For the Health of Body and Soul: An Eastern Orthodox Introduction to Bioethics
Rev. Dr. Stanley S. Harakas
Everyone living today is sensitive to the fact that medical science is making enormous advances. Not only are illnesses being treated with remarkable computerized diagnostic machines, exotic technologies, and new drug therapies, but average people are now faced with an amazing array of alternatives each time a medically related problem arises.
In ages past, medicine was always considered in the Church as an honorable profession. Some of the most beloved figures in the Orthodox Christian tradition combined faith in God and the exercise of a healing ministry. The Evangelist Luke was a physician. His Gospel and Book of the Acts of the Apostles seem to have an unusually large number of medical terms and references to medical situations. Saints such as Cosmas and Damian, the two brother physicians, and St. Panteleimon are examples of widely venerated saint-physicians of the Orthodox Church. During the Byzantine period of the history of the Orthodox Church, there were a number of priest-physicians as well who combined the sacred duties of the Altar with the healing ministrations of the physician (Constantelos, 1975). And this was not in any way an inappropriate combination. For the life of our Savior, Jesus Christ, was also dedicated to a healing ministry. The four Gospels repeatedly record Christ's concern with the physical well-being of the people. Frequently, stories are related of persons who sought out Jesus to be healed of illnesses.
Cooperation of Man with God
As a consequence, the Church has always recognized two dimensions to the healing process. On the one hand is the recognition that our whole life is in the hands of God. We are - body and soul - his creatures, and it is to Him that we turn in moments of illness, both physical and emotional. He is, in the first and most fundamental sense, "the healer of soul and body," as it says in the Orthodox priest's 'Prayer Book.' In the Orthodox Church, we not only pray for the healing of sickness through priestly "Prayers for the Sick," but the Church has always offered the healing of God to the faithful through the sacrament of Anointing, or Unction. Unlike other Churches, our Orthodox understanding of this 'sacrament of prayer - oil' has always taken the scriptural words at face value and with seriousness.
"Is there any one among you suffering? Let him pray ... Is any among you sick? Let him call for the presbyters of the Church, and let them pray over him, anointing him with oil in the name of the Lord; and the prayer of faith will save the sick man, and the Lord will raise him up; and if he has committed sins, he will be forgiven" (James 4.13 - 15).
But to emphasize the healing power of God does not mean that human efforts at healing are down-graded. On the contrary, medical treatment is also seen as a human cooperation with God's healing purposes and goals. In fact, all of Orthodox teaching recognizes a place for human effort, striving and cooperating with God's will. Technically known as 'synergy,' this belief requires the exercise of human talents and abilities for salvation, for spiritual growth, for moral behavior, for achievement of human potential as well as for the fulfillment of God's will in all things related to our community and social life. So, in principle, the use of healing, medicines, therapeutic diet practices, even surgical operations have generally been understood throughout history in the Church as appropriate, fitting and desirable ways of cooperating with God in the healing of human illnesses.
New Methods - New Choices - New Problems
But something has been happening in medicine recently which has created problems for this longstanding spirit of cooperation. The common assumptions are no longer as firm as they once were. In part, this is due to the fact that the advances in biological knowledge have present and potential applications which not only heal existing illnesses, but also manipulate and change the natural processes of the human body and mind. The birth control pill and mind-influencing drugs are examples. These new techniques create some questions for the Church. It is one thing to use medical procedures to restore the patient to normal functioning. It is another to alter, on an ongoing basis, the physiology and the psychology of the patient through continued medical intervention. Yet, even here, there has been very little objection expressed by the Church. We have seen the benefits to individual persons and have thanked God for them, by and large.
But these developments have continued and now seem to have crossed a line which no longer permits us to accept any and every thing which comes out of the laboratory with the assumption that all new discoveries are good. This new attitude is not limited to questions of medical ethics. It is to be found in contemporary attitudes regarding all scientific and technological developments. We previously accepted these developments in the name of 'progress' as remarkable examples of the good which man can achieve. But since the atomic bombs of Hiroshima and Nagasaki, we are discovering more and more that our 'progress' always carries a price tag. Every step of scientific and technical progress effects our lives in both good and bad ways. We are learning, for instance, to count the cost of progress in environmental terms, in health terms, in its effect on the moral and spiritual quality of human living.
Further, our old belief in the goodness of the application of all our scientific knowledge has been changed. In the past, all technological development was 'good.' Now, more and more people have doubts. Because we are able, technically, to do something, doesn't mean automatically and necessarily that we should do it. In medicine, for instance, the prospect of genetic manipulation, of genetic experimentation, arising from the discovery of the genetic code in DNA, has caused reputable scientists to project potential harms to mankind and to urge that this experimentation with the human chromosomal heritage be banned.
Whatever the case, we are all aware of the fact that in the area of medicine, numerous choices about medical procedures face all of us as we live out our lives. Congenital illnesses can now be determined to exist while the baby is still in the mother's womb. The law permits abortions. Thus, the alternatives confront the parents - abort or not? Here is a new kind of question which medical technology has only recently made possible. Or, take another example. A relative asks you to donate a kidney since kidney transplants are now possible. Look at the host of questions! Is it right in the first place to transplant an organ from one person to another? Do we have the right to give up an organ needed by our own bodies? Is there a duty to give an organ to a spouse or child? To a stranger? Can we rightly refuse to give an organ for transplantation? Should we take organs from the dead? Is it right to have organ banks? Who should get the organs - only those who can afford to pay? None of these questions and a host of similar questions related to every new medical advance have self-evident answers. And none of them can be answered on exclusively scientific and technological grounds. They involve profound questions of right and wrong, good and evil, virtue and sin, moral and spiritual values.
A New Field of Study: Bioethics
As a result, a new field of study has come into existence. Known as 'bioethics,' it deals with the questions of right and wrong as they effect life issues. Like everything new, it has roots in the past. For example, Orthodox Christian ethical teaching has always dealt with life issues. The Bible, the writings of the Holy Fathers of the Church, Church canon law, even worship and sacramental life have ethical implications for life issues.
Only recently, however, have secular and religious ethicists sought to address these issues in a coherent and organized way, with special reference to the emerging problems of advancing medical technological capabilities. This discipline of bioethics recognizes that answers cannot be given without reference to principles and values which do not come out of science. Thus, some bioethicists seek 'common-denominator' values; others choose a certain philosophical stance to base their thinking and teaching; others base their thinking and guidance on religious traditions.
An 'Encyclopedia of Bioethics'
In order to gather together what is known about this area of human concern, it was decided in the early seventies to publish an inter- disciplinary, intercultural and internationally-based encyclopedia. The aim of this encyclopedia was to present a comprehensive "state-of-the-discipline" reference work. The Editor-in-Chief, Dr. Warren T. Reich of Georgetown University, undertook the task with the assistance of a distinguished Editorial Advisory Board which included among its members, Professor Panagiotes Ch. Demetropoulos, Professor of Ethics and Christian Sociology, Emeritus, at the School of Theology of the University of Thessalonike, Greece. Numerous scholars of varied disciplines-medical, legal, historical, scientific, religious, and theological, as well as morals and ethics were invited to contribute. The articles, arranged alphabetically, cover a range of subject matter which makes the encyclopedia a self-contained resource for bioethics. The scope of topics is dealt with on six levels:
concrete and legal problems,
basic concepts and principles which underlie bioethical questions,
historical perspectives, and
related disciplines which bear upon bioethics.
'Eastern Orthodoxy' in the Encyclopedia of Bioethics
Two major problems faced the author of the article on the 'Eastern Orthodox Church' in the Encyclopedia of Bioethics. The first was that there was no comprehensive literature from an Orthodoxperspective on the subject. What had been written was spotty and of uneven quality. The traditional ethics handbooks did provide some guidance, but the very newness of some of the problems precluded any absolutely clear tradition for many of the questions. This was related to the second problem. Orthodox Christianity, as its name implies, not only sees itself and understands itself to be the true Church of Christ, but it has sought - in its own particular way and style - to serve as the spiritual and moral guide for her people and by extension to speak to all of mankind regarding the proper and appropriate behavior of persons growing in the image of God. The very existence of Orthodoxy implies that there must be a direction and guidance on these topics for the people of God. Consequently, that direction cannot be arbitrary and unstudied. It must reflect the commonly accepted faith of the Church and be rooted in the fundamental affirmations of Orthodox doctrine, reflecting God's revelation to His Church. Only in this sense can Orthodox Christian ethical reflection come to some conclusions about these new issues and problems related to bioethics.
In the pages which follow, you will read the first efforts at providing a comprehensive Orthodox ethical teaching on bioethical questions: the article on Eastern Orthodoxy in the Encyclopedia of Bioethics. It is offered to the Church, on the one hand, as the distillation of years of reflection and teaching at Holy Cross Greek Orthodox School of Theology in Brookline, Massachusetts, on these subjects with the conviction that the positions taken do, in fact, represent genuinely Orthodox teaching on the issues dealt with. On the other hand, no one theologian may speak for the whole Church. The Church as a whole, under the guidance of the Holy Spirit, defines its teaching, both positively and negatively. So this encyclopedia article should be seen as a studied effort to present to the Church, for its pastoral guidance, ethical direction in the area of bioethics. Where it speaks in harmony with the tradition of faith, let it be adopted, taught and followed. In those places where it may deviate from the rule of faith, let the consciousness of the Church correct and revise it. In any case, may it serve to initiate informed intra-Orthodox reflection, discussion and decision. A first step would be for all Orthodox Church libraries to purchase the Encyclopedia of Bioethics so as to make this treasure-house of information readily available to both clergy and laity alike. The bibliographical references are: Warren T. Reich, Editor in Chief, Encyclopedia of Bioethics. New York: The Free Press, A Division of Macmillan Publishing Co., Inc., 1978.
It is the prayer of the author that the pages which follow will prove to be of some value in the development of the ethical sensitivity and reflection of the people of God in reference to bioethical issues, as well as more growth to a conformity of God's people to the image of God in them.
EASTERN ORTHODOX ETHICS
Eastern Orthodox Christian ethics bases its ethical judgments on Holy Scripture and Holy Tradition. Holy Tradition consists of the "mind of the Church" and is discerned in the decisions of ecumenical and local councils, the writings of the Fathers of the Church, canon law, and the penitentials (guides for the administration of the sacrament of Penance).
Issues not directly treated in the ancient sources are dealt with by modem Orthodox ethicists by seeking to express ethical judgments that are in harmony with the "mind of the Church." Thus, their writings have a certain provisional character and are always subject to episcopal, synodical, or general ecclesial critique. There are occasionally differences of substance in the writings of modem Orthodox Christian ethicists. By and large, however, responsible Orthodox ethicists maintain a common ethical stance. Modem issues in bioethics often require of ethicists that they find parallels in the tradition and, with the help of reason, deduce new ethical applications from established doctrinal, historical, and pastoral positions.
Basic doctrine and ethical affirmations
The Eastern Christian doctrinal position tends to be cautious in defining positively the central affirmations of its faith. It prefers the via negativa, or "apophatic" method (i.e., saying what is not the case). In ethics, a practice may be proscribed as not in harmony with the ethos of the faith, but often no positive solution is offered other than the need for patience and acceptance of the situation.
Nevertheless, Eastern Orthodox Christianity does avail itself of positive or "kataphatic" doctrinal and ethical statements. These are taken seriously when they are normative in character, but not in a rigid, legalistic, or absolute fashion. All positive statements regarding divine revelation - the Tradition - are seen as limited and subject to mystery as a necessary dimension of all human understandings of the divine. In canon law and in ethics this has led to the practice of "economia," which authorizes exceptions to the rule without considering the exception a precedent or abrogating the rule. In most cases the justification for the application of "economia" is the avoidance of greater harm in the case of the strict application of the rule (Kotsonis). Several key doctrinal teachings have immediate ethical application with specific reference to bioethical issues.
The humanum of our existence is both a given and a potential. Some of the patristic authorities distinguish between the creation of human beings in the "image" of God, and in his "likeness." "Image" is the donatum of intellect, emotion, ethical judgment, and self-determination. In fallen humanity these remain part of human nature, albeit darkened, wounded, and weakened. The "likeness" is the human potential to become like God, to achieve an ever expanding, never completed perfection. This fulfillment of our humanity is traditionally referred to as theosis or "divinization." Human beings are in fact "less than fully human." To achieve theosis means to realize our full human potential. Ethically, this teaching leads to the acceptance, on the one hand, of the existence of a "human nature," but, on the other, it clearly does not restrict our "humanum" to conformity to that nature. The "image" provides a firm foundation for ethical reasoning. The "likeness" prohibits the absolutizing of any rule, law, or formulation (Maloney).
Divine energies and human self-determination.
Though God's essence is totally incomprehensible to the human mind, God's energies are present in every human experience. To speak of divine energies is to speak of God's actions in relation to the created world. The relationship of God's energies to human freedom and self-determination has obvious ethical implications. Orthodox Christianity teaches that, though God is Lord of history, he does not coerce or force obedience and conformity to his will. Coerced conformity is dehumanization, whereas fulfilled humanity - which is the divinization of human life - must be free, since God is free. This raises the question of Divine Providence and Human Responsibility. Orthodox Christianity holds these two in paradoxical tension: man is responsible and must act, but God accomplishes his will, either with or in spite of man's actions. Ideally, human actions are harmoniously integrated with divine purposes in a perfect synergy of divine and human wills. This belief is but an extension and application of the Orthodox doctrine of the divine and human natures in the one person of Jesus Christ. Ethically, this means that we are not permitted simply to wait upon God. Rather, we are committed to the exercise of self-determination and responsibility in conformity with both human reality and divine purpose (Florovsky, pp. 113-120).
God is seen as the creator of both the material and the spiritual dimensions of reality. Eastern Orthodox Christianity sees these aspects of existence as closely bound together. The icon is an example of this belief. At first sight, the icon appears to be a stylized artistic representation of a holy figure. Yet the iconographer's purpose is to capture in form, line, color, and symbol both the spiritual and the physical reality of the figure. The sacramental use of material means (such as water, oil, bread, wine, etc.) for spiritual purposes also illustrates Eastern Orthodoxy's comprehension of the intimate relationship of matter and spirit, For bioethics, this key concept is important because it leads to a serious affirmation of the psychosomatic unity of human life. "Body" and "soul" are the constituents of human existence; the Orthodox emphasis on the Resurrection confirms its view that human life and human fulfillment are inextricably bound to both the physical and the spiritual dimensions of human existence. In more contemporary terms, body and personhood are essential for the fulfillment of human potential (Antoniades, 1:204-208).
Law, motive, intent.
Based on the above, ethical reasoning in Orthodoxy is a balanced combination of law, motive, and intent. Moral law is based in large part on the donatum of human nature. For Eastern Orthodoxy, natural law refers primarily to the elementary relationships that are necessary for the constitution and maintenance of human society. For the Fathers of the Church, the Decalogue is an excellent expression of the natural law common to all men (Harakas, 1964). In a similar yet more flexible pattern, there are modes of behavior that are either prescribed or proscribed for the lives of Christians growing in the image and likeness of God toward theosis or full humanity. These positive and negative injunctions are found in the Holy Scriptures, in the writings of the Fathers and in the canons of the Church. For the Orthodox these statements are normative in the sense that they embody the mind of the Church and reflect standards of behavior that are appropriate and fitting for the members of the Church and, potentially, for all human beings growing in the image and likeness of God -for the full realization of personhood.
This first level of ethical direction is saved from legalism and rigid prescriptivism by the fundamental emphasis on love as a motive of action. Grounded thoroughly on a Trinitarian theology that understands the Holy Trinity first as a community of persons united in love, the Church teaches that being God-like means being loving. In general, the commandments - of the moral law are embodiments of loving concern for the welfare of others. Consequently, in most situations the loving action is in conformity with the guidelines provided by the commandments (Harakas, 1970).
The possibility remains open, however, for the exception, i.e., for the exercise of "economia" when conformity to the prescribed action is perceived as detracting from the basic intent of all reasoning - the advancement of each person in community toward the fulfillment of the image and likeness of God. Thus, both order and compassion are harmonized in an approach to Christian ethics that seeks to avoid the extremesof legalism and relativism.
It is convenient to treat the Eastern Orthodox approach to bioethics under two major rubrics: the protection of life and the transmission of life. Implicit in the treatment of each of the bioethical issues are the affirmations implied in the doctrines of the image and likeness, theosis, human self-determination and responsibility, the intimate bond of body and personhood, and the interpenetrating relationship of commandment, love, and the realization of true human potential.
The protection of life.
Orthodox Christian ethical thought universally holds that life is a gift of God and as such is the necessary prerequisite of all other physical, spiritual, and moral values. As a gift of God it is a moral good held by the individual and by societies in trust, and over which they do not have absolute control. Both the individual and societies, however, are charged with the moral responsibility of protecting, transmitting, and enhancing life. The concerns of bioethics relate primarily to the first two of these concerns. Generally speaking, human responsibility for the preservation of life means that we are not given the right to terminate human life. Even the exceptions to this rule are understood as arising when conflicting claims to life become mutually exclusive, and a choice must be made. The preservation and protection of life are thus seen as crucial in ethical decision making. Since life is the prerequisite of all other this-worldly goods such as education, intelligence, social worth, and service to humanity, it has an intrinsic value that may not be violated under normal circumstances.
It follows quite logically that thecare of one's own health and societal concern for public health are moral imperatives (Androutsos, pp. 191-195, 250). Throughout its history, Eastern Orthodox Christianity has concerned itself sacramentally with the physical health of the faithful. The Sacrament of Holy Unction has not been conducted as a service of the "last rites." Rather, it is a healing service conducted both publicly and privately for the faithful. One of the constituents of the condition of original sin in which man actually finds himself is sickness. Total harmony of the creation with God would in fact eliminate sickness and ill health. The spiritual and physical dimensions of health are closely bound together in Orthodox thought. Thus, it was natural for the priest and the physician often to be one and the same person (Constantelos, 1967).
The issue of the allocation of scarce medical resources demands a general principle of distribution. Neither the ability to pay nor an aristocratic criterion of greater human value or worth is acceptable. Eastern Christianity has always distinguished between the essential value of human life and social worth. In spite of the enormous difficulties involved, the ethical imperative from the Orthodox perspective calls for the widest possible distribution of health care and life-protecting facilities and resources, rather than a concentration of such resources for the select few. The famous health care center established by Saint Basil in the fourth century in Cappadocia of Asia Minor was designed to reach as many people as possible. It and similar institutions embodied the Eastern Christian view on health distribution (Constantelos, 1968, chap.11).
Rights of patients.
The understanding that each person is created in the image and likeness of God with the personal destiny of achieving theosis implies that each patient has an essential and inviolate dignity as a person. The fact that individuals can achieve personhood only in community (Unus Christianus, nullus Christianus), requires the concern of the healthy for the ill. Those who deliver health care, therefore, do not morally discharge their responsibility by the mere mechanical application of healing methods and practices. Underlying every medical procedure ought to be a basic respect for the patient as God's image and likeness. The patient is never a thing. Consequently, medical practitioners are obligated, within reason and in the light of the patient's well-being, to maintain confidentiality and to obtain informed consent for procedures that entail excessive risk. Exceptions and restrictions on this obligation should be made in the light of the patient's welfare and whenever possible in consultation with those having immediate responsibility for the patient, e.g., his or her family.
For the same reasons articulated in the previous section, the Eastern Orthodox Christians take a very hesitant stance vis-à-vis human experimentation. Medical trial and error conducted for the well-being of the patient himself is often required and necessary. However, the submission of a patient to experimental procedures without significant regard for his or her direct personal benefit is wrong. There is no moral obligation of any person to be used by another for the benefit of a third party. Human self-determination requires that the patient decide. Such a decision must be based on adequate information regarding the procedures, ends to be achieved, and risks involved. The patient does not have the right to inflict harm upon himself unnecessarily. The researcher should use human experimentation procedures only after all other means of testing have been exhausted and there is every reasonable expectation of the avoidance of harm to the subject. In every case, experimenter and subject are morally obligated to exercise great caution. The hope of benefiting mankind in general does not outweigh the moral obligation of the protection of the individual life.
Eastern Christianity has a long history of opposition to abortion. Its ethical teachings as embodied in canon law and in the penitential books, as well as in more formal ethical instruction, condemn abortion as a form of murder. Because our humanity is a psychosomatic unity and because Orthodox Christians see all of life as a continuous and never ending development of the image and likeness toward theosis and full humanity, the achievement of particular stages of development of the conceptus is not ethically relevant to the question of abortion.
In his second canon, St. Basil specifically rules out the artificial distinction between the "formed" and "unformed" conceptus (The Rudder, pp. 789-790). Thus, any abortion is seen as an evil. Since the physical and the personal aspects of human existence are understood as essential constitutive elements of our humanity, the conceptus - unfulfilled and incomplete as it may be - may not be destroyed under normal circumstances. Eastern Orthodox ethicists reject as unworthy those counterarguments which appeal to economic and social reasons and so hold fife to be less valuable than money, pride, or convenience. Armed with modem genetic information, they also reject the argument that an abortion may be justified because a woman is entitled to control her own body. That basic affirmation of self-determination is not rejected; what is rejected is the claim that the conceptus is a part of the mother's tissue. It is not her body; it is the body and life of another human being entrusted to her for care and nurture.
Only in the case in which the life of the mother is endangered by the conceptus is it morally appropriate to consider the possibility of abortion. Yet, even here, the main operative value is the preservation of life. Numerous prudential considerations will be taken into account, though it is likely that the preservation of the mother's life will most often be chosen. In any case, it falls into the class of "involuntary sin" in which the evil of the event is recognized, while the personal guilt is mitigated (Papacostas, pp. 9-13, 83-105).
In the case of organ transplants, the crucial ethical considerations are two: the potential harm inflicted upon the donor and the need of the recipient. Historically, the Orthodox Church has not objected to similar, though not identical, procedures, such as blood transfusions and skin grafts. In both cases, no radical threat to the life of the donor is perceived, and the lifesaving consequences for the recipient are substantial. Similar considerations affect the Orthodox Christian judgment of organ transplants. In no case should a person ignore or make light of the ethical implications of organ donation. Donating an organ whose loss will impair or threaten the life of the potential donor is never required and is never a moral obligation of any person. If the condition of health and the physical well-being of the donor permits, some transplants are not objectionable. Renal transplants are a case in point. A healthy person may consent to donate a kidney knowing that his or her health is not thereby impaired.
The recipient of an organ transplant ought to be in otherwise good health, and there should be a substantial expectation of restoration to normal living in order to warrant the risk to the donor.
Heart transplants present a special case. Objectively they are different from other sorts of organ transplants because they presupposed the death of the donor. Though some Orthodox hierarchs have objected to heart transplants because the "heart" is often designated in the devotional literature of the Church as the seat of the soul, most have not responded negatively to heart transplants in principle. However, caution has been expressed regarding the temptation to hasten the death of the donor for the sake of the recipient. Also, so long as this procedure does not yet have a high success rate, it is morally questionable to continue its practice until the phenomenon of tissue rejection is better understood.
The use of stimulants, depressants, and hallucinogens for any purpose other than the restoration of health or the alleviation of abnormal pain, when properly and legitimately prescribed by a physician, is condemned; but Orthodox ethics, because of its teaching on "involuntary sin," is able to recognize the evil of the condition of drug addiction and yet also recognize that the essence of the evil is that personal self-determination has been lost, and with it a large measure of personal responsibility. Orthodox texts often refer to sinful conditions as "sickness" and "illness." In the case of drug addiction the cure is the restoration of self-determination In the Orthodox view, the judgment that drug addiction and alcoholism are evil and sinful, on the one hand, and the judgment that they are illnesses, on the other hand, are not mutually exclusive. This is not to say, of course, that every sickness is the result of individual voluntary sins, a position specifically denied by the Orthodox doctrine of original sin.
Mental health: values, therapies, institutions.
At the heart of the Eastern Orthodox Christian approach to mental health is the understanding of human wholesomeness in the doctrine of theosis. True and full human well-being is the consequence of our proper relationship with God (Demetropoulos, pp. 155-157). Mental health is one dimension of this total relationship. Since no individual human being perfectly achieves this relationship, it may be noted that, just as we are all in some measure "less than fully human," in the same manner we are all in some measure lacking in full mental health. The Orthodox concept of repentance or metanoia implies a change of mind, a transfiguration and transformation of the human mind. What is significant is that the teaching of the spiritual Fathers of the Eastern Church emphasizes the need for constant repentance on the part of every human being in the direction of his human goal and destiny.
Some recent studies have related traditional spiritual methodologies to standard psychotherapeutic theories, methods, and approaches (Faros). There are differences, of course, but there is also a remarkable number of parallels to be found between the ancient spiritual disciplines and modern schools of psychology.
Orthodox ethics sees the mentally ill as fellow human beings who need compassionate assistance. Therapies that degrade their essential humanity and attitudes that dehumanize the mentally ill in the eyes of society and deny assistance, relationship, and therapeutic support are in themselves immoral and dehumanizing.
In the ethical consciousness of the Church, respect and deference for the elderly, and especially for elderly parents, is an important moral responsibility. There is a strong feeling that children ought personally to care for their aged parents. It is only when circumstances are such that it is truly impossible for children to care for their aged parents that they may be placed in appropriate institutions for care. Such institutions have long been a part of the Eastern Orthodox Church's social mission (Constantelos, 1968, chap.13).
Death, dying, and euthanasia.
The traditional definition of physical death is "the separation of soul and body." Such a definition is not subject to objective observation. Thus it is not within the province of theology to determine the medical indications of death and the onset of the dying process. However, in reference to the terminally ill person, certain distinctions can be made. Physical life is generally understood to imply the ability of the person to sustain his or her vital activities. Physical death begins when interrelated systems of the body begin to break down. Death occurs when the systemic breakdown becomes irreversible. It may well be that physical life and death are events in a continuum in which it is impossible to discern when the dying process actually begins. Nevertheless, the bias of the Church and the traditional bias of the medical practitioner (cf. Oath of Hippocrates) is to do everything possible to maintain life and hinder the onset of dying and death. The medical use of drugs, surgical operations, and even artificial organs (mechanical kidneys, lungs, hearts, etc.) are considered legitimately used when there is a reasonable expectation that they will aid the return in due time to normal or close to normal functioning of the whole organic system.
The special case arises in that it is now medically possible to keep the body "alive" with a complex array of artificial organs, medications, transfusions, and the like. Under these conditions it may not be feasible to expect, with any degree of probability, the restoration of the organic functioning of the body. When, especially, there is no evidence of brain activity in conjunction with the systemic breakdown, we can safely say that the patient is no longer alive in any religiously significant way, and that, in fact, only certain organs are functioning. In such a case there is no moral responsibility to continue the use of artificial, means. It is of interest that the Prayer book of the Eastern Orthodox Church includes a whole service devoted to those in the process of dying. In the case of the individual whose death is prolonged and attended by much "struggling to die," the key sentence in the prayer calls upon God to separate the soul from the body, thus giving rest to the dying person. It asks God "to release your servant (name) from this unbearable suffering and this continuing bitter illness and grant rest to him" (Mikron Euchologion, p. 192).
However, it must be emphasized that this is a prayer directed to God, who, for the Orthodox, has ultimate dominion over life and death. Consequently, the preceding discussion in no way supports the practice of euthanasia. Euthanasia is held by some to be morally justified and/or morally required to terminate the life of an incurably sick person. To permit a dying person to die, when there is no real expectation that life can sustain itself, and even to pray to the Authorof Life to take the life of one "struggling to die" is one thing; euthanasia is another, i.e., the active intervention to terminate the life of another. Orthodox Christian ethics rejects the alternative of the willful termination of dying patients, regarding it as a special case of murder if done without the knowledge and consent of the patient, and suicide if it is permitted by the patient (Antoniades, II, pp. 125-127). One of the most serious criticisms of euthanasia is the grave difficulty in drawing the line between "bearable suffering" and "unbearable suffering," especially from an Eastern Orthodox perspective, which has taken seriously the spiritual growth that may take place through suffering (Rom. 8:17-39).
Ethical decision making is never precise and absolute. The principles that govern it are in a measure fluid and subject to interpretation. But to elevate euthanasia to a right or an obligation would bring it into direct conflict with the fundamental ethical affirmation that as human beings we are custodians of life, which comes from a source other than ourselves. Furthermore, the immense possibilities, not only for error but also for decision making based on self-serving ends, which may disregard the fundamental principle of the sanctity of human life, argue against euthanasia.
Generally speaking, the Orthodox Church teaches that it is the duty of both physician and family to make the patient as comfortable e as possible, to provide the opportunity for the exercise of patience, courage, repentance, and prayer. The Church has always rejected inflicted, and unnecessary voluntary suffering and pain as immoral; but at the same time, the Church also has perceived in suffering a positive value that often goes unrecognized in the "logic of the world."
The only "eu-thanasia" (Greek for "a good death") recognized in Orthodox ethics is that death in which the human person accepts the end of his or her life in the spirit of moral and spiritual purity, in hope and trust in God, and as a member of his kingdom. True humanity may be achieved even on a deathbed.
The transmission of life.
Orthodox Christian ethical thought considers that the transmission of human life is no less a fundamental responsibility of mankind than its protection. The Church sees this aspect of its concern as the divinely chosen means by which human beings contribute cooperatively in God's creative work. The transmission of human life is thus a holy and sacred moral responsibility. This responsibility is a generally human one and is taken up, sanctified, and made a part of the corporate life of the body of Christ in the Sacrament of Holy Matrimony. Though not the only purpose of marriage, the transmission of human life is an important duty and moral responsibility. This is readily seen in the fact that if each and every person now alive failed to contribute to the transmission of human life, it would be only a matter of time until human life would be extinguished from the face of the earth. The divine injunction "to be fruitful and multiply" (Genesis 1:28) is a fundamental moral imperative in the teaching of the Orthodox Christian Church. It is within this larger framework that we approach the specific issues of human sexuality, fertility control, population, artificial insemination, in vitro fertilization, andgenetic screening and counseling.
The Church teaches that human sexuality is a divinely given dimension of humanlife that finds its fulfillment in the marital relationship. This is also supported by empirical observation, for at their very biological basis, sexual differences clearly exist for reproductive purposes. Because of the fact that human reproduction requires a long period of time for the newly born child to achieve a level of development permitting physical self-care, and increasingly long periods for social, educational, emotional, and economic maturity, the human race long ago recognized the need for some kind of permanent relationship of the sexes for the purpose of serving the reproductive purpose. That permanent relationship is marriage.
However, the purpose of marriage is not limited or restricted to this aspect alone. The purposes of marriage and their ranking in importance are a point of difference among Orthodox authorities (both patristic and contemporary), but scriptural and patristic evidence argue for at least four purposes for marriage, without ranking them in order of primacy:
the birth and care, of children,
the mutual aid of the couple,
the satisfaction of the sexual drive,
growth in mutuality and oneness, i.e., love.
In the mixture of these purposes, the whole purpose of human sexuality is fulfilled and completed, ethically and humanly (Constantelos, 1975).
Ethical corollaries of this position are:
all the dimensions of human sexuality are properly fulfilled in marriage, and the married have the moral obligation to seek the enrichment and fulfillment of their marriage in all of its aspects, as indicated above;
premarital sexual relations between unmarried persons are sinful and as such are labeled fornication;
sexual relations between two persons, at least one of whom is married to a third person, are morally evil and as such are labeled adultery;
sexual relations between persons for payment is sinful and is labeled prostitution;
sexual relations between brothers and sisters, parents and children, and other close relatives are morally wrong and as such are labeled incestuous;
sexual relations between persons of the same sex are immoral and as such are labeled as acts of homosexuality in the case of males, and lesbianism in the case of females;
sexual relations between a human being and animals are condemned as immoral, being labeled acts of bestiality;
autoerotic activity is adjudged as an improper expression of human sexuality, and as such is labeled masturbation.
Fertility control, or contraception, is the practice by which mechanical, chemical, or other means are used, either before or after a sexual act, in order to prevent fertilization of the ovum by the sperm, thus circumventing the possible consequences of the sexual act - the conception and ultimate birth of a child.
General agreement exists among Orthodox writers on the following two points:
since at least one of the purposes of marriage is the birth of children, a couple acts immorally when it consistently uses contraceptive methods to avoid the birth of any children, if there are not extenuating circumstances;
contraception is also immoral when used to encourage the practice of fornication and adultery.
Less agreement exists among Eastern Orthodox authors on the issue of contraception within marriage for the spacing of children or for the limitation of the number of children. Some authors take a negative view and count any use of contraceptive methods within or outside of marriage as immoral (Papacostas, pp. 13-18; Gabriel Dionysiatou). These authors tend to emphasize as the primary and almost exclusive purpose of marriage the birth of children and their upbringing. They tend to consider any other exercise of the sexual function as the submission of this holy act to unworthy purposes, i.e., pleasure-seeking, passion, and bodily gratification, which are held to be inappropriate for the Christian growing in spiritual perfection. These teachers hold that the only alternative is sexual abstinence in marriage, which, though difficult, is both desirable and possible through the aid of the grace of God. It must be noted also that, for these writers, abortion and contraception are closely tied together, and often little or no distinction is made between the two. Further, it is hard to discern in their writings any difference in judgment between those who use contraceptive methods so as to have no children and those who use them to space and limit the number of children.
Other Orthodox writers have challenged this view by seriously questioning the Orthodoxy of the exclusive and all-controlling role of the procreative purpose of marriage (Zaphiris; Constantelos, 1975). Some note the inconsistency of the advocacy of sexual continence in marriage with the scriptural teaching that one of the purposes of marriage is to permit the ethical fulfillment of sexual drives, so as to avoid fornication and adultery (1 Cor. 7:1-7). Most authors, however, emphasize the sacramental nature of marriage and its place within the framework of Christian anthropology, seeing the sexual relationship of husband and wife as one aspect of the mutual growth of the couple in love and unity. This approach readily adapts itself to an ethical position that would not only permit but also enjoin sexual relationships of husband and wife for their own sake as expressions of mutual love. Such a view clearly would support the use of contraceptive practices for the purpose of spacing and limiting children so as to permit greater freedom of the couple in the expression of their mutual love.
There would appear to be a direct contradiction between the ethical imperative to "be fruitful and multiply" and the need to respond ethically to the "population explosion."
Those few Orthodox writers who have addressed themselves to this question ask if the issue is not so much a question of population as it is one of the fair and just distribution of the world's resources. (Papacostas; Gabriel Dionysiatou; Evdokimov, pp. 163-174). However, in the light of strong evidence that food and mineral resources are limited, population control is, without question, of ethical significance. This is not necessarily in conflict with the Orthodox teaching on marriage. Of interest in this instance is a fourth-century quotation from St. John Chrysostom, made in reference to the purpose of marriage, which the saint considered to be primarily the satisfaction of the sexual drive:
It was for two reasons that marriage was introduced so that we may live in chastity [sophrosyne] and so that we might become parents. Of these the most important reason is chastity . . . especially today when the whole inhabited world [he oikoumene] is full of our race [John Chrysostom].
If overpopulation in the saint's eyes was a fact of the fourth century providing an argument to support his views on marriage, it implies that today the fact of overpopulation continues to have ethical significance. If it is true that humanity has in fact been obedient to the divine command and has been "fruitful" and has "multiplied" and has "filled the earth" (Gen. 1:28), then it would appear that this has ethical significance.
Thus, it seems valid to raise the question, within the context of Orthodox ethics, of the appropriate means of population control. Orthodox ethics disapproves of any means of population control that would violate and coerce the individual couple's choice regarding their obligation to procreate. It opposes the use of those means on a large scale that it opposes in individual cases, i.e., abortion. Those Orthodox teachers who oppose contraceptive practices of any nature, when faced with the facts of population pressures, are placed in the position of proposing widespread abstinence from sexual relations by huge numbers of people. Those who hold to the legitimacy of a reasonable use of contraceptives within marriages that have produced some offspring are prepared to accept the need and propriety of population control through educational methods, encouraging smaller families through contraceptive methods. All Orthodox ethicists, however, would hold that respect for the freedom of each couple to decide must be considered an important and significant factor of population control policy.
For obvious reasons, artificial insemination of unmarried women, or of married women without the consent and cooperation of the husband, is rejected by the Orthodox, in the first instance as a form of fornication, and in the second as duplicity and a form of adultery (Galanopoulos, pp. 455-456). What of the cases in which the husband gives his permission or urges the procedure upon his wife? In this situation, when a donor's semen is used, Orthodox ethicists readily view it as the intrusion of a third person into the sacred marital relationship and reject it as a form of adultery not ethically appropriate. In the instances in which the couple is not able to bear their own children, the other purposes of marriage remain in effect, and the marriage of the couple continues to be both valid and fulfilling. Such a couple may decide to adopt children.
In the case of insemination with the husband's sperm (AIH), there are differing opinions. Some ethicists hold that AIH is also improper because the child is not conceived as a result of natural sexual intercourse (Constantinides). This position, however, does not prohibit medical treatment of the husband for the correction of some medical defect that may be the cause of the failure to achieve conception. This view is countered by the consideration that the integrity of the marital relationship is not attacked by AIH. Rather, one of its main purposes is permitted to be fulfilled. It is questionable if the ethical argumentation connecting AIH with the requirement for the physical act of sexual intercourse is drawn from Eastern Orthodox sources.
Orthodox writers have not dealt with artificial inovulation and in vitro fertilization procedures. It would seem consistent, though, to hold that, so long as the sperm and ovum are those of the husband and wife, and the wife carried the child to term, such procedures would not in themselves be objectionable. However, egg grafts from anonymous donors and the transplantation of a fertilized ovum to a foster mother who would then carry the conceptus to term would attack the integrity of the marriage and the mother-child relationship.
Another topic that has received little treatment from Orthodox writers is sterilization: vasectomy in the case of the male and tubal ligation in the case of the female. It would appear that the irreversible character of these procedures would cause most Orthodox to see them as a violation of one of the purposes of marriage, though it is conceivable that some cases involving serious threat to the life of the wife might justify the procedures. Obviously, the use of the operation to permit promiscuous sexual living would be rejected out of hand by Orthodox ethicists (Zozos).
Genetic counseling and genetic screening.
At first glance it may appear that the Eastern Orthodox Church has little or nothing to say on genetic counseling and screening. Yet genetic counseling, which seeks to provide information to prospective parents before a child is conceived, simply makes more precise that which the Church has sought to do through its canon law, which prohibits marriages between closely related persons (The Rudder, pp. 977-999).This ancient compendium of prohibitions to inbreeding clearly has its historical antecedents in the observation that genetic defect-, tend to multiply when inbreeding takes place. Consequently, it would appear that genetic counseling most appropriately should take place before marriage. It seems equally clear that for the Orthodox the option of abortion is not ethically appropriate when amniocentesis indicates some genetic deformation.
Genetic screening of whole groups or populations to determine carriers of genetic disease would also be encouraged by Orthodox ethics, so as to provide as much information as possible to persons before marriage. Ethical prudence would cause two persons who are carriers of the same genetic disease not to marry, thus avoiding the high probability that deformed children would be born to them.
In this way, what is more or less crudely effected through the Church's rules regarding prohibited marriages because of consanguinity would be accomplished more accurately through scientific genetic screening. In the same spirit it would be possible to support legislation prohibiting marriage between two carriers of the same genetic disease, especially in the case of a disease that is widespread and a threat to the total human genetic pool.
The common denominator of all the issues discussed is the high regard and concern of the Church for human life as a gift of God. Orthodoxy tends to take a conservative approach to these issues, seeing in them a dimension of the holy and relating them to transcendent values and concerns. An intense respect for human life is needed to hold the reins upon those who would attack it. The human person, from the very moment of conception, is dependent upon others for life and sustenance. It is in the community of the living, especially as it relates to the source of life, God in Trinity, that life is conceived, nurtured, developed, and fulfilled. The trust we have in others for the continued well-being of our own lives forms a basis for generalization. Eastern Orthodox ethics, consequently, functions with a pro-life bias that honors and respects the life of each person as a divine gift, which requires development and enhancement.
ANDROUSTOS, CHRISTOS. Systema ethikes [Ethical system. 2d ed. Thessalonike, Greece: Basil Regopoulos Publishing House, 1964.
ANTONIADES, VASILEIOS. Encheiridion kata Christon ethikes [Handbook of Christian ethics]. Constantinople: Fazilet Press, 1927.
BASIL, SAINT; RALLE, G. A.; and POTLE, M. Syntagina ieron hanonon [Compendium of sacred canons]. Athens: Hartophylakos Press, 1854, vol. 4, pp. 88-294.
CONSTANTELOS, DEMETRIOS J. Byzantine Philanthropy and Social Welfare. New Brunswick, N.J.: Rutgers University Press, 1968.
______. Marriage, Sexuality and Celibacy: A Greek Orthodox Perspective. Minneapolis, Minn: Light and Life Publishing Co., 1975.
______. "Physician-Priests in the Medieval Greek Church." Greek Orthodox Theological Review, Winter 1966-1967, pp. 141-153.
CONSTANTINIDES, CHRYSOSTOM. "Technike gonimopoiesis kai theologia." [Artificial insemination and theology]. Orthodoxia 33 (1958): 66-79; and 34 (1959): 36-52.
DEMETROPOULOS, PANAGIOTES. Orthodoxos Christianike ethike [Orthodox Christian ethics]. Athens: 1970.
EVDOKIMOV [EVDOKMOFF], PAUL. Sacrement de I'amour: Le Mystere conjugal a la lumiere de la tradition orthodoxe. Paris: Editions de l'Epi, 1962. Greek ed. Mysterion tes agapes [Mystery of love). Translated by Serapheim Orphanos. Athens: 1967.
FAROS, PHILOTHEOS. "Mental Patients and Verbal Communication of the Religious Message." Theologia 42 (1971): 602-606.
FLOROVSKY, GEORGES. Bible, Church, Tradition: An Eastern Orthodox View. Belmont, Mass.: Nordland Publishing Co., 1972.
GABRIEL DIONYSIATOU. Malthousianismos: To englema tes genoktonias [Malthusianism: The crime of genocide]. Volos: Holy Mountain Library, 1957.
GALANOPOULOS, MELETIOS. Systema ieras exomologetikes [A study of penitential practice]. Athens: Orthodox Source Books, 1954.
HARAKAS, STANLEY S. "The Natural Law Teaching of the Eastern Orthodox Church." Greek Orthodox TheologicalReview, Winter 1963-1964, pp. 215-224.
______. "An Orthodox Christian Approach to the 'New Morality'." Greek Orthodox Theological Review, Spring 1970, pp. 107-139.
JOHN CHRYSOSTOM. "Eis to apostolikon reton: Dia de tas porneias ekastos ten heautou gynaika echeto" [On the words of the apostle: Concerning the fornication each has with his own wife]. Patrologiae cursus completus: Seriesgraeca [Patrologia Graeca]. 161 vols. Paris: Apud Gamier Fratres, editores & J.P. Migne Successors, 1857-1894, vol. 51, cols. 207-218, at Col. 213.
KOTSONIS, JEROME. "Fundamental Principles of Orthodox Morality." The Orthodox Ethos: Studies in Orthodoxy. Edited by A. J. Philippou. Oxford: Holywell Press, 1964.
MALONEY, GEORGE A. Man, The Divine Icon: The Patristic Doctrine of Man Made According to the Image of God. Pecos, N.M.: Dove Publications, 1973.
MANTZARIDES, GEORGE. Christianike Ethike: University Lectures. Thessalonike, Greece, 1975.
Mikron euchologion, e aghiasmatarion [Shorter prayer book]. Athens: Apostolike diakonia tes ekklesias tes Ellados, 1956.
PAPAKOSTAS, SERAPHEIM. To zetema tes teknogonias: To demographihon problema apo Christianikes apopseos [Question of the procreation of children: The demographic problem from a Christian viewpoint]. Athens: Brotherhood of Theologians "Zoe," 1933, 1947.
The Rudder. Translated by D. Cummings. Chicago: Orthodox Christian Educational Society, 1957.
WARE, TIMOTHY. The Orthodox Church. Baltimore: Penguin Books, 1972.
ZAPHIRIS, CHRYSOSTOM. "The Morality of Contraception: An Eastern Orthodox Opinion." Journal of EcumenicalStudies 11 (1974): 677-690.
ZOZOS, CONSTANTINE. "The Medical, Legal, and Moral Aspects of Sterilization." Ekfrasis, Spring 1974, pp. 33-54.