boyle, “The Catholic Teaching on War and Peace,” 256. 410 Cavanaugh, Double-Effect Reasoning, 114-7. 411 Cavanaugh, Double-Effect Reasoning, 114. 412 Cavanaugh, Double-Effect Reasoning, 115. 413 Cavanaugh, Double-Effect Reasoning, 115. 414 Cavanaugh, Double-Effect Reasoning, 115. 415 Cavanaugh, Double-Effect Reasoning, 116. 416 Cavanaugh, Double-Effect Reasoning, 116. 417 Cavanaugh, Double-Effect Reasoning, 116. 418 Cavanaugh, Double-Effect Reasoning, 116-7. 419 Cavanaugh, Double-Effect Reasoning, 116-7. 420 Cavanaugh, Double-Effect Reasoning, 108-117. 421 Cavanaugh, Double-Effect Reasoning, 89ff.

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422 Finnis et al., “‘Direct’ and ‘Indirect,’” 1-44. 423 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 314. 424 Cavanaugh, Double-Effect Reasoning, 73-108. 425 Cavanaugh, Double-Effect Reasoning, 108-117.

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CHAPTER FOUR – HEALTH CARE ETHICS CONSULTATIONS AND COOPERATION

Having explained the function of the Principle of Double Effect for Catholic health care

ethics, this chapter assesses the role of two separate, but related tools, health care ethics

consultations and the Principle of Cooperation.

4A. Health Care Ethics Consultations

This section highlights several features for health care ethics consultations. Using the

Ethical and Religious Directives for Catholic Health Care Services,1 it offers a unique approach

that incorporates aspects of the Core Competencies of the American Society for Bioethics and

Humanities, 2 the Veterans Health Administration,3 and other literature.

i. Health Care Ethics Consultation

The American Society for Bioethics and Humanities indicates that health care ethics

consultations respond to ethical dilemmas in the clinical setting.4 In particular, they facilitate the

resolution of conflicts between values that inhibit decision-making regarding clinical action.5

Ultimately, they should improve the quality of health care by helping participants to resolve

ethical dilemmas.6 This is also how health care ethics consultations differ from other consultation

services. Both the Veterans Health Administration and the American Society for Bioethics and

Humanities distinguish between case consultations and non-case consultations.7 Case

consultations pertain to a particular clinical case, whereas, non-case consultations refer to other

types of consultation, such as, answering general ethical questions, policy review, organizational,

and professional questions.8 The American Society for Bioethics and Humanities focuses its

competencies on case consultations, though the scope of application is not necessarily limited to

such.9

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While there are several approaches to health care ethics consultations, including:

authoritarian, pure consensus, and facilitation, the American Society for Bioethics and

Humanities argues that the facilitation approach works best.10 In the authoritarian approach, the

ethicist usurps the decision-making authority of the patient or surrogate and makes decisions for

them.11 This is problematic because the ethicist fails to respect the autonomy of the patient and

care team. The consensus approach is faulty because it does not necessarily incorporate values

and norms, but rather bases decision-making entirely on an agreed upon consensus.12 The

American Society for Bioethics and Humanities offers a twofold explanation in favor of the

facilitation approach. One, ethicists help identify values; and two, they assist in formulating an

ethical resolution.13

In principle, because of its integration of relevant sources, the facilitation approach

avoids sliding into moral relativism.14 For Catholic hospitals, this includes the use of the Ethical

and Religious Directives. As a facilitator, ethicists utilize a broad spectrum of skills that surpass

the role of philosopher or theologian. They develop strong interpersonal skills, such as listening,

coordinating meetings so that all voices are heard, helping people articulate their values, and

helping to resolve conflicts.15 At the same time, consultants need to avoid manipulating patients

or clinicians into adopting their personal preferences.16 This does not mean refraining from

educating or pointing out unethical practices.17 Ultimately, the facilitation approach is desirable

because it empowers patients, surrogates, and clinicians to act on well-articulated values.

One size does not necessarily fit all, when it comes to how many individuals to include in

an ethics consult. The American Society for Bioethics and Humanities and the Veterans Health

Administration differentiate three sizes: 1) individual, 2) consultation team, and 3) Ethics

committee.18 Necessity determines the size of the consultation. The American Society for

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Bioethics and Humanities recommends individual consultation when the need for information is

urgent.19 In addition to time constraints, all parties may not feel comfortable communicating in

large groups.20 Ethicists should meet with patients and clinicians before the formal meeting to

make sure all the relevant information is shared.21 Even where time is not necessarily a

constraint, the efficient use of personnel may preclude a formal meeting of the entire ethics

board.22 The disadvantage of an individual consultant is that one must have all the relevant

competencies and there is no way to guard against biases.23

The advantage of a larger group of consultants is the multidisciplinary perspective and

the representation of more competencies and experience.24 A team consult is smaller than a

whole committee. Members should be chosen for complementary competencies.25 Although they

are not as efficient as an individual consults they are quicker than committees. According to the

Veterans Health Administration, the team consultation is the most commonly used model for

health care ethics consultations.26 The full ethics board meeting presumably engages the widest

variety of expertise and competencies ensuring collective proficiency.27 Although it utilizes the

greatest personnel hours, it helps for evaluating quality of a consult and policy-making, not to

mention the avoidance of legal repercussions.28 For this reason, the American Society for

Bioethics and Humanities recommends using it for potentially high profile clinical cases.29

a. Proficiencies

Before discussing the mechanisms for health care ethics consultations, I discuss

proficiencies for handling them.30 The Veterans Health Administration and the American Society

for Bioethics and Humanities divide proficiencies into three classes: 1) knowledge; 2) skills; and

3) attributes, attitudes, and behaviors.31 Knowledge consists of the information that ethicists

ought to master for consultations. Skills consist of practical techniques important for running

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them. The American Society for Bioethics and Humanities divides these skills into three

categories: 1) ethical assessment and analysis skills; 2) process skills; and 3) interpersonal

skills.32 The American Society for Bioethics and Humanities and the Veterans Health

Administration list attributes, attitudes, and behaviors that an ethicist ought to have and

develop.33 While it may not be necessary to have advanced proficiency in all these areas, it is

important to have at least some basic proficiency in each. In the following, I discuss each

proficiency in greater detail.

First, I discuss knowledge that ethicists and board members ought to attain. The fewer the

number of members participating in a consultation, the greater amount of knowledge that single

individuals must have. To begin with, it is important for consultants to be familiar with the field

of ethics. This includes knowing various ethical theories and how to apply them. The American

Society for Bioethics and Humanities encourages proficiency in consequentialism, deontology,

virtue-based ethics, natural law, communitarian, and feminist theories.34 As an applied science, it

is important to be familiar with casuistic approaches as well.35 An ethicist for a Catholic hospital

should be familiar with the Catholic theological tradition and the Ethical and Religious

Directives.

In addition to familiarity with the philosophical and theological theories, it is important to

be familiar with the common issues and scenarios that arise necessitating its application. This

includes, but is not limited to: confidentiality, patient rights, end-of-life decision-making,

beginning-of-life decision-making, surrogate decision-making, competency, conflict of interest,

competency of minors, and organ donation.36 It is important to know institutional policies, along

with federal and local laws pertaining to healthcare.37 Even though an ethicist may not be a

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practicing clinician, it is nonetheless important to be familiar with the clinical literature, practice,

and terminology.38

As an applied field, health care ethicists need to develop certain practical skills. First,

ethicists must be able to assess and analyze information ethically.39 To begin with, one must

determine what the uncertainty or conflict of values consists of.40 In order to achieve this goal,

one must gather all relevant information from the patient, surrogate, family, clinicians, attorneys,

and administrators.41 At the same time, one must be mindful of power relations, ethnic, cultural,

and religious influences.42 It is important to maintain the scope of the consultation to ethics.43

Moreover, one must identify, articulate, and clarify the ethical concerns, values, and beliefs held

by all including oneself.44

In terms of analysis, the ethicist has to access relevant information to clarify the relevant

ethical concepts to facilitate ethical decision-making.45 Sometimes this means clarifying whom

the appropriate decision-maker is.46 Success in analyzing involves being able to integrate all

relevant information from many different sources including practical and theoretical. One must

also be able to identify personal biases and limitations so that one can seek assistance.47

Next, both the American Society for Bioethics and Humanities and the Veterans Health

Administration consider processing skills.48 To begin with, the ethicist needs to determine if a

request actually constitutes an ethical dilemma or another type of problem that needs to be

referred elsewhere.49 Next, the ethicist needs to decide which type of consultation model to

utilize: individual, team, or committee, and who needs to be involved: patient, surrogate, family,

and clinicians.50 Before having a formal meeting, the ethicist should speak to the patient, and

other parties to collect information and get an idea of what the situation entails.51 This process

180

also entails documentation in the patient’s health records.52 The ethicist must also be able to run

an effective ethics consultation, which necessitates the development of good interpersonal skills.

Perhaps the most important interpersonal skill that an ethicist must have is listening.53

While listening may seem like a passive activity, it involves lots of work, if it is done well.

Listening begins with respecting each person and being able to empathize with his or her

perspective.54 Effective health care depends on hierarchical structures, but these can lead to

moral distress for subordinate clinicians, especially when they identify inappropriate behavior or

practice in their superiors. An ethicist must be attentive to the power dynamics at work and

attend to concomitant moral distress of subordinates and helping superiors to hear their concerns

without feeling overthrown or betrayed.55 The American Society for Bioethics and Humanities

calls this leveling the playing field.56

Good listening includes active listening. This means helping others articulate their views

without adding to or taking away from the content of their message. Ethicists have an important

role to educate others on ethics and to help others express their views in ethical terms. Being able

to recapitulate another’s view in such a way that others can understand it better, sometimes

including the one espousing it, is an important tool of communication for ethicists, especially

since ethics is not the expertise of everyone.57 By using this skill with each respective party, an

ethicist ensures that all are heard helping to bring about effective resolutions amenable to all.58

Finally, the American Society for Bioethics and Humanities and the Veterans Health

Administration discuss attributes, attitudes and behaviors that they believe are requisite for an

ethics consultant.59 First, the American Society for Bioethics and Humanities says that ethicists

should be tolerant, patient, and compassionate.60 The healthcare world is high-stress and when

ethical dilemmas arise, tensions and emotions are high. An ethicist brings a sense of calm and

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understanding, working constructively even in situations of duress.61 Next on the list are honesty,

forthrightness, and self-knowledge.62 These virtues help one address uncomfortable issues that

most prefer to avoid. Ethical dilemmas are often messy; people are vulnerable. These virtues

help the ethicist to avoid tendencies toward quick resolution through manipulation.63

Courage is another important virtue that helps one raise the red flag and address unethical

behavior, especially when doing so is not popular.64 Humility and prudence are two virtues that

aid one in choosing the right battles and not over-stepping one’s bounds.65 Ethicists need to be

good leaders, acting decisively, but also having restraint at times.66 Above all, they need to be

people of integrity, which means that their words match their behavior and beliefs.67

b. Veterans Health Administration

Both the American Society for Bioethics and Humanities and the Veterans Health

Administration offer a method for running consultations. However, before discussing this, I

mention two topics related to the above proficiencies that ethicists need when leading health care

ethics consultations, that is, skills for facilitating consultations, and evaluative, quality

improvement skills.68 To facilitate an effective meeting, one first introduces the participants,

their roles and expectations.69 It is always a good idea to begin a meeting by emphasizing the

importance of confidentiality.70 Next, one lays the ground rules and clearly defines the goal and

timeframe for meeting it.71 The ethicist should run the meeting so that each party has an

opportunity to speak, but making sure that the team stays focused.72 To facilitate this, it may be

helpful to have an agenda drafted before the meeting. Finally, the ethicist needs to determine

what type of follow up is necessary, including whether to have another formal meeting.73

It is important for ethicists to also do prep work before the meeting, including picking

appropriate members that complement and represent different competencies.74 Furthermore, one

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must mentor and offer further training to members. In addition, one must maintain a good

rapport with the leadership of the institution and be familiar with procedures and policies.75

Finally, ethicists should inform staff and patients about access to health care ethics consultations.

No service is complete without some means of evaluation and quality assurance. This

involves evaluation of the access, process, and implications to the organization and policies of a

health care ethics consultations.76 The ethicist needs to provide means for collecting and

analyzing relevant data to determine not only the effectiveness of the consultation in terms of

outcome, but also in how it is accessed and run.77 Being self-reflective and not afraid to critique

one’s approach is key to success in this arena. Looking for patterns in the content of consultation

may lead one to discern the need for change in practice or policies within the organization.78

Having positive relationships with the administration can make this more effective.

For the procedure of running health care ethics consultations, the Veterans Health

Administration recommends the five step approach: clarify, assemble, synthesize, explain, and

support.79 They intends the step-by-step procedure to be analogous to a clinician’s physical

exam or history of a patient.80 In this sense, the ethicist should follow it precisely when

performing an ethics consult for an active patient case.81 This also provides an outline for

documenting in the patient’s records.82 In the following, I discuss each of these steps in detail.

According to the Veterans Health Administration’s approach, one must first clarify the

consultation request.83 They indicate that ethical problems concern values and/or conflict of

values.84 The ethicist helps the requester articulate the issue or concern at hand.85 Often, ethical

concerns accompany dilemmas that require expertise in other fields, such as, legal, medical,

psychological, spiritual, or administrative, in which case referral is necessary, in addition to

addressing the ethical concern.86 Having determined that the case involves an ethical concern,

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one determines if it is an active patient case; if it is, then one follows the procedure in the

Veterans Health Administration and records it in the patient’s records.87 Next, one obtains

preliminary information, such as, contact info, date, time, urgency, requester’s role, brief

description, assistance desired, and care setting.88 Then the ethicist should share realistic

expectations for about the process with the requester.89

Finally, regarding clarifying the request, the Veterans Health Administration asks the

ethicist to formulate the ethics question, for which they offer a five-step process.90 First, the

requester describes the situation ethically as she understands it.91 Second, the ethicist identifies

value labels for strongly held beliefs, ideals, principles, or standards, such as honesty, equality,

rights, justice, etc.92 Third, having identified values, the ethicist then describes them from the

perspective of respective parties.93 Next, of all the values mentioned, the ethicist identifies the

“central value perspective,” that is what constitutes the value or values in conflict.94 Fifth, the

ethicist formulates the main ethical concern.95 Finally, the Veterans Health Administration

recommends formulating this concern according to the format of one of three questions:

1. Given that [1st central value], but [2nd central value], what decisions or actions are

ethically justified?

2. Given that [1st central value], but [2nd central value], is it ethically justifiable to

[decision or action]?

3. What ethical concerns are raised by name of document, and what should be done to

resolve them?96

Second, the ethicist must assemble all the relevant information.97 The Veterans Health

Administration reformulates Jonsen, Siegler, and Winslade’s four topics—medical indications,

patient preferences, quality of life, and contextual features98—into three categories: 1) medical

facts, 2) patient preferences and interests, and 3) other parties’ preferences and interests.99 In

addition, they insist that ethicists gather relevant ethical information for the case.100 Although it

is not the ethicist’s job to make recommendations regarding medical decisions, the medical facts

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are important, and where the ethicist lacks clinical knowledge, he ought to ask more questions.101

Sources for information include: patient, health records, staff, family members, and friend.102

Third, the ethicist needs to synthesize the information such that it addresses the ethical

concerns.103 Because many may feel reluctant to share in a formal meeting, it is important to

gather information prior to determining whether to convene a formal meeting.104 Before a formal

meeting, the ethicist should formulate the problem in words, meet with all parties, and bring

relevant literature.105 During the meeting, the ethicist should work to level the playing field and

engage the group in creative problem solving.106

One of the most important roles of an ethicist is ethical analysis, which involves

formulating and weighing arguments and counterarguments based on ethical principles and

theoretical perspectives.107 The Veterans Health Administration recommends that ethicists use

more than one ethical perspective, such as, casuistry, consequentialism, utilitarianism,

principlism, deontology, and virtue ethics, to name a few.108 Performing quality ethical analysis

involves not only formulating arguments and counterarguments, but also weighing them to

determine a conclusive response to the dilemma.109 In addition, it is important to determine who

the appropriate decision maker is.110 This is not always easy. Often it is the patient, but if the

patient is incapacitated or a minor, then a surrogate decision maker takes over. I discuss this

topic in greater detail below. Finally, when there are multiple competing ethically sound options,

the ethicist facilitates deliberation avoiding manipulation by imposing personal preferences.111

The decision having been made by the appropriate decision maker, the ethicist now has

the responsibility of explaining this to the other participants.112 This involves contacting the

requester, clinicians, family members, and other relevant participants personally to share the

outcome of the consultation, giving them an idea for the plan going forward.113 Sometimes, this

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involves educating participants about ethics, policy, law, or medical practices.114 It also involves

documenting both in the patient’s health records and the consultation records, for which the

Veterans Health Administration offers a procedure.115

The final step is supporting the consultation process.116 The consultant should follow up

with participants to determine the effectiveness of the consult, resolve further issues, offer an

empathetic ear, and educate further, if necessary.117 This provide an opportunity to evaluate the

effectiveness of the service, and if necessary, to make adjustments to the process.118 This is also

how one may identify underlying systems issues.119

The Veterans Health Administration’s approach to health care ethics consultations is a

tried and true process that enables ethicists to provide effective services to patients, surrogates,

and clinicians. So long as an ethicist incorporates the Ethical and Religious Directives into this

approach, especially regarding ethical analysis, there is no reason Catholic Health care systems

should not embrace and follow them.

ii. Principles and Topics for Health Care Ethics Consultations

Today, much of biomedical ethics depends on principlism, an ethical theory originating

in Tom L. Beauchamp and James F. Childress’s book Principles of Biomedical Ethics.120 The

authors establish a foundation for biomedical ethics based on a common morality, which consists

of four foundational principles: autonomy, beneficence, non-maleficence, and justice.121 In the

following, I discuss these four principles, relating them to health care ethics consultations. I also

integrate recommendations from Jonsen et al.’s text, Clinical Ethics: A Practical Approach to

Ethical Decisions in Clinical Medicine.122

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a. Autonomy

The first principle is autonomy, which Beauchamp et al. discuss in the fourth chapter of

their text.123 Contrary to common misconceptions, Beauchamp et al. do not believe that respect

for autonomy trumps all other ethical principles, nor is it excessively individualistic, excessively

rational, or overly legalistic.124 While there are many definitions for autonomy, it at least means

that one has the capacity for self-rule that is free from interference and limitations or inadequate

understanding.125 More explicitly, autonomy consists of two conditions: liberty (freedom from

compelling influences) and agency (ability to intend action).126 Beauchamp et al. argue for a

three-condition theory within reach of competent agents: 1) intentionality, 2) understanding, and

3) non-control.127 For an act to be intentional, the agent must conceptualize and plan for it, but

consequences do not necessarily have to go according to plan.128 An agent only needs a

“substantial degree of understanding and freedom from constraint” for one to be autonomous.129

To be non-controlling, it must be free from forces internally or externally coercive or

manipulative.130 While acts are either intentional or non-intentional, they may be more or less

autonomous according to degrees of understanding and control, the threshold of which

determines whether an action is substantially autonomous.131

There are a number of important concepts that depend on autonomy, including:

determination of competence, informed consent, and confidentiality. Jonsen et al. also base

patient preferences on autonomy. In addition, autonomy plays an important role for quality of

life determination from the patient’s perspective.132 I begin by discussing informed consent.

Regarding patient preferences, Jonsen et al. ask six questions, the first of which pertains

to informed consent.133 To the patient, the physician describes the diagnosis, the recommended

course of treatment, and its reasons, along with alternative treatments, explaining benefits, and

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risks to each, to which the patient either accepts or declines the recommendation.134 Although

legal standards regarding quality of disclosure once depended on the perspective of the

physician, today they are patient-centered.135 The minimum legal standard is “the reasonable or

prudent patient standard,” while Jonsen et al. encourage movement toward a “subjective

standard,” disclosure uniquely conformed to the individual patient.136

Jonsen et al. offer four criteria that constitute appropriate disclosure: 1) medical status; 2)

potentially helpful interventions, including risks and benefits; 3) professional opinion regarding

alternatives; and 4) a recommendation based on the physician’s best clinical judgment.137 In

conveying this information, physicians ought to communicate it in such a way that it avoids

technical terminology, and presents statistics in common, easy to understand examples.138 Jonsen

et al. assert that physicians ought to disclose professional experience regarding outcomes of

procedures, especially when the risks are high or the treatment is elective.139 It is one thing to

provide patients with information, but quite another to ensure understanding. Jonsen et al. say,

“Physicians have an ethical obligation to make reasonable efforts to ensure comprehension.” 140

Clinicians may facilitate comprehension by not only allowing patients to ask questions, but by

asking questions of the patient to test understanding.141 Since nothing in healthcare should

happen without documentation, the clinician ought to document the conversation regarding

informed consent, including the patient’s concerns and demonstrated comprehension, which

constitutes more than a mere signature.142 Although it is true that physicians are often pressed for

time, and bad news may be difficult to explain, initially misunderstood, or induce anxiety in the

patient, taking the time to inform consent not only promotes patient shared decision-making, but

strengthens the physician-patient relationship, and engenders a better therapeutic outcome.

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Unfortunately, not all patients are mentally capable or legally competent to receive and

process information to make a reasonably informed decision concerning care. As such, clinicians

need to establish the capacity of a patient for decision-making. Legally, only a judge can make a

determination that one is incompetent to make personal decisions regarding finances and

healthcare; however, clinically, sickness, anxiety, or drugs may compromise one’s decisional

capacity.143 Clinically, mental capacity to give consent entails the ability to receive and process

information, understanding the consequences of decisions, being able to communicate and think

rationally about one’s values and goals in relationship to the physician’s recommendation.144

Obvious situations where this capacity is lacking include: comatose, unconscious, or severely

demented, in which case a surrogate acts as the decision-maker.145 However, ethical dilemmas

arise when mental capacity to give consent is questionable, for instance, under the influence of

drugs, fear, trauma, or severe illness.146 In life-threatening situations, where mental capacity is

doubtful, a physician has the right to intervene; otherwise, it is necessary to determine decisional

capacity.147

If a physician determines that a patient does not have decision making capacity, then the

following must be done: 1) determine if the patient has any written advance directives; and 2)

determine if and whom the surrogate decision-maker is.148 Jonsen et al. list several methods of

advance planning including, but not limited to: 1) a durable power of attorney for healthcare, 2)

directive to physicians, and 3) living will.149 Today healthcare institutions are required to ask for

advance directives and to offer assistance in completing them, if lacking upon admission.150 The

simplest advance planning is to appoint a durable power of attorney for healthcare, which makes

decisions regarding one’s healthcare in the event that one becomes incapacitated.151 The patient

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ought to know the surrogate and she ought to know the patient’s values and desires regarding

healthcare decisions.152

It may also be helpful to have an advance directive or directive to physicians.153 This

constitutes a legal document expressing to the physician one’s wishes if one is incapacitated.154

Often this contains a provision appointing a designated decision maker.155 A living will

expresses one’s wishes in a less formal way, but may provide more guidance regarding quality of

care or specific conditions.156

If healthcare decision-making falls to a surrogate, because of the patient’s incapacity, and

one is not designated, legislative statutes dictate an order of priority based on relation: 1) spouse,

2) parents, 3) children, 4) siblings, etc.157 Conflicts may arise because of surrogate incapacity or

financial interests. Jonsen et al. identify two standards that guide surrogate decision-making: 1)

substituted judgment and 2) the best interest standard.158 Substituted judgment occurs when the

patient either expresses preferences explicitly or the surrogate may reasonably infer from the

patient’s past statements or known values.159 Whenever the patient’s preferences are not known,

the surrogate ought to makes decisions in the best interest of the patient.160 Needless to say, this

is not always easy, but ought to be according to known beliefs and values of the patient.161

Jonsen et al. identify incapacitated patients without a surrogate or next of kin as an

“unbefriended or unrepresented patient.”162 Without representation, these patients are highly

vulnerable. Under such circumstances, the physician team often makes decisions for the

patient.163 To reduce conflict, Jonsen et al. recommend that hospitals institute policies that allow

for outside consultation.164

Regarding minors, Jonsen et al. indicate that in general, physicians need the consent of a

parent or guardian to offer treatment; however, there are some exceptions.165 In emergencies,

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minors, those below the age of 18, may be treated without permission according to presumed

consent.166 In addition, certain procedures or drugs may be administered without parental

consent, including treatment for sexually transmitted infections, contraception, drug addiction,

and abortion (though the latter is sometimes explicitly excluded by law in certain states).167

Moreover, emancipated minors may be treated without parental consent; and under specific

conditions, mature minors (15 years or older) may be treated.168 Regarding the mentally ill, only

a psychiatrist may hold a patient against his will for the sole purpose of treating the mental

illness, however, not other comorbidities, without consent.169

Conscientious objection concerns the autonomy of the clinician, sometimes limiting that

of the patient.170 Ideally, healthcare decision-making takes place within the physician-patient

relationship as a shared enterprise. If conflicts arise, however, physicians are not always obliged

to simply do whatever patients want. Physicians should not perform procedures or prescribe

medicine that is contrary to the goals of medicine.171 In addition, a clinician may object to

participating in a treatment or procedure that she believes to be immoral.172 For instance, a nurse

may refuse to assist in an abortion or a pharmacist may refuse to fill a prescription for the

RU486.173 While existing laws support conscientious objection, there are limits to its ethical

practice.174 For instance, it is unethical to refuse to treat a patient out of prejudice or for immoral

notoriety.175 Conscientious objection is a serious moral decision that a clinician must give great

consideration to, which includes the legal ramifications and potential harm to patients.176

b. Non-Maleficence and Beneficence

Non-maleficence consists of the principle to do no harm.177 Beauchamp et al. present

non-maleficence in conjunction with beneficence, according to four distinct non-hierarchical

norms: “1) one ought not to inflict evil or harm; 2) One ought to prevent evil and harm; 3) one

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ought to remove evil or harm; and 4) One ought to do or promote good.”178 The first requires one

to intentionally avoid actions, which cause harm, while the latter three, associated with

beneficence, require one to act helpfully.179 They contrast harm from wronging another.180

Specifically, harming for them means thwarting, defeating, or setting back a party’s interest.181

One who is harmed is not necessarily wronged.182 A surgeon may amputate a diseased limb that

harms a patient, but does not wrong the patient.183 Nor is one necessarily harmed when

wronged.184 For example, when an insurance company unjustly refuses to pay a patient’s hospital

bill.185

Questions concerning non-maleficence inexorably link to questions on quality of life.

William May asserts that allowing quality of life and autonomy to either determine or trump the

dignity of the human person underlies arguments condoning intrinsically evil acts such as active

voluntary euthanasia and physician-assisted suicide.186 Under the guise of mercy and respect for

autonomy proponents defend patients’ and physicians’ rights to such acts.187 Following the

Catholic tradition, based in Natural Law, May defends the dignity of every human person,

inexorably part of human nature, and therefore, constituting the basis for the principle of

autonomy.188 For May, autonomy exists for the purpose of achieving the flourishing of the

human person as a human person—body and soul.189 According to May, lines of reasoning

defending euthanasia or physician-assisted suicide, presume a dualism that differentiates the

human person from the human body.190 Moreover, quality of life constitutes the litmus test for

the dignity or worth of a person’s life, since below an arbitrary threshold life may be justifiably

terminated.191 This threshold is arbitrary because it depends on the subjective judgment of the

individual making the determination. May argues that insofar as autonomy and respect for it

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issues from the dignity of the human person, using it to violate the dignity of the human person,

under the guise of respect for it, is inconsistent.192

Some argue that the slippery slope trajectory of quality of life arguments render it

untenable for any ethical consideration whatsoever.193 However, May, following the

Congregation for the Doctrine of the Faith’s reasoning in its Declaration on Euthanasia, insists

that quality of life does have an important role to play for utilizing treatments.194 One may

classify treatments, including procedures, medicines, or interventions, as proportionate

(ordinary) or disproportionate (extraordinary).195 Proportionate treatment consists of any

treatment that has a reasonable hope of benefit with an acceptable amount of burdensomeness.196

Disproportionate treatment consists of treatment that the patient or proxy determines to be

excessively burdensome or futile.197 According to May, respect for the dignity of the human

person obliges one to accept proportionate treatment, whereas, it permits one to reject

disproportionate treatment, even when doing so hastens death.198 Quality of life is an important

factor for determining both the burdensomeness and usefulness of a treatment; as such, it

maintains an important role for biomedical ethics in the Catholic tradition.199 According to the

Catholic tradition, one does not use quality of life to make a judgment about the value of one’s

life in the absolute sense as to whether one should live or die; rather, one makes a judgment

about treatment.200

Beauchamp et al. indicate that patients and families often experience significantly more

moral distress at the thought of discontinuing treatment, once commenced, than simply foregoing

it from the beginning.201 This is particularly controversial when it comes to life sustaining

devices such as cardiovascular implantable electronic devices.202 It is quite distressing because

deactivation of such devices sometimes leads to immediate death.203 Despite controversy and

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frequent concomitant moral distress, the difference between foregoing treatment and

withdrawing does not limit one’s right to reject disproportionate treatment.204

The principle of non-maleficence obliges clinicians to do no harm.205 Insofar as it is a

negative norm, obliging one to refrain from action, non-maleficence accordingly obliges no one

to do any positive act, which active euthanasia or physician-assisted suicide constitutes.206

Therefore, alone it cannot justify such acts. Even with other principles, however, insofar as non-

maleficence is a more stringent obligation, it ought to overrule any further consideration of such

acts.207 Regardless, most medical interventions have some concomitant harm. In all cases,

however, non-maleficence, in addition to respect for autonomy, limited by respect for the dignity

of the human person from which autonomy proceeds, demands that one demure from requests to

kill patients or aiding them in any suicidal act. This exceptionless moral norm, however, does not

mean that one may not utilize quality of life, along with other factors to determine whether a

treatment is proportionate, even when one knows that its cessation accelerates death.208

c. Justice

Unlike non-maleficence, the principle of beneficence places a positive obligation, rather

than, a negative obligation on the clinician to care for a patient.209 Beauchamp et al. list five

prima facie rules which beneficence obliges: “1) protect and defend the rights of others; 2)

prevent harm from occurring to others; 3) remove conditions that will cause harm to others; 4)

help persons with disabilities; and 5) Rescue persons in danger.”210 In particular, however, the

contractual relationship between physician and patient carries specific obligations on the part of

the physician, which demand a high degree of professionalism.211

According to Jonsen et al., beneficence demands that clinicians always keep the

wellbeing of the patient above any personal goals.212 Moreover, integral to professionalism is

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honesty with the patient, collaboration with other caregivers, and respectability.213 Above all,

physicians ought to avoid exploiting patients for personal gain—financial or otherwise.214 This

important obligation to avoid exploitation, relates not only to beneficence, but justice and

fairness as well.215 In particular, it relates to the avoidance of conflicting interests.216

Jonsen et al. consider conflicts of interest in detail in the chapter pertaining to contextual

features.217 Factors such as profession, family, religion, financial, legal, and institution, influence

the physician-patient relationship, and therefore, require ethical consideration regarding their

importance in clinical cases.218 Justice, the virtue that pertains to the social distribution of

benefits and burdens in a fair and equitable manner, is the primary ethical principle for this

topic.219 Jonsen et al. narrow the focus to fairness, which delineates to participants that which

each deserves and can reasonably expect in a relationship or transaction.220 In particular, Jonsen

et al. apply fairness to conflicts of interest; situations where one’s professional role makes it

possible to take advantage of another.221 Jonsen et al. consider ten questions pertaining to

contextual features.222

First, Jonsen et al. address conflicts of interest in relation to professionalism and

professional relationships to which he connects to three principles: primacy of patient welfare,

patient autonomy, and social justice.223 Today physicians have multiple loyalties or allegiances,

but the principle of primacy of the patient, based on altruism, that is, doing what’s best for

another, means that whenever conflicts arise, the patient’s priorities take precedence.224 In

addition to loyalty to patients, physicians have relationships with other medical staff, which may

give rise to moral distress, when subordinates observe unethical practices of superiors.225 This is

precisely an issue that Jonsen et al. say ethics consultations ideally resolve.226 To avoid unethical

practices in physicians’ relationships with business, Jonsen et al. recommend transparency and

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compliance with the law and recommendations of the American Medical Association Council on

Ethics and Legal Affairs.227 Finally, Jonsen et al. acknowledge the importance of taking time for

family, which improves physicians’ health and performance.228

Next, Jonsen et al. address the interests of third parties for patient care including: family,

government, hospital, insurance company, lawyers, employers, etc.229 Family members may be a

source of aide for the patient or tension and conflict. Whenever family members act as obstacles

to care, Jonsen et al. recommend attempting to determine the source of conflict and realigning

cooperation in treatment.230 Often confidentiality, rooted in respect for autonomy of the patient,

limits the amount of information that physicians can share with family members. However, when

personal information impacts a third party, confidentiality may be breached.231

In 1996, congress passed the Health Insurance Portability and Accountability Act, which

regulates confidentiality in healthcare legally on the federal level.232 According to the Health

Insurance Portability and Accountability Act, physicians may share medical information when it

helps the patient or prevents harm to a third party.233 For instance, if a patient has a sexually

transmitted infection, the physician may inform known sexual partners, if the patient refuses.234

Furthermore, clinicians have a duty to report suspected cases of physical or sexual abuse and

when patients intend to harm themselves or others.235

Genetic conditions introduce a whole new consideration for confidentiality and its impact

on third parties, such as, spouses and family planning, and children. Not only do genetic tests

vary in accuracy, but genetic conditions vary in impact and levels of predisposition.236 In other

words, testing positive for a particular genetic mutation does not always result in developing the

pathological condition. In some cases, however, such as Huntington’s disease, genetic testing

accurately predicts future onset, but not necessarily time or degree of onset. In general, where

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there is greater accuracy and the pathology more serious, Jonsen et al. recommend that

physicians encourage patients to share information, especially, if it is likely to have an impact on

others.237 The Ethical and Religious Directives encourage families to seek genetic counseling,

and to allow it to inform designs regarding family planning, so long as one follows the Church’s

teachings regarding the transmission of life.238

Fourth, Jonsen et al. address financial conflicts of interest.239 Because of the increasing

costs relegated to the patient in copays and deductibles, physicians must take into account the

cost of prescriptions and procedures.240 Moreover, physicians are obliged to inform patients of

alternative treatment options, even though it may result in a financial loss.241 Regarding transfers

in emergency departments, Jonsen et al. say that they ought to be made based on medical

indication, rather than financial incentive.242 Indeed, all medical recommendations should be

based clinical effectiveness, rather than cost.243

Fifth, Jonsen et al. considers the impact of allocating scarce resources on patients.244

While physicians should not waste resources on futile treatments, they should avoid bedside

rationing, which is allowing societal efficiency to influence clinical treatment of patients.245

Catastrophic events may necessitate triaging, the limitation of resources to rescue workers, or the

most likely to survive, before treating terminal patients. Outside of these extreme circumstances,

physicians should make decisions based on medical indication on the clinical level, rather than

consideration for the use of societal resources.246

Sixth, Jonsen et al. address the role of religion in the clinical setting.247 Both physicians

and patient find great meaning in religion. For patients, this is especially true when they are sick,

suffering or nearing death. Jonsen et al. encourage mutual respect regarding religious views, but

not neglect or exclusion from a discussion, especially insofar as it may impact a patient’s

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openness to and compliance with treatment.248 For this reason, Jonsen et al. encourage physicians

to discuss religious views with patients in an understanding way and to seek accurate information

from appropriate resources such as chaplains.249

Seventh, Jonsen et al. consider the legal issues that may affect clinical decision-

making.250 Eighth, Jonsen et al. speak to the influence that research and education may play in

clinical decisions.251 A physician has conflicting interests whenever he or she is both a clinician

and researcher.252 Clinical research involves intervention or observation on patients or normal

volunteers for the purpose of gaining scientific knowledge.253 It is essential to appropriately

inform participants and to receive consent, without coercion.254 Institutional review boards

assure that experiments follow ethical procedures, inform participants of risks/benefits, receive

consent, compensate participants fairly, do no harm, or take advantage of vulnerable

populations.255

This section analyzes proficiencies for health care ethics consultations from the

perspective of the American Society for Bioethics and Humanities and the Veterans Health

Administration. Then discusses the impact that principlism and the Ethical and Religious

Directive have on health care ethics consultations. The following section examines another

important principle of health care ethics from the perspective of the Ethical and Religious

Directives.

4B. Principle of Cooperation

This section explores the development of cooperation, beginning with its origin in

Thomistic action theory and Liguori’s moral theology. It also considers the development of

Cooperation in the Ethical and Religious Directives for Catholic Health Care Services of the

United States Catholic Bishops. Then, it articulates two contemporary formulations of the

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Principle of Cooperation, one that addresses the impact of proportionalism and another that

considers the mirror Principle of Appropriation.

i. Principle of Cooperation

Just as acts may have more than one effect, so one’s acts may contribute to another’s bad

act. The Principle of Double Effect accounts for the former, while the Principle of Cooperation

accounts for the latter.256 This section compares Cooperation with Double Effect.

a. Cooperation and Double Effect:

Ethicists highlight the similarities between Double Effect and Cooperation.257 The former

elucidates when an act with both a good and evil effect may occur, just as the latter illuminates

when and how much one’s act may licitly contribute to the evil of another. Contrary to the

Principle of Tolerance, in Double Effect and Cooperation, an agent commits an act.258 While

Double Effect considers the morality of one’s act in relationship to two effects: one evil, the

other good, Cooperation considers the morality of two distinct acts attributable to two distinct

agents: one agent’s act contributing to another’s immoral act. Traditional formulations of Double

Effect have four or five conditions that correspond to similar conditions in Cooperation.259 First,

regarding Double Effect, the object of the act must be good or indifferent.260 Consequently, the

first condition of Cooperation insists that the act of the cooperator must be good or indifferent.261

Next, Double Effect insists that the agent must not intend the evil effect, but the good

effect.262 Put another way, one may only foresee the evil effect, but one must not intend it.263 As

such, the next condition for Cooperation concerns the intent of the cooperator. The agent must

not intend the evil that the principal agent intends.264 Formal cooperation in evil exists when the

cooperator agrees with the evil intent of the primary agent.265 The cooperator is guilty insofar as

the will conforms to the evil intent of the principal agent.266

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Clearly, intention—broadly speaking—plays a primary role for both principles. 267 First,

intention determines the proximate end of the act, which constitutes the Moral Object.268 Second,

intention determines the remote end that the agent intends.269 Therefore, the intention of the will

is the primary means for determining the sinfulness of a cooperator’s act in the aid of another’s

sin.270 The first two conditions of Cooperation rule out formal cooperation.

In Double Effect, the third condition insists that the evil effect must not be the means to

or cause of the good effect.271 Therefore, correspondingly, the condition for Cooperation insists

that the principal agent must be the cause of the evil, not the cooperator’s act.272 Thus, the

cooperator’s act must be sufficiently distant from that of the primary agent. Insofar as the

cooperator does not agree with the evil intent of the principal agent, it is material.273 However,

regarding distance, one must first determine whether an act constitutes immediate or mediate

material cooperation.274 Immediate material cooperation occurs when one cooperates in the act

itself in such a way that one’s participation is indispensable to the act’s completion.275 For

instance, a nurse assisting a physician in a sterilization constitutes immediate material

cooperation. According to traditional formulates, immediate material cooperation is always

immoral, and therefore, forbidden, which this third condition rules out ethically.276

On the other hand, mediate material cooperation is more distant from the principal

agent’s act. This occurs when one performs an act that paves the way for the immoral act to

occur.277 For instance, the nurse prepping the patient for sterilization or doing post-operative

care, both constitute mediate material cooperation. Therefore, the difference between immediate

and mediate cooperation concerns the level of participation, the former comprising the joining of

the principal agent in the act, while the latter is distant enough that the principal agent does not

depend so much on the cooperator’s act that without it the evil deed could not be done.278

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While formal cooperation in evil and immediate cooperation in evil are always morally

forbidden, mediate material cooperation in evil may be permissible if the appropriate criteria

exist.279 Alphonsus Liguori first articulates a rudimentary version of Cooperation in his Moral

Theology.280 He observes that servants, in particular, often find themselves in precarious

situations, whereby they contribute in some way to the sinful actions of their masters.281 For

example, masters may expect a servant to saddle a horse in anticipation of visiting a brothel or

accompanying the master thereto.282 Insofar as refusing to offer assistance places the servant in

jeopardy of losing his job, thus posing a grave inconvenience, Liguori argues that the servant

may comply with the expectations of the master to the extent that one’s actions remain remote to

the master’s sin.283 Liguori offers two criteria that if met satisfy his Principle of Legitimate

Material Cooperation:284 1) the act in question must be morally good or indifferent itself; and 2)

there must be a proportionately good reason for committing the act.285 The first two conditions of

Cooperation address Liguori’s first criteria, as the above demonstrates. His second criterion,

however, corresponds to the fourth condition. In Double Effect, the good effect must be

proportionate to the evil effect.286 For instance, in the removal of a cancerous, gravid uterus,

saving the mother’s life is proportionate to the evil of the child’s death. For Cooperation, the

cooperator’s decision to act must be proportionate to either the evil avoided or the good

promoted.287

Based on the condition of proportionality, Liguori indicates that the obligation of charity

does not extend to the point of gravely inconveniencing the cooperator.288 For instance, Liguori

argues that for grave reason, such as fear of losing one’s job, a servant could saddle a horse or

accompany a master to a brothel.289 Moreover, a nurse may decide to cooperate in a mediate

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material way in the sterilization of a patient by prepping or caring for the patient post-

operatively, because failing to do so means losing one’s job or harms the patient.

Therefore, according to the fourth condition of Cooperation, ethicists further differentiate

mediate material cooperation utilizing: distance and dispensability.290 Regarding distance one

may further distinguish between proximate and remote cooperation.291 If the cooperator’s act is

causally close to that of the primary agent’s act, then it is proximate.292 If causally further away,

then the act is remote.293 For instance, the nurse prepping a patient for sterilization proximately

cooperates, while the administrative assistant at the front desk remotely cooperates.294 In both

cases of mediate material cooperation, the agent performs a good or indifferent act that the

primary agent uses as an occasion for sin.295 However, the closer one is to the primary agent’s

act, the more serious one’s justification must be.

In addition to considering how closely one’s act relates to the primary agent’s act, one

may also consider how indispensable one’s mediate material cooperation is.296 To be clear, one is

not answering whether one’s act inexorably connects to the principal agent’s act—the affirmative

constituting immediate material cooperation (always forbidden) and the negative making it

mediate material cooperation (sometimes permitted)—but how indispensable one’s already

constituted mediate material cooperating act is to supporting the principal agent’s act. If one’s

participation is necessary, that is, if one refuses to perform one’s job, thereby preventing the

occurrence of the immoral procedure, then one needs a more serious reason not to object; for

instance, if one is the only nurse that can prep a patient for an immoral procedure.297 On the other

hand, if one is more dispensable or free, then one needs a less serious reason to object; for

instance, if another nurse could simply step in and fill the role.298

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At first glance, this may seem counterintuitive. One may object, for instance, insisting

that since in the second scenario other nurses could perform the objectionable task one is freer,

and therefore, more obliged to object than in the first scenario, where the nurse is seemly less

free to object without graver consequences. The rationale is that the more indispensable one is,

the greater one’s duty to object.299 In other words, because other nurses could just as easily step

in and complete the task in the second scenario, it is more efficacious for one to object.

Orville N. Griese in Catholic Identity and Health Care: Principles and Practice

highlights a corollary condition to the proportionality condition in these principles.300 Just as

there ought not to be any legitimate alternative to the act in question for Double Effect,301 so one

may perform an act that cooperates with another’s evil, if and only if, a legitimate alternative

does not exist.302 This constitutes the fifth condition in both principles.303 For example, if a nurse

could excuse oneself from assisting in immoral procedures without fear of retribution, he ought

to do so.304

The above demonstrates a connection between these principles that ethicists traditionally

maintain. Intention plays a primary role, both in characterizing the proximate end and the remote

end in the first two conditions. In addition, sufficient separation from the principal agent’s action

also has a vital role for justifying mediate material cooperation. The following subsection

elucidates Cooperation through its application to sterilizations in Catholic health care facilities.

ii. Cooperation and Sterilization

This subsection closely scrutinizes the United States Bishops’ use of Cooperation to

mitigate relationships between Catholic hospitals and secular hospitals.

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a. Sterilization

Catholic hospitals receive pressure to perform intrinsically evil procedures such as

abortions and sterilizations in their facilities.305 Moreover, economic advantages also coerce

Catholic institutions to form joint ventures with non-Catholic hospitals that do perform

procedures that violate exceptionless moral norms. J. F. Keenan and Thomas R. Kopfensteiner in

“The Principle of Cooperation: Theologians Explain Material and Formal Cooperation,” defend

the use of Cooperation not only by individuals, but also by institutions.306 Gerard Magill in

“Organizational Ethics” indicates that while one applies moral responsibility to institutions, this

is only done analogously, since moral responsibility ultimately belongs to individual persons.307

Because so much is on the line when considering such enterprises—including the closing of

facilities—bishops use Cooperation to justify joint ventures where possible.308 The wide

availability, high public acceptability, and high utilization of contraceptive services, including

sterilization makes this a particularly precarious sticking point for Catholic hospitals considering

joint ventures.

In 1975, the Congregation for the Doctrine of the Faith responds to a request for

clarification on the Church’s stance on sterilization in Catholic health care facilities.309 It

categorically rejects any Catholic hospitals formally cooperating in—giving approval or consent

to—procedures that are “directed to a contraceptive end,” including sterilizations that

deliberately impede “the natural effects of sexual actions.”310 It also affirms the traditional

doctrine regarding material cooperation “to be applied with the utmost prudence, if the case

warrants.”311 In addition, it advises, “great care must be taken against scandal and the danger of

any misunderstanding by an appropriate explanation of what is really being done.”312

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In 1977, the National Conference of Catholic Bishops offers commentary on the above

mentioned document.313 After restating the three principles that the Congregation offers

verbatim, the United States Bishops present six guidelines for hospital policy.314 First, citing the

Congregation’s document, it affirms that Catholic hospitals may not approve sterilization

procedures that are directly contraceptive, even for medical reasons, for instance, to prevent

pregnancy in women in which pregnancy foreseeably aggravates a serious condition.315 Two, the

United States Bishops acknowledge that Catholic hospitals have both the responsibility and legal

right to choose which procedures it will or will not perform.316 However, in the extraordinary

circumstance where hospitals are under duress or pressure, and “when it will do more harm than

good,” hospitals may materially cooperate in such procedures.317 Three, since this may only

happen in extraordinary circumstances, the decision making must involve the bishop or his

representative, to allay scandal.318 Fourth, they insists that after carefully weighing the evidence,

hospitals must cooperate only in a material sense, not a formal sense.319 In other words, the

hospital must not agree to the sterilization procedure because of medical reasons, which

constitute formal cooperation, but because of pressure to cooperate that results in more harm

than good.320 Fifth, because of the extraordinary nature of such circumstances, the Bishops insist

that hospitals consider each situation on a case-by-case basis, not presuming that the same

decision applies to all cases.321 Finally, to diminish scandal, the Bishops recommend that

hospitals explain their decision, reaffirming their disapproval for sterilization, of which material

cooperation does not constitute.322

In 1980, the United States Bishops promulgate another document on the topic of

sterilization, focusing more specifically on tubal ligations.323 After reaffirming the prohibition on

sterilization in the two previously mentioned documents, they further emphasize that the

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reasoning for justification must be extrinsic to the case in consideration.324 Thus, one must avoid

formal cooperation with evil, which choosing sterilization for medical reasons constitutes. An

extrinsic example that they offer in their commentary on the Congregation’s document is the

greater evil of closing a hospital by, for instance, exhausting the financial resources of the

hospital on litigation.325 Moreover, they recommend increased and continued collaboration

between the local ordinary, the health care facility, and the sponsoring religious community.326

The reemphasis on the extrinsic nature of the justification for material cooperation in Catholic

health care facilities foreshadows the vacillation on presenting the Church’s teaching on material

cooperation in future editions of the Ethical and Religious Directives.

b. The United States Bishops’ and Cooperation

The third edition of the Ethical and Religious Directives contains an articulation of the

Principle of Cooperation in its appendix that diverges slightly from traditional versions, which

later gives rise to conflict with the Congregation for the Doctrine of the Faith.327 First, it

highlights the distinction between formal and material cooperation, emphasizing that in formal

cooperation the cooperator intends the same object as the principal agent.328 In addition, based on

an argument that intention not only constitutes an explicit act of the will, they argue that implicit

formal cooperation occurs when the object of the cooperator’s action is indistinguishable from

that of the principal agent’s, regardless of what she says.329 Next, they distinguish between

immediate and mediate material cooperation.330 Immediate material cooperation, like implicit

formal cooperation has the same object as the principal agent, but acts under duress or pressure,

some of which, but not all may morally justify one’s acting.331 Alternatively, if the cooperator’s

object remains distinct from the principal agent’s, then it constitutes mediate material

cooperation, “and can be morally licit.”332 The United States Bishops also mention the role that

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distance and proportion play in characterizing and justifying mediate material cooperation.333

Finally, they mention the virtue of prudence, the factor of scandal, and the prophetic role of the

Church in the world.334

Only six years later, in the fourth edition of the Ethical and Religious Directives, the

newly formed United States Conference of Catholic Bishops eliminate the appendix on “The

Principles Governing Cooperation,” indicating in the introduction to the sixth part on “Forming

New Partnerships with Health Care Organizations and Providers,” that the brief summary did not

forestall misinterpretations and even gave rise to problems in application.335 Kevin D. O’Rourke

et al. offer some explanation for the change in their article “A Brief History: A Summary of the

Development of the Ethical and Religious Directives for Catholic Health Care Services.”336

First, O’Rourke explains that the need for a more authoritative set of directives for Catholic

health care systems in the United States, one that overcomes so-called “geographical morality,”

first arose in the late 1960s because of the rise in proportionalism and its use to justify

intrinsically evil acts such as sterilizations in Catholic hospitals.337 Because of the poor reception

among proportionalist ethicists, the Bishops submit the matter to the Congregation for the

Doctrine of the Faith.338 Which, in turn, leads to the above mentioned response on sterilization

by the Congregation to the United States Bishops.339

O’Rourke explains that the third edition of the Ethical and Religious Directives results

from the necessity to provide a theological basis for the legalistic pronouncements of the

previous two editions, and to address new issues that arise since its first two promulgations,

including, consent in research, advance directives, and cooperation with non-Catholic

facilities.340 Contrary to what Keenan and Kopfensteiner hold,341 O’Rourke contends that the

United States Bishops did not have approval from the Congregation for the Doctrine of the Faith

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for the appendix on Cooperation, before its vote approving the third edition, which includes the

appendix, in November of 1994.342 In the spring of 1999, the Congregation for the Doctrine of

the Faith asks Bishop Joseph A. Fiorenza, the president of the National Conference of Catholic

Bishops to revisit the sixth part of the third edition of the Ethical and Religious Directives, the

appendix on cooperation and the 1977 commentary on the Congregation’s document on

sterilization, insisting that these documents contribute to misapplication of cooperation and the

principle of partnerships.343 The fourth edition incorporates four changes to the sixth part of the

third edition of the Ethical and Religious Directives: 1) a new directive, 70 forbids Catholic

health care institutions from engaging in immediate material cooperation in intrinsically evil acts

such as sterilization, 2) they eliminate the appendix on cooperation altogether, 3) a footnote

indicates that the directive 70 supersedes the 1977 commentary on Quaecumque Sterilizatio, and

4) they give a definition for scandal that coincides more with the Catechism’s definition.344

c. The Object of the Cooperator

O’Rourke’s article implies that the United States Bishops took liberty in their

interpretation on Cooperation not consistent with traditional articulations and the Congregation

for the Doctrine of the Faith calls them to task on this.345 I argue that this misinterpretation by the

United States Bishops centers on a misunderstanding of the Moral Object and its relationship to

Cooperation. First, the appendix says that formal cooperation exists when the cooperator intends

the same object as the principal agent.346 Second, the appendix distinguishes between implicit

and explicit formal cooperation, suggesting that the difference consists in the spoken intention of

the agent, while, once again, the commonality is in the Moral Object.347

By definition, however, Cooperation always has two distinct agents and two distinct

actions.348 In formal cooperation, the cooperator agrees with the intention of the principal agent,

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but his act always remains distinct, contributing nonetheless to the principal agent’s act.

Otherwise it does not constitute a case of Cooperation at all, but of two people choosing the same

object, which amounts to the same act, which amounts to two co-principal agents. As such, it is

one thing to agree with another’s Moral Object, and to aid him in completion, and quite another

to intend the same Moral Object in act. This is because, by definition, the Moral Object is the

species of the act itself.349

Shedding more light on intention gives greater clarity. Aquinas indicates that intention is

an act of the will towards an end.350 Broadly speaking, intending may refer to the remote end or

the proximate end (Moral Object).351 In act, however, one always chooses a specific means to

one’s end, the means constituting a Moral Object.352 Conceptually, one may distinguish the end

from the means, in act they constitute a single act of the will.353 Therefore, if one intends the

same Moral Object as another, then one no longer merely cooperates, but commits the same act,

which constitutes co-principal agents, and Cooperation does not apply.354 In Compromise and

Complicity, Chiara Lepora and Robert E. Goodin distinguish ‘complicity simpliciter’ from other

colloquial uses that involve co-prinicipalship: full joint wrongdoing, co-operation, conspiracy,

and collusion.355 In complicity simpliciter, the secondary agent contributes causally to the

principal agent’s wrongdoing, as opposed to merely doing wrong together.356

Another important distinction is that between the physical act itself—prescinded from its

voluntariness—and the act as moral, which also clarifies that choosing the same Moral Object is

choosing the same act. Acts are moral insofar as they are voluntary, and therefore on the moral

order, not the natural order.357 Consequently, two distinct physical acts may indeed constitute a

common Moral Object; however, insofar as they do, they also constitute the same moral act. For

instance, if one chooses to kill someone, it does not matter how one does it in the physical sense,

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that is, whether one uses a gun or a knife, the Moral Object remains the same, a choice to kill

another person. As such, insofar as two individuals have the same Moral Object, they also have

the same act, even if, in manifestation, they commit unique physical acts. Therefore, once again,

insofar as they commit the same act, Cooperation does not apply.

As such, the appendix on Cooperation in the third edition of the Ethical and Religious

Directives should maintain the distinction between agreeing with another’s action—regardless of

whether it is object or remote end—and having the same object as the principal agent. Although

Cooperation necessitates that the cooperator’s object be distinct from the principal agent’s,

formal cooperation, by definition also means that the cooperator’s act is immoral.358 For

instance, the getaway driver in a bank robbery plays a distinctly different role in the activity, but

nonetheless, agrees with the principal agent’s object of stealing money and provides an

invaluable role as the getaway driver. An inexorable link between the two actions exists, but the

objects remain distinct. The principal agent, the bank robber steals believing that the getaway

driver will provide a necessary means of escape. Likewise, the getaway driver provides the

means of escape to the robber agreeing with the Moral Object of the principal agent’s act,

probably presuming a share in the loot.

The premise that intention consists of something more than an explicit act of the will,

which specifies the distinction between explicit and implicit formal cooperation is ambiguous, if

not misleading, and therefore, in need of greater clarification. The above demonstrates that

intention abstracted from its voluntariness consists of the physical act alone (genus naturae).359

To be sure, one may speak as though there is a difference between intending the proximate end

or remote end, but in action there is one act of the will.360 The ethicists of the National Catholic

Bioethics Center offer a definition for explicit and implicit formal cooperation in evil that

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accounts for this difference in Moral Objects that the Cooperation necessitates. For them, explicit

formal cooperation occurs when one agrees with the evil acts of the principal agent and

intentionally chooses acts, which make it possible for the agent to do them.361 Alternatively,

implicit formal cooperation occurs when one “intentionally contributes to the principal agent’s

act not for the sake of the evil act itself, but as a means to some other end of the cooperator.”362

For example, a Catholic hospital may agree with a non-Catholic hospital’s intention to provide

sterilizations, making the process for obtaining these within the joint venture more attainable. On

the other hand, the Catholic hospital may actually not agree with the practice of sterilizations, but

nonetheless expedite the process for obtaining them in the non-Catholic portion of the facility,

because doing so increases the bottom line. The former constitutes explicit cooperation, because

the cooperator agrees with the principal agent, while the latter constitutes implicit cooperation,

because although they disagree with the principal agent’s intention, they nonetheless choose

means which contribute both to the attainment of the principal agent’s means and goal—

providing sterilizations—and the goal of making more money. In implicit cooperation, the act of

the principal agent becomes a means to the goal of the cooperator. Regardless, in no way does

this definition fit the United States Bishops’ definition, which maintains that the agent intends

the same Moral Object as the principal agent.363

In addition to agreeing with the evil intention of the principal agent, formal cooperation

also has the cooperator committing an immoral act, that is, choosing a distinct, but nonetheless

immoral object.364 On the other hand, in material cooperation, the cooperator both disagrees with

the intention of the principal agent and commits an act that is morally good or indifferent.365

While ethicists unequivocally forbid any form of formal cooperation, if sufficient distance exists

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between the cooperator’s act and the principal agent’s act and a proportionate reason exists, then

ethicists permit, at least, mediate material cooperation.366

In contrast, the appendix asserts that both immediate material cooperation and implicit

formal cooperation have the same object as the principal agent and that the only difference

between the former and the latter is that the cooperator experiences duress in immediate materia l

cooperation, but not in implicit formal cooperation.367 Again, if the cooperator and the agent

have the same object, then they are co-principal agents and Cooperation does not apply.368

Following the traditional formulation of the Principle of Cooperation, the ethicists of the

National Catholic Bioethics Center maintain that immediate material cooperation “occurs when

the cooperator assists in or contributes to the essential circumstances of the immoral act.” 369

Mediate material cooperation, on the other hand, “occurs when the cooperator assists in or

contributes to the nonessential circumstances of an immoral act.”370 Since one assists in a

derivative sense in bringing about an intrinsically evil act in immediate material cooperation, this

constitutes an immoral act that one must always avoid.371

Peter J. Cataldo in “Models of Health Care Collaboration” offers four characteristics for

licit collaboration between Catholic and non-Catholic health care entities.372 First, Cataldo insists

that collaborations must avoid institutional integration of governance, management, or

finances.373 Second, certain powers must be reserved for institutional integrity and

independence.374 Third, each institution must maintain its own assets and liabilities.375 Finally,

any and all joint activities must be incompliance with the Ethical and Religious Directives.376

Consequently, Catholic health care institutions commit formal cooperation if the management of

the non-Catholic entity that performs immoral procedures falls under the Catholic executive

management, if one does not adequately delineate the earnings from immoral procedures or if the

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Catholic entity provides space or support for the non-Catholic entity to perform these

procedures.377

The above mentioned changes to the Ethical and Religious Directives and the retraction

of what the United States Bishops say in its commentary on the Congregation for the Doctrine of

the Faith’s document on sterilization point to a faulty interpretation of Cooperation, which

connects to its poor use of the object of the act in the appendix to the third edition of the Ethical

and Religious Directives. Though not an explicitly written teaching, the Congregation for the

Doctrine of the Faith simply reaffirms a traditional interpretation of Cooperation, based on a

Thomistic understanding of the object of the act, one that forbids both formal cooperation and

immediate material cooperation in intrinsically evil acts.

d. The United States Bishops’ 2018 Articulation of Cooperation

In 2018, the United States Conference of Catholic Bishops published the sixth edition of

the Ethical and Religious for Catholic Health Care Services, which offers new directives for

collaborative arrangements, and a new introduction to the Principle of Cooperation. This

subsubsection briefly illuminates this.

To begin with, the United States Bishops define formal cooperation quoting Pope John

Paul II’s definition in Evangelium Vitae, “Formal cooperation ‘occurs when an action, either by

its very nature or by the form it takes in a concrete situation, can be defined as a direct

participation in an [immoral] act…or a sharing in the immoral intention of the person committing

it.’”378 Moreover, they insist that formal cooperation not only includes holding the same

intention as the principal agent, but also participating directly in the immoral act.379 In addition,

they contend that one formally cooperates even if one does agree with the intention of the

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principal agent, but simply uses one’s participation as a means to some other end.380 The above

discussion identifies this as implicit formal cooperation.381

In contrast, they define material cooperation as disagreeing with the principal agent’s

intention, not participating directly in the immoral act (including as a means to another end), but

contributing causally, not essentially.382 In addition, they hold that some instances of this are

morally wrong, while others are justifiable. Then, they delineate factors for consideration: moral

object of the cooperator; how much the cooperator’s act causally contributes to the evil act, and

how important the goods are to be preserved or harms to be avoided.

Importantly, the United States Bishops, in contrast to the articulation of Cooperation in

the third edition of the Ethical and Religious Directives replace object with intention.383

Moreover, in accord with editions following the third, they continue to prohibit immediate

material cooperation and uniquely any material cooperation with abortion.384 The following

subsection considers contemporary authors on Cooperation.

iii. Contemporary Contributions to Cooperation

This subsection discusses two contributions to the development of Cooperation. Luke

Gormally highlights important differences between a consequentialist interpretation of

Cooperation and one that is consistent with Thomistic virtue ethics. M. Cathleen Kaveny offers a

mirror principle to Cooperation, that accounts for appropriation of evil.

a. Rejecting the ‘No Difference Argument’

Christopher Kutz in Complicity: Ethics and Law for a Collective Age highlights an

important deficiency in consequentialism, which bases the determination of right action on the

consequences of one’s act.385 According to Kutz, consequentialism does not account for

wrongdoing, where choosing otherwise does not have an impact on the outcome of a scenario.386

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For example, since one pilot’s decision to not drop his bombs in an air raid does not change the

outcome for innocent civilians, consequentialism does not account for such an ethical

decision.387 Luke Gormally in “Why Not Dirty Your Hands? Or: on the Supposed Rightness of

(Sometimes) Intentionally Cooperating in Wrongdoing,” attributes the latter form of reasoning,

which he calls the “‘no difference’ argument,” to consequentialism.388 Contrary to the

implication of the title of his paper, which makes use of a common cliché for complicity,389 he

subscribes to a Thomistic virtue ethic that emphasizes intention and affirms the existence of

absolute moral norms determined by Natural Law.390 Gormally rejects the above mentioned line

of reasoning by revealing the faulty logic issuing from consequentialism.391 Second, he affirms

the traditional Christian position that actions form character, and therefore, one intention in

cooperation is primary. The following articulates the Thomistic action theory that underlies

Gormally’s critique of consequentialism’s version of Cooperation.

First, Gormally connects human dignity with the good through the first principle of

Natural Law: Insofar as the good leads to human flourishing it ought to be sought and evil,

leading to diminution, ought to be avoided.392 Insofar as connaturality abides between the good

and flourishing human nature, objective moral absolutes that guide human action also exist.393

Moral absolutes, such as the prohibition of killing innocent people and exclusion of adultery,

correspond to respect for the good in each and every human person due to their dignity.394 Most

importantly, Gormally indicates that moral absolutes constitute types of action that have

reference to practical reason issuing as proposals for choice.395 Proposals, as reasons for action

constitute the Moral Object.396 While virtue ethicists often make a distinction between the Moral

Object and the remote end, both incorporate intention, which consists of an act of the will as

choice for a particular proposal configured by reason.397

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Gormally uses Thomistic action theory to debunk four erroneous propositions that

consequentialism engenders.398 First, consequentialism perpetuates a myth that one is equally

responsible for the foreseeable consequences of refusing to cooperate as one is for

cooperating.399 Second, the right choice depends on a calculation of utility and disutility based on

foreseeable consequences.400 Third, there are no moral absolutes; the right circumstances or

goals can justify any action.401 Fourth, all effects are important for calculating the utility of

action.402 By implication, Double Effect and Cooperation do not matter.403

In a consequentialist framework, the right action gives rise to the best state of affairs,

regardless of intention as means or end.404 It presumes that humans have more control than they

actually do; for instance, not only to control outcomes, but also to judge what the best outcome

in fact is.405 Moreover, consequentialism neglects the formative nature of acts. One becomes

virtuous by choosing virtuous acts; conversely, one becomes vicious by choosing vicious acts.406

Gormally defends a Thomistic action theory as foundational for Cooperation. In

articulating the errors of consequentualism, he demonstrates the formative role of intention.

b. M. Cathleen Kaveny’s Appropriation of Evil

In Evangelium Vitae, Pope John Paul II insists that it is immoral to support intrinsically

unjust laws that permit immoral acts such as abortion or euthanasia.407 However, Gerard Magill

recalls in “Complicity of Catholic Healthcare Institutions with Immoral Laws,” John Paul II

permits politicians to support laws that restrict immoral procedures in societies where

overturning permissive laws entirely is not possible, a notion that John Finnis articulates in

“Helping Enact Unjust Laws without Complicity in Injustice.”408 In “Voting and Complicity in

Wrongdoing,” M. Cathleen Kaveny notes that Joseph Ratzinger, unlike several United States

Bishops and clergy, with moderation applies Cooperation to citizens voting for politicians who

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support laws that permit immoral acts.409 She contends that individuals who highjack

Cooperation to mobilize for pro-life politicians misuse the principle, which traditionally helps

one identify and avoid sinful acts that support other sinful acts.410 Just like the lack of integrity in

the analogy between slavery and abortion, so the lack of integrity in the use of material

cooperation to mobilize voters to support pro-life politicians does more damage to the cause than

good.411

In “Appropriation of Evil: Cooperation’s Mirror Image,” Kaveny argues for a mirror

principle to Cooperation, appropriation of evil, what I call the Principle of Appropriation that

accounts for dilemmas where agents must decide whether or not to utilize the fruits or

byproducts of another’s evil act.412 In Cooperation, the morally conscientious cooperator

deliberates to what extent one’s acts may licitly contribute to a principal agent’s evil act.413

Alternatively, in Appropriation the morally conscientious agent (the appropriator) considers

whether one may appropriate the evil results of another agent’s (auxiliary agent) evil act to

complete one’s end.414 Kaveny indicates that the similarity between the two consists in an

auxiliary agent performing an action that facilitates or supports the principal agent’s efforts in

performing his or her own act.415

In short, Kaveny sees the development of Appropriation as consistent with the

reemergence of a Thomistic virtue theory that focuses on morality of action from the first-person

perspective since it proceeds from intention and forms character.416 Intent on forming well-

equipped confessors, under the manualists, morality becomes increasingly extrinsic with

increasing emphasis on the objective causality of action and less attention to how intention forms

character.417 With such a prospective focus, manualists simply do not adequately account for

how the appropriation of other’s evil acts impact character.418 The retrieval of the first-person

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perspective of morality, true to Aquinas, opens the door to considering not only how one’s

actions may contribute to another’s evil actions or goals, as in Cooperation, but also how

another’s evil may contribute to one’s own actions or goals, as in Appropriation .419 Essentially,

Kaveny identifies an irreducible difference between Cooperation and Appropriation that is the

difference between the first-person perspective of the auxiliary agent and the first-person

perspective of the principal agent, respectively.420

In practice, moral analysis consists of a snapshot of a scenario. For Kaveny, Cooperation

and Appropriation constitute two unique perspectives for moral analysis that explain some

dilemmas. Their irreducibility means that one or the other is a better fit for a given situation, the

determination of which boils down to whether the decision maker is using or contributing to

another’s bad action.421 To illustrate, Kaveny deconstructs Russell E. Smith’s use of Cooperation

to explain why researchers ought not to use aborted fetuses in research.422 Although Smith

identifies the use of electively aborted fetuses for research as proximate, mediate, contingent,

material cooperation, his objection to their use in research has to do with the further denigration

of the lives of the aborted children insofar as researchers treat them merely as instruments for

medical progress.423 Moreover, he argues that research on electively aborted fetuses gives

scandal insofar as it gives the impression of formal cooperation in evil.424 For Kaveny, the

weakness of Smith’s argument is that the primary ethical dilemma is a problem of appropriation,

not cooperation.425

Kaveny holds that the difference between intention—purposeful causality,426 wishing—

desire uncoupled from causation,427 and prediction—a judgment that an event will happen,428

illustrates exactly who is morally culpable for which action. Agents are responsible for the

means that they intend, less for what they wish, and not at all for what they predict.429 Kaveny

218

exemplifies the uniqueness regarding the moral scrutiny for wishing by explaining that parents

wishing for an organ for their dying child do not necessarily wish for the death of a would-be

donor.430 In wishing, one may pick and choose which mean lead to desired ends, without regard

for causation.431 Intending, on the other hand, according to Kaveny includes the choosing of

specific causal means to achieve one’s end.432 Unlike intending or wishing, predicting only

involves the intellect, which judges based on evidence the likelihood that a particular event may

happen.433

In light of these distinctions, Kaveny illustrates the dilemma of using electively aborted

fetuses for research.434 First, she insists that the problem is one of appropriation, not cooperation.

Second, although the researchers predict the availability of the fetuses for research, they do not

necessarily intend the abortion.435 Moreover, she asserts that they certainly wish for and predict a

successful outcome for their research, which depends on a steady supply of fetal tissue, but this

does not constitute intending the fetuses’ death, since wishing is uncoupled with causality.436

Kaveny presents two other concepts for Cooperation and Appropriation that account for

contamination: seepage and self-deception.437 Seepage occurs when the description of one’s act

by another influences the self-concept of one’s own acting.438 For instance, if an abortionist

presumes that a researcher making use of fetal tissue approves of his immoral act, and the

researcher begins to approve of abortion. Self-deception occurs when one deceives oneself into

accepting the immoral intentions of the other.439 For example, if a researcher begins to intend

more abortions to increase the stock of fetal tissue for research.

c. Double Effect and Appropriation

If Appropriation is similar to Cooperation, then the conditions of Double Effect that

apply analogously to Cooperation should apply to Appropriation.

219

The first two conditions of Double Effect and Cooperation pertain to intention, as Moral

Object and remote end. First, for Double Effect the Moral Object in question must be either good

or indifferent.440 For Cooperation, the cooperator’s act must be morally good or indifferent.441

Therefore, for Appropriation the appropriator’s act must be morally good or indifferent. Second,

for Double Effect the agent must intend the good effect and not the bad effect.442 For

Cooperation, the cooperator must not intend the evil of the principal agent.443 For Appropriation,

the principal agent must not intend or ratify the act of the auxiliary agent.444 In Cooperation, a

cooperator intending the evil of the principal agent constitutes formal cooperation, just as an

appropriator ratifying the evil act of an auxiliary agent constitutes formal appropriation, both of

which are unquestionably immoral.445

The third condition of Double Effect is that the bad effect must not cause (or be the

means to) the good effect.446 In Cooperation, the principal agent, not the cooperator, must be the

primary cause of the evil act, which she appropriates from the cooperator.447 In Appropriation the

principal agent utilizes the evil act or byproduct to accomplish one’s goal. Accordingly, the

principal agent must not depend on the auxiliary’s evil act in an inexorable way to accomplish

his task. Just as the third condition for Cooperation rules out immediate material cooperation, so

it should rule out immediate material appropriation.

The fourth condition for Double Effect necessitates that one have a proportionate reason

to permit the foreseen, yet unintended evil effect.448 Similarly, for Cooperation, the more serious

the evil of the principal agent, the more serious the justification for accepting the mediate

material cooperation, of which distance and dispensability play a crucial role in determining.

Consequently, for Appropriation, the principal agent must have a proportionate reason for

220

appropriating the immoral act of an auxiliary agent. Just as distance and dispensability play a

role in justifying cooperation, it ought to play a role in appropriation.

d. Appropriation Fetal Tissue Remains of Elective Abortion

Insofar as the bishops unequivocally forbid any form of material cooperation in abortion,

it is very likely that they would forbid any form of appropriation as well, including the use of

fetal tissue remains of electively aborted children.449 Regardless, the topic illustrates how

Appropriation works. First, in principle, doing research on fetal tissue is a morally indifferent

act. Second, so long as the researchers do not intend the evil of the auxiliary agent, that is, the

death of the child, they are not guilty of formal appropriation. Third, so long as the auxiliary

agent’s act of abortion does not connect inexorably to the object or goal of the researcher, the

principal agent avoids both formal cooperation and immediate material appropriation. Finally,

the researcher must have a proportionately justifiable reason to use electively aborted fetuses for

research, such as a severe shortage of other sources or an extremely high cost. Moreover, the

foreseeable good must be great as well, such as a cure for the flu. Practically speaking, however,

I agree with Kaveny that such a justifiable scenario is most unlikely.450

This section articulates the Principle of Cooperation, comparing, yet differentiating it

from Double Effect. This chapter discusses proficiencies in health care ethics consultations, the

benefits and limitations of principlism, and the complexities of the Principle of Cooperation. The

following chapter applies the preceding to the use of prophylactic, sterilizing procedures and

emergency contraception in victims of sexual assault.

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184 Beauchamp et al., Principles of Biomedical Ethics, 153. 185 Beauchamp et al., Principles of Biomedical Ethics, 153. 186 William May, Catholic Bioethics and the Gift of Human Life, 3rd ed. (Huntington, IN: Our

Sunday Visitor, 2013), 262-3. 187 May, Catholic Bioethics and the Gift of Human Life, 262. 188 May, Catholic Bioethics and the Gift of Human Life, 263. 189 May, Catholic Bioethics and the Gift of Human Life, 263-7. 190 May, Catholic Bioethics and the Gift of Human Life, 266. 191 May, Catholic Bioethics and the Gift of Human Life, 265. 192 May, Catholic Bioethics and the Gift of Human Life, 263. 193 Beauchamp et al., Principles of Biomedical Ethics, 172. 194 May, Catholic Bioethics and the Gift of Human Life, 271; Congregation for the Doctrine of

the Faith (CDF), Declaration on Euthanasia, 5 May 1980,


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226

226 Jonsen et al., Clinical Ethics, 172. 227 Jonsen et al., Clinical Ethics, 172-3. 228 Jonsen et al., Clinical Ethics, 174. 229 Jonsen et al., Clinical Ethics, 174. 230 Jonsen et al., Clinical Ethics, 175. 231 Jonsen et al., Clinical Ethics, 179. 232 Jonsen et al., Clinical Ethics, 180. 233 Jonsen et al., Clinical Ethics, 180. 234 Jonsen et al., Clinical Ethics, 186. 235 Jonsen et al., Clinical Ethics, 184-6. 236 Jonsen et al., Clinical Ethics, 176-9. 237 Jonsen et al., Clinical Ethics, 176-9. 238 USCCB, ERDs, #54. 239 Jonsen et al., Clinical Ethics, 187. 240 Jonsen et al., Clinical Ethics, 188. 241 Jonsen et al., Clinical Ethics, 188. 242 Jonsen et al., Clinical Ethics, 192. 243 Jonsen et al., Clinical Ethics, 192. 244 Jonsen et al., Clinical Ethics, 195. 245 Jonsen et al., Clinical Ethics, 195. 246 Jonsen et al., Clinical Ethics, 199-200. 247 Jonsen et al., Clinical Ethics, 208. 248 Jonsen et al., Clinical Ethics, 210. 249 Jonsen et al., Clinical Ethics, 210. 250 Jonsen et al., Clinical Ethics, 211. 251 Jonsen et al., Clinical Ethics, 212. 252 Jonsen et al., Clinical Ethics, 213. 253 Jonsen et al., Clinical Ethics, 214. 254 Jonsen et al., Clinical Ethics, 213. 255 Jonsen et al., Clinical Ethics, 215. 256 Gerard Magill, “Complicity of Catholic Healthcare with Immoral Laws,” in Contemporary

Controversies in Catholic Bioethics (Philosophy and Medicine), ed. Jason T. Eberl, (Cham,

Switzerland: Springer International Publishing, 2017), 526-7. 257 Magill, “Complicity of Catholic Healthcare with Immoral Laws,” 526-7; See also Gerard

Magill, “Complicity,” in Encyclopedia of Global Bioethics, ed. Henk ten Have, (Dordrecht,

Switzerland: Springer, 2016) 710-9. NCBC Ethicists, “Cooperating with Non-Catholic

Partners,” in Catholic Health Care Ethics: A Manual for Practitioners, 2nd ed. Edited by Edward

Furton et al., (Philadelphia, PA: National Catholic Bioethics Center, 2009), 268. 258 James F. Keenan, “Collaboration and Cooperation in Catholic Health Care,” Australasian

Catholic Record 77, no. 2 (2000): 163-174; see also James F. Keenan, “Prophylactics, Toleration

and Cooperation: Contemporary Problems and Traditional Principles,” International

Philosophical Quarterly 29, no. 2 (1989): 205-220. 259 Edward J. Furton and Albert S. Moraczewski, “Double Effect,” in Catholic Health Care

Ethics: A Manual for Practitioners, 2nd ed., ed. Edward Furton et al., (Philadelphia, PA: National

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Principles and Practice, (Braintree, MA: The Pope John Center, 1987), 246-299.

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260 Furton et al, “Double Effect,” 24. 261 NCBC Ethicists, “Cooperating with Non-Catholic Partners,” 268. 262 Furton et al, “Double Effect,” 24. 263 Furton et al, “Double Effect,” 24. 264 NCBC Ethicists, “Cooperating with Non-Catholic Partners,” 268. 265 NCBC Ethicists, “Cooperating with Non-Catholic Partners,” 266-7. 266 Griese, Catholic Identity in Health Care, 387. 267 John Finnis, Aquinas: Moral, Political and Legal Theory (Founders of Modern Political and

Social Thought), (Oxford: Oxford, 1998), 63-4. 268 Aquinas, Summa Theologica, I-II, q. 12, a. 2, c. 269 Aquinas, Summa Theologica, I-II, q. 12, a. 2, c. 270 Griese, Catholic Identity in Health Care, 387. 271 Furton et al, “Double Effect,” 25-6. 272 NCBC Ethicists, “Cooperating with Non-Catholic Partners,” 268. 273 NCBC Ethicists, “Cooperating with Non-Catholic Partners,” 267-8. 274 Griese, Catholic Identity in Health Care, 388. 275 Catholic Health Association of the United States (CHA), “The Principles Governing

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the Catholic Health Ministry 21, no.1 (2013): 26. (25-9) 276 CHA, “The Principle Governing Cooperation,” 27. 277 CHA, “The Principles Governing Cooperation,” 26. 278 Griese, Catholic Identity in Health Care, 388. 279 CHA, “The Principles Governing Cooperation,” 27. 280 Alphonsus Liguori, Moral Theology, Vol. 1, bk. I-III, trans. Ryan Grant, (Post Falls, ID:

Mediatrix Press, 2015), Vol. 1, Book III, trac. III, cap. 2, Dub. V, art. III, n. 63. For the Latin

version see: S. Alphonsi M. de Ligorio, Theologia moralis, Vol. 1, (Turin, IT: Ex Typis

Hyacinthi Marietti, 1879) pp. 253-254. 281 Liguori, Moral Theology, Vol. 1, Book III, trac. III, cap. 2, Dub. V, art. III, n. 63. 282 Liguori, Moral Theology, Vol. 1, Book III, trac. III, cap. 2, Dub. V, art. III, n. 63. 283 Liguori, Moral Theology, Vol. 1, Book III, trac. III, cap. 2, Dub. V, art. III, n. 63. 284 Griese, Catholic Identity in Health Care, 389. 285 CHA, “The Principles Governing Cooperation,” 26, see Liguori, Moral Theology, Vol. 1,

Book III, trac. III, cap. 2, Dub. V, art. III, n. 63. 286 Furton et al, “Double Effect,” 26. 287 Griese, Catholic Identity in Health Care, 390. 288 Liguori, Moral Theology, Vol. 1, Book III, trac. III, cap. 2, Dub. V, art. III, n. 63. 289 Liguori, Moral Theology, Vol. 1, Book III, trac. III, cap. 2, Dub. V, art. III, n. 64. 290 Liguori, Moral Theology, Vol. 1, Book III, trac. III, cap. 2, Dub. V, art. III, n. 63. Griese,

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298 Griese, Catholic Identity in Health Care, 390. 299 Michael D. Bayles, “A Problem of Clean Hands: Refusal to Provide Professional Services,”

Social Theory and Practice 5, no. 2 (1979): 165-81. 300 Griese, Catholic Identity in Health Care, 390. 301 Griese, Catholic Identity in Health Care, 252-3. 302 Griese, Catholic Identity in Health Care, 390. 303 Griese, Catholic Identity in Health Care, 252-3, 390. 304 Griese, Catholic Identity in Health Care, 390. 305 John Paul II, Evangelium Vitae, March 25, 1995, http://w2.vatican.va/content/john-paul-

ii/en/encyclicals/documents/hf_jp-ii_enc_25031995_evangelium-vitae.html, 62, 91; John Paul II,

Veritatis Splendor, August 6 1993, http://w2.vatican.va/content/john-paul-

ii/en/encyclicals/documents/hf_jp-ii_enc_06081993_veritatis-splendor.html, 80; Pius XII,

“Address to the Associations of the Large Families,” Acta Apostolicae Sedis 43 (1951): 859

http://www.vatican.va/archive/aas/documents/AAS-43-1951-ocr.pdf. 306 J. F. Keenan and Thomas R. Kopfensteiner, “The Principle of Cooperation: Theologians

Explain Material and Formal Cooperation,” Health Progress 76, no. 3 (1995): 24; see also James

F. Keenan, “Institutional Cooperation and the Ethical and Religious Directives,” Linacre

Quarterly 64, no. 3 (1997): 53-76. 307 Gerard Magill, “Organizational Ethics,” in Contemporary Catholic Health Care Ethics, 2nd

ed. David F. Kelly et al. (Washington D. C.: Georgetown University Press, 2013), 272. 308 National Conference of Catholic Bishops (NCCB), “Commentary on the Reply of the Sacred

Congregation for the Doctrine of the Faith to National Conference of Catholic Bishops on

Sterilization in Catholic Hospitals,” September 15, 1977, reprinted in Griese, Catholic Identity in

Health Care, 425. 309 Congregation for the Doctrine of the Faith (CDF), Responses to Questions Concerning

Sterilization in Catholic Hospitals, March 13, 1975,


3_quaecumque-sterilizatio_en.html. 310 CDF, Responses to Questions Concerning Sterilization in Catholic Hospitals, 3a. 311 CDF, Responses to Questions Concerning Sterilization in Catholic Hospitals, 3b. 312 CDF, Responses to Questions Concerning Sterilization in Catholic Hospitals, 3c. 313 National Conference of Catholic Bishops (NCCB), “Commentary on the Reply of the Sacred

Congregation for the Doctrine of the Faith to National Conference of Catholic Bishops on

Sterilization in Catholic Hospitals,” September 15, 1977, reprinted in Griese, Catholic Identity in

Health Care, 422-425. 314 NCCB, “Commentary on the Reply of the CDF to the NCCB,” 423-5. 315 NCCB, “Commentary on the Reply of the CDF to the NCCB,” 424. 316 NCCB, “Commentary on the Reply of the CDF to the NCCB,” 424. 317 NCCB, “Commentary on the Reply of the CDF to the NCCB,” 424. 318 NCCB, “Commentary on the Reply of the CDF to the NCCB,” 424. 319 NCCB, “Commentary on the Reply of the CDF to the NCCB,” 424-5. 320 NCCB, “Commentary on the Reply of the CDF to the NCCB,” 424-5. 321 NCCB, “Commentary on the Reply of the CDF to the NCCB,” 425. 322 NCCB, “Commentary on the Reply of the CDF to the NCCB,” 425. 323 NCCB, “ Statement on Tubal Ligation,” July 3, 1980, in Griese, Catholic Identity in Health

Care, 425-6.




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324 NCCB, “Statement on Tubal Ligation,” 426. 325 NCCB, “Commentary on the Reply of the CDF to the NCCB,” 425. 326 NCCB, “Statement on Tubal Ligation,” 426. 327 NCCB, Ethical and Religious Directives for Catholic Health Care Services, 3rd edition

(Washington, D. C.: United States Catholic Conference, 1995), 29. 328 NCCB, ERDs 3rd ed., 29. 329 NCCB, ERDs 3rd ed., 29. 330 NCCB, ERDs 3rd ed., 29. 331 NCCB, ERDs 3rd ed., 29. 332 NCCB, ERDs 3rd ed., 29. 333 NCCB, ERDs 3rd ed., 29. 334 NCCB, ERDs 3rd ed., 29. 335 USCCB, “Ethical and Religious Directives for Catholic Health Care Services,” 4th edition,

(Washington D. C.: United States Conference of Catholic Bishops (USCCB), 2001), 36. 336 Kevin D. O’Rourke et al, “A Brief History: A Summary of the Development of the Ethical

and Religious Directives for Catholic Health Care Services,” Health Progress 82, no. 6 (2001):

18-21. 337 Kevin D. O’Rourke et al, “A Brief History,” 19. 338 Kevin D. O’Rourke et al, “A Brief History,” 19-20. 339 Kevin D. O’Rourke, “A Brief History,” 20. 340 Kevin D. O’Rourke, “A Brief History,” 20. 341 Keenan and Kopfensteiner, “The Principle of Cooperation,” 27. 342 Kevin D. O’Rourke, “A Brief History,” 20. 343 Kevin D. O’Rourke, “A Brief History,” 20-1. 344 Kevin D. O’Rourke, “A Brief History,” 21. 345 Kevin D. O’Rourke, “A Brief History,” 20-21. 346 NCCB, ERDs 3rd ed., 29. 347 NCCB, ERDs 3rd ed., 29. 348 Magill, “Complicity of Catholic Health Care with Immoral Laws,” 527. 349 Thomas Aquinas, Scriptum Super Sententiis Magistri Petri Lombardi, in “S. Tommaso d’

Aquino Commento alle Sentenze di Pietro Lombardo,” Vol. 1-10, Edizioni Studio Dominicano,

Bologna 1999-2002, lib. 1, d. 48, q. 1, a. 2, c. see Duarte Sousa-Lara, “Aquinas on the Object of

the Human Act: A Reading in Light of the Texts and Commentators,” Josephinum Journal of

Theology 15, no. 2 (2008): 245-6; John Paul II, Veritatis Splendor, 78. 350 Aquinas, Summa Theologiae, I-II, q. 12, a. 1, c. 351 Aquinas, Summa Theologiae, I-II, q. 8, a. 2, sed contra. 352 Aquinas, Summa Theologiae, I-II, q. 13, a. 3, sed contra. 353 Aquinas, Summa Theologiae, I-II, q. 12, a. 4, c. 354 Chiara Lepora and Robert E. Goodin, On Complicity and Compromise, (Oxford: Oxford

University Press, 2013), 41. 355 Lepora, On Complicity and Compromise, 41. 356 Lepora, On Complicity and Compromise, 41-2. 357 Aquinas, Super Sent., lib. 2, d. 40, q. 1, a. 1, c. see Duarte Sousa-Lara, “‘Genus naturae’ and

‘Genus moris’ in Aquinas” 2008

http://www.eticaepolitica.net/eticafondamentale/dsl_genus_naturae_genus_moris.pdf, pp. 1. 358 NCBC Ethicists, “Cooperating with Non-Catholic Partners,” 266.

http://www.eticaepolitica.net/eticafondamentale/dsl_genus_naturae_genus_moris.pdf

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359 Aquinas, Super Sent., lib. 2, d. 40, q. 1, a. 1, c. 360 Aquinas, Summa Theologica, I-II, q. 12, a. 4, sed contra: “Ergo non est idem motus intention

finis, cum voluntate eius quod est ad finem.” Therefore in things pertaining to the will, the

intention of the end is the same movement as the willing of the means. 361 NCBC Ethicists, “Cooperating with Non-Catholic Partners,” 266. 362 NCBC Ethicists, “Cooperating with Non-Catholic Partners,” 266. 363 NCCB, ERDs 3rd ed., 29. 364 NCBC Ethicists, “Cooperating with Non-Catholic Partners,” 266-7. 365 NCBC Ethicists, “Cooperating with Non-Catholic Partners,” 267. 366 NCBC Ethicists, “Cooperating with Non-Catholic Partners,” 267; see also Griese, Catholic

Identity in Health Care, 388ff. 367 NCCB, ERDs 3rd ed., 29. 368 NCBC Ethicists, “Cooperating with Non-Catholic Partners,” 267. 369 NCBC Ethicists, “Cooperating with Non-Catholic Partners,” 267. 370 NCBC Ethicists, “Cooperating with Non-Catholic Partners,” 267. 371 NCBC Ethicists, “Cooperating with Non-Catholic Partners,” 268; see CHA, “The Principles

Governing Cooperation,” 27; ERD 5th edition, 70. 372 Peter J. Cataldo, “Models of Health Care Collaboration,” in Catholic Health Care Ethics: A

Manual for Practitioners, 2nd Ed., edited by Edward J. Furton et al, (Philadelphia: The National

Catholic Bioethics Center, 2009), 271-3. 373 Cataldo, “Models of Health Care Collaboration,” 271. 374 Cataldo, “Models of Health Care Collaboration,” 271. 375 Cataldo, “Models of Health Care Collaboration,” 271. 376 Cataldo, “Models of Health Care Collaboration,” 271. 377 Cataldo, “Models of Health Care Collaboration,” 272-3. 378 USCCB, “Ethical and Religious Directives for Catholic Health Care Services,” 6 th edition,

(Washington D. C.: United States Conference of Catholic Bishops (USCCB), 2018), pp. 24; John

Paul II, Evangelium Vitae, March 25, 1995, http://w2.vatican.va/content/john-paul-

ii/en/encyclicals/documents/hf_jp-ii_enc_25031995_evangelium-vitae.html, 74. 379 USCCB, ERDs 6th ed., pp. 24. 380 USCCB, ERDs 6th ed., pp. 24. 381 NCBC Ethicists, “Cooperating with Non-Catholic Partners,” 266. 382 USCCB, ERDs 6th ed., pp. 24. 383 USCCB, ERDs 3rd ed., pp. 29; USCCB, ERDs 6th ed., pp. 24. 384 USCCB, ERDs 4th ed., 70; ERDs 5th ed., 70; ERDs 6th ed., 70, 45. 385 Christopher Kutz, Complicity: Ethics and Law for a Collective Age, (Cambridge: Cambridge

University Press, 2000), 124ff. 386 Kutz, Complicity: Ethics and Law for a Collective Age, 125. 387 Kutz, Complicity: Ethics and Law for a Collective Age, 125. 388 Luke Gormally, “Why Not Dirty Your Hands? Or: on the Supposed Rightness of

(Sometimes) Intentionally Cooperating in Wrongdoing,” in Cooperation, Complicity and

Conscience: Problems in Healthcare, Science, Law and Public Policy, edited by Helen Watt,

(London: The Linacre Centre, 2005), 15, 12-26. 389 Bayles, “A Problem of Clean Hands,” 165-181; Leslie C. Griffin, “The Problem of Dirty

Hands,” Journal of Religious Ethics 17, no. 1 (1989): 31-61. 390 Gormally, “Why Not Dirty Your Hands?” 18ff.



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391 Gormally, “Why Not Dirty Your Hands?,” 16. 392 Gormally, “Why Not Dirty Your Hands?” 18. 393 Gormally, “Why Not Dirty Your Hands?” 18. 394 Gormally, “Why Not Dirty Your Hands?” 19. 395 Gormally, “Why Not Dirty Your Hands?” 19. 396 Gormally, “Why Not Dirty Your Hands?” 19. 397 Gormally, “Why Not Dirty Your Hands?” 23. 398 Gormally, “Why Not Dirty Your Hands?” 18ff. 399 Gormally, “Why Not Dirty Your Hands?” 16. 400 Gormally, “Why Not Dirty Your Hands?” 16. 401 Gormally, “Why Not Dirty Your Hands?” 16. 402 Gormally, “Why Not Dirty Your Hands?” 16. 403 Gormally, “Why Not Dirty Your Hands?” 23ff. 404 Gormally, “Why Not Dirty Your Hands?” 17. 405 Gormally, “Why Not Dirty Your Hands?” 22. 406 Gormally, “Why Not Dirty Your Hands?” 23. 407 John Paul II, Evangelium Vitae, 73. 408 Gerard Magill, “Complicity of Catholic Healthcare Institutions with Immoral Laws,” 524;

John Paul II, Evangelium Vitae, 73; John Finnis, “Helping Enact Unjust Laws without

Complicity in Injustice,” American Journal of Juris Prudence 49 (2004): 11-42. 409 M. Cathleen Kaveny, “Voting and Complicity in Wrongdoing,” in Law’s Virtue: Fostering

Autonomy and Solidarity in American Society, (Washington D. C.: Georgetown University Press,

2012), 254; see also “Vatican, US Bishops: On Catholics in Political Life,” Origins 34 (2004):

133. 410 Kaveny, “Voting and Complicity in Wrongdoing,” 260. 411 Gerard Magill, “A Parallel that Limps: The Rhetoric of Slavery in the Pro-Life Discourse of

U.S. Bishops,” in Voting and Holiness: Catholic Perspectives on Political Participation, Kindle

Edition, Edited by Nicholas P. Cafardi (New York: Paulist Press, 2012), kindle location 3741-

4216. 412 M. Cathleen Kaveny, “Appropriation of Evil: Cooperation’s Mirror Image,” Theological

Studies 61, no. 2 (2000): 280-313. 413 Kaveny, “Appropriation of Evil,” 282-6. 414 Kaveny, “Appropriation of Evil,” 286. 415 Kaveny, “Appropriation of Evil,” 287. 416 Kaveny, “Appropriation of Evil,” 289. 417 Kaveny, “Appropriation of Evil,” 288-9. 418 Kaveny, “Appropriation of Evil,” 288-9. 419 Kaveny, “Appropriation of Evil,” 290. 420 Kaveny, “Appropriation of Evil,” 290ff. 421 Kaveny, “Appropriation of Evil,” 290. 422 Kaveny, “Appropriation of Evil,” 294-6, see Russell E. Smith, “The Principle of Cooperation

in Catholic Thought,” in The Fetal Tissue Issue: Medical and Ethical Aspects, ed. Peter J.

Cataldo and Albert S. Moraczewiski (Braintree, MA: Pope John Center, 1994), 81-92. 423 Kaveny, “Appropriation of Evil,” 296; see Smith, “The Principle of Cooperation in Catholic

Thought,” 90ff.

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424 Kaveny, “Appropriation of Evil,” 296; see Smith, “The Principle of Cooperation in Catholic

Thought,” 90ff. 425 Kaveny, “Appropriation of Evil,” 297. 426 Kaveny, “Appropriation of Evil,” 296. 427 Kaveny, “Appropriation of Evil,” 298. 428 Kaveny, “Appropriation of Evil,” 299. 429 Kaveny, “Appropriation of Evil,” 299-300. 430 Kaveny, “Appropriation of Evil,” 299. 431 Kaveny, “Appropriation of Evil,” 298. 432 Kaveny, “Appropriation of Evil,” 298. 433 Kaveny, “Appropriation of Evil,” 299. 434 Kaveny, “Appropriation of Evil,” 300. 435 Kaveny, “Appropriation of Evil,” 300. 436 Kaveny, “Appropriation of Evil,” 300-1. 437 Kaveny, “Appropriation of Evil,” 306. 438 Kaveny, “Appropriation of Evil,” 306. 439 Kaveny, “Appropriation of Evil,” 306. 440 Furton et al, “Double Effect,” 24. 441 NCBC Ethicists, “Cooperating with Non-Catholic Partners,”268. 442 Furton et al, “Double Effect,” 24. 443 NCBC Ethicists, “Cooperating with Non-Catholic Partners,”268. 444 Kaveny, “Appropriation of Evil,” 307. 445 Kaveny, “Appropriation of Evil,” 306-7. 446 Furton et al, “Double Effect,” 24. 447 NCBC Ethicists, “Cooperating with Non-Catholic Partners,”268. 448 Furton et al, “Double Effect,” 24. 449 USCCB, ERDs, 45. 450 Kaveny, “Appropriation of Evil,” 310.

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CHAPTER FIVE – OOPHORECTOMIES AND EMERGENCY CONTRACEPTION

This chapter uses Natural Law, the Moral Object, and the Principle of Double Effect to

ethically justify procedures that physically defined are sterilizing and contraceptive, respectively.

5A. Risk Reducing Bilateral Salpingo-Oophorectomies

This section explores the ethical decision-making regarding prophylactic operations that

both preempt the development of cancer in patients carrying the breast-cancer susceptibility gene

1 (BRCA1) or BRCA2 mutations, and has an unintended, yet foreseen sterilizing effect. The first

subsection explores the history, clinical context, and medically indicated procedures for BRCA1

and BRCA2 mutation carriers. The second subsection uses the Principle of Totality and the

Principle of Double Effect to justify risk-reducing bilateral salpingo-oophorectomies in BRCA

mutation carriers. The third subsection explores factors that health care ethics consultants may

encounter concerning confidentiality and genetic discrimination, especially in light of the

complexity of genetic testing. Finally, the fourth subsection utilizes the organizational ethics

paradigm to elucidate how Catholic health care institutions that prohibit sterilizations may

nonetheless permit bilateral salpingo-oophorectomies for BRCA mutation carriers.

i. Clinical Explanation

Both BRCA1 and BRCA2 are tumor suppressor genes, some mutations of which

significantly increase one’s risk for developing breast, ovarian, or prostate cancer.1 Not all

mutations of these genes have the same effect; some are more deleterious than others.2 The

following subsection elucidates the history of identifying the BRCA1 and BRCA2 genes

responsible for increasing one’s susceptibility to the abovementioned cancers. Then, it articulates

its physiological role. Finally, it explains various options for addressing the condition.

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a. Discovering BRCA1 and BRCA2

According to Joi L. Morris et al., physicians knew as early as the mid-nineteenth century

that breast cancer had a heritable connection because of its devastating impact on certain

families.3 In the 1970s Mary-Claire King began researching heritable links in breast cancer.4 By

the 1980s, she uses statistical analysis of women with breast cancer to demonstrate an autosomal

dominant link to some cases, which counters the dominant theory at the time, namely that

multiple genes and environment cause cancer.5 She focuses on discovering one gene responsible

for engendering breast cancer, which she dubs BRCA1 for breast cancer gene 1.6 Using Southern

blotting, King’s team genotyped 173 different markers from family members of breast cancer

patients.7 By 1990, she narrows the location of BRCA1 to chromosome 17—an enormous

accomplishment before the completion of the Human Genome Project.8

After King announces this achievement, scientists throughout the world set out to

discover BRCA1’s precise location on the chromosome and to sequence the gene.9 In 1994,

Mark Skolnick and his team of researchers at Myriad Genetics and the National Institute of

Health successfully sequenced BRCA1.10 In the early 1990s, scientists know that BRCA1

explains some cases of breast cancer, but not all, which sparks another race to discover the

BRCA2 gene.11 In September 1994, Michael Stratton and Richard Wooster narrow its location to

chromosome 13.12 In October 1994, Yoshoi Miki identifies several mutations that engender

breast cancer in its carriers.13 In 1996, Myriad Genetics begins providing genetic testing for

which it receives a patent in 1998.14 In 2013, however, the United States Supreme Court

overturns this patent.15

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b. Cancer Inhibition

In the abstract of their review article, “Role of BRCA1 and BRCA2 as Regulators of

DNA Repair, Transcription, and Cell Cycle in Response to DNA Damage,” Kiyotsugu Yoshida

and Yoshio Miki explain that for one to understand the damaging role mutations to the BRCA1

and BRCA2 gene, it is important first to know what these respective proteins do as tumor

suppressors.16 They elaborate on the respective functions that BRCA1 and BRCA2 play in DNA

repair, transcriptional response to DNA damage and cell cycle check pointing.17 Many types of

damage occurs to DNA, but one of the most destructive to life is Double Strand Breaks, which

consists of a complete break in both chains of a helical strand of DNA.18 This poses a serious

risk, since no template remains to guide either end’s repair process.19 When this occurs, DNA-

damage binding protein triggers a protein kinase cascade that initiates several processes to

correct the error.20 In mammals, the protein kinase ATM phosphorylates (adds a phosphate)

several substrates including BRCA1 that initiates homologous recombination, which is one of

two mechanisms for repairing the DNA.21 According to Yoshida and Miki, evidence indicates

that BRCA1 plays an important role in regulating the Rad50-Mre11-NBS1 complex, while

BRCA2 regulates the Rad51 protein, both of which play an important role in homologous

recombination.22

In addition, BRCA1 and BRCA2 regulate transcription when DNA damage occurs.23

Transcription consists of the complex process whereby RNA polymerase uses a DNA template

to produce a strand of messenger RNA, which functions as a template for protein synthesis.

When DNA damage occurs, it is important to limit the transcription of messenger RNA so that

the cell does not produce faulty proteins. When DNA damage occurs, BRCA1 regulates the

activity of RNA polymerase II, the complex responsible for messenger RNA transcription.24 In

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addition, BRCA1 is a co-activator of the cell cycle inhibitor p53.25 BRCA2’s role is less clear,

but nonetheless present, and important.26

Finally, BRCA1 and BRCA2 provide checkpoints for cellular responses to DNA damage

during the cell cycle.27 The cell cycle consists of the entire process of DNA replication and

mitotic cellular division.28 DNA replication occurs during the S-phase of interphase. The G2-

phase consists of a repair phase for mistakes that occur during replication. When DNA damage

occurs, the ATM phosphorylation of BRCA1 plays an important role in arresting the cell cycle

during the G2-phase just before mitosis begins.29 Again, BRCA2’s role is less direct, but still

important for the arresting the cell cycle when DNA damage occurs.30

Yoshida and Miki indicate that scientists identify over 200 deleterious germ line

mutations to the BRCA1 gene alone.31 The three-abovementioned functions represent only a few

of the roles that such mutations may interrupt giving rise to cancer in its carriers. Undoubtedly

more processes remain to be discovered.

c. Prophylactic Treatments

In the general population, 12 percent of women develop breast cancer in their lifetime,

while 55 to 65 percent of women with a deleterious BRCA1 mutation and 45 percent of women

with a harmful BRCA2 mutation develop breast cancer by the age of 70.32 Moreover, studies

suggest that while 1.3 percent of women in the general population develop ovarian cancer in

their lifetime, 39 percent of women who inherit a BRCA1 mutation and 11 to 17 percent of

women who inherit a BRCA2 mutation develop ovarian cancer by the age of 70.33 With such an

increase in risk, some physicians perform risk-reducing bilateral mastectomies and risk-reducing

bilateral salpingo-oophorectomies—the removal of the ovaries and Fallopian tubes.34 While such

operations reduce the risk of developing breast and ovarian cancers, they do not eliminate the it

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altogether.35 It is still possible for cancer to originate in the scar tissue or the remaining primary

peritoneal.36 This section explores the effectiveness of a variety of prophylactic options.

In 2007, the American Cancer Society recommends that women with BRCA1 or BRCA2

mutations begin a surveillance regimen of alternating breast magnetic resonance imaging and

mammograms every six months.37 The American Cancer Institute recommends that women

testing positive for the abovementioned mutations begin this surveillance regime at 25 years of

age.38 Some suggest women begin ten years before the age of a diagnosed family member, but no

earlier than age 20.39 Even surveillance comes with a risk, since mammograms utilize X-rays that

expose women to radiation.40 Because of this, some recommend using mammograms at 35,

utilizing magnetic resonance images only until then.41 Unfortunately, surveillance is not 100%

accurate in catching and preventing lethal cases of breast cancer; as such, many physicians

recommend other means of risk-reduction.42

Women with the BRCA1 or BRCA2 mutation who get breast cancer have a 30% chance

of developing cancer in the other breast—contralateral breast cancer—in the ten years following

the initial diagnosis.43 Yet not all carriers with breast cancer opt for bilateral mastectomy or even

unilateral mastectomy for the affected breast.44 In fact, only 50% of North American carriers opt

for bilateral mastectomy when diagnosed with breast cancer, even though it reduces one’s risk of

developing breast cancer by 97% in the other breast.45 Morris et al, indicates that the decision to

remove one’s breasts is highly personal, and depends on many factors.46

The BRCA1 mutation not only increases one’s chance of getting cancer, but of acquiring

a higher-grade as well.47 For instance, 75% of cancers in BRCA1 carriers are estrogen-receptor-

negative, and 69% are triple negative or estrogen receptor-negative, progesterone-receptor-

negative and human epidermal growth factor receptor 2-negative.48 BRCA2 carriers, on the other

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hand, have the increased risk of developing cancer, but not the higher proportion of high-grade

cancers; rather, their proportion is comparable to the general population (77% ER-positive and

16% triple negative).49

Surveillance and risk-reducing surgery are not the only options for reducing cancer risk.

It is also possible for one to take tamoxifen, which when digested by the cytochrome P450

enzymes isoform CYP2D6 and CYP3A4, produces high affinity metabolites, afimoxifene and

endoxifen, for the estrogen receptor,50 to which it antagonistically binds, inhibiting the

transcription of genes.51 Since tamoxifen reduces one’s risk of developing estrogen receptor-

positive cancer, it is medically-indicated for BRCA2 mutation carriers, but not for BRCA1

mutation carriers.52 Still, it only reduces one’s risk of getting estrogen receptor-positive breast

cancer by 50% in BRCA2 mutation carriers.53 In addition, oral contraceptive use for five years

reduces one’s risk of developing ovarian cancer by at least 40%.54 Current research does not

indicate that oral contraception either reduces or increases one’s chances of getting breast

cancer.55

For BRCA-mutation carriers, as the abovementioned statistics indicate, the number one

risk factor for cancer is age.56 Consequently, current guidelines recommend risk-reducing

bilateral salpingo-oophorectomies for BRCA-mutation carriers between the ages of 35 and 40

after completing childbearing.57 In an effort to stave off surgical menopause, and in light of the

serous origin of ovarian cancer in the Fallopian tubes, some physicians are opting for bilateral

salpingectomies alone, followed later by oophorectomies.58 This practices is not, however,

considered standard of care by the National Comprehensive Cancer Network.59 Lynn M.

Hartmann and Noralane M. Lindor in “The Role of Risk-Reducing Surgery in Hereditary Breast

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and Ovarian Cancer,” say the jury is out as to whether or not bilateral salpingo-oophorectomies

before menopause actually reduces BRCA-mutation carriers’ risk for breast cancer.60

According to the United States Preventative Services Task Force risk-reducing bilateral

mastectomies decreases a mutation carrier’s chances of getting breast cancer by 85-100% and

breast cancer mortality by 81-100%.61 Bilateral salpingo-oophorectomies reduce a mutation

carrier’s chance of getting ovarian cancer by 69-100% and of getting breast cancer by 37-

100%.62 While no option is perfect, clearly the risk-reducing bilateral mastectomy and bilateral

salpingo-oophorectomies have the best statistical results. The following subsection considers the

ethics surrounding such prophylactic procedures.

ii. Double-Effect Reasoning

Ethically, bilateral salpingo-oophorectomies pose several dilemmas. The surgeon not

only removes healthy organs, but also renders the patient sterile; both of which seems to violate

important Catholic ethical principles—the Principle of Totality and prohibition against direct

sterilization.63 The following demonstrates that Totality justifies bilateral salpingo-

oophorectomies for BRCA mutation carriers. Moreover, Double Effect justifies bilateral

salpingo-oophorectomies for BRCA mutation carriers, even though it renders the patient sterile.

This justification depends on Pope John Paul II’s understanding of intention and the Moral

Object in Veritatis Splendor.64

a. Totality

In his Summa Theologica, Thomas Aquinas articulates his formulation of the Principle of

Totality in response to the question as to whether or not it is ever possible to maim or mutilate

another person.65 He argues that certain conditions warrant maiming the body, but this is

permissible since the parts of the body are for the sake of the whole.66 To explicate, he uses an

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example from a previous question concerning members of a state.67 Just as it may be necessary

to remove a person from a community for the good of the whole—keeping that individual from

sinning and harming others—so it may be necessary to remove a decaying bodily member for the

good of the whole person.68 This justifies amputation of diseased limbs, but not health organs.

Pope Pius XII develops Aquinas’s articulation of Totality. In his “Address to the First

International Congress on the Histopathology of the Nervous System,” he highlights an

important distinction between the analogy of the community and the physical human person.69 In

“Pope Pius XII and the Principle of Totality,” Gerald Kelly observes that Pius XII distances

himself from Aquinas’s analogy of the community, because he does not support the totalitarian

governments that subjugate the individual for the whole.70 Unlike living organisms, communities

do not have a unity subsisting in them; therefore, Pius XII argues that they constitute moral

entities, rather than, physical entities.71 Therefore, in deference to their natural finality, physical

entities that possess a subsisting unity may dispose of their members, integral parts, and organs

immediately and directly.72 This, however, is not true for authority regarding members of state.73

In 1953, Pius XII addresses the 26th assembly of Italian Urologists defending the removal

of healthy organs that exacerbates an unhealthy condition.74 He argues that three conditions must

exist for one to justifiably remove a healthy organ that aggravates another condition: 1) the

healthy organ’s presence causes harm or threat to the whole person; 2) the damage or threat can

only be avoided by removing the healthy organ and its effectiveness is certain; and 3) one can

reasonably expect the benefit to compensate for the negative effect.75 He emphasizes that the

healthy organ does not constitute the threat, but its functioning directly or indirectly causes for

the whole body a serious threat.76 For such cases, he advances the application of Totality not

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only for the removal of diseased organs that threaten the whole, but also the removal of healthy

organs that harm or threaten the whole.

To illustrate, Pius XII argues that a surgeon may licitly remove healthy testicles from a

man suffering with prostate cancer, even though it renders him sterile, because the removal of

the testicles indirectly slows the growth of cancer by reducing the presence testosterone, which

accelerates the cancer’s growth.77 This case meets the three-abovementioned criteria. First, the

presence of the healthy testicles accelerates the growth of prostate cancer by producing

testosterone. Second, the only effective way to remove the threatening presence of testosterone—

at that time—was to perform an orchiectomy, removing the testosterone producing testicles.

Third, the positive effects—slowing the growth of life-threatening cancer—outweigh the

negative, sterilizing effects of losing one’s testicles.

In contrast, Pius XII argues that the abovementioned criteria do not justify a surgeon

removing a woman’s oviducts to prevent pregnancy in one who has a condition that worsens

during pregnancy.78 First, the healthy Fallopian tubes do not contribute either directly or

indirectly to the condition in question. Second, removing the Fallopian tubes is not the only way

to prevent the dangerous condition of pregnancy from occurring. Third, although one may argue

that one’s life is more important than one’s openness to life in the marital act, the inability to

satisfy the first two criteria renders this point feeble for defending the act by Totality.

Bilateral salpingo-oophorectomies for BRCA mutation carriers meets the three criteria

that Pius XII offers in his address to the urologists. Even though one may argue that the organ is

cancer free and healthy at the moment, the statistical likelihood of it becoming cancerous in

BRCA mutation carriers constitutes a genuine threat to the whole person, especially considering

how deadly ovarian cancer is.79 Because of the significant, increased risk of developing ovarian

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cancer and the lack of reliable surveillance, following the recommended guidelines of having

bilateral salpingo-oophorectomies between the age of 35 and 40 constitutes the best method of

preventing ovarian cancer.80 Although bilateral salpingo-oophorectomies render patients sterile,

the lifesaving positive certainly outweighs the negative.

b. Double-Effect Reasoning

Aquinas is the first to formulate an argument using Double-Effect Reasoning in his

Summa Theologica.81 In II-II, q. 64, a. 7, he explains how one may justifiably kill another person

in self-defense.82 He begins with the premise that an act may have more than one effect, not all

of which one intends.83 In morally licit, lethal self-defense, he maintains with Augustine that one

must not actually intend to kill one’s assailant; rather, one must intend self-defense.84 The death

of the assailant is praeter intentionem, beside intention.85 In addition, he contends that one’s

action must be proportionate to the assailant’s assault.86

From an appropriate understanding of several key terms one may derive a set of criteria

that configures a contemporary formulation of the Principle of Double Effect. First, one must

understand what Aquinas means by intention. In Aquinas: Moral, Political, and Legal Theory,

John Finnis indicates that Aquinas uses intention in both a broad sense and a narrow sense.87

Broadly speaking, intention concerns ends.88 In On Evil, Aquinas makes a distinction between

intending something as a remote (ulterior) end (finis operantis) versus as a proximate end (finis

proximus).89 Intention, as the proximate end forms the act’s species, which Aquinas identifies as

the Moral Object.90 In the Prima Secundae of the Summa Theologica, he highlights an important

distinction between the proximate end (means) and the remote end, namely that one chooses

(electio) a means for an end,91 while one intends (intentio) a remote end.92 The latter constitutes

the narrower sense of intention, while the broader sense includes intention as choice of the will.93

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To illustrate, Finnis refers the reader to Aquinas’s On Evil, where Aquinas offers the example of

one wanting to steal in order to give alms.94 Narrowly speaking, the person has a good intention,

to give to the poor, but the act is evil because the means chosen is evil—stealing; therefore,

broadly speaking, the intention is evil. Finnis insists that Aquinas is using the broad sense of

intention in his discourse on self-defense.95 As such, both the proximate end and the ulterior end

must be good for the act to be good.

Another important concept for Aquinas that relates to intention is praeter intentionem.96

In “Per se and Praeter Intentionem in Aquinas,” Duarte Sousa-Lara identifies three distinct uses

of praeter intentionem in Aquinas’s works: 1) to indicate that one does not will a moral evil per

se; 2) to identify unforeseen outcomes that may affect an action; and 3) to refer to foreseen, but

unintended effects of action that, in turn, do not specify the act.97 Sousa-Lara contends that

Aquinas uses the third form for Double-Effect Reasoning in his discussion of killing in self-

defense.98 Insofar as the agent does not intend to kill the assailant, but merely to defend oneself

from an unjust aggressor using lethal force, the evil effect of the death of the attacker remains

outside one’s intention. Foreseeing the death of the assailant by means of lethal defense does not

change the Moral Object. It does not affect the species of the act since it remains outside of

intention. This builds on the principle that knowing (foreseeing) does not entail causing.

Concerning Aquinas’s understanding of intention, one may derive two or three of the

conditions of Double Effect. First, the Moral Object of the Act must be good or neutral.99

Second, one must not intend the evil effect, but the good effect.100 Third, from a casuistic

perspective, for instance, following that of Jean Pierre Gury, the bad effect must not cause the

good effect.101 From a Thomistic perspective, however, the third is simply a restatement of the

first, namely, that one must not choose evil means for a good end.

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Finally, Aquinas has a proportionality clause in his argument for self-defense: one’s use

of self-defense ought to be proportionate to the force that the attacker uses in the assault.102

Double Effect does not justify the use of lethal force to counter non-lethal threats. Causally, one

must have a serious reason for causing the evil effect; that is, the good must outweigh the bad.103

Having summarized an account of Principle of Double Effect that adequately accounts

for intention from a Thomistic perspective, I now apply it to bilateral salpingo-oophorectomies

for BRCA mutation carriers. First, I argue that this procedure is not evil in its species but

depends on the broad interpretation of intention of the will that includes both the proximate end

and the ulterior end. Accordingly, it meets the first three conditions of Double Effect. Finally, the

lifesaving risk-reduction satisfies the proportionality condition of Double Effect.

c. Object of the Act

The first, and arguably most important condition for the Principle of Double Effect is that

the Moral Object of the Act must be good or indifferent.104 Using the broad sense of intention,

Aquinas maintains that the intention morally specifies an act.105 Recall that the proximate end of

an act determines the Moral Object.106 Therefore, above all, one must determine whether the

means chosen in the act is good or evil.

For Aquinas, morality centers on the will.107 In particular, the will intends goods that the

intellect rationally configures.108 Regarding species of acts, it is possible to consider actions from

the perspective of their voluntariness, that is, on the moral order (genus moris); and

independently thereof, that is, purely as physical acts on the metaphysical order (genus

naturae).109 Insofar as the orders differ, so the ends differ, and consequently, the objects differ.110

As such, one act may have two species, one of the moral order and the other of the physical

order.111 For example, on the physical order, an act may be killing, but on the moral order, that

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is, in its voluntariness, the act is one of self-defense. The physical species of the act is evil

insofar as it results in the death of another, but morally, the act is good insofar as the agent

intends something good, self-defense. Although distinct in nature from the ontological order,

human actions, constitutive of the moral order, by analogy have a fullness of being that

corresponds both to reason and being.112 It is precisely the Moral Object’s correspondence to

reason, or the lack thereof, which renders it good or evil.113 In self-defense, the agent intends

(intentio) a good end—preservation of one’s life. At the same time, regarding the proximate end,

the will chooses (electio) a particular means to this end, hitting an attacker on the head with a

bat. The intellect rationally configures the good such that the will may choose and then command

(praeceptum) a particular action.114 Consequently, a human action is only good or evil insofar as

reason configures it; otherwise it is morally indifferent.115

Purely from the perspective of the physical order, bilateral salpingo-oophorectomies

constitute the removal of organs, which renders the patient sterile. If one conflates the moral and

the physical order, one may conclude that bilateral salpingo-oophorectomies under any

circumstance are immoral insofar as they render patients sterile. This reduction of orders

constitutes the Naturalistic Fallacy.116 The above demonstrates that a morality true to the

Thomistic tradition maintains the distinction of orders.117 As such, morally, it is not enough to

merely consider the physical act alone. Rather, one must take into account the will and more

specifically intention, both as the ulterior end and proximate end.118 For BRCA mutation carriers,

the ulterior end is the preservation of one’s life. The means chosen (finis proximus) is the

removal of organs that have a high likelihood of becoming cancerous—the Fallopian tube and

the ovaries. As such, ethically, from the perspective of the proximate end chosen, bilateral

salpingo-oophorectomies are good because they constitute a means that greatly diminishes one’s

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chance of getting ovarian cancer.119 Furthermore, this satisfies the first condition of Double

Effect, which necessitates that the Moral Object is either good or neutral.120

The ulterior end—the preservation of one’s life—is good, and with the addition of a

corollary—one does not intend the evil of sterilization—this satisfies the second condition, that

one intends the good effect and not the bad.121 In other words, so long as one does not intend the

bad effect, it is outside of one’s intention, even if foreseen.122 Bilateral salpingo-oophorectomies

for BRCA mutation carriers satisfies the third requirement that the bad effect not cause the good,

since it is not the sterilization that diminishes one’s risk of getting cancer, rather, it is the

removal of the potentially cancerous organs that causes both. Finally, it meets the fourth

condition of proportionality insofar as the good of foreseeably preserving one’s life from the

likelihood of developing deadly ovarian cancer outweighs the negative effect of sterilization.

Moreover, since no viable alternative exists for either preventing ovarian cancer or catching it

early, it is not only the best, but also the only medically-indicated option.123

This subsection demonstrates that the Principle of Double Effect does justify bilateral

salpingo-oophorectomies in BRCA mutation carriers. The next subsection considers other ethical

challenges for BRCA mutation carriers and their clinicians.

iii. Health Care Ethics Consultations

Genetic testing is a relatively new development in medicine with several important

ethical implications. Antonella Surbone, in “Social and Ethical Implications of BRCA Testing,”

defines genetic testing as “any analysis to detect genotypes, genetic mutations, or chromosomal

changes, not including analysis of proteins or metabolites directly related to a manifest disease,”

which can lead to genetic exceptionalism, that is, treating patients with genetic disorders

differently than patients with other diseases.124 As the above demonstrates, genetic testing for

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BRCA mutations plays an important role in testing for heritable cancer mutations. At the same

time, it raises questions about reliability of testing, genetic discrimination, and sharing of

information with third parties, including family members. The following addresses these ethical

issues.

a. Genetic Testing

Genetic testing, even for a well-known and relatively straightforward condition like

BRCA1 or BRCA2 mutations does not always provide a simple answer. In fact, testing for

genetic mutations is quite complex. In 2004, Kiyotsugu Yoshida and Yoshio Miki, in their

review article, “Role of BRCA1 and BRCA2 as Regulators of DNA Repair, Transcription, and

Cell Cycle in Response to DNA Damage,” identify no less than 200 possible mutations that have

potentially deleterious effects in BRCA1 alone.125 In 2010, Ake Borg et al., in “Characterization

of BRCA1 and BRCA2 Deleterious Mutations and Variants of Unknown Clinical Significance in

Unilateral and Bilateral Breast Cancer: The WECARE Study,” detect 470 unique sequence

variants in both unilateral and contralateral breast cancer patients, of which they contend 113 are

deleterious, 57 on BRCA1 and 56 on BRCA2, reducing the estimate significantly.126 Borg et al.

categorizes the 357 other variants as variants of unknown clinical significance.127 These account

for some of the ambiguous results that 10% of test-patients receive, but not all.128 Although

patients with negative results tend to develop cancer at the same frequency as those with

ambiguous results, the latter tend to experience greater frustration and anxiety.129 Genetic

counseling fills a void for those seeking guidance, especially with unclear results.

b. Genetic Discrimination

More than a lack of clarity concerning results and their implications, genetic

discrimination deters some women with a family history of breast cancer from receiving genetic

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testing, especially when they plan on using insurance to cover the cost.130 Women fear

discrimination from employers or insurance companies, because of implications of a pre-existing

condition for insurance acceptance.131 In addition, some women fear living with the looming risk

of getting cancer, or being seen as less than ideal marital partners.132 This not only puts many at-

risk women at greater risk, because they are not engaging in meticulous surveillance or

prophylactic treatments, but this hurts research too, since fewer women are willing to participate

in studies.133

In 2008, the United States Congress passed the Genetic Information Non-discrimination

Act.134 This law specifically addresses discrimination from health insurance companies and

employers.135 Title I, concerning insurance companies, prohibits insurers using genetic

information to make decisions about eligibility, coverage, underwriting, or premiums.136 In

addition, insurers may not request or require individuals or family members to provide genetic

information.137 Title II, concerning employment, prohibits employers from using genetic

information to make decisions regarding hiring, firing, promotions, pay, or job assignments.138

While legislation addresses some discrimination, it does not deal with social discrimination or

the spiritual or psychological impact. In fact, because of the deep impact such personal

knowledge may have on individuals’ self-concept, and because of little that can be done

clinically before the age of 25, many experts advice not performing genetic testing on minors or

sharing one’s genetic status until later.139

c. Confidentiality

This raises an important issue regarding confidentiality and the ethical dilemma of

sharing important information that may impact other family members, especially regarding

genetic information. Legally, in the United States, the Health Insurance Portability and

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Accountability Act of 1996 delimits confidentiality in healthcare.140 If healthcare workers do not

respect patient’s confidentiality, the trust between patient and caregiver will undoubtedly erode.

Confidentiality is important and strict, but not unlimited.141 Albert Jonsen et al, in Clinical

Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine maintains that when the

patient’s health depends on sharing information, the principle of beneficence justifies an

exception to confidentiality.142 In addition, the principle of non-maleficence demands that if

withholding information poses a threat or harms to a third party, one must not withhold it.143

Clint Parker, in “Disclosing Information about the Risk of Inherited Disease,” presents a

vignette of a physician in an ethical dilemma with two sisters, one of whom has been diagnosed

with a BRCA mutation and the other who has an increased risk.144 Mrs. Durham, the sister

diagnosed with the BRCA mutation is estranged from her sister, Mrs. Weir, and does not want to

tell her sister that she has cancer.145 Parker insists that the physician must not violate

confidentiality, by telling Mrs. Weir about Mrs. Durham’s diagnosis, nor should he do

nothing.146 Instead, if after persistently trying to convince Mrs. Durham to disclose the

information to her sister does not work, Parker contends that the physician should advise Mrs.

Weir that it is in her best interest to have genetic testing for a BRCA mutation.147 He contends

that this approach maintains the confidentiality of Mrs. Durham, and also provides for the needs

of her estranged sister, Mrs. Weir.148

Parker blurs the lines of confidentiality to solve a dilemma between confidentiality and

the potential threat to a third party. If this were the sacrament of reconciliation, such an act

would constitute an indirect violation of the seal—using confidential information outside the

confessor-penitent relationship. Needless to say, the patient-physician relationship is

qualitatively different, but the example nonetheless highlights the use of confidential information

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from one patient for another does constitute an exception to confidentiality. The principle of non-

maleficence demands such an exception for the third party.149 To be sure, the threat that

exceptions to patient-physician confidentiality poses means that sharing personal information

will always be tenuous.

While this subsection highlights the complexity of ethical implications of genetic testing,

the following explains the ethical consistency of a Catholic hospital that prohibits sterilizations,

but allows prophylactic, but physically sterilizing procedures.

iv. Catholic Health Care Policy

Gerard Magill and Lawrence Prybil, in Governance Ethics in Healthcare, develop a

paradigm for organizational ethics rooted in skills for health care ethics consultations and

professionalism.150 The first component is foundational, embodying the concept of identity, it

focuses on the organizational stewardship of the mission of the organization answering the

leitmotif question: “Who are we?”151 The second component is process, focusing on decision-

making that is participative deliberation and in the executive oversight context, answers the

leitmotif question: “How we function?,” which concerns the concept of accountability.152 The

third component is practical, focusing on best practices for standards of conduct, in the context

of organizational culture, it answers the question, “What we do?,” thereby embodying the

concept of quality.153 In the following, I utilize the three-abovementioned components of

organizational ethics to articulate a consistent application of the prohibition on sterilizations and

the use of bilateral salpingo-oophorectomies for BRCA mutation carriers in Catholic Health Care

Institutions.

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a. Prohibiting Sterilization

Again, the first component of the organizational ethics paradigm concerns the

institution’s identity.154 The United States Conference of Catholic Bishops’ Ethical and

Religious Directives for Catholic Health Care Services, defines mission of every Catholic health

care institution in the United States.155 For the Church, health care is a constitutive part of the

healing mission of Christ.156 The Ethical and Religious Directives “reaffirm the ethical standards

of behavior that flow from the Church’s teaching about the dignity of the human person.” 157 The

United States Bishops base these ethical standards on the Revelation of Jesus Christ and the

Natural Law, which the Church authoritatively interprets.158

The Catholic Church deeply roots its prohibition on sterilization in its teaching on

marriage and the human person that corresponds to the prohibition on contraception.159 Many

conflate the Church’s prohibition of contraception with its prohibition of abortion, attempting to

identify both as violations of the fifth commandment “thou shall not kill.”160 Martin Rhonheimer,

in Ethics of Procreation and the Defense of Human Life: Contraception, Artificial Fertilization,

and Abortion, argues that contraception primarily violates the virtue of chastity.161 He attributes

the misconception to John Paul II’s connection of contraception with abortion in Evangelium

Vitae, where he notes that abortion acts as a failsafe for contraception, both of which thereby

contribute to the so-called culture of death.162

In the same paragraph, however, John Paul II says that contraception “contradicts the full

truth of the sexual act as the proper expression of conjugal love…[and] is opposed to the virtue

of chastity in marriage.”163 This is precisely what Rhonheimer, argues Pope Paul VI teaches in

Humanae Vitae.164 Although Paul VI connects the Church’s prohibition to contraception with the

Inseparability Principle—that the unitive and procreative significance of marriage are

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inseparable and ought to remain so in every act—this alone does not suffice.165 Rhonheimer

insists that periodic continence, a constitutive part of responsible parenthood, also provides a

means for growing in chastity; that is, virtuously integrating the sexual drives under the domain

of reason and will.166 This integration of the bodily with the spiritual is precisely what raises

sexual drive to the order of personal love.167 Insofar as contraception eliminates the need for

periodic continence—a natural means for growing in chastity—it violates the virtue of

chastity.168 This explanation avoids the reduction of contraception to merely the physical act of

taking an anovulant. Rather, it takes into account intention, the human person, and virtue.

Therefore, for Paul VI, John Paul II and Rhonheimer, the use of contraception is wrong

insofar as the intention, understood as the Moral Object, consists in a vicious choice against

chastity.169 When, however, the agent’s intention changes, for example, a victim of sexual assault

preventing conception, the Moral object changes to one of self-defense, which is clearly not a

means to circumventing chastity.170 Although the physical act of taking an anovulant is the same,

the intention—as the proximate end—is very different. One is to circumvent chastity, the other to

defend oneself from conceiving through an unjust sexual assault.

That the same physical act can have two different Moral Object demonstrates the

importance of intention for determining the morality of the act, both as proximate end and

ulterior end. As the above indicates, there are exceptions to the rule prohibiting operations that

render one sterile.171 For this reason, the United States Bishops, in the Ethical and Religious

Directives while prohibiting direct sterilization, permit procedures that induce sterility “when

their direct effect is the cure or alleviation of a present and serious pathology and a simpler

treatment is not available.”172 One must go beyond the mere physical act to the intention of the

person. As the above demonstrates, when physicians use bilateral salpingo-oophorectomies in

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BRCA mutation carriers to remove organs that will very likely become cancerous, they intend to

maintain the health of the patients, not to sterilize for the purpose of responsible parenthood.

b. Non-BRCA Mutation Carriers

Becket Gremmels et al., in “Opportunistic Salpingectomy to Reduce the Risk of Ovarian

Cancer,” argue that a patient and physician may opt for bilateral salpingectomies, even though

the risk of developing ovarian cancer is low in non-BRCA mutation carriers, because the

screening options for ovarian cancer are so poor.173 On June 7, 2016, the National Catholic

Bioethics Center, the publishers of the article, released a statement indicating their disagreement

with the views of the authors on this topic.174 They argue that without a heightened risk for

cancer, the average risk of developing ovarian cancer is not proportionate to the irreversible loss

of fertility.175 Such a statement does not limit the use of bilateral salpingectomies or bilateral

salpingo-oophorectomies for BRCA mutation carriers only; in fact, they admit that genetic

testing, family history, and other means may justify such a decision to pursue bilateral

salpingectomies, but average risk does not suffice.176 I concur with their statement for two

reasons. First, current medical guidelines do not medically-indicate bilateral salpingectomies or

bilateral salpingo-oophorectomies for women with an average risk for developing ovarian

cancer.177 Second, physicians and patients may use this procedure as a means to circumvent the

Church’s prohibition on sterilizations. Using bilateral salpingectomies to sterilize women not

only violates the mission of a Catholic hospital, it defies medically-indicated guidelines.

Moreover, such an abuse gives scandal and renders institutions vulnerable to lawsuits of

malpractice and discrimination.

The Church’s teaching against sterilization relates deeply to its mission, but is also a

source of conflict with other providers that see contraceptive services as a vital part of women’s

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healthcare.178 Moreover, opponents level seemingly countless lawsuits against Catholic

healthcare institutions, claiming that they do not provide adequate care by denying contraception,

including sterilization to its patients.179 Rather than caving to popular opinion, I suggest that

Catholic institutions use this as an opportunity to re-evangelize regarding its teaching. In fact,

one of the benefits of health care ethics boards is the education of hospital directors and staff.

Paul VI indicates that the prohibition against contraception is not a prohibition against

responsible parenthood.180 For this reason, Catholic Healthcare Institutions ought to provide

effective alternatives to contraception as a means for responsible parenthood that includes

training for staff, patients and the community in acceptable methods for responsible

parenthood.181 For some opponents, no alternative to contraceptive services suffices, but failing

to offer any alternative renders one vulnerable to false criticism, namely, that the Church is

against all forms of birth control.

This section orients the use of bilateral salpingo-oophorectomies in BRCA mutation

carriers in the context of the Church’s prohibition of sterilization, advising against the use of

bilateral salpingectomies for women with an average risk for ovarian cancer, since it contradicts

current medical guidelines and may be subject to abuse. In the face of opposition, I contend that

Catholic health care providers ought to use ethics boards to re-evangelize staff and directors and

to implement practices amenable to Church teaching regarding responsible parenthood.

Using the ethical Principle of Totality and Double Effect, this section evaluates the use of risk

reducing bilateral salpingo-oophorectomies in BRCA mutation carriers. Keeping the Moral

Object in the moral order, this section demonstrates the liceity of such procedures. The following

section holds that a non-consequentialist definition of the Moral Object of self-defense from

conception after sexual assault precludes recourse to the Principle of Double Effect.

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5B. Emergency Contraceptive for Victims of Sexual Assault

In the Ethical and Religious Directives for Catholic Health Care Services, 6th edition, the

United States Conference of Catholic Bishops assert that women have the right to defend

themselves from conception in cases of sexual assault.182 Because of the Church’s strict

prohibition of abortion,183 which begins from the moment of fertilization, the United States

Bishops insists that the method must not remove, destroy, or interfere with a conceptus.184 This

section explores the ethical principles that justify such a position. In particular, it articulates the

Moral Object of self-defense, of which the use of emergency contraception constitutes for

victims of sexual assault. Second, it illustrates how the Principle of Double Effect is not

necessary to defend such a stance, so long as one does not define the object consequentially.


This subsection elucidates the complex physiological events that constitute the ovulatory

cycle in women and the impact that emergency contraceptives such as levonorgestrel have on it.

a. Menstrual-Ovulatory Cycle

The ovulatory cycle consists of the recurrent process whereby the female body undergoes

physiological changes in anticipation of fertilization and implantation. This involves three

primary organs, 1) the brain—hypothalamus and the pituitary gland, 2) the uterus, and 3) the

ovaries, in response to complex interactions of hormones. Marc A. Fritz and Leon Speroff, in

Clinical Gynecologic Endocrinology and Infertility, articulate the process in three phases: 1)

follicular, 2) ovulation, and 3) luteal.185 Similarly, they breakdown the events in the uterus to five

phases: 1) menstrual emdometrium, 2) proliferative, 3) secretory, 4) anticipation of implantation,

and 5) endometrial breakdown.186 This subsection discusses each of these in detail.

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Ovulation begins in the ovaries when females reach puberty.187 At puberty, the germ cell

mass consists of between 300,000 to 500,000 cells, of which only 400 to 500 ovulate.188

Apoptosis or programmed cell death in follicles, also called atresia, begins even before birth,

when the number of follicles exceeds 6 million and continues until menopause.189 The body

rescues a few follicles from atresia, which mature to ovulation. Although several follicles grow

only one dominant follicle matures to ovulation per cycle in a process called folliculogenesis,

that is, the development of a primary follicle into a mature oocyte, which takes 85 days.190 The

development of a primordial follicle right up to the point of ovulation is the follicular phase of

ovulation in the ovaries.191

Within the brain, the hypothalamus releases gonadotropin releasing hormone in a

pulsating manner.192 With a half-life of just 2-4 minutes, the body can regulate gonadotropin

releasing hormone with a high degree of specificity.193 Gonadotropin releasing hormone induces

the anterior pituitary to release both luteinizing hormone and follicle stimulating hormone.194

Under the influence of follicle stimulating hormone, the number of granulosa cells around

primordial follicles increases and form an intragranulosa cavity, which Emma Call and Sigmund

Exner discover and name Call-Exner bodies.195

The primordial follicle becomes a primary follicle when the granulosa cells, that is, the

cells which surround and nourish the oocyte become cuboidal and multiply to at least 15 in

number.196 The basal layer separates the granulosa cells from the stromal cells that differentiate

into theca interna and theca externa depending on their proximity to the oocyte.197 Once the

intragranulosa cavity, also called an antrum appears, the follicle enters the antral phase. During

the preantral phase, however, follicle stimulating hormone induces the production of an

aromatase enzyme system that converts androgen to estrogen in granulosa cells.198

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Synergistically, follicle stimulating hormone and estrogen increase the production of follicle

stimulating hormone receptors in granulosa cells that increase the number of granulosa cells and

the production of estrogen.199 This increases the production of follicular fluid, which generates

the production of the antrum, thereby pushing the follicle from the preantral phase to the antral

phase.200

Early in the antral phase, the granulosa cells only have follicle stimulating hormone

receptors and luteinizing hormone receptors are only on the theca interna cells.201 There,

luteinizing hormone induces the production of androgen, which feeds the production of estrogen

by aromatase in the granulosa cells, thus producing a higher proportion of estrogen.202 All

follicles do not develop, because there is a tendency for granulosa cells to produce a more potent

molecule, 5 reduced androgen, which inhibits aromatase’s activity, thus reducing the presence

of estrogen and inhibiting follicular development.203 Another inhibiting factor is estrogen that

provides a negative feedback loop with the hypothalamic-pituitary gland, reducing the amount of

follicle stimulating hormone available to other follicles.204 Consequently, only the follicle that

has the most number of follicle stimulating hormone receptors and the highest amount of

estrogen matures to ovulation. Eventually, the granulosa cells of the mature antral follicle

acquire luteinizing hormone receptors, which enables the corpus luteum to function after

ovulation.205 In fact, follicle stimulating hormone induces the growth of luteinizing hormone

receptors in the granulosa cells.206

Primates regulate folliculogenesis through peptide members of the transforming growth

factor- family, including activin and inhibin, which the granulosa cells produce.207 Inhibin

inhibits follicle stimulating hormone, but not luteinizing hormone secretion, while activin

increases the secretion of follicle stimulating hormone.208 In theca cells, inhibin and activin

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regulate androgen synthesis.209 Activin increases the activity of aromatase in granulosa cells.210

Follistatin, a peptide secreted by the pituitary cells, suppresses follicle stimulating hormone

synthesis and secretion. 211 Moreover, it binds to activin, decreasing its activity.212 Researchers

have yet to complete the full picture regarding the impact that these and other growth factors

have on ovulation in humans.

In the late follicular phase, estrogen increases according to an exponential growth

curve—slow at first then rapid—peaking at 24-36 hours before ovulation.213 The elevation in

estradiol triggers the luteinizing hormone surge.214 The average luteinizing hormone surge lasts

48-50 hours, but 14-27 hours suffice to fully mature the oocyte.215 Ovulation typically occurs 10-

12 hours after the luteinizing hormone peak.216 Luteinizing hormone, not estrogen, stimulates

both the production of progesterone and the expression of progesterone receptors in the

granulosa cells of the dominant follicle.217 In addition, luteinizing hormone instigates

luteinization, that is the process by which the postovulatory follicle differentiates and becomes

the corpus luteum.218 Additionally, luteinizing hormone stimulates the resumption of meiosis in

the oocyte.219 Progesterone levels have to be just right in order for the luteinizing hormone surge

to occur. If the progesterone levels, which originate endogenously from the adrenal gland before

the luteinizing hormone surge,220 are too high before the estrogen surge, the luteinizing hormone

surge does not occur.221 This is how the administration of exogenous progesterone prevents

ovulation and works as a contraceptive.

Follicle stimulating hormone, luteinizing hormone, and progesterone instigate activity of

proteolytic enzymes in the follicular fluid that degrade the collagen in the follicular wall, thus

enabling the oocyte along with the cumulus oophorus to escape the ovary.222 Stimulated by the

gonadotropin surge, granulosa and theca cells produce two plasminogen activators, of which

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unique inhibitors regulate.223 These plasminogen activators activate plasminogen in the follicular

fluid to produce plasmin, which generates active collagenase that breaks down the follicular

wall.224 Inhibitors prevent the activators from being active except at the precise moment of

ovulation.225 Prostaglandins activate plasminogen activators.226 In addition, they cause smooth

muscle contractions of the ovary that aid in expelling the oocyte-cumulus cell mass.227 The

follicle stimulating hormone surge in mice induce granulosa cells in the cumulus mass to release

hyaluronic acid, which separates the cumulus from the basement membrane of the follicle.228 In

addition, follicle stimulating hormone stimulates the production of luteinizing hormone receptors

in the granulosa layer that differentiates into the corpus luteum.229

In terms of timing, the luteinizing hormone surge generally occurs on day 14 of the

ovulatory cycle and ovulation commences between 12 and 36 hours later.230 In general, there is a

six-day window in which fertilization may occur.231 This is because sperm may survive up to

five days in the female reproductive tract,232 and the oocyte is fertile for only 24 hours after

ovulation.233 The extreme window is six days prior and 3 days after ovulation, which makes for a

nine-day window.234 However, the majority of conceptions happen when coitus occurs within

three days before ovulation.235 It takes about 3 to 4 days for an ovum to traverse the fallopian

tube and enter the uterus and implantation ensues about 2-3 days after entering the uterus.236

Implantation follows as soon as 6 and as late as 12 days after ovulation.237

The luteal phase lasts between 11 and 17 days.238 Even before ovulation, granulosa cells

increase in size developing vacuoles that contain lutein. After ovulation, theca and stroma cells

become theca lutein cells, even as granulosa cell continue to enlarge, and angiogenesis, that is,

vascularization of the surrounding tissue occurs.239 The luteinized granulosa cells, in response to

luteinizing hormone produce vascular endothelial growth factor and angiopoietins, which induce

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angiogenesis. Vascularization, which peaks by day 8 or 9,240 is essential for transporting low-

density lipoprotein cholesterol to the luteal cells that use it to produce progesterone.241

Progesterone levels peak 8 days after the luteinizing hormone surge.242

The corpus luteum rapidly declines 9-11 days after ovulation, if pregnancy does not

occur.243 In humans, nitric oxide acts as a luteolytic factor, activating the production of

prostaglandin F2.244 Matrix metalloproteinases act as proteolytic enzymes and degrade the

corpus luteum. Pervasively present throughout luteal phase, tissue inhibitors of

metalloproteinases keep matrix metalloproteinases inactive. Activin-A eventually blocks tissue

inhibitors of metalloproteinases’ activity, allowing the matrix metalloproteinases to degrade the

corpus luteum.245 When pregnancy does occur, the blastocyst, even before implantation produces

human chorionic gonadotropin, which rescues the corpus luteum from luteolytic demise.246

Human chorionic gonadotropin inhibits the expression of matrix metalloproteinases by

increasing the production of follistatin, a glycopeptide that binds to activin-A.247

Once the corpus luteum deteriorates, steroidogenesis of estrogen and progesterone

diminishes along with the decrease in inhibin, which permits an increase in follicle stimulating

hormone in the pituitary.248 This constitutes the luteal-follicular transition. The decrease in

steroids estrogen and progesterone, remove the negative feedback suppression of gonadotropin

releasing hormone in the pituitary, thus allowing for an increase in gonadotropin releasing

hormone.249 The consequent elevation in follicle stimulating hormone saves a dominant follicle

from atresia.250

Concomitant to activity in the ovaries is activity in the uterus. In particular, the most

active portion of the uterus constitutes the endometrium. The withdrawal of progesterone, due to

the demise of the corpus luteum triggers menses.251 Upon the completion of menses, the

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endometrium enters the phase of menstrual endometrium that constitutes a phase of regeneration

originating in both epithelial and stromal stem cells.252 After 5-6 days the entire uterine cavity is

re-epithelialized over a stromal fibroblast layer.253

Next, the uterus enters the proliferative phase, which correlates with the ovarian follicle

grow and an increase in estrogen production.254 Although estrogen is not necessary for the early

proliferative phase, it contributes to the increase in vascular endothelial growth factor, which

induces angiogenesis in the stromal cells.255 In addition to growth in size, microvillous and

ciliated cells appear around the openings of glands and aid the distribution of secretions during

the secretory phase.256 Finally, lymphocytes and macrophages accumulate in the stroma cells.257

After ovulation, the endometrium no longer increases in height, but glands and spiral

vessels continue to grow, increasing the tortuosity of the endometrium.258 Consequently, the

endometrium secretes glycoproteins, peptides, immunoglobulins, and plasma into the

endometrial cavity, reaching a peak 7 days after the midcycle gonadotropin surge, just in for

blastocyst implantation.259

During the implantation phase, the endometrium consists of three layers: 1) the basalis, 2)

the stratum spongiosum, and stratum compactum.260 Endometrial stromal cells, originating from

primitive uterine mesenchymal stem cells, differentiate into decidual cells, beginning during the

luteal phase under the influence of progesterone and other factors.261 They have the potential to

aid the blastocyst in implantation or to breakdown the endometrium with the withdrawal of

estrogen and progesterone support.262

If implantation does not occur, then estrogen and progesterone support wanes with the

demise of the corpus luteum.263 Lysosomes are ubiquitous in the endometrium and the integrity

of their membranes depends on progesterone.264 So, when it declines, the lysosomes release

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enzymes that degrade the endometrium. Vascular endothelial growth factor increases the blood

flow to the endometrium releasing influencing the expression of matrix metalloproteinases and

releasing white blood cells.265 Just as tissue inhibitors of metalloproteinases keep the matrix

metalloproteinases inactive while progesterone is high in the corpus luteum, so it does so in the

endometrium.266 The breakdown of the endometrium by enzymes and the increase blood flow

induces menstrual bleeding.267 At the same time, however, vasoconstrictors and estrogen

promote healing of the remaining tissue in anticipation of the next cycle.268

This subsubsection elucidates the complex network of hormones, transcription factors,

and enzymes emanating from the hypothalamic-pituitary plexus of the brain, ovaries, and

endometrium to regulate the menstrual-ovulatory cycle.

b. Physiology of Contraceptives

This subsection analyzes methods of emergency contraception. Today, there are four

contraceptive methods available for emergency contraception: copper intrauterine device, oral

contraceptive pills combining estrogen and progestin, ulipristal acetate, and progestin-only

levonorgestrel.269 All methods impact the physiological dynamics of the menstrual-ovulatory

cycle, thereby impeding conception. In addition, copper intrauterine devices unquestionably act

as an abortifacient by preventing implantation of blastocysts.270

In 1984, the United States Food and Drug Administration approves the TCu-380A

intrauterine device contraceptive.271 Today, CooperSurgical markets the copper intrauterine

device as Paragard TCu-380A intrauterine device.272 As foreign bodies, non-medicated

intrauterine devices induce a sterile inflammatory response that causes minor tissue injury to the

endometrium.273 Copper intrauterine devices release free copper and copper salts that have an

additional biochemical impact on the endometrium, its secretions and the cervical mucus inhibit

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the mobility of sperm.274 Martti Ämmälä et al. suggest that an increase in cytokine production

that copper intrauterine devices induce may account for its antifertility effects.275

Maria Elena Ortiz and Horacio B. Croxatto, in “Copper-T Intrauterine Devices and

Levonorgestrel Intrauterine System: Biological Bases of Their Mechanism of Action,” indicate

that the ordinary mechanism of action associated with chronic use, is not necessarily the same as

post-coital insertion.276 Thus it is important to distinguish the usual mechanism of preventing

pregnancy, which I illustrate in the above paragraph, versus the exceptional, which constitutes its

mechanism for preventing pregnancy as an emergency contraception inserted post-coitally.277

Their research indicates that chronic use of copper intrauterine devices prevents fertilization

from ever occurring by creating an environment that is hostile to both sperm and oocytes.278

However, as an emergency contraception, copper intrauterine devices prevent implantation, if

fertilization occurs.279 Although current recommendations restrict insertion of copper intrauterine

devices to 5 days after implantation, Norman D. Goldstuck insists that this recommendation is

faulty, because evidence indicates that copper intrauterine device are just as effective at

preventing pregnancy after implantation occurs.280 He insists that researchers base the

recommendation on the philosophical position that pregnancy begins with implantation, not its

clinical effectiveness at preventing or halting pregnancy.281 The indisputable abortifacient quality

of copper intrauterine device and their prolonged contraceptive function preclude its use in

Catholic hospitals as an option for emergency contraception.

There are three pill options for emergency contraception: 1) combined pills containing

both estrogen and progestin, 2) ulipristal acetate, and levonorgestrel. Using combined pills for

emergency contraception is obsolete, however, it involves taking one dose followed by a second

dose in twelve hours within 120 hours postcoital.282 Ulipristal acetate is a progesterone receptor

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modulator that suppresses follicular growth and delays endometrial maturation.283 The United

States Food and Drug Administration approved Ella for emergency contraception in 2010.284

Another antiprogestin is mifepristone, however, it works as a first trimester abortifacient, and is

not approved for use as an emergency contraception in the United States.285

Today, the most commonly prescribed emergency contraception is the progestin only pill

containing levonorgestrel.286 The original formulation consists of two .75mg pills of

levonorgestrel taken 12 hours apart within 120 hours after unprotected sex.287 Studies, however,

indicate that a single 1.5mg dose is just as effective as two doses of .75mg taken with a 12 hour

internal.288 Consequently, two-dose levonorgestrel emergency contraception pills are no longer

available in the United States.289 The United States Food and Drug Administration approved Plan

B One-Step in 2009.290 Generic forms include Next Choice One Dose, My Way, Take Action

and AfterPill.291

Evidence indicates that levonorgestrel works “primarily by preventing or delaying

ovulation and by preventing fertilization.”292 Lena Marions et al., in “Emergency Contraception

with Mifepristone and Levonorgestrel: Mechanism of Action,” conclude that the increase in

progestin inhibits the luteinizing hormone peak prior to ovulation, thus inhibiting or delaying

ovulation.293 Donald C. Young et al., in “Emergency Contraception Alters Progesterone-

Associated Endometrial Protein in Serum and Uterine Luminal Fluid,” concludes that at high

levels progestin alters protein synthesis in the endometrium, lowering the secretory proteins in

the uterus, thereby affecting sperm mobility.294 After ovulation, progestin appears to have little

effect on the endometrium.295 When administered before the luteinizing hormone peak, progestin

levels affect the maturation of glandular and stromal components of the endometrium.296 Insofar

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as the administration of levonorgestrel after ovulation has little effect on both the ovaries and the

endometrium, it prevents pregnancy less effectively when administered after ovulation.297

Fritz and Speroff, in Clinical Gynecologic Endocrinology and Infertility, assert that

levonorgestrel does not act as an abortifacient.298 At the same time, they admit that

levonorgestrel may prevent implantation.299 Norman D. Goldstuck highlights the ambiguity

regarding the definition of pregnancy and thus the definition of abortifacient versus emergency

contraception.300 He attributes this to the definition of an emergency contraception by the Centre

for Disease Control and the World Health Organization as anything that acts before

implantation.301 Goldstuck argues that since it is difficult to epistemically determine when

pregnancy occurs or which stage it is in during the first trimester, he sees no inconsistency in

using an abortifacient like Mifepristone (RU 486) and calling it an emergency contraception.302

The Church’s understanding of an abortifacient includes anything that deliberately and directly

kills the human being from conception to birth, which clearly includes the time before

implantation.303 Consequently, the United States Bishops in their Ethical and Religious

Directives, prohibit any treatments that directly interfere with implantation.304 Kathleen Mary

Raviele, in “Levonorgestrel in Cases of Rape: How Does It Work?,” holds a distinction between

three distinct actions: 1) contraceptive—preventing conception, 2) interceptive—preventing

implantation, and 3) contragestive—reversing implantation.305 The latter two constitute

abortifacient actions insofar as they interrupt a conceptus’s normal progression.

Consistent with the Church’s understanding of an abortifacient, Marie T. Hilliard, in

“Moral Certitude and Emergency Contraception,” argues that clinicians ought to administer a

test for the luteinizing hormone surge to ensure with moral certitude—as opposed to statistical

probability or absolute proof—that levonorgestrel acts as an anovulant, not an abortifacient.306

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She bases this on the premise that once the luteinizing hormone surge occurs emergency

contraception alone cannot prevent ovulation.307 For this reason, she insists that one ought to

administer levonorgestrel only before the luteinizing hormone surge occurs.308

Although more precise means exist for determining the exact day of ovulation, such as

administering a serum progesterone test, Hilliard contends that these are not practical because

many emergency departments do not have them readily available and it does not provide

sufficient certitude to ensure that fertilization cannot occur.309 She acknowledges one study that

indicates that administering meloxicam, a cyclooxygenase-2 inhibitor with levonorgestrel

prevents ovulation after the luteinizing hormone surge.310 More information is available today

regarding the use of cyclooxygenase-2 inhibitors as an anovulant, including Nicole C. McCann

et al.’s “The COX-2 Inhibitor Meloxicam Prevents Pregnancy When Administered as an

Emergency Contraceptive to Nonhuman Primates.”311 McCann et al., determine that meloxicam

alone is effective at preventing pregnancy when administered to breeding macaques for 5 days

prior to ovulation.312 They conclude that meloxicam delays, but does not prevent ovulation.313

Raviele highlights evidence from Durand et al.’s study on levonorgestrel,314 which

suggests that it does not effectively prevent ovulation when given 4 days before ovulation.315

Consequently, levonorgestrel, as an emergency contraception, does not primarily act as an

anovulant. In another study, Durand et al. determine that levonorgestrel given before the

luteinizing hormone surge, alters the pattern of luteal phase secretion of glycodelin-A, a natural

killer cell inhibitor, thus providing a hostile environment for blastocysts attempting to implant in

the endometrium.316 They conclude that levonorgestrel acts primarily as an abortifacient, or an

interceptor. Both Durand et al. and Palomino et al.317 determine that levonorgestrel given on the

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day of the luteinizing hormone surge does not prevent ovulation or affect progesterone receptors,

plasma levels of glycodelin-A or L-selectin ligand or integrin.318

Regarding sperm, Raviele cites several studies including Yeung et al.319 and Brito et al.320

The acrosome reaction is necessary for the spermatozoa to attach to the zona pellucida of the

egg.321 If the acrosome reaction occurs early, before it reaches the egg, then the sperm loses its

fertilizing capacity.322 At high concentrations, levonorgestrel acts as a weak agonists to

progesterone receptors and at high concentrations (200-800ng/ml) it induces the acrosome

reaction in sperm.323 Yeung et al. determine that levonorgestrel only affects sperm at high

concentrations.324 Brito et al.’s results verify those of Yeung et al.325 In light of this information,

Raviele recommends re-evaluating the use of levonorgestrel as an emergency contraception.326

She advises that clinicians should not give levonorgestrel as an emergency contraception from

days -4 to -2, because of its probable interceptive impact on the conceptus.327

Although against using levonorgestrel as an emergency contraceptive, Raviele contends

that one could administer meloxicam as an emergency contraception.328 Raviele bases her

conclusion on evidence that meloxicam prevents ovulation in women even after the luteinizing

hormone surge.329 As such, the primary concern is ovulation, that one can rule out with a

progesterone test. If the result is less than or equal to 2.0ng/ml, then one can administer

meloxicam with the assurance that it acts as an anovulant.330 A. Patrick Schneider II et al., in

“Appreciation for Analysis of How Levonorgestrel Works and Reservations with the Use of

Meloxicam as Emergency Contraception,” point out the practical challenge of attaining a

progesterone level, which could take as long as four days.331 They contend that because evidence

indicates meloxicam could act as an abortifacient, an absolute protection for the human embryo

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from the moment of conception, precludes its use as an emergency contraception.332 I contend

that Hilliard’s argument invoking moral certitude suffices to supplant this position.333

In 2010, Ron Hamel declares the notion that levonorgestrel acts as an abortifacient a

lie.334 To which Edward J. Furton responses that the debate is not closed; evidence points in both

directions.335 The above discussion demonstrates that the debate continues. While several

methods exist, levonorgestrel remains the standard emergency contraception.336 However, the

above suggests that meloxicam may be a better emergency contraception in the future since it

acts as an effective anovulant, even when given on or after the luteinizing hormone surge.337

With the presumption of moral certitude that the contraceptive acts as a contraceptive and not as

an abortifacient, the following subsection examines the use of the Principle of Double Effect to

justify such an act.

ii. Principle of Double Effect

After addressing the clinical use of emergency contraception, I now consider its use

ethically. Some ethicists use the Principle of Double Effect to justify using contraception to

prevent conception after sexual assault.338 However, the following subsection demonstrates that

an accurate articulation of the Moral Object dissolves any need for recourse to Double Effect.

Ethical objections to contraception necessitate a clear delineation between it and defending

oneself from conception. Since the two acts are physically indistinguishable, it is all the more

important to provide an adequate account of the difference in Moral Objects of the Acts.

a. Object of the Act

In the Summa Theologica, Thomas Aquinas, in his explanation for killing in self-defense,

first devises three criteria that evolve into the Principle of Double Effect.339 Of the three, the

first, which contemporary ethicists reformulate as a prohibition against willing an act with an

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evil Moral Object, is by far the most complex and deserving of attention, to which I devote this

entire subsection.340 The bulk of the argument depends on the precise meaning of the Moral

Object, the importance of which Pope John Paul II re-emphasizes in Veritatis Splendor.341 In

accord with Aquinas, John Paul II reaffirms that “the morality of the human act depends

primarily and fundamentally on the ‘object’ rationally chosen by the deliberate will.”342

Consequently, having an accurate understanding of the Moral Object and its relationship to the

will is essential.

Aquinas observes that acts sometimes have two effects, one intended the other

unintended.343 He describes the unintended effect as praeter intentionem, which literally means

beside the intention of the act.344 In other words, it is outside the realm of intention. To illustrate,

using force, one may intend to protect oneself from an assailant, but at the same time

unintentionally kill the attacker. Even though one may foresee the death of an assailant in one’s

act of self-defense, in accord with Augustine,345 Aquinas insists that one ought never to intend to

kill another person.346 Cavanaugh highlights the centrality of not intending to kill for both

Augustine and Aquinas.347 Both object to intending to kill because it violates an exceptionless

moral norm.348

Finnis in Moral Absolutes: Tradition, Revision, and Truth, explains that Augustine is

against any action that violates an exceptionless moral norm;349 a view which he articulates in

two works concerning lying: De mendacio350 and Contra mendacium.351 In De mendacio,

Augustine says that it is worse to steal than to suffer murder.352 Finnis calls this an early

formulation of the Socratic Principle, which Augustine solidifies in the later Contra mendacium,

contending that it is better to suffer wrong than to do it.353 Democritus of Abdera first formulates

the argument that it is better to suffer evil than to do it.354 However, Plato attributes this dictum

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to Socrates, who not only teaches it, but also lives by it.355 Finnis holds that Paul’s maxim from

Romans 3:8, that one may not do evil that good may come from it, is a reformulation of the

Socratic Principle.356 Thus Augustine contends that no amount of good justifies performing an

evil act.357

Peter Abelard in his Ethics contends that external physical acts do not constitute sin;

rather, sin abides in voluntary consent.358 Consequently, for Abelard, the goodness of an act

depends entirely on intention.359 Accordingly, the physical works that proceed from one’s

intention are indifferent.360 Abelard is not a relativist; he holds that intention is right or wrong

according to its conformity with God’s will.361 Servais Pinckaers in “A Historical Perspective on

Intrinsically Evil Acts,” cautions against accusing Abelard of denying intrinsically evil acts.362

For Pinckaers, Abelard is responding to the legalism of his time and placing the essence of sin

back in reason and the will, rather than external action or desires.363 Unfortunately, in accord

with his famous dictum sic et non, Abelard rejects too completely his adversaries, throwing out

desire and consequences altogether.364

Peter Lombard, in his Sentences responds to Abelard in an attempt to safeguard

Augustine’s prohibition against certain intrinsically evil acts.365 In most cases, Lombard agrees

with Abelard that intention is the cause of evil in an action.366 However, he makes an exception

regarding the per se mala, that is, acts which are evil in themselves including: stealing from the

poor; falsifying a will; or adultery to save another’s life.367 These acts, which are evil in

themselves, cannot be done without some transgression; regardless of the disposition of the

intention.368

In his Scriptum super sententiis, Aquinas disagrees with Lombard’s conclusion that per

se mala are not wrong according to the will, intention, or purpose (finis).369 To the contrary, he

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says an external act is good or bad according to the will, but not only because of the intention of

the will (intentio), but also because of the choice of the will (electio).370 The distinction between

intending and choosing is of supreme importance for Aquinas, but it is not always clear. Recall,

Finnis indicates that Aquinas speaks of intention broadly and narrowly.371 Broadly speaking,

intending simply means willing that includes intending and choosing.372 Finnis argues that this is

how Aquinas uses intention in his discussion regarding Double-Effect Reasoning.373 Narrowly

speaking, however, Aquinas contrasts intending with choosing.374 In the narrow sense,

intentions concern ends, while choices concern means—which are actions—ordered to ends.375

To distinguish the object of intending from the object of choosing, Aquinas uses the

proximate end (finis proximus), which he associates with the choice of the will (electio) and the

ultimate end (finis ultimus), which he associates with the intention (intentio).376 Concerning

actions, there may be more than one end, hence the distinction between proximate and ultimate

end.377 However many ends exist, the ultimate end co-ordinates the proximate end.378 The

goodness of an external act depends on both the goodness of the proximate end or that which the

will chooses and the goodness of the ultimate end, the purpose that one chooses an act.379

In the same commentary, Aquinas identifies the proximate end with the Moral Object of

the Act.380 Terminologically, he equates the ultimate end with the remote end.381 In addition, he

insists that the object gives the species to acts. 382 Again, in On Evil, Aquinas holds that acts

receive their species from the object, not the remote end.383 The more precise meaning of object

becomes increasingly difficult to pin down not only in the later writings of Aquinas, but

especially in the commentators that follow, as Duarte Sousa-Lara demonstrates in “Aquinas on

the Object of the Human Act: A Reading in Light of the Texts and Commentators.”384 In

particular, a distinction that Aquinas makes between the material and formal element of the

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object leads some commentators, such as John of Saint Thomas to conclude that the Moral

Object is a physical object.385 Sousa-Lara demonstrates that for Aquinas, the Moral Object of a

human act is not a physical effect or thing, but a single object of choice with a quasi-material and

formal element.386

In this case, Aquinas uses the Aristotelian description of matter and form as an analogy

for the relationship between the object of intention (finis ultimus or finis operantis) and the

object of the act, that is the object of choice (finis proximus or finis operis). Sousa-Lara, in

“Aquinas on Interior and Exterior Acts: Clarifying a Key Aspect of His Action Theory,” explains

that Aquinas differentiates the object of intention from the object of choice by the distinction

between interior act of the will and external act of the will, respectively.387 Thus, Aquinas

considers the moral species of the act formally with regard to the object of the interior act.388 For

example, one who steals for the purpose of committing adultery is more an adulterer than a

thief.389 Thus, according to the analogy of form and matter, just as form gives shape to matter, so

the ultimate end qualifies the Moral Object.

In using this analogy, Aquinas is not saying that the proximate end is material. Nor is he

saying that the Moral Object receives its entire intentional content from the ultimate end. Indeed,

Aquinas is very clear that exterior acts, insofar as they are voluntary not only abide in the moral

order, but also have their own intentional content. Martin Rhonheimer, in Natural Law and

Practical Reason: A Thomistic View of Moral Autonomy, shows that for Aquinas this intentional

content is rational insofar as he attributes this to reason.390 The moral quality of the Moral Object

depends on its conformity to its proper matter (materia debitae) or proper circumstances

(materia circumstantiae), which reason derives.391 In The Perspective of Morality: Philosophical

Foundations of Thomistic Virtue Ethics, Rhonheimer explains at great length the intelligible

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nature of the Moral Object, which he calls basic intentional content.392 As a quick aside, the

proximate end does not always have to have an intelligible or intentional content associated with

it, in which case the proximate end is purely instrumental and receives all of it from the ultimate

end only.393 It is essential to understand that for Aquinas, a practical concept is different than a

speculative or theoretical concept.

To highlight the distinct quality of a moral act, Finnis in draws attention to an important

distinction that Aquinas makes concerning orders in the prologue to his Commentary on

Aristotle’s Politics.394 Aquinas argues that there are four irreducibly distinct orders: natural,

logical, moral, and technical.395 These orders correspond to exclusive sciences or methods of

knowing: 1) physics and metaphysics; 2) logic and mathematics; 3) moral philosophy; and 4)

artistic and technical.396 Finnis asserts that the irreducibility of these orders means that principles

apply uniquely, even if analogically to the respective orders.397 Moreover, each order has a

distinct object or end.398

Knowledge pertaining to the natural order is speculative, while knowledge pertaining to

action, either moral or technical, is practical.399 David Hume famously formulates the argument

that ought-statements are not derivative of is-statements.400 This is a way of saying that practical

knowledge is different from speculative knowledge. This, however, does not mean that ought-

statements are irrational.401 Moreover, it is not a different faculty that formulates practical

reason, but the same intellect that formulates speculative arguments devises practical arguments,

but the intellect acts in a distinct manner, by extension.402 Since moral acts are in a different

order, reason formulates them according to practical syllogisms, rather than theoretical

syllogisms.403 Practical syllogisms may contain theoretical premises, but the conclusion is a

statement, or better an act of striving or doing.404

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The failure to maintain the distinction between practical knowledge and speculative

knowledge results in the Naturalistic Fallacy,405 which asserts that the Natural Law is derivative

of laws of nature.406 Rhonheimer identifies the Naturalistic Fallacy as a physicalism.407 He

attributes this to the manualist tradition of moral theology, which is casuistic, that is, taught using

cases.408 Hermeneutically, this approach presumes a third-person perspective regarding morality.

In other words, it presumes that an observer can identify the Moral Object of the Act simply by

viewing the person’s external action. Prima facie, this seems to jive with Aquinas’s action

theory; after all, he does identify the external act with the Moral Object.409 However, if one can

observe the Moral Object from the third-person perspective, then it is no longer in the moral

order, but the natural order.

In “‘Materia ex qua’ and ‘Materia circa quam’ in Aquinas,” Sousa-Lara observes that

Aquinas connects the Moral Object with materia circa quam, not materia ex qua.410 In addition,

in De Veritate, Aquinas identifies the Moral Object with the materia circa quam.411 Sousa-Lara

equates the materia ex qua as the physical dimension of an act.412 For example, in the natural

order, the act of marital love is indistinguishable from adultery or fornication. For Sousa-Lara,

the materia ex qua is the physical act of coitus.413 The materia circa quam, that is, the Moral

Object, according to the moral order, determines the species of the act.414 The coital act,

considered materia ex qua has restricted potency for receiving form from the materia circa

quam. In fact, he observes that the act has potential to be of three different forms specifically:

conjugal love, fornication, or adultery.415 Thus, from the third-person perspective, although one

cannot necessarily know the Moral Object or remote end, it nonetheless limits the options. After

all, a person buying flowers is not driving a car.

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Just as Aquinas uses the hylomorphic phenomenon of form and matter to illustrate the

relationship between the ultimate end and the proximate end,416 so he uses such an analogy to

illustrate the formal role of the materia circa quam with regard to the material role of the materia

ex qua.417 Sousa-Lara associates both the materia circa quam and the materia ex qua with the

external act; however, each signifies something different regarding the external act.418 Recall,

that for Aquinas, the external act is part of the moral order only insofar as it is voluntary, that is,

the will configures it.419 Since Sousa-Lara associates the materia circa quam with the Moral

Object, this constitutes what the will chooses.420 The materia ex qua, on the other hand,

regarding the external act, constitutes the physical content of the act, which the will

commands.421 Thus, the materia circa quam, that is, Moral Object in the moral order, morally

configures the materia ex qua, that is, the object of the commanded act in the natural order.

This subsection demonstrates how an accurate account of Aquinas’s Moral Object of an

Act keeps it in the moral order, rationally formulated and proceeding from the will. The Moral

Object is clearly distinct from the ultimate end (object of intention) insofar as he understands it

as the proximate end (Moral Object of a choice). Moreover, regarding the external act he uses

materia circa quam to identify and distinguish the Moral Object in the moral order, from the

external act in the physical order that the will commands—the materia ex qua.

b. Nominalism, Manualism, and Proportionalism

After Aquinas, a divide arises between the Dominican emphasis of the experience of

beatitude through the intellect and the Franciscan emphasis of beatitude through the will in

love.422 In the wake of this divide William of Ockham introduces nominalism, which rejects

universals.423 This subsubsection demonstrates the influence that nominalism has on the

methodology of moral theology, especially regarding manualism and proportionalism.

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For Ockham, the only thing that exists is the reality of individual beings. Forms or

natures exist in name only. In the Platonic sense universals are forms. In the Aristotelian sense,

the form inheres in beings. In turn, the universal constitutes the nature of individual beings.

Regarding action, natures influence inclinations.424 In humans, the object of practical reason is

the good that they naturally incline to.425 Because human nature is universal—shared by all

individuals of the same species—it is possible to formulate Natural Laws that articulate good for

human behavior.

Insofar as God creates and providentially governs humanity according to the eternal law,

the natural law constitutes a human participation in the eternal law.426 Finnis, in Natural Law and

Natural Rights explains that for Aquinas participation conjoins two concepts: causality and

similarity.427 God causes humans to share in the light of reason, in a manner that is similar to the

divine.428 In this regard there is a difference between the intelligible nature of other animals and

the intelligent nature of humans.429 Animals participate in the divine law passively insofar as

they follow their inclinations,430 whereas humans take an active role in the divine providence

insofar as they use reason to formulate ends and their will to achieve them.431 Since law itself

constitutes a measure according to reason for action, only rational beings truly participate in

law.432 The illuminating power of reason enables one to grasp the good in actions, including

desires and inclinations.433 Moreover, the voluntary nature of human action entails freedom and

the possibility for self-mastery.434 Thus, Rhonheimer describes this participatory role of the

humans in the eternal law as participated autonomy.435 Accordingly, Pinckaers indicates that for

Aquinas, freedom proceeds from both reason and the will.436 Consequently, nature, which

includes the restrictions of inclinations, desires, bodily nature itself, and reason limit freedom.

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Contrary to Aquinas’s limited autonomy, Ockham argues for a freedom of

indifference.437 Again, influenced by the Franciscan emphasis on the will, Ockham understands

freedom to proceed entirely from the will.438 Since there are no universals, for Ockham, each

individual stands in absolute freedom from the influence of natures.439 Since each choice stands

in complete freedom, there is no longer any need to stress growth in virtue.440 Just as human

freedom is absolute, so God’s freedom is omnipotent.441 In fact, for Ockham, the veracity of all

laws depends on nothing other than its divine command.442 No rational foundation grounds them.

The absolute freedom of God means that God could change them at any moment. Consequently,

under the influence of Ockham, the emphasis of moral theology becomes law and obligation.443

Moreover, Natural Law is no longer based on human nature and its inclinations, but entirely on

divine command.444 In this sense, it is entirely extrinsic to the human person.

Ockham’s nominalism continues to influence moral theology right up to the present day.

In the manualist tradition of the seventeenth through the early twentieth century, the

hermeneutical method is casuistic, that is, case-based.445 The conscience has a central role in

discerning proper courses of action that stand in the void between freedom of indifference and

moral obligation that God externally imposes.446 The manualists not only blur the line between

the internal and external act, but seem to eliminate any real consideration for the internal at all in

favor of a morality that is entirely discernable from the third-person perspective.447 Thomas Petri

in Aquinas and the Theology of the Body: The Thomistic Foundation of John Paul II’s

Anthropology, quotes John McHugh and Charles Callan’s manual highlighting the extrinsic

nature of morality.448 McHugh and Callan hold that morality is “the agreement or disagreement

of a human act with the norms that regulate human conduct with reference to man’s last end.” 449

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The casuistic approach of the manuals to morality is underequipped to deal with the

complex dilemma of contraception. For example, John T. Noonan, Jr., in Contraception: A

History of Its Treatment by the Catholic Theologians and Canonists, observes that the most

popular manual, Jean-Pierre Gury’s Compendium of Moral Theology, addresses contraception

purely from the physical dimension, objecting to it merely on the basis that it violates the

prohibition of onanism—extra-vaginal ejaculation.450

Peter Knauer attempts to breathe new life into moral theology with his article, “The

Hermeneutic Function of the Principle of Double Effect.”451 Like Abelard and Aquinas, Knauer

refocuses moral theology on intention and the will. Unfortunately, he identifies moral evil with

intending or causing physical evil, without a commensurate reason.452 Josef Fuchs calls this

physical evil pre-moral evil453 and Louis Janssens calls it ontic evil.454 In part, because moral

acting involves causing physical evil, Knauer uses the criteria of proportionality in the Principle

of Double Effect to argue for what Richard McCormick calls an “extended notion of the

object.”455 Knauer, understands both the finis operis and the finis operantis as ends, however, he

understands the first to have a causal relationship to the second.456 In other words, the Moral

Object of the Act (finis operis) causes the remote end (finis operantis). Moreover, the Moral

object is good if there is commensurate reason to justify it, that is, if the remote end is good

enough.457 For Knauer, such a statement is not the same as saying the ends justify an evil means,

because presumably one has not yet determined that the means is good or evil yet, since one

cannot know this without a consideration of the end.458

Rhonheimer in “Intentional Actions and the Meaning of Object: A Reply to Richard

McCormick,” objects to the proportionalist methodology, because it weighs the consequences of

actions, not actions themselves.459 Put another way, proportionalism reduces moral decision-

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making to discerning whether or not to cause certain effects. This makes morality eventistic,

since an action’s value rests on its effect and has no use for the perspective of the acting

person.460 The object of intention swallows the Moral Object, totally neglecting its inherent

intentional character, which Rhonheimer calls the basic intentional content.461 Rhonheimer

explains that the Moral Object has an intention, formed by reason, which he and Aquinas

describe as the object of choice.462 For Rhonheimer, the basic intentional content of the Moral

Object is precisely what keeps it in the realm of the moral order.463

In accord with a proportionalistic understanding of the Moral Object, Knauer contends

that a couple might discern that using contraception is a viable option for them, so long as they

have a commensurate reason, such as economic or health reasons.464 Since the Moral Object has

no rational or intentional value itself, choosing to contracept is indistinguishable for Knauer from

choosing to periodically abstain.465 Accordingly, the expanded notion of the object, essentially

amounts to saying that the intentional content of the object comes from the remote end (object of

intention).466 Unfortunately, as Rhonheimer indicates, this relegates moral decision-making to

the purely physical realm, rendering it eventistic.467 So, moral decision-making has little to

nothing to do with a deliberate will choosing a certain kind of behavior,468 that is, a human action

with a basic intentional content,469 what Aquinas calls the forma a ratione a concepta.470

c. The Object: Contraception and Self-Defense

In accord with Aquinas’s action theory, John Paul II’s understanding of the Moral Object,

and Paul VI’s argument against contraception,471 Rhonheimer carefully identifies the Moral

Object of contraception.472 This subsubsection follows Rhonheimer’s articulation of the Moral

Object of contraception and how he distinguishes it from one of self-defense, which using

emergency contraception to prevent conception after sexual assault constitutes.

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First, Rhonheimer explains Paul VI’s argument in Humanae Vitae that the contraceptive

choice violates the natural law.473 According to the Natural Law, the two fundamental meanings

of human sexuality, the unitive and the procreative, are inseparable.474 This is the Inseparability

Principle, which Paul VI refers to in Humanae Vitae.475 In other words, humans, on their own

initiative may not break this connection, which contraception does.476 The Inseparability

Principle builds on an adequate anthropology,477 one that accounts for the bodily and spiritual

dimensions of the human person.478 Consequently, for Rhonheimer, the human body is not

merely the object of human action, but part of the subject.479 Therefore, the bodily reality of

procreation receives its full human specification from spiritual love. Moreover, the spiritual love

specifies the procreative dimension of the body.480

Precisely because this concerns a choice, which abides on the moral order, each choice

for the marital act must be open to the procreative significance, not its procreative functionality,

that is, physically intending to conceive.481 Consequently, sterile couples may engage in the

marital act and still be open to the procreative dimension of the marital act.482 Likewise, fertile

couples, in accord with the call to responsible parenthood, may choose to practice periodic

continence, abstaining from the conjugal act, except during the infertile times, without violating

the Inseparability Principle.483 Thus, Rhonheimer identifies the Moral Object of the marital act as

loving bodily union, which serves procreation by its very nature.484

To identify the Moral Object of contraception, Rhonheimer does not have recourse to the

Inseparability Principle, but the virtue of chastity.485 He argues that periodic continence is a

constitutive means for growth in chastity for married couples insofar as it helps them to grow in

self-mastery.486 This is what Pius XI says in Casti Cannubii487 and Paul VI says in Humanae

Vitae.488 By implication, not only a couple’s engagement in the marital act constitutes a conjugal

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act, but their intentional abstinence also forms a conjugal act, that is an act of mutual love.489 The

contraceptive choice, on the other hand, renders needless the specific sexual behavior—periodic

continence—that responsible parenthood entails.490 Moreover, it is a choice against virtuous self-

control by abstaining from the sexual act.491

Precisely because Rhonheimer places the contraceptive choice in the moral order, he is

able to morally qualify its use as an emergency contraceptive in an act of self-defense, in cases of

sexual assault.492 Rhonheimer recalls the response of three theologians regarding whether or not

a woman could have recourse to contraception in the face of rape, including for example

Congolese nuns in the war-torn Congo.493 Rhonheimer finds their arguments tending toward

physicalism insofar as they focus the debate on the physical effect of contraception, namely,

temporary sterilization.494 According to Rhonheimer, Francesco Hürth considers the physical act

one of sterilization in the absolute sense, but on the moral level, that is, in the relative sense, it is

not an act of contraception, but self-defense, since the woman does not both freely and

deliberately desire or will sexual intercourse and to deprive the act of its reproductive

potential.495 Palazzini and Lambruschini use Double Effect and Totality to justify the woman’s

recourse to contraception.496 Rhonheimer objects to this, because of its casuistic formulation.497

Just like Knauer, they are formulating the argument in such a way that one needs sufficient

reason to choose an immoral act—contraception.498

Rhonheimer, however, insists that since the act in question is not merely on the natural

order, it is not a question of finding sufficient reason to choose an act that is per se immoral, but

a matter of accurately formulating the Moral Object as one of self-defense on the moral order.499

Again, the proportionalists’ expanded notion of the object amounts to rendering the intentionality

of the object indistinguishable from the ulterior intentions.500 Consequently, the formulation of

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the object by proportionalists is just as casuistic as that of the manualists. In particular, the

eventistic and physicalistic formulation of the object demonstrates this.501 Insofar as force

removes the sexual act, on the woman’s part, from the realm of freedom, the choice to use

contraception constitutes an act of self-defense from the unwanted effect of conceiving.502

d. Genus Moris

I now discuss the derivation of the other criteria of Double Effect. Just as Ockham’s

nominalism and the casuistic methodology of the manualists and the proportionalists obscures

the Thomistic meaning of the Moral Object, so it obfuscates Double Effect. This subsubsection

demonstrates this. Moreover, it contrasts the consequentialist and Thomistic formulation in its

application to emergency contraception for sexual assault victims.

In the Secunda Secundae of the Summa Theologica Aquinas uses Double-Effect

Reasoning to explain how one may use self-defense to unintentionally kill an assailant.503 An

action may have two effects one intended and the other unintended (praeter intentionem).504

Praeter intentionem means accidental.505 Sousa-Lara explains that Aquinas is asserting that the

evil effect must not constitute the Moral Object.506 This jives with Aquinas’s agreement with

Augustine that one must not intend to kill the assailant.507 Moreover, this agrees with Finnis’s

assertion that Aquinas is using the broad sense of intention here, which includes both intending

as choosing the Moral Object (proximate end) and intending the ultimate end.508

Ethicists often use the example of performing a hysterectomy on a pregnant woman with

a cancerous uterus.509 Insofar as cancer constitutes a grave threat to the mother’s life, the

situation necessitates a hysterectomy. Ethically, this procedure entails a choice to save the

mother’s life, by removing a grave threat. Unfortunately, the surgery foreseeably results in the

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death of the child. Using this example, I illustrate the difference between the consequentialist and

the non-consequentialist formulation of Double Effect.

Cavanaugh contends that Gury’s version of Double Effect,510 which Joseph T. Mangan

reproduces in his “An Historical Analysis of the Principle of Double Effect,”511 represents a

contemporary formulation.512 Under the influence of nominalism and the casuistic hermeneutic,

Gury adopts a cause-effect articulation of Double Effect.513 For Gury, the criterion pertaining to

the Moral Object identifies it as a cause. 514 Thus, he indicates that the cause itself must be good

or indifferent.515 In non-consequentialist terms, the Moral Object must be good.516 Put another

way, the Moral Object must not be an intrinsically evil act.

In the case of a pregnant woman with a cancerous uterus, the procedure in question is the

hysterectomy. Using cause-effect terminology, it is difficult to distinguish the physical act of the

hysterectomy from the Moral Object that one chooses in performing a hysterectomy. For this

reason, Rhonheimer claims that by using causal language consequentialists reduce actions to

events.517 Understanding the Moral Object as a cause removes the personal perspective.518

Consequentially, one is simply performing a physical procedure: a hysterectomy. In purely

physical terms, one is removing a cancerous, gravid uterus.

A non-consequentialist formulation of the Moral Object takes into account the

perspective of the acting person.519 In other words, it describes in terms of striving or willing

what the acting person chooses.520 At the same time, it avoids the pitfalls of so narrowly defining

the Moral Object that it does not account for its physical consequences.521 For example,

Cavanaugh accuses John Finnis, Germain Grisez and Joseph Boyle in “‘Direct’ and ‘Indirect’: A

Reply to Critics of our Action Theory,”522 of so narrowly defining the object of a craniotomy that

it conceptually excludes the death of a child.523 Cavanaugh contends, however, that it is

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impossible to define a craniotomy without the death of a child.524 Therefore, taking into account

the consequences of the act, which include the unintended, yet foreseen death of a child, one may

say that the physician and patient choose to remove the grave threat of a cancerous, gravid uterus

using a hysterectomy, foreseeing, but not intending the death of a child. This non-consequential

formulation accounts for what the acting person chooses with due regard for the foreseen, but

unintended consequences.

The next two criteria derive from the same statement. Since Aquinas uses intention in the

broad sense, one may conclude that he not only prohibits intending the evil effect as a means, but

also as a remote end. Casuistically, one must only intend the good effect, not the bad.525 Non-

consequentially, this means that the evil effect must not be the ultimate end of one’s intention.526

Moreover, insofar as praeter intentionem means accidental, it does not mean unforeseen as in a

mishap.527 To the contrary, Aquinas presumes that one foresees the unintended evil. For this

reason, Cavanaugh stresses the intended/foreseen distinction.528 Concerning the abovementioned

example, one must not intend the death of the child. Rather, foreseeing the death of the child, one

intends the restoration of health to the mother.

The third criterion, casuistically, insists that the evil effect must not cause the good

effect.529 This articulation highlights the non-personalistic formulation of action, which

Rhonheimer criticizes as being physicalistic and eventistic.530 According to such a construction,

effects cause effects. Since Aquinas only understands morality in terms of persons in action, he

has no analogous criterion. However, Thomistic ethicists often describe this criterion as one must

not choose an evil means to attain a good end.531 This, however, is indistinguishable from the

first criterion that insists one’s Moral Object must not be evil.

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Consequentially, ethicists often maintain that a hysterectomy is distinct from a direct

abortion, because one performs the physical procedure on the uterus, rather than the child.532 The

above discussion concerning the definition of contraception demonstrates that a physicalistic

definition of the Moral Object does not suffice. Rhonheimer, for example, observes that although

the physical act of a female athlete taking an anovulant to prevent menstruation to compete in a

sporting event is the same as a woman taking an anovulant to prevent conception, the Moral

Objects differ.533 The former is indifferent, while the latter is immoral, because it constitutes an

alternative to an act of continence, which is constitutive of responsible parenthood and an

inherent means to growth in chastity.534

Finally, Aquinas insists that one’s means must be proportionate to one’s end.535 Once

again, the consequentialists use cause-effect language to articulate this criterion. Therefore, in

consequential terms, the final criterion insists that one must have a proportionately serious reason

to cause an evil effect.536 Insofar as removing the cancerous uterus saves the mother’s life, this is

proportionate to the negative effect, the death of the child.

For Aquinas, disproportionate means imply a change in the Moral Object.537 For

example, if one uses deadly force to repel an attacker who clearly does not use deadly force, it is

difficult to say that one is really defending oneself, rather than intending to kill another person. A

corollary to the fourth criteria is that one must have no alternative.538 Presumably, the only

medically indicated procedure is a hysterectomy for a woman with a gravid, cancerous uterus.

Thus, a casuistic argument in favor of using a contraceptive is as follows. First, the act in

question must be either good or indifferent. Rhonheimer indicates that unless one maintains the

moral character of the Moral Object, it is impossible, to distinguish it from a contraceptive

choice, physically defined.539 Thus, Palazzini and Lambruschini cannot get past the physicalistic

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notion that the choice is inexorably one to sterilization.540 As such, it is difficult to avoid the

proportionalistic trap of finding commensurate reason to justify one’s means.541 In this sense, the

whole argument stands or falls on the re-defined proportionate criteria. Regarding the second and

third criteria, it is hard to see how the evil effect does not cause the good effect—no conception,

or that the one does not intend the evil effect—physically defined as sterilization.

Rhonheimer’s definition of the Moral Object as self-defense resolves the tension in the

argument and renders it unnecessary to use Double Effect. By defining the Moral Object as self-

defense, one avoids the need to justify evil. One is simply using the means available to prevent

conception from taking place without a loving bodily union. Only when one does not clearly

differentiate the Moral Object from a physical event, does it become difficult to justify or find a

commensurate reason to use a contraceptive method to prevent conception.

This section shows that a non-consequentialist description of the Moral Object—one that

clearly distinguishes the object of choice from intention and keeps it in the moral order—of self-

defense from sexual assault excludes any necessity of recourse to Double Effect.

This chapter uses a non-consequentialist definition of the Moral Object and the Principle

of Double Effect to justify risk reducing bilateral salpingo-oophorectomies in BRCA mutation

carriers and the use of emergency contraception to prevent conception in victims of sexual

assault. The following chapter considers ethical justifications for sex reassignment surgery in

patients with gender dysphoria and using contraception for non-contraceptive benefits.

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275 Martti Ämmala et al., “Effects of Intrauterine Contraceptive Devices on Cytokine Messenger

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295 Lena Marions et al., “Emergency Contraception with Mifepristone and Levonorgestrel:

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319 William S. B. Yeung et al., “The Effects of Levonorgestrel on Various Sperm Functions,”

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Regimen,” The Lancet 353, no. 9154 (1999): 721. 324 Yeung et al., “The Effects of Levonorgestrel on Various Sperm Functions,” 455. 325 Brito et al., The In Vitro Effect of Emergency Contraception Doses of Levonorgestrel on the

Acrosome Reaction of Human Spermatozoa,” 228. 326 Raviele, “Levonorgestrel in Cases of Rape: How Does It Work?” 124. 327 Raviele, “Levonorgestrel in Cases of Rape: How Does It Work?” 124. 328 Raviele, “Levonorgestrel in Cases of Rape: How Does It Work?” 127-8. 329 Raviele, “Levonorgestrel in Cases of Rape: How Does It Work?” 127; Christián Jesam et al.,

“Suppression of Follicular Rupture with Meloxicam, a Cyclooxygenase-2 Inhibitor: Potential for

Emergency Contraception,” Human Reproduction 25, no. 2 (2010): 368-73. 330 Raviele, “Levonorgestrel in Cases of Rape: How Does It Work?” 127-8. 331 A. Patrick Schneider II et al., “Appreciation for Analysis of How Levonorgestrel Works and

Reservations with the Use of Meloxicam as Emergency Contraception,” The Linacre Quarterly

83, no. 1 (2016): 59. 332 Schneider II et al., “Appreciation for Analysis of How Levonorgestrel Works and

Reservations with the Use of Meloxicam as Emergency Contraception,” 61. 333 Hilliard, “Moral Certitude and Emergency Contraception,” 154. 334 Ron Hamel, “Thinking Ethically about Emergency Contraception: Critical Judgments Require


(2010): 39-41. 336 James Trussell et al., “Emergency Contraception: A Last Chance to Prevent Unintended

Pregnancy,” 2. 337 Jesam et al., “Suppression of Follicular Rupture with Meloxicam, a Cyclooxygenase-2

Inhibitor: Potential for Emergency Contraception,” 372. 338 Pietro Palazzini, “Si può e si deve proteggere l’equilibrio della persona,” Studi Cattolici 27

(1961): 62-4; Ferdinando Lambruschini, “È legittimo evitare le conseguenze dell’aggressione,”

Studi Cattolici 27 (1961): 68-72. 339 Thomas Aquinas, Summa Theologica, trans. Fathers of the English Dominican Province

(Chicago: Benzinger Brothers, 1947), http://dhspriory.org/thomas/summa/index.html, II-II, q. 64,

a. 7. 340 Edward J. Furton and Albert S. Moraczewski, “Double Effect,” in Catholic Health Care

Ethics: A Manual for Practitioners, 2nd ed., ed. Edward J. Furton et al., (Philadelphia: National

Catholic Bioethic Center, 2009), 24. 341 John Paul II, Veritatis Splendor, (August 6, 1993), http://w2.vatican.va/content/john-paul-

ii/en/encyclicals/documents/hf_jp-ii_enc_06081993_veritatis-splendor.html. 342 John Paul II, Veritatis Splendor, 78; Aquinas, Summa Theologica, I-II, q. 18, a. 6.




300

343 Aquinas, Summa Theologica, II-II, q. 64, a. 7. 344 Aquinas, Summa Theologica, II-II, q. 64, a. 7. 345 Augustine, “On Free Choice of the Will,” in On the Free Choice of the Will, On Grace, and

Free Choice, and Other Writings, ed. & trans. Peter King (Cambridge: Cambridge University

Press, 2010), 11. 346 Aquinas, Summa Theologica, II-II, q. 64, a. 7, reply 1. 347 Cavanaugh, Double-Effect Reasoning, 3. 348 Cavanaugh, Double-Effect Reasoning, xxii. 349 John Finnis, Moral Absolutes: Tradition, Revision, and Truth (Washington D.C.: Catholic

University of America, 1991), 62-5. 350 Augustine, “De mendacio (On Lying),” in Nicene and Post-Nicene Fathers, vol. 3, ed. Philip

Schaff and trans. H. Browne (Buffalo, NY: Christian Literature Publishing Co., 1887).

http://www.newadvent.org/fathers/1312.htm. 351 Augustine, “Contra mendacium (Against Lying),” in Nicene and Post-Nicene Fathers, vol. 3,

ed. Philip Schaff & trans. H. Browne. (Buffalo, NY: Christian Literature Publishing Co., 1887).

http://www.newadvent.org/fathers/1313.htm. 352 Augustine, De mendacio, 14. 353 Finnis, Moral Absolutes, 64; Augustine, Contra mendacium, 22. 354 John Finnis, Fundamentals of Ethics (Washington D.C.: Georgetown University Press, 1983),

109. 355 Finnis, Fundamentals of Ethics, 8, 109. 356 Finnis, Fundamentals of Ethics, 109 357 Augustine, De mendacio, 1. 358 Peter Abelard, Ethics, Ed. & trans. D. E. Luscombe (Oxford: Clarendon Press, 1971), 23-5. 359 Abelard, Ethics, 53. 360 Abelard, Ethics, 45-7. 361 Abelard, Ethics, 55. 362 Servais Pinckaers, “A Historical Perspective on Intrinsically Evil Acts,” in The Pinckaers

Reader: Renewing Thomistic Moral Theology, Ed. John Berkman & Craig Steven Titus

(Washington D.C.: Catholic University of America, 2005), 195. 363 Pinckaers, “A Historical Perspective on Intrinsically Evil Acts,” 195. 364 Pinckaers, “A Historical Perspective on Intrinsically Evil Acts,” 196. 365 Peter Lombard, The Sentences: Book 2: On Creation, trans. Giulio Silano (Toronto: Pontifical

Institute of Medieval Studies, 2008), 198-202. 366 Lombard, The Sentences: Book 2: On Creation, 201-2. 367 Lombard, The Sentences: Book 2: On Creation, 202; Pinckaers, “A Historical Perspective on

Intrinsically Evil Acts,” 199. 368 Lombard, The Sentences: Book 2: On Creation, 202. 369 Thomas Aquinas, Scriptum super libros Sententiarum magistri Petri Lombardi episcopi

Parisiensis, Vol. 2, ed. P. Mandonnet (Parisiis: Sumptibus P. Lethielleux, 1929),

http://www.corpusthomisticum.org/snp2035.html, lib. II, d. 40, q. 1, a. 2; Finnis, Moral

Absolutes, 66. 370 Aquinas, Scriptum super sent., II, d. 40, q. 1, a. 2, ad. 2, “Ad secundum dicendum, quod

secundum voluntatem dicitur actus exterior bonus vel malus; sed non secundum voluntatem

intendentem solum, sed secundum voluntatem eligentem.”


301

371 John Finnis, Aquinas: Moral, Political, and Legal Theory, (Oxford: Oxford University Press,

1998), 64. 372 Finnis, Aquinas, 64; Aquinas, On Evil, q. 2, a. 2, ad. 8. 373 Finnis, Aquinas, 64 footnote 17, Aquinas, II-II, Q. 64, a. 7, answer. 374 Finnis, Aquinas, 64; Aquinas, Summa Theologica, I-II, q. 8, a. 2, answer. 375 Finnis, Aquinas, 64; Aquinas, Summa Theologica, I-II, q. 13, a. 4, answer. 376 Aquinas, Scriptum super sent., II, d. 40, q. 1, a. 2, co. 377 Finnis, Aquinas, 32-4. 378 Finnis, Aquinas, 35. 379 Aquinas, Scriptum super sent., II, d. 40, q. 1, a. 2, co. 380 Aquinas, Scriptum super sent., II, d. 36, q. 1, a. 5, arg. 5. 381 Aquinas, Scriptum super sent., II, d. 36, q. 1, a. 5, arg. 5. 382 Aquinas, Scriptum super sent., I, d. 48, q. 1, a. 2, co. “species autem cujuslibet actus

voluntarii trahitur ex objecto.” 383 Aquinas, On Evil, trans. Richard Regan and ed. Brian Davies, (Oxford: Oxford, 2003), q. 2, a.

4, ad. 9, pp. 108. 384 Duarte Sousa-Lara, “Aquinas on the Object of the Human Act: A Reading in Light of the

Texts and Commentators,” Josephinum Journal of Theology 15, no. 2 (2008): 243-76. 385 Sousa-Lara, “Aquinas on the Object of the Human Act,” 253. 386 Sousa-Lara, “Aquinas on the Object of the Human Act,” 257; Aquinas, Scriptum super sent.,

I, d. 48, q. 1, a. 2, c. 387 Duarte Sousa-Lara, “Aquinas on Interior and Exterior Acts: Clarifying Key Aspects of His

Action Theory,” Josephinum Journal of Theology 15, no. 2 (2008): 283; Aquinas, On Evil, q. 7,

a. 3, answer. 388 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 283; Aquinas, On Evil, q. 7, a. 3,

answer. 389 Sousa-Lara, “Aquinas on Interior and Exterior Acts,” 283; Aquinas, On Evil, q. 7, a. 3,

answer. 390 Martin Rhonheimer, Natural Law and Practical Reason: A Thomistic View of Moral

Autonomy, trans. Gerald Malsbary, (New York City: Fordham, 2000), 91-3, 160; Aquinas,

Summa Theologica, I-II, q. 20, a. 1. 391 Aquinas, Summa Theologica, I-II, q. 20, a. 1. 392 Martin Rhonheimer, The Perspective of Morality: Philosophical Foundations of Thomistic

Virtue Ethics, trans. Gerald Malsbary (Washington D.C.: Catholic University of America, 2011). 393 Sousa-Lara, “Aquinas on Interior and Exterior Acts: Clarifying a Key Aspect of His Action

Theory,” 307. 394 Finnis, Aquinas, 21; Thomas Aquinas, Commentary on Aristotle’s Politics, trans. Richard J.

Regan, (Indianapolis: Hackett Publishing Company, 2007), 1-3. 395 Finnis, Aquinas, 21; Aquinas, Commentary on Aristotle’s Politics, 1-3. 396 Aquinas, Commentary on Aristotle’s Politics, 1-3. 397 Finnis, Aquinas, 31. 398 Finnis, Aquinas, 31. 399 Finnis, Aquinas, 38. 400 David Hume, A Treatise on Human Nature, ed. D. F. Norton and M. J. Norton (Oxford:

Oxford University Press, 2007), III, 1, sect. 1, 302. 401 Rhonheimer, The Perspective of Morality, 123.

302

402 Aquinas, Summa Theologica, I, q. 79, a. 11. 403 Rhonheimer, The Perspective of Morality, 115-23. 404 Rhonheimer, The Perspective of Morality, 116. 405 G. E. Moore, Principia Ethica, rev. ed., ed. Thomas Baldwin, (Cambridge: Cambridge

University Press, 1993), 69-72. 406 Rhonheimer, Natural Law and Practical Reason, 43, 88; Rhonheimer, The Perspective of

Morality, 268. 407 Rhonheimer, Natural Law and Practical Reason, 3-5. 408 Rhonheimer, Natural Law and Practical Reason, 3-5. 409 Aquinas, Scriptum super sent., II, d. 40, q. 1, a. 2, co. 410 Duarte Sousa-Lara, “‘Materia ex qua’ and ‘Materia circa quam’ in Aquinas,” 2008,

http://www.eticaepolitica.net/eticafondamentale/dsl_materia_ex_qua_materia_circa_quam.pdf.,

3; Aquinas, Summa Theologica, I-II, q. 18, a. 2, ad. 2: “obiectum non est materia ex qua, sed

materia circa quam.” 411 Sousa-Lara, “‘Materia ex qua’ and ‘Materia circa quam’ in Aquinas,” 3; Thomas Aquinas,

Questiones Disputatae de Veritate (Truth), trans. James V. McGlynn (Chicago: Henry Regnery

Company, 1953) https://dhspriory.org/thomas/QDdeVer.htm, 412 Sousa-Lara, “‘Materia ex qua’ and ‘Materia circa quam’ in Aquinas,” 10. 413 Sousa-Lara, “‘Materia ex qua’ and ‘Materia circa quam’ in Aquinas,” 10. 414 Sousa-Lara, “‘Materia ex qua’ and ‘Materia circa quam’ in Aquinas,” 10. 415 Sousa-Lara, “‘Materia ex qua’ and ‘Materia circa quam’ in Aquinas,” 10. 416 Sousa-Lara, “Aquinas on Interior and Exterior Acts: Clarifying a Key Aspect of His Action

Theory,” 283. 417 Sousa-Lara, “Aquinas on Interior and Exterior Acts: Clarifying a Key Aspect of His Action

Theory,” 277-316. 418 Sousa-Lara, “Aquinas on Interior and Exterior Acts: Clarifying a Key Aspect of His Action

Theory,” 277-316. 419 Sousa-Lara, “Aquinas on Interior and Exterior Acts: Clarifying a Key Aspect of His Action

Theory,” 278; Aquinas, On Evil, q. 2, a. 2, ad. 13. 420 Sousa-Lara, “Aquinas on Interior and Exterior Acts: Clarifying a Key Aspect of His Action

Theory,” 302. 421 Sousa-Lara, “Aquinas on Interior and Exterior Acts: Clarifying a Key Aspect of His Action

Theory,” 302. 422 Servais Pinckaers, The Sources of Christian Ethics, trans. Mary Thomas Noble (Washington

D.C.: Catholic University of America, 1995), 240. 423 Pinckaers, The Sources of Christian Ethics, 242. 424 Rhonheimer, The Perspective of Morality, 146; following Aquinas, Summa Theologica, I-II,

q. 18, a. 5; q. 71, a. 2. 425 Rhonheimer, The Perspective of Morality, 274. 426 Aquinas, Summa Theologica, q. 91, a. 2, answer. 427 John Finnis, Natural Law and Natural Rights, 2nd ed., (Oxford: Oxford University Press,

2011), 399. 428 Finnis, Natural Law and Natural Rights, 400; Aquinas, Summa Theologica, I, q. 79, a. 4,

answer. 429 Finnis, Natural Law and Natural Rights, 400.


https://dhspriory.org/thomas/QDdeVer.htm

303

430 Finnis, Natural Law and Natural Rights, 400; Aquinas, Summa Theologica, I-II, q. 91, a. 2,

answer. 431 Finnis, Natural Law and Natural Rights, 400; Aquinas, Summa Theologica, I-II, q. 93, a. 5; a.

6. 432 Aquinas, Summa Theologica, I-II, q. 90, a. 1, answer. 433 Finnis, Natural Law and Natural Rights, 400; Aquinas, Summa Theologica, I-II, q. 94, a. 2

answer; q. 10, a. 1, answer. 434 Rhonheimer, Natural Law and Practical Reason, 237. 435 Rhonheimer, Natural Law and Practical Reason, 234-56. 436 Pinckaers, The Sources of Christian Ethics, 245. 437 Pinckaers, The Sources of Christian Ethics, 243. 438 Pinckaers, The Sources of Christian Ethics, 245. 439 Pinckaers, The Sources of Christian Ethics, 242-3; 440 Pinckaers, The Sources of Christian Ethics, 245-6. 441 Pinckaers, The Sources of Christian Ethics, 246-7. 442 Pinckaers, The Sources of Christian Ethics, 246-7. 443 Pinckaers, The Sources of Christian Ethics, 247. 444 Pinckaers, The Sources of Christian Ethics, 249. 445 Pinckaers, The Sources of Christian Ethics, 254ff. 446 Pinckaers, The Sources of Christian Ethics, 268-72. 447 Pinckaers, The Sources of Christian Ethics, 271. 448 Thomas Petri, Aquinas and the Theology of the Body: The Thomistic Foundation of John Paul

II’s Anthropology, (Washington D. C.: Catholic University of America Press, 2016), 41-2; from

John A. Gallagher, Time Past, Time Future: An Historical Study of Catholic Moral Theology

(New York: Paulist Press, 1990), 76; John A. McHugh and Charles J. Callan, Moral Theology: A

Complete Course Based on St. Thomas Aquinas and the Best Modern Authorities (New York:

Joseph F. Wagner, 1929), 1:23. 449 Petri, Aquinas and the Theology of the Body, 41-2; McHugh and Callan, Moral Theology,

1:23. 450 John T. Noonan, Jr., Contraception: A History of its Treatment by the Catholic Theologians,

enlarged ed. (Cambridge, MA: Harvard University Press, 1986), 396-8; Jean-Pierre Gury,

Compendium Theologiae Moralis (Compendium of Moral Theology), 7th ed., Vol. 1, (Rome: S.

C. de propaganda fide, 1882), 417. 451 Peter Knauer, “The Hermeneutic Function of the Principle of Double Effect,” Natural Law

Forum, Paper 127. http://scholarship.law.nd_naturallaw_forum/127. 452 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 133. 453 Josef Fuchs, “The Absoluteness of Moral Terms,” Readings in Moral Theology: Moral

Norms and Catholic tradition, ed. Charles E. Curran and Richard A. McCormick (New York:

Paulist Press, 1979), 119. 454 Louis Janssens, “Ontic Evil and Moral Evil,” Readings in Moral Theology: Moral Norms and

Catholic tradition, ed. Charles E. Curran and Richard A. McCormick (New York: Paulist Press,

1979), 60. 455 Richard McCormick, “Some Early Reactions to Veritatis Splendor,” Theological Studies 55

(1994): 501; Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 137ff;

William F. Murphy, Jr., “Introduction,” The Perspective of the Acting Person: Essays in the


304

Renewal of Thomistic Moral Philosophy, ed. William F. Murphy, Jr. (Washington D.C.: Catholic

University of America Press, 2008), xxviii. 456 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 144-5. 457 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 145. 458 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 148. 459 Martin Rhonheimer, “Intentional Actions and the Meaning of Object: A Reply to Richard

McCormick,” The Perspective of the Acting Person: Essays in the Renewal of Thomistic Moral

Philosophy, ed. William F. Murphy, Jr. (Washington D.C.: Catholic University of America

Press, 2008), 79. 460 Rhonheimer, “Intentional Actions and the Meaning of Object: A Reply to Richard

McCormick,” 73-8. 461 Rhonheimer, “Intentional Actions and the Meaning of Object: A Reply to Richard

McCormick,” 77-8; Rhonheimer, The Perspective of Morality, 151. 462 Rhonheimer, “Intentional Actions and the Meaning of Object: A Reply to Richard

McCormick,” 72; Rhonheimer, Natural Law and Practical Reason, 92-3; Aquinas, Summa

Theologica, I-II, q. 19, a. 1, ad. 3. 463 Rhonheimer, Natural Law and Practical Reason, 90; Rhonheimer, The Perspective of

Morality, 153. 464 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 157-62. 465 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 160. 466 Martin Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a Central

Teaching of Veritatis Splendor,” The Perspective of the Acting Person: Essays in the Renewal of


of America Press, 2008), 39ff. 467 Rhonheimer, “Intentional Actions and the Meaning of Object: A Reply to Richard

McCormick,” 77. 468 John Paul II, Veritatis Splendor, 79. 469 Rhonheimer, The Perspective of Morality, 40, 151. 470 Aquinas, Summa Theologica, I-II, q. 18, a. 10. 471 Paul VI, Humanae Vitae, (July 25, 1968), https://w2.vatican.va/content/paul-

vi/en/encyclicals/documents/hf_p-vi_enc_25071968_humanae-vitae.html. 472 Martin Rhonheimer, Ethics of Procreation and the Defense of Human Life: Contraception,

Artificial Fertilization, and Abortion, ed. William F. Murphy, Jr., (Washington D.C.: Catholic

University of America, 2010), 1-132. 473 Rhonheimer, Ethics of Procreation, 44. 474 Rhonheimer, Ethics of Procreation, 44. 475 Paul VI, Humanae Vitae, 12. 476 Rhonheimer, Ethics of Procreation, 44. 477 John Paul II, Man and Woman He Created Them: A Theology of the Body, trans. Michael

Waldstein (Boston: Pauline Books, 2011), 13:2, 14:3, 15:1, 23:3, 25:2, 26:2. 478 Rhonheimer, Ethics of Procreation, 71ff. 479 Rhonheimer, Ethics of Procreation, 72. 480 Rhonheimer, Ethics of Procreation, 77. 481 Rhonheimer, Ethics of Procreation, 78-81. 482 Rhonheimer, Ethics of Procreation, 80. 483 Rhonheimer, Ethics of Procreation, 83.

https://w2.vatican.va/content/paul-vi/en/encyclicals/documents/hf_p-vi_enc_25071968_humanae-vitae.html


305

484 Rhonheimer, Ethics of Procreation, 83. 485 Rhonheimer, Ethics of Procreation, 88-90. 486 Rhonheimer, Ethics of Procreation, 90-1. 487 Pius XI, Casti Cannubii, December 31, 1930, https://w2.vatican.va/content/pius-

xi/en/encyclicals/documents/hf_p-xi_enc_19301231_casti-connubii.pdf, 101. 488 Paul VI, Humanae Vitae, 22. 489 Rhonheimer, Ethics of Procreation, 96-7. 490 Rhonheimer, Ethics of Procreation, 100. 491 Rhonheimer, Ethics of Procreation, 100. 492 Rhonheimer, Ethics of Procreation, 133-150; first published as “Minaccia di stupro e

prevenzione: un’eccezione?” La Scuola Cattolica 123 (1995): 75-90; and in English “The Use of

Contraceptives under Threat of Rape: An Exception?” Josephinum Journal of Theology 14, no. 2

(2007): 168-81. 493 Rhonheimer, Ethics of Procreation, 134ff; Pietro Palazzini et al., “Una donna domanda: come

negarsi alla violenza? Morale esemplificata. Un dibattito,” Studi Cattolici 27 (1961): 62-72. 494 Rhonheimer, Ethics of Procreation, 135. 495 Rhonheimer, Ethics of Procreation, 135; Hurth, “Il premunirsi rientra nel diritto all legittima

difesa,” Studi Cattolici 27 (1965): 65. 496 Pietro Palazzini, “Si può e si deve proteggere l’equilibrio della persona,” Studi Cattolici 27

(1961): 62-4; Ferdinando Lambruschini, “È legittimo evitare le conseguenze dell’aggressione,”

Studi Cattolici 27 (1961): 68-72. 497 Rhonheimer, Ethics of Procreation, 136. 498 Rhonheimer, Ethics of Procreation, 136. 499 Rhonheimer, Ethics of Procreation, 143-7. 500 Rhonheimer, Ethics of Procreation, 148-9; Rhoneheimer, “Intentional Actions and the

Meaning of Object: A Reply to Richard McCormick,” 77ff; Rhonheimer, “‘Intrinsically Evil

Acts’ and the Moral Viewpoint: Clarifying a Central Teaching of Veritatis Splendor,” 39ff. 501 Rhonheimer, Ethics of Procreation, 149; Rhoneheimer, “Intentional Actions and the Meaning

of Object: A Reply to Richard McCormick,” 77ff 502 Rhonheimer, Ethics of Procreation, 147. 503 Aquinas, Summa Theologica, II-II, q. 64, a. 7, answer. 504 Aquinas, Summa Theologica, II-II, q. 64, a. 7, answer. 505 Duarte Sousa-Lara, “Per Se and Praeter Intentionem in Aquinas,” Josephinum Journal of

Theology 18, no. 2 (2011): 418-53. 506 Sousa-Lara, “Per Se and Praeter Intentionem in Aquinas,” 424ff. 507 Aquinas, Summa Theologica, II-II, q. 64, a. 7, answer. 508 Finnis, Aquinas, 64. 509 Cavanaugh, Double-Effect Reasoning, xiii. 510 Jean Pierre Gury, Compendium Theologiae Moralis, Vol. 1, 17th ed. (Romae: Typis

Civilitatis Catholicae, 1866). https://archive.org/details/compendiumtheo01gury

, c. 2, no. 9, pp. 9-10. 511 Joseph T. Mangan, “An Historical Analysis of the Principle of Double Effect,” Theological

Studies 10, no. 1, (1949): 60-1. 512 Cavanaugh, Double-Effect Reasoning, 25. 513 Cavanaugh, Double-Effect Reasoning, 25. 514 Mangan, “An Historical Analysis of the Principle of Double Effect,” 60.



306

515 Mangan, “An Historical Analysis of the Principle of Double Effect,” 60. 516 Furton and Moraczewski, “Double Effect,” 24. 517 Rhonheimer, The Perspective of Morality, 398. 518 Rhonheimer, The Perspective of Morality, 398ff. 519 Rhonheimer, The Perspective of Morality, 401. 520 Rhonheimer, The Perspective of Morality, 6ff. 521 Cavanaugh, Double-Effect Reasoning, 69-70. 522 John Finnis, Germain Grisez, and Joseph Boyle, "'Direct' and 'Indirect': A Reply to Critics of

Our Action Theory," The Thomist 65, no. 1 (2001): 1-44. 523 Cavanaugh, Double-Effect Reasoning, 70-2. 524 Cavanaugh, Double-Effect Reasoning, 70-2. 525 Cavanaugh, Double-Effect Reasoning, 26. 526 Furton and Moraczewski, “Double Effect,” 24. 527 Cavanaugh, Double-Effect Reasoning, 7; Sousa-Lara, “Per Se and Praeter Intentionem in

Aquinas,” 422-3. 528 Cavanaugh, Double-Effect Reasoning, 73ff. 529 Cavanaugh, Double-Effect Reasoning, 26. 530 Rhonheimer, The Perspective of Morality, 398. 531 Furton and Moraczewski, “Double Effect,” 25. 532 Kevin L. Flannery, “What Is Included in a Means to an End?” Gregorianum 74, no. 3 (1993):

499-513. 533 Rhonheimer, Ethics of Procreation, 145. 534 Rhonheimer, Ethics of Procreation, 144. 535 Aquinas, Summa Theologica, II-II, q. 64, a. 7, answer. 536 Cavanaugh, Double-Effect Reasoning, 26. 537 Aquinas, Summa Theologica, II-II, q. 64, a. 7, answer. 538 Cavanaugh, Double-Effect Reasoning, 160. 539 Rhonheimer, Ethics of Procreation, 136. 540 Rhonheimer, Ethics of Procreation, 136; Palazzini, “Si può e si deve proteggere l’equilibrio

della persona,” 63-4; Lambruschini, “È legittimo evitare le conseguenze dell’aggressione,” 68-

72. 541 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 136; Rhonheimer,

Ethics of Procreation, 136.

307

CHAPTER SIX – SEX REASSIGNMENT SURGERY AND CONTRACEPTION

This chapter considers the ethics surrounding sex reassignment surgery for gender

dysphoria and the use of contraceptives in Catholic hospitals for non-contraceptive benefits.

6A. Sex Reassignment Surgery for Gender Dysphoria

Two recent articles in Health Care Ethics USA: A Quarterly Resource for the Catholic

Health Ministry argue that the Principle of Double Effect and the Principle of Totality and

Integrity justify the use of sex reassignment surgery in patients diagnosed with gender

dysphoria.1 This section demonstrates how Catholic theological anthropology not only precludes

the so-called ideology of gender—that underlies justifications for sex reassignment therapies—

which Pope Francis along with his predecessors condemn,2 but also does not admit justification

for sex reassignment surgery by means of Double Effect or Totality, especially in light of an

accurate articulation of the Moral Object.

The first subsection explicates the definition of sex, gender, gender dysphoria, and

current therapies. The second subsection examines three categories that the Church uses to reject

gender ideology: medical, philosophical, and theological. The third subsection demonstrates how

an accurate understanding of Totality and Double Effect, which includes a Thomistic

understanding of the Moral Object, excludes the possibility of sex reassignment surgery for

gender dysphoria.

i. Sex, Gender, and Gender Dysphoria

This subsection explains the complex categories of sex, gender, and gender dysphoria.

The first subsubsection explicates the multivariable definition of biological sex utilizing intersex

conditions to clarify and highlight its complexity. The second subsubsection discusses the origins

and development of the concept of gender. The third subsubsection reveals the evolution of the

308

concept of gender dysphoria, especially as the Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition3 and Diagnostic and Statistical Manual of Mental Disorders, Fifth

Edition4 reflect it. Finally, the fourth subsubsection briefly discusses sex reassignment therapies.

a. Defining Sex

Defining sex biologically as male or female is not as easy as it may at first appear. This is

true not only because of the variance of terminology, but also because of the many factors that

contribute to even a somatic definition. The Diagnostic and Statistical Manual of Mental

Disorders, Fifth Edition identifies sex with the biological indicators of male and female, which I

further elucidate in this subsubsection, whereas it identifies the lived experience of man or

woman as gender, which I discuss in the following subsubsection.5

Several physiological criteria exist for defining sex, including: genetic, gonadal, ductal,

and phenotypic or genital.6 Genetically, in its most unambiguous form, the male and female

karyotypes consist of 46,XY and 46,XX, respectively. There may, however, be several unique

combinations of sex chromosomes including, but not limited to: 45,X (Turner Syndrome),

47,XXX, 47,XXY (Klinefelter Syndrome), 47,XYY. In addition, early in embryonic

development, mitotic errors may give rise to cell populations with unique chromosomal

complements, called mosaicism.7 For instance, it is possible to have a 46,XX/46,XY karyotype,

which constitutes 50% of cases of true hermaphroditism.8 Strictly speaking, however, one is

genetically male if one has a Y chromosome and female if one does not, regardless of the

number of X chromosomes one may have additionally.9

The variety of genotypes, including mosaics, gives rise to the various expressions.

Klinefelter syndrome, for instance consists genetically of one or more Y chromosomes in

combination with one or more X chromosomes, which results in male hypogonadism

309

(underdeveloped male sex organs). Turner syndrome is a partial or complete monosomy of the X

chromosome that engenders hypogonadism in phenotypic females.10 In both Klinefelter

syndrome and Turner syndrome, the sexual identity is less ambiguous, but simply

underdeveloped.

Alternatively, there are forms of hermaphroditism—true and pseudo—that make sexual

identity externally more difficult to pinpoint. The gonads refer to the germ cells that migrate,

becoming testes in males and ovaries in females. Although initially neutral, the gonads have an

inherent tendency to develop femininely, “unless influenced by Y chromosome-dependent

masculinizing factors.”11 In terms of ductal development, females develop Müllerian ducts and

males develop Wolffian ducts. Phenotypic or genital sex refers to the respective external sex

organs. Hermaphroditism consists of a combination of almost any variety of the above-

mentioned structures.

True hermaphroditism occurs when one has both testicular and ovarian tissue. This

phenomenon is very rare. Genetically, half are mosaics, while the other half have a 46,XX

karyotype with an active SRY gene that has either translocated to an autosomal chromosome, or

one of the sex chromosomes has a cryptic chimerism.12 Pseudo-hermaphroditism, on the other

hand, occurs when one has sexually the opposite genitals of the gonads. For instance, a female

pseudo-hermaphrodite has ovaries, but male genitalia; and a male pseudo-hermaphrodite has

testes and female genitalia. Female pseudo-hermaphrodites are genetically female, 46,XX, but

have ambiguous or virilized (masculinized) genitalia caused by excessive exposure to androgen

steroid during gestation, which originates from congenital adrenal hyperplasia.13 Male pseudo-

hermaphrodites are genetically male, but due to problems with either androgen synthesis or

androgen insensitivity, the male ducts and/or external genitalia do not fully develop.

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As complex as disorders of sex development are, there is less disagreement about its

treatment than conditions relating to gender, despite the variety of historical approaches.14

Perhaps this is because it is evident that these conditions are largely somatic, rather than,

psychosocial. In 2006, several groups wrote “Consensus Statement on Management of Intersex

Disorders.”15 The move is to classify intersex conditions genetically, even though they present

somatically differently.16 The above analysis demonstrates that while intersex conditions

manifest in the gonads, ducts, and genitals, they originate genetically. Thus, even in intersex

conditions, the genetic classification of individuals according to a binary sexual classification is

possible.

b. Defining Gender

Much more complex, not only because of the divergence in terminology, but also because

of the underlying theories is the definition of gender. The following largely represents an

elucidation of the understanding of gender in the Diagnostic and Statistical Manual of Mental

Disorders, Fifth Edition and the social constructionist perspective that underlies it.

Sex or sexual refers to the biological indicators of male or female, including

chromosomes, gonads, and genitalia.17 However, it is precisely because of the intersex condition

that the need arose for another term to denote the lived experience of a person as a man or

woman.18 John Money is the first to use the term gender to highlight such a difference.19 Gender

denotes the lived role of an individual as a boy or girl, man or woman.20 The American

Psychological Association defines gender as a social construct that one attributes to male and

female individuals.21 One’s natal gender—the gender assigned at birth—may not constitute one’s

gender identity.22 One may, therefore, reassign one’s gender. Gender identity, though often in

coordination with traditional masculine and feminine roles, may constitute neither, in which case

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one identifies as non-binary.23 Transgender refers to those who “transiently or persistently

identify with a gender different from their natal gender.”24 Transsexual, on the other hand, refers

to those who have undergone a social transition from male to female, or female to male, that may

include somatic transition with cross-sex hormone treatment and/or sex reassignment surgery.25

Sociologist, Linda L. Lindsey, argues that society and culture largely construct gender

roles.26 In “Gender Identity,” Lawrence S. Mayer and Paul R. McHugh27 attribute the concept of

gender as a social construct to feminist writers such as Simon de Bouvoir,28 Ann Oakley,29

Suzaane J. Kessler and Wendy McKenna,30 Gayle Rubin,31 and Judith Butler.32 In “On the

Construction of Gender, Sex and Sexualities,” Jeanne Marecek et al., hold that knowledge is a

collaborative product of society.33 Merecek et al. indicate that social constructionists do not

mean to say that gender, sex, and sexuality are inherently built by society as opposed to biology,

environment, or innate, but that society constructs the terms and concepts they represent.34

Moreover, these linguistic constructs influence how one understands gender and sex.35 Social

constructionists are interested in processes; for example, how terms change in meaning over

time.36 Judith Butler, for instance, understands gender according to a performativity theory of

doing.37 In other words, gender is not being, but doing. In addition, they do not understand the

human person as distinct from society, insofar as both are mutually dependent upon each other.38

Consequently, social constructionists understand gender, not as a personality trait, but as a social

process.39 Additionally, they understand the concepts and terms that reflect biology and sex and

sexual to be social constructs as well, which also falls under the purview of social processes.40

Marecek et al. dedicate the remainder of the paper to demonstrating the relativism of both

biology and gender.41

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According to such a constructionist understanding of sex, sexuality, and gender, the

concept of transexualism arises, which not only implies the possibility of changing one’s gender

in a binary sense, but in a non-binary sense as well.42 As Margaret H. McCarthy indicates in

“Gender Ideology and the Humanum,” many contemporary theorists attempt to raze any notion

that gender is attributable to sex or the body.43 Inherent in the constructionists view is the notion

of a disembodied will and the dictatorship of relativism.44 Although Merecek et al. deny that they

are asserting that gender, sex, etc. is socially constructed as opposed to being nature-determined,

in practice, this is what social constructionism does.45 Such a relativistic disposition not only

presumes that the authentic person is the soul, but that the body is a tabula rasa. Both

anthropological theories contrast with the Catholic understanding of the human person and have

origins in Enlightenment philosophy as I demonstrate in the next subsection.

c. Gender Dysphoria

Here, I follow the development of the clinical understanding of gender dysphoria as

relevant diagnostic texts articulate. Diagnostic and Statistical Manual of Mental Disorders,

Fourth Edition identifies gender dysphoria as a disorder concerning identity,46 whereas

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, no longer views the

condition as such.47 Rather, it identifies the clinical problem with the experience of dysphoria,

that is, the distressing experience of identifying as transgender, which one may presumably

resolve by changing the individual’s sex.48 It no longer considers the transgender condition

pathological.49 The respective approaches inform the increasing affinity for sex reassignment

therapies.

According to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,

gender identity disorders “are characterized by strong and persistent cross-gender identification

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accompanied by persistent discomfort with one’s assigned sex.”50 The name for the condition

suggests that the pathology consists in having the experience of a gender different from one’s

natal birth. Accordingly, one may not have an intersex condition, increasingly called a disorder

of sexual development in the literature (Criteria C).51 At the same time, one must have a

persistent discomfort with one’s natal sex or the gender role assigned to it (Criteria B), and a

strong identification with the opposite gender (Criteria A).52 In other words, one must not only

experience discomfort with one’s given gender, but one must identify with the opposite gender.

Finally, there must be evident distress or impairment of social, occupational, or other areas of life

(Criteria D).53

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, in changing

the name to gender dysphoria removes the pathology from the incongruent experience of having

a gender unique to one’s natal sex and places it on the distress that such an experience causes. By

de-pathologizing the transgender experience, they open the door to transsexual therapies. Alice

Dreger, in “Why Gender Dysphoria Should No Longer Be Considered a Medical Disorder,”

highlights the intentional motivation behind this change of approach.54 It further delineates

criteria for diagnosis in two subgroups based on age—children and adolescents and adults.55 It

defines gender dysphoria more concretely for children, having more criteria that must be met (six

instead of two).56 In both cases, the patient must experience the incongruence for at least six

months.57 Children must present with either a strong desire to be the opposite gender or the

insistence of being the opposite gender.58 Moreover, they must present with five more distinct

behavioral patterns, such as cross-dressing, a strong preference for: playing the opposite gender

role in make-believe, opposite gender toys, opposite gender playmates, rejection of same-sex

playmates, a strong dislike of one’s sexual anatomy, and strong desire for primary/secondary

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sexual characteristics that match one’s experienced gender.59 Finally, this experience must

impair the child’s functioning socially or in school, for instance.60

In adolescents and adults, patients present with marked incongruence between one’s

experienced gender and the assigned gender, with a strong desire to be rid of primary and

secondary sex characteristics of one’s natal gender and a strong desire to have the primary and

secondary sex characteristics of the opposite gender.61 In addition, there may be a strong desire

to be treated as opposite of one’s natal gender and a conviction that one has the typical feelings

or reactions of the other gender.62 As with children, the experience of dysphoria must interfere

with one’s social, occupational, or other areas of one’s life.63

Prevalence varies, but overall, more natal males experience gender dysphoria than natal

females.64 Rates of persistence from childhood to adolescence or adulthood vary between 2.2%

and 30%.65 Until 1923, when Magnus Hirschfeld argues to the contrary,66 clinicians did not

distinguish gender dysphoria from homosexuality.67 There is, however, a strong correlation

between gender dysphoria and same sex attraction. Sexual attraction among individuals varies,

especially in men, however, most experience sexual attraction to one’s natal sex.68 Natal males

who present later in life with gender dysphoria tend to be attracted to natal females.69 Differential

diagnoses include nonconformity to gender roles, transvestic disorder, body dysmorphic

disorder, psychotic disorders including schizophrenia, and other clinical presentations.70

Comorbidities include emotional and behavioral problems most commonly anxiety, disruptive

impulsive control, and depression.71

d. Sex Reassignment Therapies

Expert opinions diverge on appropriate treatment for gender dysphoria. Some encourage

the pursuit of counseling that helps one identify with one’s natal sex.72 Others encourage people

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struggling with gender dysphoria to change the body to match the so-called inside. The latter

advocate the use of hormone replacement therapies and sex reassignment surgeries to facilitate

the transition.73 There are multiple types of sex reassignment surgery. These include male-to-

female and female-to-male operations that consist of genital reconstruction, breast augmentation,

chest reconstruction, and hysterectomy. In addition, less invasive procedures include facial

feminization surgery, vocal cord surgery, and Adam’s apple shaving. Some delineate between

top or bottom procedures. Top sex reassignment surgeries refer to procedures that address the

secondary sexual characteristics from the chest up to the face, while bottom sex reassignment

surgeries refer to procedures that change the genitals.

This subsection addresses the complex definitions of sex, gender, gender dysphoria, and

possible treatments. The following subsection analyzes three categories which the Catholic

Church uses to preclude sex reassignment therapies.

ii. Objections to Sex Reassignment Therapies

On December 12, 2016, the Committee on Doctrine of the United States Conference of

Catholic Bishops sent a memorandum to bishops addressing the rapid increase in people

identifying as transgender.74 The committee highlights its concern that the Affordable Care Act

recognizes gender identity as a protected category for antidiscrimination and the implications

that this may have for Catholic Healthcare Services.75 The committee objects to sex reassignment

therapies on three grounds: medical, philosophical, and theological.76 This subsection

illuminates these three categories.

a. Medical

To be sure, researchers in the field face many challenges when it comes to data for

gender dysphoria patients and outcomes of procedures. In part, this is due to the relatively small

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number of individuals presenting with gender dysphoria (0.005% to 0.014% in adult males and

0.002% to 0.003% in adult females).77 But it may also be due to limited responses to surveys and

poor therapeutic outcomes.78 Lawrence S. Mayer and Paul R. McHugh in “Gender Identity”

examine scientific research and find little to no evidence that medical procedures to change

gender have any psychological benefit.79 Moreover, in spite of the predominant view that gender

identity originates at birth, they find no scientific evidence to support this belief.80

Mayer and McHugh offer two well-documented cases that contradict the plasticity of

gender that social constructionists advocate.81 First, John Money’s most famous patient is David

Reimer.82 After a botched circumcision, physicians used both surgical and hormonal intervention

attempting to raise Reimer as a girl.83 In spite of attempts to conceal the truth, Reimer self-

identified as a boy.84

Second, Mayer and McHugh offer a follow up study by William G. Reiner and John P.

Gearhart of 16 genetic males with cloacal exstrophy—deformed bladders and genitalia—which

underwent surgical procedures to construct female genitalia and were to be raised as girls.85

According to the article, two subjects were raised as male, 8 of the 14 others self-identified as

male during the course of the study, five persistently declared themselves female and one refused

to respond.86 In addition, all showed moderate-to-marked male-typical behavior.87

Mayer and McHugh argue that the abovementioned findings indicate that biological sex

is clear, binary, and stable from almost all humans.88 Moreover, exceptions to sex-typical

behavior do not contradict this biological reality, nor can surgery or social conditioning change

it.89 Mayer, speaking on behalf of Johns Hopkins Psychiatry Department, concludes that human

sexual identity is mostly built into one’s constitution by both genetics and embryogenesis.90

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Even if gender lacks the plasticity that constructionists defend, perhaps the incongruence

lies in biology itself. For example, Robert Sapolsky suggests a neurobiological derivation for

cross-gender identification.91 He suggests that people with cross-gender identification have a

brain that is opposite their biological sex.92 Other researchers presume a similar line of thinking

as they develop experiments to confirm biological differences between transgender and cis-

gender brains including Nancy Segal,93 Michael Bostwick and Kari A. Martin,94 Giuseppina

Rametti et al.,95 Emiliano Santarnecchi,96 Hsaio-Lun Ku et al.,97 and Hans Berglund et al.98

Mayer and McHugh find the above-mentioned studies inconclusive and mixed.99 Even if

studies could demonstrate conclusively that neurological differences exist in cross-gender

individuals, this does not necessarily imply that these differences are biological or innate; rather,

one could just as easily implicate environment or psychology.100 Accordingly, the only way to

unequivocally establish biological causality is to “conduct prospective, longitudinal, preferably

randomly sampled and population-based studies.”101 Unfortunately, to attain statistical

significance, many of these studies would need to be larger than is realistically possible to

achieve.102 To the contrary of the above-mentioned studies and a constructionist understanding

of gender, Meyer and McHugh show that scientific evidence overwhelmingly supports the

position that biological development and sex corresponds with gender identity.103 Consequently,

research ought to look for social and psychological origins for cross-gender identification.104

Paul W. Hruz, in Experimental Approaches to Alleviating Gender Dysphoria in Children,

highlights that current research indicates that gender dysphoria is a multifactorial condition with

genetic and environmental origins.105 He faults the rapid transition to non-psychiatric

interventions for gender dysphoria to the strong ideological agenda that redefines the meaning

and purpose of human sexuality.106 In addition, he attributes the rise in children presenting with

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gender dysphoria to social affirmation. His article also raises challenges that research and

treatment for gender dysphoria faces. Insofar as interventions supportive of gender transition

contrast with Catholic anthropology, doing so, even for research purposes, may constitute

proximate material cooperation with evil.107 In addition, Hruz underlines that children and

adolescents do not have the maturity to give informed consent to procedures that have lifelong

consequences.108 For Hruz, the high rate of spontaneous remission supports a cautious

psychological approach that is antithetical to prevailing medical practice.109 Positively, he

contends that Catholic hospitals stand in a unique position to occupy the void of reason, by

treating patients in a manner consistent with their dignity and integrity.110

Body dysmorphic disorder is similar to gender dysphoria with some pronounced

differences.111 Suffers obsess or fixate on an aspect of one’s body that one believes to be

disproportionate with the rest of the body.112 In body dysmorphic disorder individuals exhibit

preoccupation with physical appearance not attributable to concern with body fat or weight.113

This may involve fixation over a body part, such as one’s nose, hairline, or genitalia, or it may

pertain to one’s perception of musculature.114 As with gender dysphoria, individuals experience

social anxiety and functional impairment.115 Comorbidities include anxiety, depression, and

obsessive-compulsive disorder.116 They often seek cosmetic surgery, but experience

dissatisfaction with results.117 They are high risk for suicide, especially in adolescents.118

In “A New Way to Be Mad,” Carl Elliott explores the phenomenon of patients presenting

with an obsessive desire to live as an amputee, which John Money calls apotemnophilia and

relates to gender dysphoria.119 Apotemnophilia is distinct from acrotomophilia, which is a sexual

attraction to amputees. Elliott highlights the similarity between gender dysphoria regarding

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identity and selfhood.120 Suffers describe themselves as amputees.121 He speculates that cultural

fixation on self explains why so many describe desires using reference to self and identity.122

Elliott argues that apotemnophilia is more like gender dysphoria, because suffers tie

amputation more closely to their identity than in body dysmorphic disorder, where the individual

simply believes that an aspect of one’s body is disproportionate.123 He argues that just as culture

creates apotemnophilia so it creates the transsexual by introducing the terminology and offering

sex reassignment surgery as a solution.124 Ian Hacking uses the phrase semantic hacking to

describe this phenomenon.125 Elliott points to the less than controversial relationship between

psychiatry and surgery throughout its history including clitoridectomies for excessive

masturbation and frontal lobotomies, as evidence for questioning the use of sex reassignment

surgery as a remedy for gender dysphoria or amputations as a cure for apotemnophilia.126

b. Philosophical

There are a number of philosophical tendencies that predominate in the ideology of

gender, including, but not limited to: anthropological dualism, physicalistic determinism, and

existential voluntarism. This subsubsection elucidates these tendencies and their disagreement

with Christian anthropology.

Advocates of the ideology of gender presume an anthropology that relegates sexuality to

choice, at best, largely rooted in anthropological dualism that originates in Rene Descartes’

Meditations on First Philosophy.127 Anthropological dualism emphasizes the separation between

the body and the soul and the superiority of the latter, which Martin Rhonheimer calls

spiritualism.128 Although historically present in various heterodox doctrines such as Gnosticism

and Manichaeism, it is especially pronounced in the Rationalism.129 Descartes advocates radical

dualism whereby two unique substances exist, yet abide in a tenuous relationship.130

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Descartes methodically questions everything from his sense perception to his own

existence and even the existence of God.131 He ultimately concludes that the only thing certain is

“Cogito, ergo sum.”132 This dictum becomes the subjective foundation for all knowledge and

being.133 In this process, he divorces the spiritual from the corporeal establishing two mutually

opposing substances.134 The mind becomes the sole principle of truth and being, whereas, he

relegates the body to the unintelligible.135 Since the mind or soul exists independently of the

body, Descartes conceives of the human person merely as the soul, trapped, so-to-speak, within

the body.136 Hence he rejects Boethius’s definition of the human person as a rational animal.137

Similarly, Rhonheimer attributes such an anthropological dualism to Karl Rahner’s

definition of the human person as a spirit in the world.138 Rather, Rhonheimer, following

Aquinas insists that the human person constitutes a substantial unity of body-soul composite.139

The soul is not the human person; rather, the human person is a composite of these two sub-

personal entities.140 The body with its natural inclinations and desires contribute more than just

neutrally to morality.

Concomitant to the development of continental rationalism is the expansion of British

Empiricism, with its emphasis on knowledge derived from physical evidence.141 Empiricism,

which originates with Francis Bacon, corresponds with the Scientific Revolution that emphasizes

experimentation, induction, and material and efficient causality over formal and final

causality.142 Science describes and predicts interactions between physical objects, which become

the basis for the laws of physics.143 The nature of matter itself and its inherent purpose are of

little consequence. Not only is sense knowledge of primary importance, it becomes the sole

source of truth. The universal laws of physics govern not only the inanimate objects of the world,

but also the more complex animate beings, which constitute merely a complex conglomeration of

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the former. While Rationalism emphasizes the division between the body and the soul, the

superiority of the soul, and the denigration of the body, Empiricism reduces the body to the

interaction between its constitutive parts. For both, the body is only a slightly more complex

combination of parts than a cotton gin, which the laws of physics govern. Hence, on the one

hand, the body is undifferentiated matter and on the other, physicalistic or biological

mechanisms determine it.

However, the Empiricist David Hume calls into question even the apparent cause-effect

relationships between material bodies, insisting that they too originate from sense experience,

and are therefore, a posteriori, not a priori.144 In other words, the laws of physics, for Hume,

constitute synthetic rather than analytic propositions. Put another way, the laws of physics

depend on sense experience for their confirmation and formulation and are not self-evidently true

merely according to the formulation of the terms as if analytic.

Immanuel Kant further severs the divide between the mind—noumenon—and the

external world or thing-in-itself—phenomenon—by responding to Hume in his Critique of Pure

Reason.145 Kant argues that synthetic a priori knowledge is possible through reason.146 Unlike

the dogmatic idealism of Berkeley,147 which denies the existence of the material world external

to that of ideas, or the problematic idealism of Descartes, which doubts the existence of an

external world, Kant knows the world through a transcendental idealism, which uses sense

experience and reason to formulate the synthetic a priori.148

Although Kant attempts to resolve the anthropological, dualistic divide that Rationalism

and Empiricism creates, he only succeeds in solidifying it in his metaphysics. In Kant’s ethics,

the divide is between the person and action, since the right action depends on a good will

configured by the duty to an externally formulated moral law.149 Rhonheimer, in The Perspective

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of Morality: Philosophical Foundations of Thomistic Virtue Ethics criticizes Kant’s ethics

because it takes it away from the first-person perspective.150 In “Karol Wojtyla, Sex

Reassignment Surgery, and the Body-Soul Union,” Jacob Harrison indicates that Wojtyla

dislikes the evacuation of bodily, human experience from morality in Kant’s ethics.151 Wojtyla

finds a synthesis for this division between bodily human experience and duty in Aquinas.152

In addition to being dualistic and deterministic, the ideology of gender builds on an

existential voluntarism. The problematic idealism of Descartes renders the body insignificant, at

best, and deceptive or burdensome, at worst. Since the body lacks meaning, it becomes the role

of the mind to give it meaning and definition. Consequently, constructionists utilize what I call

an existential voluntarism to define the person and the body. It is existential insofar as the

individual gives definition to the body, just as in contemporary existentialism the individual

defines his or her purpose for existing.153 It is voluntaristic insofar as such an act presumes

absolute freedom. Theological voluntarism, which emphasizes the omnipotent will of God over

the omniscient intellect, originates with Duns Scotus.154 In Schopenhauer155 and Nietzsche156 the

will provides the content of intelligibility. Speaking to this tendency, John Paul II, in Veritatis

Splender says, “a freedom which claims to be absolute ends up treating the human body as a raw

datum, devoid of any meaning and moral values until freedom has shaped it in accordance with

its design.”157 Not only is the body relative, but the ethics that govern the body are relative too.

Each individual is free to ascribe meaning to the unintelligible body. It is in this philosophical

milieu that Bruce Jenner tells Diane Sawyer that he feels like a woman trapped in a man’s

body.158

In Amoris Laetitia Pope Francis, denies the omnipotent freedom which the ideology of

gender presumes insisting that as creatures humans must receive creation as a gift.159 Francis

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challenges the faithful to help young people accept their bodies as created—male and female.160

In a General Audience on Man and Woman, Francis speculates that people attempt to cancel out

sexual difference because they do not know how to confront it.161 However, he warns that

removing difference only creates problems.162 Instead, he recommends listening to others as

means to understanding the other.163

c. Theological

While Descartes builds his philosophy on doubt, Christian anthropology builds on a

foundation of trust. It presumes ontological and epistemic realism; namely, that the human

person, beginning with the bodily senses, accurately perceives the world. Implicitly, this means

that God is trustworthy. Because God creates according to an intelligible and immutable order,

humans are able to engage with the world and even perceive God’s handiwork in creation.

Furthermore, Christian anthropology is holistic; the human person is not merely a soul

trapped in a body. Following the proceedings of the Fifth Lateran Council, John Paul II asserts

that for the human person, “the rational soul is per se et essentialiter the form of the body.”164

The human person is not merely the soul; rather, the human person constitutes the substantial

unity of body and soul.165 The unity between the body and the soul is so strong that the very

definition and existence of the human person depends on it. Indeed, Aquinas holds that in

death—the separation of the body from the soul—the human person dies.166 In an address to the

18th International Congress of the Transplant Society, John Paul II defines death of the person as

a single event, which consists of the total disintegration of the unitary and integrated whole that

is the personal self.167

John Paul II addresses human sexuality in his Theology of the Body, which is largely an

extended theological commentary on Scripture passages that form the foundation for Christian

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theological anthropology beginning with Genesis 1-3.168 Far from a literalist account of how God

creates the world, Genesis 1-3 is a theological explication of the human condition.169 God creates

everything from nothing. Humans, however, are unique in that God creates them in His own

image and likeness.170 God gives humans stewardship over the rest of creation.171 God also

creates humans, male and female.172 It is precisely in this difference between male and female,

which manifests a difference in the human person, that it is possible for humans to mirror the

communion of persons in the Triune God.173 Concretely, this is actualized in the marital act,

which is also the means for fulfilling the command to be fruitful and multiply.174

In chapter 5 of his book, Sex and Virtue, John S. Grabowski highlights the challenges that

sexual difference poses for an adequate philosophy of human nature.175 Equality and difference

are two important Scriptural features that one must preserve.176 Grabowski distinguishes between

essentialists and constructionists.177 This is analogous to the divide between biology or nature

and environment or nurture. Essentialists point to biological difference and emphasize that sex is

part of nature.178 As the above articulation demonstrates, constructionists argue that one largely

constructs gender and sexuality through culture and society.179 Extreme essentialism tends

toward determinism, which clashes with human freedom, while extreme constructivism—

reflective of a dualistic separation of the person from the body—denies the integral impact the

body has on the human person.180

Grabowski holds that human sexuality is not a difference of essence, since such a

difference implies a difference of natures. If natures are different, then equality is also lost.

Neither does he argue that human sexuality is merely a cultural construct. Rather, he argues that

human sexuality is based on the person. Just as the relations between persons in the Trinity

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account for the respective persons therein, so relations give definition to human persons. Of

course, for humans, the capacity for communion is reflected in the body by sexual difference.

Elliott Bedford and Jason Eberl, in “Is the Soul Sexed? Anthropology, Transgenderism,

and Disorders of Sex Development,” hold that sexual difference transcends even the level of the

body to the soul as well.181 They contend that strictly speaking, the soul is not sexed since it is

immaterial; however, insofar as it connects from the moment of creation with a sexed body it

constitutes an inseparable accidental quality of the human being.182 Therefore, they hold that the

soul is sexed.183 Edward Furton, in “The Soul Is Not Sexed,” argues that Bedford and Eberl’s

perspective not only diverges from traditional Thomistic anthropology, but that it also introduces

undesirable possibilities, such as, the possibility that God places the wrong soul in the wrong

body.184 In addition, according to such a formulation, it runs aground of dualistic tendencies

insofar as it connects sexual difference to the soul.

Bedford and Eberl respond to Furton’s critique in “Actual Human Persons Are Sexed,

Unified Beings,” asserting that the soul in abstract—logically without reference to the body—is

not sexed, however, in accord with Aquinas, just as the soul is individuated after creation by its

connection to the body, so the soul is sexed, so-to-speak, after its connection to the body.185

Therefore, insofar as the soul and the body do not exist ontologically or temporally before each

other and the so-called sexing of the soul takes place precisely because of its connection to a

sexed body, it is impossible for God to put the wrong soul in the wrong body.186 In particular,

Bedford and Eberl are concerned about the individuation and sex of the soul during the time after

death—when the soul is separated from the body—and before the resurrection.187 Although the

human person dies, they contend that the inseparable, accidental quality of sex that the body

confers on the soul abides.188 By asserting that the sexing of the soul is not an essential

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characteristic of the soul, he successfully avoids Furton’s critique that God or some other entity

could mistakenly place the sexed soul in the wrong body.

In addition to arguing that the soul is sexed by the body, so-to-speak, they assert that

intersex conditions and disorders of sexual development do not pose issues regarding ontology,

but merely epistemology.189 In other words, while intersex conditions may render it difficult for

one to determine one’s biological sex, it does not mean that one cannot determine which binary

sex one belongs to ontologically or biologically. In fact, as the first subsubsection in the previous

subsection demonstrates, genetic determination of biological sex does support such a view.

Consequently, the sexual body influences the human person and contributes to one’s

fulfillment.190 In other words, every human person is a sexual human person, which also relates

to the human vocation of love.191 For Grabowski, and John Paul II, human persons are unique

precisely because they are created in the image and likeness of God. In Mulieris Dignitatem,

John Paul II explains that having been endowed with a rational intellect and a free will, humans

have the capacity to love in their nature, which entails the capacity for relationship.192 They are

able to relate to God and one another. Humans relate to one another as a community of

persons.193 But the primary form of human relations is the communion of persons physically

manifest by the marital act, whereby husband and wife become one flesh.194 This is possible

precisely because of the physical differences between the sexes, which also manifests the

inherent complementarity and speaks to the longing for communion that every person

experiences.195

Analogously, just as the eternal love between the Father and the Son engenders the

spiration of the Holy Spirit, so the communion of persons manifest in the marital act engenders

human life by giving rise to offspring. For this reason, marriage and the family constitute a

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primordial cell for larger communities.196 Whenever a husband and a wife engender a child

through the marital act, they are cooperating in the sacred act of creation of a new human

person.197 While the mother and father contribute the biological seeds for creation, God creates

the human soul.198

God does not create arbitrarily; rather each individual has a particular calling or vocation

that has eternal implications. Charity is the form of all vocations.199 In other words, God calls

everyone to make a sincere gift of oneself for the sake of others.200 This form of love is self-

sacrificial, in that it considers the wellbeing of the other before oneself. It constitutes the agape

love, which Christ demonstrates by his death on the Cross.201 While most are called to the

married life, some are called to a vocation of charity that entails celibacy.202 Regardless, one’s

sexuality is foundational for forging one’s life of charity. Put another way, everyone lives out his

or her vocation through his or her sexuality.203 In the married life this entails the marital act,

while in celibate vocations it does not.

While society focuses on conjugal relations as the ultimate expression of one’s sexuality,

for the Church, sexuality has a deeper meaning. John Paul II argues for a spousal meaning of the

body, which corresponds to the masculinity and femininity of the human person.204 Insofar as

sexuality characterizes the human person it also forms how one lives out one’s vocation to

Christian charity.205 Every man has a vocation to fatherhood, while every woman has a vocation

to motherhood.206 This is not restricted to mere physical parenthood.207 Indeed, some are called

to spiritual fatherhood or motherhood, as is the case with priests and religious.208 Essentially, a

woman’s femininity shapes how she loves just as a man’s masculinity shapes how he loves.

This subsection demonstrates the incompatibility of the ideology of gender, which

underlies arguments in favor of sex reassignment therapies, on the basis of three categories:

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medical, philosophical, and theological. The following subsection considers sex reassignment

surgery in light of the Principle of Totality and Double Effect.

iii. Totality and Double Effect

This subsection shows that the Principle of Totality and the Principle of Double Effect do

not justify sex reassignment surgery in patients with gender dysphoria, especially in light of the

above-discussed implications for anthropology.

a. The Principle of Totality and Integrity

In general, respect for the human person precludes the mutilation of one’s body.

Whenever something causes harm to even the smallest part of one’s body, it harms the whole

person. Theologians argue that the human body belongs to God. As such, no one is

unequivocally free to harm oneself or another. However, circumstances arise when it is

necessary to perform operations that harm the body but benefits the whole person. The Principle

of Totality and Integrity justifies such acts.209 The United States Conference of Catholic Bishops’

Ethical and Religious Directives for Catholic Health Care Services, insists that everyone has a

right and duty to protect and preserve the body and its functional integrity; however, one may

sacrifice the latter to maintain the health or life of the person, if no other permissible means

exists.210 The following constitutes an articulation of the Principle of Totality as Aquinas and

Pius XII articulate it and theologians apply it to sex reassignment surgery.

In the Summa Theologica, Aquinas addresses circumstances that may warrant maiming

the body.211 He argues that removing a healthy member of a person’s body does harm to the

whole person, and therefore, is unlawful.212 However, one may lawfully remove a diseased body

part, if doing so benefits the whole person.213 This line of reasoning justifies the amputation of

diseased limbs. This constitutes a rudimentary form of the Principle of Totality.

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In 1735, Claudius Amyand performed the first successful appendectomy on an 11-year-

old boy.214 While Aquinas’s articulation justifies the removal of diseased limbs or organs, it does

not yet address circumstances whereby one may need to surgically damage healthy tissue to get

to and extract diseased organs or remove healthy organs that exacerbate medical conditions. Pius

XII develops the Principle of Totality in an “Address to the Delegates at the 26 th Congress of

Urology,” that covers such circumstances.215 Although it renders the patient sterile, Pius XII

argues that one may remove a prostate cancer-sufferer’s testicles (bilateral orchiectomy), since

male hormones—that the testicles produce—speed the growth of prostate cancer.216

He offers three conditions that must be met to justify the removal of a healthy organ that

exacerbates another condition.217 First, the continuing function of the organ in question must

cause serious damage or constitute a threat.218 Second, the only way to avoid this damage or

threat is to mutilate (remove) this organ, and that the effectiveness of doing so it well assured.219

Finally, the positive effect of removing the organ must outweigh any negative effects.220

Becket Gremmels argues in “Sex Reassignment Surgery and the Catholic Moral

Tradition: Insight from Pope Pius XII on the Principle of Totality,” that one struggling with

gender dysphoria may meet the three criteria for the Principle of Totality and Integrity that Pius

XII proposes to justify sex reassignment surgery. 221 First, he acknowledges that theologians

traditionally argue against sex reassignment surgery because it renders the patient sterile.222

Gremmels insists that for one struggling with gender dysphoria, his or her genitalia contribute to

and exacerbate gender dysphoria, thereby meeting the first criteria and the first part of the second

criteria.223 However, Gremmels is unsure if sex reassignment surgery meets the second criteria—

well-assured effectiveness—and the third criterion.224

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Gremmels argues that although the Principle of Totality normally refers to parts of the

body for the sake of the whole, one may envision sacrificing body parts for the sake of other

parts of the person.225 To explain, he introduces a Cartesian, dualistic understanding of the

human person.226 In “The Principle of Totality Does Not Justify Sex Reassignment Surgery,” I

explain the incongruence between the Cartesian, dualistic understanding of the human person

and the integral understanding of the human person as body-soul unity.227 Similarly, John F.

Brehany, in “Pope Pius XII and Justifications for Sex Reassignment Surgery,” indicates that the

first criteria could never be met since a real disjunction between the body and the soul cannot

exist.228

Brehany insists that Natural Law limits the scope of application for the Principle of

Totality.229 He refers to a previous statement by Pius XII regarding immanent teleology of

human nature and a hierarchy of values, which he argues contextualizes and limits the use of the

Principle of Totality.230 Brehany observes that Pius XII offers two instances that fail to respect

the hierarchy and teleology due to Natural Law: one, destroying one’s freedom to relieve a

psychological disorder, and two, “overcoming sexual repression through immoral behavior,”

both of which sex reassignment surgery attempts to do.231 E. Christian Brugger, in “Catholic

Hospitals and Sex Reassignment Surgery: A Reply to Bayley and Gremmels,” argues that this

same statement by Pius XII places a duty upon health care workers to affirm each person in the

sex that nature determines.232 Finally, Brehany understands Pius XII’s third criterion for the

Principle of Totality to only apply in circumstances that constitute life and death, which gender

dysphoria does not include.233

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b. The Principle of Double Effect

Carol Bayley, in “Transgender Persons and Catholic Healthcare,” argues that the

Principle of Double Effect justifies the use of sex reassignment surgery in persons with gender

dysphoria.234 This subsubsection articulates the Principle of Double Effect and demonstrates

how in the context of Catholic anthropology sex reassignment surgery is not morally permissible.

First, I elucidate the Principle of Double Effect. Second, I summarize Bayley’s argument. Third,

I pinpoint the Moral Object of the Act for sex reassignment surgery.

Like the Principle of Totality, Aquinas is the first to introduce Double-Effect Reasoning

in the Summa Theologica.235 In response to the question of killing in self-defense, Aquinas

observes that some actions have a good and a bad effect, one intended and the other

unintended.236 For example, in self-defense, one may intend to save one’s life by an action that

has an unintended effect of killing an assailant.237 Self-defense, however, is not a veil for an

immoral intention. Aquinas agrees with Augustine that one should never intend to kill another

person, even for a good ulterior motive—saving one’s life.238 Consequently, Aquinas insists that

one’s defensive act must be proportionate to the assailant’s attack.239

T. A. Cavanaugh, in Double-Effect Reasoning: Doing Good and Avoiding Evil, offers a

contemporary formulation of the Principle of Double Effect.240 First, the act in question must be

good in itself, or at least indifferent.241 In other words, the Moral Object must be good or neutral.

Second, the agent must intend the good effect, and not the bad effect.242 In Thomistic terms, the

bad effect must be praeter intentionem—beside the good effect.243 Cavanaugh argues that

foreseen is the best way to describe the will’s relationship to the bad effect.244

Third, the bad effect must not cause the good effect.245 This third criterion arises from a

casuistic approach to ethics, that is, a third-person approach.246 During the manualist period of

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ethics, that is, when instructors taught ethics from manuals, ethicists focus on the perspective of

the outside observer, as opposed to the first-person perspective.247 From the perspective of the

acting person one may reword this third criterion as no good end justifies an evil means (Moral

Object).248 Fourth, there must be a proportionately grave reason for performing the act with such

a negative consequence.249 This corresponds to Aquinas’s concept of using proportionate means

to repel an attack, for instance.250 One corollary to the fourth criterion is that no legitimate

alternative may exist.251

Bayley argues that one may justify sex reassignment surgery for patients presenting with

gender dysphoria. First, in accord with the first criterion of Double Effect, she insists that sex

reassignment surgery is morally neutral.252 Second, Bayley asserts that the good effect is that the

inside experience matches the outside of the person.253 The sterilization does not cause the good

effect, but merely constitutes an unintended, yet foreseen consequence of correcting a birth

defect.254 Although not stated explicitly, presumably sex reassignment surgery is not only

proportionate to the pathology, but the only legitimate alternative.

Bayley’s line of reasoning contends that transgenderism is analogous to disorders of

sexual development.255 She holds that hormonal delivery and brain structure influence gender

dysphoria.256 Consequently, since physicians are willing to utilize the whole gamut of procedures

to correct anomalies associated with mastectomies or so-called bottom correcting surgeries on

patients recovering from cancer or disorders of sexual development, respectively, then they

ought to perform them on patients with the pathology of gender dysphoria.257The problem with

this line of reasoning lies in the faulty anthropology, which Bayley utilizes to formulate her

argument. Bedford and Eberl argue that there is an essential difference between procedures that

treat disorders of sexual development and sex reassignment surgery, which reflects an

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anthropological difference.258 Accordingly, disorders of sexual development do not challenge the

binary sexual complementarity, but only make sense in the context of such a binary milieu.259

As the above section demonstrates, advocates for sex reassignment surgery hold three

anthropological positions that are contrary to Catholic anthropology: Cartesian dualism,

materialistic determinism, and existential voluntarism. Bayley, holds that the internal sex of the

person may differ from one’s natal sex.260 Bedford and Eberl refer to this as the subconscious sex

or the sex of the mind.261 Cartesian dualism is inherent in this position, because it presumes a

dichotomous relationship between one’s internal experience and the external body. In addition,

advocates hold the mutually exclusive positions that culture and society construct gender and

that biology determines it.262 Presumably, if biology determines the subconscious sex of the

mind, then the transgender experience merely constitutes a birth defect that one ought to correct

with sex reassignment surgery.263 Contrarywise, if gender is merely constitutive of social or

cultural construction, then it does not depend on biology at all; rather, one is free to change one’s

biology to accord with one’s socially-constructed subconscious sex, which reflects existential

voluntarism. As the above demonstrates, advocates of gender ideology use both arguments to

justify sex reassignment surgery. Both contradictory positions cannot be correct; however, both

can be wrong.

Bayley intimates that sex reassignment surgery is no different than a surgical procedure

in patients with disorders of sexual development and therefore, the act itself is neutral.264 The

action itself refers to the Moral Object, which constitutes one of the three criteria that determine

the morality of the act according to the Catechism of the Catholic Church: object, end, and

circumstances.265 For Beford and Eberl, the difference between therapies to treat disorders of

sexual development and sex reassignment surgery not only reflects a difference in anthropology,

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but also a difference in the Moral Object.266 The following elucidates the Moral Object, in

general, and in particular, for sex reassignment surgery.

For Aquinas, all actions have ends.267 Properly speaking, human actions proceed from a

deliberate will, that is, reason configures an action such that the will chooses it as a good end.268

What is last on the order of execution is first on the order of intention; therefore, actions begin

with intention.269 In other words, whenever one sets out to do something, one has a purpose in

mind for doing it. The purpose is what Aquinas identifies as the intention or end of the act—the

second of the three above-mentioned criteria that determine the morality of an act.270

In contrast, the Moral Object constitutes a means chosen for an end, which constitutes an

action.271 Insofar as the Moral Object is an action, which the will chooses and executes, Aquinas

distinguishes between the internal and external act; the former concerns intention/end, while the

latter concerns choice/Moral Object.272 Concerning the exterior act, Aquinas insists that materia

circa quam identifies the Moral Object which reason configures and presents to the will as an

object of choice.273 The external act, materia ex qua, on the other hand, identifies the physical act

itself, devoid of intention.274 Because the Moral Object has intentional content, Aquinas uses

proximate end to distinguish the Moral Object from the ulterior end.275

Ethicists get into trouble when they equate the Moral Object with either the physical act

devoid of intentional content, that is, the external act materia ex qua, or when they equate it with

the intention, that is, the purpose of the act. Both tendencies occur when one approaches moral

decision making from a third-person perspective, rather than a first-person perspective.

Manualists, for example, tend to equate the Moral Object with merely the physical act itself. By

way of illustration, manualists define the sin of contraception as coitus interruptus.276

Conversely, proportionalists such as Peter Knauer, equate the Moral Object with intention.277

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Knauer establishes proportionalism in opposition to the manualists, but he retains the

physicalistic methodology, defining moral evil as the causing of evil in the world.278 Both

commit the Naturalistic Fallacy. They assume that the moral order derives from the natural

order.279 To avoid this ethical pitfall, one must maintain the first-person perspective of ethics, not

defining moral evil in purely physical terms. Consequently, Gremmels moral intuition is correct

to reject an ethical objection against sex reassignment surgery merely because it results in the

physical condition of sterilization.280

In accord with the above-mentioned philosophical theories, Bedford and Eberl determine

that the immediate (or proximate) end, that is, the Moral Object in question, sex reassignment

surgery for patients experiencing gender dysphoria is bodily or personal integration.281 Insofar as

Catholic theological anthropology denies such a dualistic understanding of the body-soul

composite of the human person, such a presumptive Moral Object is immoral.282 At the same

time, they reject a reductive materialistic concept that presumes a divide between the sex of the

mind and the sex of the body.283

Therefore, strictly speaking, sex reassignment surgery is not immoral because of the

physical consequence of sterility which it unequivocally induces, but because it presumes to

correct a problem that cannot exist—an internal sexual identity that diverges from one’s so-

called external sex. Of course, as Brugger suggests, such a line of reasoning not only calls into

question sex reassignment surgery, but any therapies that collude with the patient in such a way

that one presumes to alter another’s biological sex so as to accord with one’s internal gender.284

In a culture where action—especially physical intervention—seems to outweigh apparent

inactivity, the appropriate response to gender dysphoria is accompaniment, which the Ethicists of

The National Catholic Bioethics Center advise.285 By accompanying individuals suffering with

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gender dysphoria one not only avoids causing irreparable harm, but also aides them in achieving

authentic human flourishing.

This section reveals that a Thomistic understanding of the Moral Object steeped in the

context of Catholic anthropology, prohibits an argument in favor of sex reassignment surgery for

patients presenting with gender dysphoria either with recourse to either the Principle of Totality

or Double Effect. The following section examines the use of contraceptives for non-


6B. Non-Contraceptive Benefits of Contraceptives

This section analyzes the clinical mechanism of several contraceptive methods focusing

on intrauterine devices and implants, because of the complexity of their physiological

mechanism of action and the longevity of their use. Second, I articulate a Thomistic

understanding of the Moral Object so as to distinguish utilizing a contraceptive medication as a

contraceptive versus using it for its non-contraceptive benefits. Third, in light of the negative

side effects, including potential abortifacient activity, I use the Principle of Double Effect to

further analyze and justify the potential use of contraceptive medications for non-contraceptive

benefits.


This subsection analyzes the clinical use of intrauterine devices as a contraceptive. Then,

it explores the use of implants as contraceptives. Finally, it considers the non-contraceptive

benefits of both.

a. Intrauterine Devices as a Contraceptive

According to Marc A. Fritz and Leon Speroff, historically, the first intrauterine devices

are stem pessaries, that is, small button-like structures with stems that cover the opening of the

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cervix.286 Carl Hollweg is the first physician to patent such a device, which he originally

intended to support the uterus, not, however, to act as a contraceptive.287 According to Lazar

Margulies in “History of Intrauterine Devices,” Richard Richter is the first physician to patent an

intrauterine device as a contraceptive, utilizing silkworm, catgut, and a wire that extends through

the cervix.288 Karl Pust replaces the wire with a catgut string.289 In the late 1920s, Ernest

Graefenberg experiments with metallic rings of various alloys of gold, silver, copper, nickel, and

zinc.290 Great Britain, Canada, and Australia use these early intrauterine devices, while the

United States and continental Europe largely reject them because of high rates of expulsion and

infection.291

In 1960, Margulies develops the first plastic intrauterine device called Margulies Coil.292

The turgid plastic tail proves precarious for sexual partners. In response, Jack Lippes offers the

first intrauterine device with a filament thread at the first international conference on intrauterine

devices in 1962.293 In subsequent years entrepreneurs develop alternate devises, which lead to

wide utilization during the 1960s and 1970s. However, the Dalkon Shield proves dangerous

because its multifilament plastic-covered tail transmits bacteria giving rise to many cases of

pelvic inflammatory disease.294 Subsequent lawsuits and negative publicity—from the lawsuits

and allegations that intrauterine devices cause infertility—lead to a bad rap for all intrauterine

devices and their use diminishes during the 1980s and 1990s.295 In 2009, only 2% of women who

use contraceptives in the United States choose an intrauterine device.296

In the late 1960s, Jaime A. Zipper and Howard J. Tatum develop the first intrauterine

device that uses copper.297 Although there is no consensus, Fritz and Speroff hold that copper

prevents implantation of a fertilized ovum.298 Daniel R. Mishell in “Intrauterine Devices,” argues

that copper-bearing intrauterine devices disrupt the ability of sperm to survive and move into the

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fallopian tubes.299 Mishell holds that the low number of ectopic pregnancies indicates that

fertilization rarely occurs.300 The ESHRE Capri Workshop Group in “Intrauterine Devices and

Intrauterine Systems,” argues that since insertion of a copper intrauterine device in early luteal

phase is highly effective as an emergency contraceptive, it must perform some post-fertilization

action, producing an embryotoxic environment.301 In the United States, TCu-380A, also called

ParaGard represents the copper intrauterine device still in use today.302 While it is only approved

to prevent pregnancy for 10 years, wearing it for 20 years carries a small risk for pregnancy.303

The levonorgestrel-releasing intrauterine system, marketed as Mirena® and manufactured

by Schering-Oy,304 has been available in Europe since 1990 and the United States since 2000.305

This device prevents pregnancy for at least 5 years by releasing 20μg of levonorgestrel per day,

in the first year, and 11μg by the end of the fifth year.306 Similar to copper intrauterine devices, it

induces an immunological response as a foreign body causing the endometrium to release

leukocytes and prostaglandins.307 In addition, the levonorgestrel thickens the cervical mucus

preventing the transport of sperm through the cervical canal.308 As Mishell, indicates both copper

intrauterine devices and levonorgestrel-releasing intrauterine systems induce an inflammatory

response, which causes leukocytes to phagocytize the sperm.309 In addition, levonorgestrel-

releasing intrauterine systems act as abortifacients by thinning the endometrium, preventing

implantation should fertilization occur.310

b. Long-Acting Contraceptives

There are two unique, long-acting contraceptives available for market in the United

States: implants and depot-medroxyprogesterone (Depo-Provera).311 As with intrauterine

devices, the advantage for long-acting contraceptives is that they do not require a high degree of

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user compliance in order to get a high degree of contraceptive efficiency. This subsubsection

discusses the history and mechanism of these two contraceptives.

The Population Council develops the first implant, which they market as Norplant and

receives approval for use in Finland in 1983.312 The United States Food and Drug Administration

approves it for use in the US in 1991; however, because of profit and liability disputes, the

United States market withdrawals it in 2002.313 Norplant consists of six small capsules

containing levonorgestrel, which leaches 39μg into the body per day elevating plasma

progesterone levels providing at least five years of pregnancy prevention.314 Norplant’s primary

mechanism of action is anovulation.315 In addition, the elevated levels of progesterone impair

sperm ascent to the fallopian tubes.316 It also appears to inhibit endometrial development, thereby

preventing implantation, should fertilization occur.317 However, Sheldon et al. argue that it is

very unlikely that fertilization occurs, since they did not observe elevations in human chorionic

gonadotropin, which the trophoblast produces in order to maintain the function of the corpus

luteum, for which survival of the pregnancy depends.318

There are two United States Food and Drug Administration-approved contraceptive

implants in the United States: Implanon and Jadelle.319 The United States Food and Drug

Administration approves Organon-manufactured Implanon in July 18, 2006.320 Implanon is an

etonogestrel 65mg single-rod implant that a physician implants under skin of the woman’s

underarm.321 It constitutes a slow-release progestin that last for at least three years.322 Note that

progestin refers to synthetic progesterone analogues.323 Jadelle, United States Food and Drug

Administration-approved in 1996, similar to Implanon, consists of two thin rods each containing

75mg of levonorgestrel, wrapped in steroid-permeable silastic tubing.324 Fritz and Speroff say

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that implants are a good method of contraceptive for women of reproductive age that are

sexually active and want to stave off pregnancy for 2 to 3 years.325

There are three primary mechanisms for implants. First, progestin suppresses luteinizing

hormone at both the pituitary and hypothalamus, which is necessary to induce ovulation.326 In

some women ovulation does occur toward the end of five years, but the luteal is insufficient.327

In addition, progestin affects cervical mucus causing it to thicken and decrease, which inhibits

sperm penetration.328 Finally, progestin suppresses the estradiol-induced cyclic maturation of the

endometrium.329 Consequently, if fertilization does occur—of which there is no evidence—

implantation will not ensue.330

The last contraceptive to consider is depot-methroxyprogesterone acetate marketed as

Depo-Provera. Historically, Searle and Upjohn simultaneously discover depot-

methroxyprogesterone acetate in 1956.331 The United States Food and Drug Administration first

approves Upjohn’s medroxyprogesterone acetate, the active ingredient in Depo-Provera, in 1959

to treat amenorrhea—the absence of menstruation—irregular uterine bleeding and

miscarriages.332 In 1960, the United States Food and Drug Administration approves Depo-

Provera to treat endometriosis—the growth of endometrial tissue outside the uterus.333 In 1974,

the United States Food and Drug Administration rescinds its approval of Depo-Provera for

treating miscarriages and endometriosis.334 In 1972, the United States Food and Drug

Administration approves it for treating inoperable and metastatic endometrial and renal cancer.335

Although the United States Food and Drug Administration notes the effectiveness of 150mg

injections at preventing pregnancy, it repetitively questions its safety because of two long-term

animal studies in which beagles develop breast cancer and monkeys develop endometrial

cancer.336 In Contraceptive Risk: The FDA, Depo-Provera, and The Politics of Experimental

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Medicine, William Green follows, in detail, the chronological development of the United States

Food and Drug Administration’s eventual approval of Depo-Provera in 1992.337

The current prescribed dosage remains a 150mg injection every three months.338 The

mechanism is slightly different from the abovementioned implants insofar as the progestin level

are high enough to completely block luteinizing hormone surges, thereby completely preventing

ovulation.339 In addition, the cervical mucus thickens and the endometrium changes.340 Depot-

methroxyprogesterone acetate does not inhibit follicular stimulating hormone, so follicular

growth continues, consequently, estrogen levels remain normal.341

c. Non-Contraceptive Benefits of Contraceptives

Each of the abovementioned contraceptive methods has both positive and negative side

effects. Some argue that the negative side effects suffice for a wholesale rejection of these

methods for any beneficial use. This subsubsection highlights the clinical side effects of each of

the abovementioned methods, focusing especially on the positive. In particular, it focuses on the

use of these medications to treat amenorrhea and pain associated with endometriosis.

In his medical glossary in Contraceptive Risk: The FDA, Depo-Provera, and the Politics

of Experimental Medicine, William Green defines endometriosis as a painful condition in which

the tissue that lines the inside of the uterus grows outside of it.342 Like ordinary endometrial

tissue, it thickens, breaks down, and bleeds with each menstrual cycle; with nowhere to go, it

irritates surrounding tissue and eventually gives rise to cysts.343 Although there is no generally

accepted explanation for the pathogenesis of endometriosis there are several working theories.

John Sampson, the first gynecologist to use the term to describe cysts associated with

endometriosis,344 develops the first theory to explain its pathogenesis called retrograde

menstruation and implantation.345 Essentially, he argues that during menstruation endometrial

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tissue transfers through the Fallopian tubes into the peritoneal cavity, where it implants on pelvic

organs.346 The coelomic metaplasia theory holds that coelomic epithelial cells in the peritoneum

and the pleura that differentiate into mesothelial cells experience spontaneous metaplastic

change.347 The induction theory holds that such change occurs because of exposure to menstrual

effluent.348 Although other theories exist, these constitute the most obvious explanations.

Immunologically, ectopic endometrial cells in women with endometriosis are less

vulnerable to macrophages-mediated immune surveillance and clearance.349 In addition,

endometrial cells are resistant to apoptosis—gene-regulated programed cell death.350 Estrogen

overproduction occurs in endometriotic—ectopic endometrial cells—stromal cells—cells

pertaining to connective tissue—because of the presence of steroidogenic factor 1, which

combines to induce the expression of steroidogenic acute regulatory protein and CYP19A1.351

Women with endometriosis also seem to have resistance to progesterone,352 which may be

attributable to progesterone receptor deficiency in endometrial and endometriotic stromal

cells.353 Progesterone activates the retinoic acid pathway in normal endometrial stromal cells,

which gives rise to differentiation and apoptosis.354

Treatment for endometriosis depends largely on the extent of the disease and severity of

symptoms.355 Physicians treat more severe cases with surgery.356 Medical treatment consists of

estrogen-progestin contraceptives, progestin, gonadotropin-releasing hormone agonists, danazol,

and aromatase inhibitors.357 All of these treatments inhibit fertility insofar as they prevent

ovulation.358 Estrogen-progestin contraceptives mimic the hormonal environment of pregnancy

and may improve apoptosis in eutopic endometrial tissue.359 At the same time, estrogen has been

shown to activate endometrial growth, exacerbating the condition and symptoms.360 Moreover,

the withdrawal of estrogen reverses endometrial cell viability.361 Joon Song holds that estrogen

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acts as a survival factor inhibiting apoptosis.362 Progesterone, on the other hand, induces

apoptosis.363 Hence many physicians find progestin-releasing contraceptives particularly

effective for treating endometriosis, which includes all of the methods in the first

subsubsection.364 Unfortunately, in women with endometriosis, the endometrial and

endometriotic cells are more sensitive to estrogen and resistant to progesterone, limiting the

effectiveness of progestin-releasing contraceptives for treating endometriosis and its

symptoms.365

Gonadotropin-releasing hormone agonists induce pseudomenopause preventing the

ovaries from receiving gonadotropin stimulation, thereby depriving the body of estrogen support

and inducing amenorrhea—the absence of menstruation, which prevents further seeding in the

peritoneal.366 Unfortunately, gonadotropin-releasing hormone causes significant decrease in bone

density in patients with endometriosis.367 Danazol, the first drug United States Food and Drug

Administration approved specifically to treat endometriosis prevents the luteinizing hormone

surge; therefore, inducing a state of indefinite anovulation.368 Unfortunately, the many

androgenic and hypoestrogenic side effects limit its utility.369 Finally, Aromatase inhibitors have

had very limited outcomes, but warrant further research, especially in combination with other

medications.370

Another common condition that affects women is abnormal uterine bleeding sometimes

called menorrhagia, which may be associated with any number of underlying conditions

including: pregnancy, anovulation, uterine pathology, or coagulopathies.371 Bleeding is common

with menses, that is, menstruation, which is part of the normal ovarian cycle. During the

follicular phase, estrogen levels rise in an exponential fashion causing the functional layer of the

endometrium to grow.372 After ovulation—the release of a mature ovum—the remaining corpus

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luteum continues to produce estrogen, but also begins producing progesterone.373 Both hormones

rise with the maturation of the corpus luteum, causing further development of the endometrium

in anticipation of implantation should fertilization occur.

If fertilization does not occur, then the corpus luteum spontaneously dies in apoptosis,

causing levels of both estrogen and progesterone to fall.374 The steady decrease in these

hormones induces an inflammatory response, whereby lysosomes release enzymes into the

cytoplasm of epithelial, stromal, and endothelial cells of the endometrium and the intercellular

spaces, which, in turn, digest these cells and their constituents.375 The enzymatic activity on the

endometrium eventually reaches the subsurface capillaries and veins causing interstitial

hemorrhaging, the components of which escape into the endometrial cavity.376 Vasoconstrictors

halt menstrual bleeding in the exposed spiral arterioles of the basal layer endometrium.377 Once

re-epithelialization concludes bleeding halts completely.378

Since the presence or absence of estrogen and progesterone has such an important role in

regulating menstruation, these hormones are also instrumental in helping to reduce bleeding in

women with heavy bleeding during menses. At the same time, the exogenous addition or

subtraction of estrogen and progesterone (or progestin) can cause breakthrough bleeding—

bleeding before menses—or estrogen/progestogen withdrawal bleeding—primarily due to the

disproportionate presence of these hormones.379 In spite of this risk, estrogen-progestin

contraceptive and levonorgestrel-releasing intrauterine system are common medicinal treatments

for heavy menstrual bleeding, since the progestin, the dominant hormone, inhibits menses.380

In addition, these medications are effective at preventing anovulatory bleeding.

Anovulation amounts to a perpetual state of follicular phase, since ovulation does not occur.381

Consequently, the body only releases estrogen, which causes the endometrium to grow without

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the limiting effect of progesterone. The endometrium lacks sufficient stromal support cells

giving rise to focal breakdowns that bleed.382 For women with anovulatory bleeding, the addition

of exogenous progestin restores the natural mechanism whereby the endometrium sheds through

regular menses.383

This subsection demonstrates that the physiological mechanisms of contraceptives have

positive effects on endometriosis and heavy bleeding. The following subsection delineates the

Moral Object of using contraceptives for non-contraceptive benefits.

ii. Object

This subsection analyzes the development of the Catholic Church’s teaching concerning

the use of contraceptives as a means of birth control, especially focusing on identifying its Moral

Object. Then, it identifies the Moral Object of utilizing the abovementioned contraceptive

methods for their non-contraceptive benefits.

a. Contraception, Casti Cannubii, and the Manualist

In Contraception: A History of Its Treatment by the Catholic Theologians and Canonists,

John T. Noonan, Jr. meticulously follows the precarious relationship between the Catholic

Church and contraception.384 Noonan correlates the sharp decline in birth rate in Catholic France

during the nineteenth century to the increased use of contraception.385 He attributes the

acceptability of contraception to the rationalist malaise that sets in after the Revolution.386 In

direct opposition to Catholic teaching, the anti-clerical French embrace the individualistic and

radical ideals of rationalism, which instigates the Revolution. Consequently, they embrace the

concept that the human body is merely a machine, the parts of which one may manipulate to

achieve one’s ends.387 Noonan adds that the prospect of economic success also motivates the

French working class to diminish their obligations, by reducing the number of progeny.388

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Noonan concludes that the initial motivation for the spread of contraception is irreligious,

calculating, and egoistic.389

Noonan stresses that moral theology was at a nadir during the nineteenth century,

essentially amounting to seminary courses based on manuals, such as Jean Pierre Gury’s

Compendium of Moral Theology.390 In contrast to the rigidity of French Jansenism, Alphonsus

Liguori’s approach is more tolerant and guides Rome’s initial response to contraceptive acts,

which until the 1900s is indistinguishable from onanism or coitus interruptus.391 During the

second half of the nineteenth century, the use of contraception spreads as a social reform and

gains acceptance from medical, scientific, and religious authorities.392 At the Lambeth

Conference of 1930, Anglican bishops adopt a resolution that permits couples to use

contraceptive methods where they deem it morally expedient to avoid pregnancy.393

On December 31, 1930, Pope Pius XI responds with his encyclical Casti Connubii.394

Noonan describes this as an excellent distillation of past doctrinal statements.395 After

recapitulating the goods of marriage according to the Augustinian triad—offspring, fidelity, and

sacrament396—Pius XI reaffirms the necessity of growth in chastity with recourse to God’s

grace; rather than, circumventing such efforts by means of biology.397 Thus, Pius XI builds his

argument against contraception on two pillars: Natural Law and growth in chastity.

After enumerating several of the reasons couples give for avoiding children, Pius XI

argues that no reason justifies acts that are intrinsically contrary to nature, namely, anything

which frustrates the natural power for begetting children.398 He, with recourse to Augustine and

Scripture—recalling Onan—solemnly defends the Catholic Church’s position that any frustration

of the natural power of matrimony to generate life not only offends God, but also nature.399

Moreover, he chastises confessors who lead penitents into sin by approving of such acts, either

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by silence or in words.400 For him, the chief obstacle to couples fulfilling the law of matrimony is

unbridled lust that one can only overcome by subjecting oneself to God.401 Recourse to biology

and science to curb one’s carnal desires cannot establish chastity.402 Pius XI recommends humble

reflection on the sound wisdom of Church teaching concerning marriage, a steadfast

determination of will to observe God’s sacred law, and recourse to the grace of the sacrament.403

Until Paul VI publishes Humanae Vitae, Casti Cannubii constitutes the Church’s most

solemn pronouncement on contraception.404 Much of the debate following Casti Cannubii

centers on the meaning of Natural Law, since this constitutes the foundation of Pius XI’s

philosophical objection. Pius XI focuses on physical acts that interfere with or frustrate the

generative potential of the marital act. At the same time, Pius XI’s words in Casti Cannubii

implicitly permit couples desiring to postpone or space children to reserve the marital act for

times of natural infertility, 405 even if this is not what he originally intends.406 Of course, so-

called rhythm methods lack the reliability of barrier methods at the time. Since so much of the

debate focuses on the physical frustration of the act, when birth control pills arise in the 1950s,

moral theologians lack unanimity in their response. In fact, one of the pioneer physicians

utilizing progesterone, John Rock, insists that it conforms well to the theological expectations of

Catholic morality.407 In 1958, Louis Janssens writes “L’inhibition de l’ovulation, est-elle

moralement licite?,” in which he argues in favor of women taking progesterone to inhibit

ovulation.408 Progesterone appeals to Janssens because it only temporarily prevents ovulation and

does not kill any eggs.409

For Thomas Petri, much of the opposition after Casti Cannubii centers on objections to

the methodology of moral theology, which overly focuses on physical action and strict obedience

to the law.410 These characteristics of the manualist approach, Petri, in accord with Servais

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Pinckaers,411 John Mahoney,412 John A Gallagher,413 and Albert R. Jonsen and Stephen

Toulmin,414 attributes more to the nominalism of William of Ockham, than to Thomas

Aquinas.415 Ockham’s nominalism begins with the denial that universal forms exist

independently of human reason.416 Regarding morality, Ockham emphasizes freedom of

indifference over inclinations.417 For him, freedom constitutes one’s ability to choose actions

without persuasion from inclinations.418 Consequently, the sole cause of human action is self-

determination.419 Moreover, just as no universal forms exist independently of the human mind,

so moral truths depend exclusively on divine command.420 Hence, the morality of the manuals

emphasizes divine command and mere physical adherence to laws.

b. Proportionalistic Reformulation of the Moral Object

In turn, so-called proportionalists such as Louis Janssens attempt to retrieve the authentic

teaching of Aquinas to counter the impersonal and physicalistic inclinations of the manualist

tradition. In “Ontic Evil and Moral Evil,” Janssens attributes his distinction between ontic evil—

physical evil—and moral evil—the intending of physical evil in the world—to Aquinas.421

According to Janssens’s interpretation of Aquinas, there is a distinction between the means and

the end of an action. The means corresponds to the external action or the material element of an

act.422 Alternatively, the end corresponds to the internal act of the will, which constitutes the

formal act.423 Just as Knauer uses his interpretation of Aquinas’s proportion criterion for Double

Effect to explain how a commensurate reason may justify one choosing a means that causes

physical evil in the world,424 so Janssens argues that so long as the ends justify the means one

may indeed choose to cause ontic evil.425

More precisely, the debita proportio must suffice to justify the means chosen.426 Put

another way, Janssens argues that there must be no intrinsic contradiction between the means and

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the end.427 To illustrate, he uses the example of stealing. If one chooses to steal something from

another person as a means to affirming one’s right to ownership, the means do not justify the end

since one attempts to affirm the value of one’s own ownership at the cost of one’s neighbor’s

ownership.428 In this case, one is using a means that constituted as a value, contradicts the value

that one affirms as one’s end. Janssens applies this line of reasoning to responsible parenthood.

He argues that parents who know they do not have sufficient resources to raise more children sin

by engaging in the marital act during the fertile periods.429 Therefore, insofar as both the so-

called rhythm method and contraception do not obstruct conjugal love or responsible parenthood,

they constitute acceptable means of achieving responsible parenthood.430

c. Keeping the Object of the Act in the Genus Naturae

For Rhonheimer and John Finnis, maintaining the distinction between the moral order

and the natural order is essential for any authentic ethical methodology and failure to do so

constitutes the Naturalistic Fallacy.431 Hume first articulates the un-derivability of the moral

order from the natural order by asserting that one cannot derive ought-statements from is-

statements.432 Put another way, there is an irreducible difference between practical and

speculative reason. For Aquinas, the same intellect acts by extension in practical knowing.433

Although practical knowing of the self-evident principles of the Natural Law depends one first

knowing being speculatively,434 contrary to what Ralph McInerny says in Aquinas on Human

Action: A Theory of Practice,435 this does not mean the former derives from the latter. Indeed,

the formulations of practical syllogisms versus speculative syllogisms demonstrate this.436

At the same time, this does not mean that one must sacrifice objectivity or universality in

Natural Law.437 Finnis, in Moral Absolutes: Tradition, Revision, and Truth, contends that

exceptionless moral norms do exist.438 Ethicists call them intrinsically evil acts and formulate

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them as prohibitions. In Humanae Vitae, Pope Paul VI argues that contraception is an

intrinsically evil act.439 An intrinsically evil act constitutes an act whose Moral Object is

immoral, that is, contrary to reason.440 Intrinsically evil acts bear undue matter (indebitam

materiam).441 Unfortunately, as the above discussion demonstrates, manualism, under the

influence of nominalism, falls into the Naturalistic Fallacy insofar as it focuses on external

physical acts being in or out of conformity with the divine law, regardless of intent. John Paul II,

in Veritatis Splendor, insists that insofar as these acts are inherently contrary to reason, there is

no exception to their prohibition.442 No amount of good intention or plight of circumstances

justifies one deliberately choosing such an act. Janssens, however, argues that intrinsically evil

acts do not exist; sufficient intention can justify any means.443 While John Paul II’s argument

constitutes the traditional position of the Catholic Church against contraception, its methodology

is unique.

By refocusing the discussion of ethics on intention, proportionalists attempt to correct the

defective approach of the manualists; however, according to Rhonheimer, they fall victim to the

same Naturalistic Fallacy they rebuke.444 Just as the manualists mistakenly identify the Moral

Object as the physical content of an act, so proportionalists do the same. For Knauer, as well as

Janssens, the Moral Object constitutes the causing of physical good or evil in the world.445 In

method, this is no different than the manualist’s external conformity to divine law.

Janssens, Knauer, and Richard McCormick’s446 Moral Object diverges from Aquinas.

Rhonheimer accuses McCormick of expanding the notion of the object by placing the sole source

of intentional content in the remote end.447 Like McCormick, Janssens understands the external

act, which he and Aquinas equate with the Moral Object to be a material entity—completely

devoid of voluntariness.448 In one respect this is true. For example, Janssens understands the act

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commanded by the will—the external act—to be the physical act.449 This agrees with what

Aquinas says concerning the external act in On Evil.450

However, Aquinas also attributes intentional content to the external act, independent of

the remote end, what Rhonheimer calls intentional basic action.451 Thus, the external act is part

of the moral order.452 Regarding the will commanding (imperium) an act, Finnis insists that the

intellect constitutes the primary active faculty insofar as before one commands an action through

the will, one discerns and chooses a particular course of action as the means for achieving one’s

end.453 Moreover, insofar as one’s chosen means contain an intelligible content, they have an

aspect of an end, which is what Aquinas says multiple times regarding the Moral Object.454

This, of course, is not to say that the will has nothing to do with commanding; rather, as

Rhonheimer says that the will commands an act that reason configures.455

In “‘Materia ex qua’ and ‘Materia circa quam’ in Aquinas,” Duarte Sousa-Lara shows

how Aquinas uses materia circa quam (matter concerning which) and materia ex qua (matter out

of which) to distinguish important elements of a human act.456 Aquinas says that materia ex qua

is not the Moral Object, but materia circa quam is the Moral Object. 457 In “Aquinas on Interior

and Exterior Acts: Clarifying a Key Aspect of His Action Theory,” Sousa-Lara demonstrates that

Aquinas uses this distinction to differentiate when Aquinas is speaking of the external act

constitutive of the Moral Object versus the external act merely as the material, physical act

alone.458 Materia circa quam denotes the inherent voluntariness of the external act, which

constitutes it as the Moral Object (in the moral order).459 Materia ex qua connotes the external

act prescinding from its voluntariness, thereby constituting it as part of the natural order.460

Sousa-Lara illustrates the distinction between materia circa quam and materia ex qua

using the sexual act.461 The physical act of sexual intercourse—whether it is adultery,

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fornication, or marital love—constitutes a single external act materia ex qua according to the

natural order. 462 In the moral order, the materia circa quam differs insofar as adultery and

fornication differ from marital love.463 So, the materia circa quam corresponds to the Moral

Object in the moral order.

d. The Object of Contraception

In Humanae Vitae, Paul VI reaffirms the Church’s prohibition of contraceptive acts, that

is “any action which either before, at the moment of, or after sexual intercourse, is specifically

intended to prevent procreation.”464 Contrary to the opinion of most critics, Rhonheimer insists

that Humanae Vitae is not merely a defense of Natural Law according to a naturalistic

understanding.465 Rather, Paul VI’s argument conforms with a Thomistic articulation of Natural

Law that constitutes the Moral Object in the moral order, precisely because it places its

prohibition on the level of intention, not the physical or biological.466 On the order of intention,

Rhonheimer defines the Moral Object of contraception. However, before doing so, he first

explains the principle that it violates and then situates it within the framework of virtue and vice.

Rhonheimer, in accord with Aquinas, and John Paul II in Veritatis Splendor, insists that

Natural Law is nothing but the light of reason aiding one in discernment of good and evil in

action.467 One derives statements of Natural Law through speculative reflection on natural reason

in action.468 Hence, ethicists often articulate the universal precepts of Natural Law as normative

statements such as “do good and avoid evil.”469 However, the content of Natural Law is practical,

thus in concrete action it takes the form of a command or precept.470 While Natural Law does not

constitute a law of nature, it nonetheless works within the metaphysical and physical confines of

nature, specifically human nature.471 Consequently, Paul VI explains how contraception violates

the Inseparability Principle, which, in accord with human nature, holds that the unitive

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significance of the marital act is inseparable from its procreative significance.472 However, the

violation of this principle does not suffice for an ethical argument against contraception.473

Rhonheimer situates his definition of the Moral Object of contraception in the context of

virtue.474 First, he explains that the Moral Object of marital love consists of loving bodily union,

which as mutual self-giving is naturally open to procreation.475 Insofar as marital love involves

self-donation, it presumes self-possession, which is constitutive of temperance regarding sexual

inclination, that is, chastity.476 Indeed, for Paul VI, responsible parenthood is also an essential

component of marital love.477 In fact, for Paul VI and Rhonheimer, procreative responsibility is a

means to growth in chastity, because it entails periodic continence, which is an expression of

love that maintains the inseparable connection between the procreative and unitive meaning.478

Against the backdrop of this understanding of the Moral Object of the marital act in

reference to chastity, Rhonheimer explains that contraceptive acts eliminate the need to regulate

sexual behavior through periodic continence by dismantling its procreative potential.479 It is a

choice against chastity, since one contracepts to avoid procreative responsibility, which

inherently entails the need for periodic continence. Consequently, Rhonheimer connects

contraceptive intention to the vice of lust, since it circumvents a couple’s means to growth in

chastity by eliminating the need for periodic continence.480 This formulation keeps Moral Object

on the level of intention and in the moral order.

e. The Object of Using Contraceptives for Non-Contraceptive Benefits

The above discussion demonstrates several key factors for determining the Moral Object.

First, the Moral Object is in the moral order, not the natural order. Consequently, one cannot

determine it merely by observing external, physical behavior. Just because a woman takes a

contraceptive pill or has an intrauterine device, does not necessarily mean that she intends to

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contracept. Without reducing the Moral Object to the remote end, one must enter the moral order

to determine it. As a proximate end, the Moral Object has intentional content, that is, an inherent

rationality that makes it a viable choice as a means to an end.

The above clinical analysis indicates that sufficient medical benefit exists to justify the

use of any of the abovementioned contraceptives solely for the purpose of their non-

contraceptive benefits. Thus, just as one takes Tylenol or Advil for a headache, it is conceivable

to formulate a practical syllogism that involves one choosing a contraceptive method for its non-

contraceptive benefit.481 Accordingly, one may begin with the practical premise: “1) I want to

have good health.” Next, one may observe a theoretical truth that 2) “increasing progesterone

reduces bleeding for women with heavy bleeding during menses.”482 Presuming that one

experiences heavy menstrual bleeding, one may conclude: “3) it is good for me to choose a

means to increase my exogenous progestin to reduce my bleeding.” One could make a similar

argument regarding the benefits of progestin for endometriosis.

This subsection identifies the Moral Object of using contraception for its non-contraceptive

benefits. The following subsection uses the Principle of Double Effect to further justify it.

iii. The Principle of Double Effect

Because of the negative side effects of the above-mentioned contraceptive methods—

especially sterilization, one must pursue further ethical analysis to determine its moral

permissibility. Simply determining that the Moral Object is licit does not necessarily justify its

use for non-contraceptive benefits. The Principle of Double Effect justifies acts with bad effects.

a. Thomistic Formulation of Double-Effect Reasoning

Aquinas, in the Summa Theologica, is the first to formulate criteria that eventually gives

rise to the Principle of Double Effect.483 He devises these conditions concerning killing in self-

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defense. First, he observes that some actions have two effects, one good, and the other bad.484

Moreover, one may not intend both effects.485 For example, in self-defense, one may

unintentionally kill an assailant.486 Here, there are two effects: self-protection and death of the

aggressor. One intends self-defense, not killing the assailant. Since one does not intend to kill the

attacker, it is praeter intentionem—beside the intention of the agent.487

In contemporary formulations of Double Effect, the first two criteria concern intention.

Joseph T. Mangan, in “An Historical Analysis of the Principle of Double Effect,” says that the

first criterion is that the act itself must be good or indifferent.488 For Edward Furton and Albert S.

Moraczewski in “Double Effect,” this first criterion excludes intrinsically evil acts, that is, any

act that has an immoral object.489 The second criterion is that one must intend the good effect,

and not the bad.490 While the first criterion addresses the proximate end, the second addresses the

ulterior end. Not only must the means chosen be good, but the purpose for choosing it must be

good as well.

Aquinas uses praeter intentionem to identify the unintended bad effect.491 Cavanaugh,

explains that praeter intentionem conveys the notion of accidental in that it is outside the realm

of intention, even though one may foresee it.492 Thus, knowing or foreseeing is not necessarily

intending. The defender may foresee that one’s act of self-defense will inexorably kill the

assailant. Similarly, a physician may foresee that removing a cancerous, gravid uterus results in

the death of the child. Foreseeing the invariable consequences does not change intention: self-

defense or the preservation of a mother’s life by removing a cancerous organ. Insofar as the bad

effect is praeter intentionem—foreseen, but unintended, it does not ethically preclude the act.

Aquinas does, however, introduce a proportionality criterion that may render an act

unjust.493 To illustrate, he insists that one ought not to use more force than necessary to ward off

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an assailant; otherwise, though one’s intention is good, the act may nonetheless be immoral.494

Thus, in casuistic tradition, one must weigh the effects.495 Regarding self-defense, one uses

deadly force only if the assailant attacks with deadly force. Concerning the removal of a

cancerous, gravid uterus, one weighs the life of the mother in relationship to the life of the child.

Under the influence of nominalism, manualists add a fourth physicalistic criterion: the

negative effect must not cause the good effect.496 With due regard for the role of the Moral

Object as the proximate end, Furton and Moraczewski reword this criterion asserting that one

may not choose an evil means for a good end.497 Put this way, one is just a restating the first

principle, that the Moral Object must be good. Arguably, this redundancy is why Aquinas does

not include it in his formulation of Double-Effect Reasoning.

b. Intention

Using the Principle of Double Effect as an instrument of ethical analysis, I further

elucidate intention concerning contraception for non-contraceptive benefits. Insofar as ethical

decision-making takes place from the perspective of the acting person, one must discern one’s

intention—as a proximate end and ulterior end—for using a contraceptive method.498 In the

above analysis, I determine that the Moral Object of using contraceptive methods for non-

contraceptive benefits is not immoral. Ethically, choosing to use a contraceptive method for its

contraceptive function is immoral according to its Moral Object—proximate end, because, as

Rhonheimer indicates, it not only violates the Inseparability Principle, but also constitutes a

choice to subvert one’s procreative responsibility to avoid periodic continence, a constitutive part

of responsible parenthood and a means for growth in chastity, which as a virtue concerns marital

love.499 Insofar as the Moral Object of contraception constitutes an intrinsically evil act, one

must not vacillate. For example, one should not say, “I take progestin for heavy menstrual

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bleeding, but I also like the contraceptive benefits.” In such a case, one clearly intends both,

regarding the proximate end.

Concerning the second criterion, one’s intention as ulterior end of avoiding pregnancy

may be bad or good.500 A couple may exclude or limit the number of children for selfish reasons,

such as to have a luxurious lifestyle. Alternatively, for ethically sound reasons, a couple may

discern that they cannot afford to have more children or that pregnancy is too risky for the

mother.501 Even so, the Inseparability Principle demands that couples remain open to the

possibility of transmitting life in the marital act, which one can do by observing periodic

abstinence.502 Rhonheimer explains that periodic continence constitutes a form of birth control

that remains open to the procreative significance of the marital act, even though one avoids its

procreative function.503 What separates this from a contraceptive act, however, is intention; thus

it is not merely a physical difference.504 The use of a contraceptive method includes the intention

to render procreation impossible.505 The above demonstrates the immorality of such an act

chosen as a proximate end, but one’s ulterior end also configures the morality of the act. Thus,

one must also have a good intention, as ulterior motive.

c. Proportionality and Abortifacient Risk

Next, one must use the proportionality criterion to weigh the non-contraceptive benefits

against the negative contraceptive effect. In Difficult Moral Questions, Germain Grisez provides

circumstances under which a physician may prescribe contraceptives for therapeutic reasons.506

First, he highlights that for women who are sterile or fertile, but not engaging in the marital act,

prescribing a contraceptive for non-contraceptive benefits is no more controversial, ethically,

than prescribing any other medication.507 For fertile women engaging in the marital act, Grisez’s

primary concern is the possible unfairness to an embryonic individual, should fertilization occur

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after an unlikely breakthrough ovulation and the method acts as an abortifacient by preventing

implantation.508

Mark Yavarone in “Do Anovulants and IUDs Kill Early Human Embryos?: A Question

of Conscience,” indicates that part of the ambiguity of classifying a drug’s effect as an

abortifacient depends on the divergent definition of pregnancy, which some argue only occurs

after implantation.509 If true, Yavarone’s statistics concerning the number of unintended

intrauterine device or oral contraceptive-induced abortions is alarming.510 In light of the

abortifacient properties of contraceptive methods, Grisez insists that one must have significant

benefit to outweigh the possible risk to a third person embryo.511

To remedy this, Grisez suggests that women who can estimate breakthrough ovulation

could practice periodic abstinence to minimize the risk of an unintended abortion.512 At the same

time, Grisez advises physicians not to prescribe contraceptive for non-contraceptive benefits, if

withholding it does not constitute malpractice by omission.513 He even recommends surgery over

using a contraceptive.514 This, however, is problematic because it may mean forgoing medically

indicated treatment or choosing a more invasive procedure over a more conservative option.

Ethically, this violates the principle of beneficence and non-maleficence.515 If one does not

inform the patient this violates respect for autonomy as a form of paternalism.516

Regarding the question of levonorgestrel acting as an abortifacient, Edward J. Furton

observes that some authors, such as Ron Hamel,517 have come to the conclusion that the debate is

settled and it does not act in such a way.518 To the contrary, Furton indicates that it is not a

settled question; evidence points in both directions.519 Thus, he cautiously counsels health care

workers to follow Marie T. Hilliard’s recommendation to perform a blood test checking for the

luteinizing hormone surge, which accompanies ovulation, before administering levonorgestrel as

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an emergency contraceptive.520 According to Hilliard and Furton, only then does one have moral

certitude—as opposed to absolute certitude—that fertilization will not occur and that the

contraceptive does not act as an abortifacient.521 This stipulation concurs with the bishops’

directive regarding the administration of emergency contraceptive for rape victims, that

appropriate testing rule out conception and that it “not interfere with the implantation of a

fertilized ovum.”522

In 2009, the Congregation for the Doctrine of the Faith publish Instruction Dignitas

Personae on Certain Bioethical Questions, in which they insist that anyone—patient or

clinician—who “seeks to prevent the implantation of an embryo which may possibly have been

conceived and who therefore either requests or prescribes such a pharmaceutical, generally

intends abortion.”523 Thus, Kathleen Mary Raviele in “Levonorgestrel in Cases of Rape: How

Does It Work?” objects to the use of contraceptive methods such as levonorgestrel that may act

as an abortifacient, preventing implantation, should conception occur.524

While there are similarities, using an emergency contraception, as a contraceptive is not

the same as using contraception as a medication for non-contraceptive benefits. The difference

centers on intention. Giving contraception to a rape victim is an act of defense, against

conception. Following Hilliard and Furton’s advice, ensures with moral certitude that it is not a

defense against implantation. Although the external act materia ex qua is the same—taking

levonorgestrel—the external act differs regarding its materia circa quam, that is, its proximate

end. As an emergency contraceptive it constitutes an act of defense against conception; however,

once fertilization occurs, or for Hilliard and Furton, could occur, it becomes an act of defense

against implantation, or an abortifacient.

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Regarding the use of contraception for non-contraceptive benefits, as long as one rules

out intention as the proximate end and ulterior end, one in no way intends the medication to act

as a contraceptive or an abortifacient. This may be easier said than done, however, because the

very same physical mechanisms that the medication induces, which make it a good

contraceptive, also make it a good remedy for endometriosis and heavy menstrual bleeding.525

Thus, on the level of the external act materia ex qua, it is impossible to differentiate. Moreover,

the better the drug is, as a contraceptive, the less likely breakthrough ovulation and fertilization

will occur. Thus, theoretically, the better the medication is at preventing conception, the less

likely unintended fertilization occurs.

It is important to remember that all medications have risks of side effects; sometimes

these risks include death. Just as it is important for a patient to work with the physician to

determine and weigh risks, so patients must do so regarding the unlikely and unintended risk of a

contraceptive taken for non-contraceptive benefits, acting as an abortifacient. Leaving this to the

deliberation of the conscience of the patient is not diminishing the seriousness of the side effect,

nor is it relativizing the ethical significance of a medication’s potential risk. Rather, it is referring

the decision to its proper place, the perspective of the acting person, concerning a side effect that

is praeter intentionem.526 Thus, insofar as one does not seek to prevent implantation, one does

not intend abortion.527

The fourth condition of the Principle of Double Effect insists that the negative side effect

does not cause the positive effect.528 In intentional terms, one must not will the negative effect as

a means to the good effect.529 As I indicate above, insofar as the physiological mechanism of

action is the same, the external act materia ex qua is the same, but the intentionally, that is, the

external act materia circa quam differs. Thus, so long as one clearly uses the medication for non-

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contraceptive benefits, one has a good proximate end and avoids any violation of the fourth

criteria.

After articulating the physiological mechanisms of various contraceptive medications,

both in terms of their contraceptive qualities and their non-contraceptive benefits, this section

differentiates the Moral Object for each, respectively. Then, it uses the Principle of Double

Effect to further justify the non-contraceptive benefits over the ethically negative side effects of

contraceptives, including their potentially abortifacient qualities.

This chapter identifies the Moral Object of sex reassignment surgery and using

contraceptives for non-contraceptive benefits and analyzes them further in light of the Principle

of Double Effect. The following chapter concludes the dissertation.

1 Carol Bayley, “Transgender Persons and Catholic Healthcare,” Health Care Ethics USA: A

Quarterly Resource for the Catholic Health Ministry 24, no. 1 (2016): 1-5; Becket Gremmels,

“Sex Reassignment Surgery and the Catholic Moral Tradition: Insight from Pope Pius XII on the

Principle of Totality,” Health Care Ethics USA: A Resource for the Catholic Health Ministry,

24.1 (January, 2016), 6-10. 2 Pope Francis, Apostolic Exhortation Amoris Laetitia, March 19, 2016,


francesco_esortazione-ap_20160319_amoris-laetitia_en.pdf, no. 56. 3 American Psychiatric Association, “Gender Identity Disorder,” Diagnostic and Statistical

Manual of Mental Disorders, 4th ed. [hereafter DSM-IV], (Washington D.C.: American

Psychiatric Association, 1994), 532-8. 4 American Psychiatric Association, “Gender Dysphoria,” Diagnostic and Statistical Manual of

Mental Disorders, 5th [hereafter DSM-V], (Arlington, VA: American Psychiatric Publishing,

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104 Mayer et al, “Gender Identity, 105. 105 Paul W. Hruz, “Experimental Approaches to Alleviating Gender Dysphoria in Children,” The

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University Press, 1996). 150 Rhonheimer, The Perspective of Morality, 7. 151 Jacob Harrison, “Karol Wojtyla, Sex Reassignment Surgery, and the Body-Soul Union,” The

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167 John Paul II, “Address of the Holy Father John Paul II to the 18th International Congress of

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23, no. 29 (1994). See the distinction between literalists and literal under the title literal. 170 Genesis, 1:26-7 171 Genesis, 1:28. 172 Genesis, 1:27 173John Paul II, Man and Woman He Created Them, 163. 174 Genesis, 1:28 175 John S. Grabowski, “Male and Female: Equality, Difference, Dignity,” Sex and Virtue: An

Introduction to Sexual Ethics, (Washington, D.C.: Catholic University Press, 2003), 96-126. 176 Grabowski, Sex and Virtue, 98. 177 Grabowski, Sex and Virtue, 97. 178 Grabowski, Sex and Virtue, 97; see also Yves Christen, Sex Differences: Modern Biology and

the Unisex Fallacy, trans. Nicholas Davidson (New Brunswick, NJ: Transaction Books, 1991). 179 Grabowski, Sex and Virtue, 97. 180 Grabowski, Sex and Virtue, 98. 181 Elliott Louis Bedford and Jason T. Eberl, “Is the Soul Sexed? Anthropology,

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195 John Paul II, Man and Woman He Created Them, 162-5. 196 John Paul II, Familiaris Consortio: The Role of the Christian Family in the Modern World,

(Boston: Pauline, 1981), n. 42. 197 John Paul II, Evangelium Vitae: The Gospel of Life, (Boston: Pauline, 1995), n. 43. 198 John Paul II, Evangelium Vitae, 43. 199 John Paul II, Familiaris Consortio, 11. 200 Second Vatican Council, Gaudium et Spes, n. 24. 201 Benedict XVI, Deus Caritas Est, December 25, 2005, http://w2.vatican.va/content/benedict-

xvi/en/encyclicals/documents/hf_ben-xvi_enc_20051225_deus-caritas-est.html, no. 12-14. 202 John Paul II, Familiaris Consortio, 11. 203 John Paul II, Man and Woman He Created Them: A Theology of the Body, 438-9. 204 John Paul II, Man and Woman He Created Them: A Theology of the Body, 188-90. 205 John Paul II, Man and Woman He Created Them: A Theology of the Body, 189-90. 206 John Paul II, Man and Woman He Created Them: A Theology of the Body, 432. 207 John Paul II, Man and Woman He Created Them: A Theology of the Body, 432. 208 John Paul II, Mulieris Dignitatem, n. 21. 209 Germain Kopaczynski, “Selected Moral Principles: A. Totality and Integrity,” in Catholic

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Catholic Health Care Services, 6th edition, (Washington D. C.: USCCB, 2018), # 29. 211 Aquinas, Summa Theologica, II-II, q. 65, a. 1. 212 Aquinas, Summa Theologica, II-II, q. 65, a. 1, answer. 213 Aquinas, Summa Theologica, II-II, q. 65, a. 1, answer. 214 Claudius Amyand, “Of an Inguinal Rupture, with a Pin in the Appendix Coeci, Encrusted

with Stone,” Philosophical Transactions 39, no. 443 (1736): 329-42.

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http://www.vatican.va/archive/aas/documents/AAS-45-1953-ocr.pdf. 216 Pius XII, “Address to Delegates at the 26th Congress of Urology,” 674-5. 217 Pius XII, “Address to Delegates at the 26th Congress of Urology,” 674. 218 Pius XII, “Address to Delegates at the 26th Congress of Urology,” 674. 219 Pius XII, “Address to Delegates at the 26th Congress of Urology,” 674. 220 Pius XII, “Address to Delegates at the 26th Congress of Urology,” 674. 221 Becket Gremmels, “Sex Reassignment Surgery,” 6-10. 222 Richard P Fitzgibbons, et al., “The Psychopathology of ‘Sex Reassignment’ Surgery,” The

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Schools,” The National Catholic Bioethics Quarterly 12, no. 1 (2012): 93-4. 223 Gremmels, “Sex Reassignment Surgery,” 7.

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224 Gremmels, “Sex Reassignment Surgery,” 7. 225 Gremmels, “Sex Reassignment Surgery,” 8. 226 Gremmels, “Sex Reassignment Surgery,” 8. 227 Travis Stephens, “The Principle of Totality Does Not Justify Sex Reassignment Surgery,”

Ethics and Medics 41, no. 11 (2016): 1-2. 228 John F. Brehany, “Pope Pius XII and Justifications for Sex Reassignment Surgery,” Health

Care Ethics USA: A Quarterly Resource for the Catholic Health Ministry 24, no. 4 (2016): 19. 229 John F. Brehany, “Pope Pius XII and Justifications for Sex Reassignment Surgery,” 20. 230 John F. Brehany, “Pope Pius XII and Justifications for Sex Reassignment Surgery,” 20; Pope

Pius XII, “Address to the First International Congress on the Histopathology of the Nervous

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bioethics/pope-pius-xii/ 231 John F. Brehany, “Pope Pius XII and Justifications for Sex Reassignment Surgery,” 20. 232 E. Christian Brugger, “Catholic Hospitals and Sex Reassignment Surgery: A Reply to Bayley

and Gremmels,” The National Catholic Bioethics Quarterly 16, no. 4 (2016): 596. 233 John F. Brehany, “Pope Pius XII and Justifications for Sex Reassignment Surgery,” 20. 234 Carol Bayley, “Transgender Persons and Catholic Healthcare,” 1-5. 235 Aquinas, Summa Theologica, II-II, q. 64, a. 7. 236 Aquinas, Summa Theologica, II-II, q. 64, a. 7, answer. 237 Aquinas, Summa Theologica, II-II, q. 64, a. 7, answer. 238 Augustine, On the Freedom of the Will, trans. Anna S Benjamin et al., (Englewood Cliffs, NJ:

Prentice Hall, 1964), Book 1, V, pp. 12. Aquinas, Summa Theologica, II-II, q. 64, a. 7, objection

1 and 2, reply 1. 239 Aquinas, Summa Theologica, II-II, q. 64, a. 7, answer. 240 T. A. Cavanaugh, Double-Effect Reasoning: Doing Good and Avoiding Evil, (Oxford:

Oxford, 2007), 26. 241 Cavanaugh, Double-Effect Reasoning, 26. 242 Cavanaugh, Double-Effect Reasoning, 26. 243 Aquinas, Summa Theologica, II-II, q. 64, a. 7, answer. 244 Cavanaugh, Double-Effect Reasoning, 73-117. 245 Cavanaugh, Double-Effect Reasoning, 26. 246 Martin Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a Central


of Thomistic Moral Philosophy, ed. William P. Murphy Jr. (Washington D.C.: Catholic

University Press, 2008), 45-9. 247 Servais Pinckaers, The Sources of Christian Ethics, 3rd edition, translated by Mary Thomas

Noble, (Washington D. C.: Catholic University of America Press, 1995), 254-79. 248 Edward J. Furton and Albert S. Moraczewski, “D. Double Effect” in Catholic Health Care

Ethics: A Manual for Practitioners, 2nd edition, ed. Edward J. Furton et al, (Philadelphia, PA:

The National Catholic Bioethics Center, 2009), 25. 249 Cavanaugh, Double-Effect Reasoning, 26. 250 Aquinas, Summa Theologica, II-II, q. 64, a. 7, answer. 251 Griese, Catholic Identity in Health Care: Principles and Practice, 253. 252 Bayley, “Transgender Persons and Catholic Healthcare,” 4. 253 Bayley, “Transgender Persons and Catholic Healthcare,” 4. 254 Bayley, “Transgender Persons and Catholic Healthcare,” 4.

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255 Bayley, “Transgender Persons and Catholic Healthcare,” 1-5. 256 Bayley, “Transgender Persons and Catholic Healthcare,” 3. 257 Bayley, “Transgender Persons and Catholic Healthcare,” 3. 258 Bedford and Eberl, “Is the Soul Sexed?,” 25-8. 259 Bedford and Eberl, “Is the Soul Sexed?,” 23-4. 260 Bayley, “Transgender Persons and Catholic Healthcare,” 3. 261 Bedford and Eberl, “Is the Soul Sexed?, 24. 262 Bayley, “Transgender Persons and Catholic Healthcare,” 3. 263 Bayley, “Transgender Persons and Catholic Healthcare,” 4. 264 Bayley, “Transgender Persons and Catholic Healthcare,” 4. 265 Catholic Church, Catechism of the Catholic Church: Revised in accordance with the official

Latin text promulgated by Pope John Paul II, (Vatican City: Libreria Editrice Vaticana, 1997),

no. 1755; Aquinas, Summa Theologica, I-II, q. 18, a. 2-4. 266 Bedford and Eberl, “Is the Soul Sexed?,” 25-8. 267 Aquinas, Summa Theologica, I-II, q. 1, a. 1, sed contra. 268 Aquinas, Summa Theologica, I-II, q. 1, a. 1, answer. 269 Aquinas, Summa Theologica, I-II, q. 1, a. 4, answer. 270 Aquinas, Summa Theologica, I-II, q. 13, a. 4, answer. 271 Aquinas, Summa Theologica, I-II, q. 13, a. 4, answer. 272 Aquinas, Summa Theologica, I-II, q. 19-20. 273 Aquinas, Summa Theologica, I-II, q. 20, a. 1, answer, reply 1. See also Rhonheimer, Natural

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Action Theory,” Josephinum Journal of Theology 15, no. 2, (2008):

281-2, Aquinas, Commentary on the Sentences, lib. 2, d. 40, q. 1, a. 3, c; Rhonheimer, Natural

Law and Practical Reason, 90. 275 Rhonheimer, Natural Law and Practical Reason, 159; Aquinas, Commentary on the

Sentences, II, d. 36, q. 1, a. 5, 4um; Summa Theologica, I-II, q. 72, a. 3, ad 2; De Malo q. 2, a. 4,

ad. 9. 276 John T. Noonan, Jr., Contraception: A History of Its Treatment by the Catholic Theologians

and Canonists, (Cambridge, MA: Harvard University Press, 1986), 364. 277 Peter Knauer, “The Hermeneutic Function of the Principle of Double Effect,” Natural Law

Forum, Paper 127, (1967): 132-162. 278 Knauer, “The Hermeneutic Function of the Principle of Double Effect,” 157. 279 Rhonheimer, “‘Intrinsically Evil Acts’ and the Moral Viewpoint: Clarifying a Central

Teaching of Veritatis Splendor,” 44. 280 Becket Gremmels, “Sex Reassignment Surgery,” 6. 281 Bedford and Eberl, “Is the Soul Sexed?, 26-7. 282 Bedford and Eberl, “Is the Soul Sexed?, 26-7. 283 Bedford and Eberl, “Is the Soul Sexed?, 26. 284 Brugger, Catholic Hospitals and Sex Reassignment Surgery, 587-97. 285 Ethicists of The National Catholic Bioethics Center, “National Catholic Bioethics Center

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287 Diana Fotinos, “Gold Stemmed Pessaries: A Shadow of the Past,” July 31, 2018,

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Intrauterine Devices,” 664. 293 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1096. 294 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1097. 295 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1098. 296 Megan N Beatty and Paul D Blumenthal, “The Levonorgestrel-Releasing Intrauterine System:

Safety, Efficacy, and Patient Acceptability,” Therapeutics and Clinical Risk Management 5 (21

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NJ: Wiley-Blackwell, 2011), 94. 300 Mishell, “Intrauterine Devices,” 94. 301 The ESHRE Capri Workshop Group, “Intrauterine Devices and Intrauterine Systems,”

Human Reproduction Update 14, no. 3 (2008): 200; Jie Shen et al., “Interventions for

Emergency Contraception, (Review)” The Cochrane Library Issue 8 (2 August 2017):

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Obstetrics and Gynecology 157, no. 4.2 (1987): 1090-2. 315 Sheldon J. Segal et al., “Norplant Implants: The Mechanism of Contraceptive Action,”

Fertility and Sterility 56, no. 2 (1991): 273. 316 Segal et al., “Norplant Implants: The Mechanism of Contraceptive Action,” 274.

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317 Segal et al., “Norplant Implants: The Mechanism of Contraceptive Action,” 274; Horacio B.

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in Long Acting Contraceptive Delivery Systems, ed. Gerald L Zatuchni (Philadelphia: Harper and

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Speroff, Clinical Gynecologic Endocrinology, 289; Pratap Kumar, et al., “Hormones in

Pregnancy,” Nigerian Medical Journal 53, no. 4 (2012): 179-183. 319 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1059. 320 FDAnews Drug Daily Bulletin, “FDA Approves Organon’s Contraceptive Implant,” July 27,

2006 https://www.fdanews.com/articles/61216-fda-approves-organon-s-contraceptive-implant. 321 FDAnews Drug Daily Bulletin, “FDA Approves Organon’s Contraceptive Implant.” 322 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1061. 323 Stanley M. Roberts, “Hormone Replacement Therapy,” in Introduction to Biological and

Small Molecule Drug and Research and Development: Theory and Case Studies, edited by C.

Robin Ganellin (New York: Elsevier, 2013), 345. 324 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1060. 325 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1061. 326 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1064; Segal et al., “Norplant

Implants: The Mechanism of Contraceptive Action,” 274. 327 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1064. 328 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1064. 329 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1064. 330 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1064; Segal et al., “Norplant

Implants: The Mechanism of Contraceptive Action,” 277. 331 Roberts, “Hormone Replacement Therapy,” 345. 332 William Green, “The Odyssey of Depo-Provera: Contraceptives, Carcinogenic Drugs, and

Risk-Management Analyses,” Food Drug Cosmetic Law Journal 42, (1987): 568. 333 Green, “The Odyssey of Depo-Provera,” 568. 334 Green, “The Odyssey of Depo-Provera,” 568. 335 Green, “The Odyssey of Depo-Provera,” 568-9. 336 Green, “The Odyssey of Depo-Provera,” 569. 337 William Green, Contraceptive Risk: The FDA, Depo-Provera, and the Politics of

Experimental Medicine (New York: New York University Press, 2017). 338 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1082. 339 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1083. 340 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1082-3. 341 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1083. 342 Green, “Contraceptive Risk,” 348; Mosby’s Medical Dictionary, 7th ed. (Saint Louis, MO:

Mosby, Elsevier, 2006), 44-5. 343 Green, “Contraceptive Risk,” 348; Mosby’s Medical Dictionary, 44-5. 344 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1222. 345 John Albertson Sampson, “Peritoneal Endometriosis Due to the Menstrual Dissemination of

Endometrial Tissue into the Peritoneal Cavity,” American Journal of Obstetrics and Gynecology

14, no. 4 (1927): 422-69. 346 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1222. 347 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1223.

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348 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1223. 349 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1224-6; Annalisa Capobianco and

Patrizia Rovere-Querini, “Endometriosis, a Disease of the Macrophage,” in Frontiers in

Immunology 4, article 9 (28 January 2013): https://doi.org/10.3389/fimmu.2013.00009. 350 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1227. 351 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1227-8; Douglas M. Stocco and

Barbara J. Clark, “Role of the Steroidogenic Acute Regulatory Protein (StAR) in

Steroidogenesis,” Biochemical Pharmacology 51, no. 3 (1996): 197-205. 352 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1228. 353 Ji-Yong Julie Kim et al., “Progesterone Action in Endometrial Cancer, Endometriosis,

Uterine Fibroids, and Breast Cancer,” Endocrine Review 34, no. 1 (2013): 142. 354 Kim, “Progesterone Action in Endometrial Cancer, Endometriosis, Uterine Fibroids, and

Breast Cancer,” 141-2. 355 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1239. 356 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1239; 1244-8. 357 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1239-43. 358 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1243. 359 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1239. 360 Fernando M. Reis et al., “Endometriosis: Hormone Regulation and Clinical Consequences of

Chemotaxis and Apoptosis,” Human Reproduction Update 19, no. 4 (2013): 413; Joana D.

Amaral et al., “Role of Nuclear Steroid Receptors in Apoptosis,” Current Medicinal Chemistry

16, no. 29 (2009): 3886-3902. 361 Reis, “Endometriosis: Hormone Regulation and Clinical Consequences of Chemotaxis and

Apoptosis,” 413; Joon Song et al., “Hormonal Regulation of Apoptosis and the Fas and Fas

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447-55. 362 Joon Song et al., “Hormonal Regulation of Apoptosis,” 454. 363 Reis, “Endometriosis: Hormone Regulation and Clinical Consequences of Chemotaxis and

Apoptosis,” 413. 364 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1240; 1064. 365 Reis, “Endometriosis: Hormone Regulation and Clinical Consequences of Chemotaxis and

Apoptosis,” 414. 366 Fritz and Speroff, Clinical Gynecologic Endocrinology, 1241. 367 Tsuguo Uemura, “Effect of Gonadotropin-Releasing hormone Agonist on the Bone Mineral

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379 Fritz and Speroff, Clinical Gynecologic Endocrinology, 598-9. 380 Fritz and Speroff, Clinical Gynecologic Endocrinology, 614-5. 381 Fritz and Speroff, Clinical Gynecologic Endocrinology, 599. 382 Fritz and Speroff, Clinical Gynecologic Endocrinology, 599. 383 Fritz and Speroff, Clinical Gynecologic Endocrinology, 605-608. 384 John T. Noonan, Jr., Contraception: A History of Its Treatment by the Catholic Theologians

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Proposals to End the Battle over Birth Control (New York: Alfred A Knopf, 1963), 167-8. 408 Louis Janssens, “L’Inhibition de L’Ovulation, Est-Elle Moralement licite?” Ephemerides

Theologicae Lovanienses 34, no. 2 (1958): 357-360. 409 Wannes Dupont, “Of Human Love: Catholics Campaigning for Sexual Aggiornamento in

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Europe, 1945-1975 ed. Alana Harris (London: Palgrave MacMillan, 2018), 55. 410 Thomas Petri, Aquinas and the Theology of the Body: The Thomistic Foundations of John

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411 Servais Pinckaers, The Sources of Christian Ethics, trans. Mary Thomas Noble, (Washington

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Reasoning (Berkeley: University of California Press, 1988), 21-136. 415 Petri, Aquinas and the Theology of the Body, 11. 416 Petri, Aquinas and the Theology of the Body, 25. 417 Petri, Aquinas and the Theology of the Body, 26; Pinckaers, Sources of Christian Ethics, 242. 418 Petri, Aquinas and the Theology of the Body, 26; William of Ockham, Quodlibeta, q. 1, a. 16. 419 Petri, Aquinas and the Theology of the Body, 28. 420 Petri, Aquinas and the Theology of the Body, 28; William of Ockham, Super quattor libros

sententiarum II, dist. 5. 421 Louis Janssens, “Ontic Evil and Moral Evil,” in Proportionalism: For and Against ed.

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John Finnis, Fundamentals of Ethics (Washington D.C.: Georgetown University Press, 1983), 1-

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11. 434 Aquinas, Summa Theologica, I-II, q. 94, a. 2.


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435 Ralph McInerny, Aquinas on Human Action: A Theory of Practice (Washington D.C.:

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University of America Press, 1991), 31-57. 439 Paul VI, Humanae Vitae, 14. 440 Aquinas, Summa Theologica, I-II, q. 73, a. 3. 441 Aquinas, Summa Theologica, II-II, q. 100, a. 1, c. 442 John Paul II, Veritatis Splendor, August 6, 1993, http://w2.vatican.va/content/john-paul-

ii/en/encyclicals/documents/hf_jp-ii_enc_06081993_veritatis-splendor.html68. 443 Janssens, “Ontic Evil and Moral Evil,” 131. 444 Martin Rhonheimer, “Intentional Action and the Meaning of Object: A Reply to Richard

McCormick,” in The Perspective of the Acting Person: Essays in the Renewal of Thomistic

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a. 4 c. 450 Thomas Aquinas, On Evil, trans. Richard Regan and ed. Brian Davies (Oxford: Oxford,

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Key Aspect of His Action Theory,” in Josephinum Journal of Theology 15, no. 2 (2008): 279. 451 Rhonheimer, “Intentional Action and the Meaning of Object: A Reply to Richard

McCormick,” 77. 452 Rhonheimer, Natural Law and Practical Reason, 88ff. 453 Finnis, Natural Law and Natural Rights, 339. 454 Aquinas, On Evil, q. 2, a. 2, ad. 5; Aquinas, Summa Theologica, I-II, q. 18, a. 6, c.; q. 73, a. 3,

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http://www.eticaepolitica.net/eticafondamentale/dsl_materia_ex_qua_materia_circa_quam.pdf. 457 Sousa-Lara, “‘Materia ex qua’ and ‘Materia circa quam’ in Aquinas,” 3; Aquinas, Summa

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Theologica, I-II, q. 73, a. 3, ad. 1. 459 Sousa-Lara, “‘Materia ex qua’ and ‘Materia circa quam’ in Aquinas,” 1ff. 460 Sousa-Lara, “Aquinas on the Interior and Exterior Acts, 278. 461 Sousa-Lara, “‘Materia ex qua’ and ‘Materia circa quam’ in Aquinas,” 10.


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462 Sousa-Lara, “‘Materia ex qua’ and ‘Materia circa quam’ in Aquinas,” 10. 463 Sousa-Lara, “‘Materia ex qua’ and ‘Materia circa quam’ in Aquinas,” 10. 464 Paul VI, Humanae Vitae, July 25, 1968, https://w2.vatican.va/content/paul-

vi/en/encyclicals/documents/hf_p-vi_enc_25071968_humanae-vitae.html, 14. 465 Martin Rhonheimer, Ethics of Procreation and the Defense of Human Life: Contraception,

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Splendor, 12, 38-44; Aquinas, Summa Theologica, I-II, q. 91, a. 2 c. 468 Rhonheimer, Natural Law and Practical Reason, 58-9. 469 Rhonheimer, Natural Law and Practical Reason, 59, 63. 470 Rhonheimer, Natural Law and Practical Reason, 63-4. 471 Rhonheimer, Ethics of Procreation and the Defense of Human Life, 39; Rhonheimer, Natural

Law and Practical Reason, 63-4; 472 Paul VI, Humanae Vitae, 12. 473 Rhonheimer, Ethics of Procreation and the Defense of Human Life, 47. 474 Rhonheimer, Ethics of Procreation and the Defense of Human Life, 48ff. 475 Rhonheimer, Ethics of Procreation and the Defense of Human Life, 83. 476 Rhonheimer, Ethics of Procreation and the Defense of Human Life, 91. 477 Paul VI, Humanae Vitae, 10. 478 Paul VI, Humanae Vitae, 16; Rhonheimer, Ethics of Procreation and the Defense of Human

Life, 96-7. 479 Rhonheimer, Ethics of Procreation and the Defense of Human Life, 100. 480 Rhonheimer, Ethics of Procreation and the Defense of Human Life, 99. 481 Rhonheimer, The Perspective of Morality, 117ff. 482 Fritz and Speroff, Clinical Gynecologic Endocrinology, 598-9. 483 Aquinas, Summa Theologica, II-II, q. 64, a. 7. 484 Aquinas, Summa Theologica, II-II, q. 64, a. 7, c. 485 Aquinas, Summa Theologica, II-II, q. 64, a. 7, c. 486 Aquinas, Summa Theologica, II-II, q. 64, a. 7, c. 487 Aquinas, Summa Theologica, II-II, q. 64, a. 7, c. 488 Joseph T. Mangan, “An Historical Analysis of the Principle of Double Effect,” in Theological

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Catholic Bioethic Center, 2009), 24. 490 Mangan, “An Historical Analysis of the Principle of Double Effect,” 43. 491 Aquinas, Summa Theologica, II-II, q. 64, a. 7, c. 492 Cavanaugh, Double-Effect Reasoning, 43, 73ff. 493 Aquinas, Summa Theologica, II-II, q. 64, a. 7, c. 494 Aquinas, Summa Theologica, II-II, q. 64, a. 7, c. 495Mangan, “An Historical Analysis of the Principle of Double Effect,” 43. 496 Mangan, “An Historical Analysis of the Principle of Double Effect,” 43. 497 Furton and Moraczewski, “Double Effect,” 25.



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498 John Paul II, Veritatis Splendor, 78; Martin Rhonheimer, “The Perspective of the Acting

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IL: Franciscan Press, 1997), 310-11. 507 Grisez, Difficult Moral Questions, 310. 508 Grisez, Difficult Moral Questions, 310-11. 509 Mark Yavarone, “Do Anovulants and IUDs Kill Early Human Embryos?: A Question of

Conscience,” in The National Catholic Bioethics Quarterly 4, no. 1 (2004): 69; R.J. Cook et al.,

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Approach to Ethical Decisions in Clinical Medicine, 8th ed. (New York: McGraw-Hill

Education, 2015), 11ff. 516 Beauchamp, Principles of Biomedical Ethics, 220ff. 517 Ron Hamel, “Thinking Ethically about Emergency Contraception: Critical Judgments Require


(2010): 39-41. 519 Furton, Selective Citations, 40. 520 Marie T. Hilliard, “Moral Certitude and Emergency Contraception,” Catholic Health Care

Ethics: A Manual for Practitioners, 2nd ed. (Philadelphia: National Catholic Bioethics Center,

2009), 153-61. 521 Furton, Selective Citations, 40; Hilliard, “Moral Certitude and Emergency Contraception,”

155. 522 United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic

Health Care Services, 6th ed. (Washington D.C.: United States Conference of Catholic Bishops,

2018), #36, pp. 15. 523 Congregation for the Doctrine of the Faith, Instruction Dignitas Personae on Certain

Bioethical Questions, June 20, 2008,

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8_dignitas-personae_en.html, 23. 524 Kathleen Mary Raviele, “Levonorgestrel in Cases of Rape: How Does It Work?” The Linacre

Quarterly 81, no. 2 (2014): 117-29. 525 Fritz and Speroff, Clinical Gynecologic Endocrinology, 949-1119, 591-620, 1221-1248. 526 John Paul II, Veritatis Splendor, 78. 527 CDF, Instruction Dignitas Personae on Certain Bioethical Questions, 23. 528 Mangan, “An Historical Analysis of the Principle of Double Effect,” 43. 529 Furton and Moraczewski, “Double Effect,” 25.

http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_20081208_dignitas-personae_en.html


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CHAPTER SEVEN – CONCLUSION

This dissertation elucidates the moral methodology for Catholic health care ethics,

focusing especially on the relationship between Natural Law, the Moral Object of an act, and the

ethical Principles of Double Effect and Cooperation. Although Augustine and Thomas Aquinas

introduce these concepts, Pope John Paul II not only identifies them as official teaching of the

Catholic Church, he also provides the most systematic articulation of them in his encyclical

Veritatis Splendor. This dissertation offers a methodological bridge between Veritatis Splendor

and the United States bishops’ Ethical and Religious Directives for Catholic Health Care

Services, and then applies these concepts to emerging issues in health care ethics.

Chapter two explicates the concepts of Natural Law and the Moral Object that Aquinas

first introduces in the Summa Theologica. Avoiding the Naturalistic Fallacy, which maintains

that the moral genus derives from the natural genus, this chapter demonstrates the former’s

unique origin. Moreover, defining the human person as a composite of body and soul, it dodges

two dualistic vulnerabilities of the Naturalistic Fallacy: physicalism and spiritualism. In turn, this

provides a conceptual framework for the Church’s prohibition on contraception.

Chapter three shows that a non-consequentialist understanding of Natural Law and the

Moral Object is consistent with Aquinas’s articulation of Double Effect Reasoning. After

discussing Aquinas’s use of Double Effect, this chapter further elucidates the interpretation of

subsequent commentators that culminates in Jean Pierre Gury’s manualist formulation. In an

effort to make moral theology more teachable, commentators externalize the Moral Object,

identifying it as positing external causes. Peter Knauer uses Gury’s version of Double Effect to

devise proportionalism, which contends that one may posit any cause to achieve a good end so

long as one has commensurate reason. Insofar as Gury’s Double Effect and Knauer’s

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proportionalism externalize the Moral Object, their theories fall victim to the same pitfalls of the

Naturalistic Fallacy discussed in the second chapter.

The third chapter also contrasts non-consequentialist versions of Double Effect. First, it

enunciates a defense of craniotomies by John Finnis, Germain Grisez and Joseph Boyle. In

accord with T. A. Cavanaugh’s critique, however, it demonstrates that they too narrowly define

the Moral Object of craniotomy, such that it excludes an inexorable component, the direct killing

of the child. This highlights that physical consequences influence the definition of the Moral

Object, even if the latter is not constituted of the former. Finally, this chapter contrasts the Moral

Objects of three distinct applications: euthanasia/terminal sedation, terror bombing/tactical

bombing, and craniotomy/hysterectomy. It uses Cavanaugh’s distinction between intention and

foreseen to further illuminate the Principle of Double Effect.

Chapter four is the procedural bridge between the theoretical chapters two and three and

the applied chapters five and six. First, the chapter explains health care ethics consultations.

Then, it explicates the process in the context of the core principles of health care ethics:

autonomy, beneficence, non-maleficence, and justice.

Foreseeing organizations with conflicting missions working together, the second section

illuminates the Principle of Cooperation, a related principle to Double Effect. This section

follows the development of the United States Catholic Bishops’ response to sterilization and

their articulation of Cooperation in succeeding editions of their Ethical and Religious Directives.

The third edition follows the consequentialist methodology of conflating the Moral Object with

the remote end. In addition, they permit mediate material cooperation, something that

Cooperation traditionally forbids. However, in future editions, they correct these mistakes.

Further analysis in this section reveals that such a conflation makes it difficult to explain why

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certain moral absolutes are inviolable. Finally, this section explicates the Principle of

Appropriation, a mirror principle to Cooperation that attempts to justify the use of or product of

another’s immoral act.

Using the above discussion regarding Natural Law, the Moral Object, and the Principle of

Double Effect, chapter five argues that given certain conditions one may legitimately choose a

procedure that are physically sterilizing or contraceptive. When one keeps the Moral Object in

the moral genus, one is no longer limited to defining the Moral Object of contraception or

sterilization in purely physical terms. The first section shows that the significant increased risk of

developing ovarian cancer in BRCA1 and BRCA2 mutation carriers justifies them choosing the

physically sterilizing procedure of a bilateral salpingo-oophorectomy, so long as they choose it

for its prophylactic benefits, not its sterilizing effect. Delimiting the Moral Object of

contraception to the moral genus, Martin Rhonheimer defines it as a choice against chastity,

insofar as one circumvents the need for periodic continence, a constitutive part of responsible

parenthood that provides a means to growth in chastity. Accordingly, the Moral Object of a

BRCA mutation carrier using a bilateral salpingo-oophorectomy is a choice to prevent cancer.

Insofar as the negative effect of sterilization is beyond intention—either as remote end or

proximate end—the Principle of Double Effect justifies one’s tolerance of it, especially in light

of the life-threatening risk of developing ovarian cancer.

The second section discusses the use of the contraceptive levonorgestrel to prevent

conception in victims of sexual assault. First, this section explicates the function of various

contraceptives in the context of the menstrual-ovulatory cycle. Although certain contraceptives

clearly have abortifacient properties, the literature remains inconclusive and heavily debated

regarding levonorgestrel’s role at preventing pregnancy by forestalling ovulation. There is,

383

however, persuasive evidence that meloxicam does prevent ovulation. Presuming that one uses a

means that acts as an effective contraceptive, rather than an abortifacient, this section

demonstrates that a properly formulated Moral Object and a non-consequentialist understanding

of Double Effect dissolves any need for recourse to the latter principle. Avoiding a physical

definition of the Moral Object of using a contraceptive to prevent pregnancy in a victim of sexual

assault, one may understand it as an act of self-defense. Although the physiological mechanism

of action is the same, the Moral Object, defined according to the moral order, differs between an

act of contraception or an act of self-defense. Moreover, since the use of contraceptive is an act

of self-defense when a woman uses it to prevent conception after sexual assault, there is no

negative side effect justify using the Principle of Double Effect. Only a definition of the Moral

Object that fails to keep it in the moral order runs into the error of presuming the need to justify

the physically conceived evil of avoiding conception.

The sixth chapter further explicates the use of Double Effect applying it to sex

reassignment surgery and using contraception for non-contraceptive benefits. The first section

considers the justification of Double Effect to justify sex reassignment surgery. First, it

highlights the challenges of defining sex, gender, gender dysphoria, and sex reassignment

therapies. Next, building on Natural Law, this section elucidates three grounds by which the

Catholic Church objects to sex reassignment therapies: medical, philosophical, and theological.

Finally, this section shows that although some theologians use the Principle of Totality or

Double Effect to justify sex reassignment surgery, this is a non-sequitur, since Catholic

anthropology precludes the dualistic understanding of the human person.

The second section analyzes the use of physically contraceptive means for their non-

contraceptive benefits. First, it examines the contraceptive function of intrauterine devices and

384

long-acting contraceptive. Next, it explores their non-contraceptive benefits specifically

highlighting their treatment for endometriosis and menorrhagia. The next subsection traces the

historical development of consequentialist methodology of the manualists and the proportionalist

especially highlighting the influence of William of Ockham’s nominalism. The final subsection

uses Double Effect to justify the negative effect of sterilization when using long-acting

contraceptive methods. In particular, it emphasizes that Double Effect excludes intending

sterilization both as a Moral Object or a remote end. This subsection illuminates the debate on

the potential abortifacient properties of contraceptive, but contends that since this is beyond

intention—Moral Object and remote end—it, like sterilization, is an evil that one tolerates.

385

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natural law, the object of the act, and double effect

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