Bioethical perspective of ontologically-based personalism

Abstract

This article presents a bioethical perspective of ontologically-based personalism.

The aim of this model applied to bioethics is to provide a suitable framework for moral issues that arise from biomedical applications to human beings.

Firstly, an explanation is offered on how the ethical model it proposes has an ontological foundation, with a view to associating human dignity and rights – most notably at the beginning and at the end of life – with the substantial reality of the person, as opposed to associating it with a set of capacities that an individual may or may not exhibit. The reader is then introduced to a case analysis method that links empirical data, anthropological dimensions, and ethical assessment, as well as a set of four practical principles aimed at guiding decisions in a biomedical context.

Finally, it outlines the key components of a personalist, ontologically based, model, by comparing its theoretical setting and its main implications with those of some current bioethical trends.

Resumen

Este artículo presenta la perspectiva bioética del personalismo con fundamentación ontológica. El objetivo de este modelo aplicado a la bioética es proponer un marco adecuado para las cuestiones morales que surgen de las aplicaciones biomédicas a los seres humanos. En primer lugar, se explica que este modelo ético se basa en un fundamento ontológico, con el fin de conectar la dignidad y los derechos de los individuos implicados en cuestiones de bioética —por ejemplo, al principio y al final de la vida— con la realidad sustancial de la persona y no con un conjunto de capacidades que un determinado individuo puede exhibir o puede no exhibir. Después, se presenta el método de análisis de casos propuesto por este modelo, que relaciona los datos empíricos, las dimensiones antropológicas y la valoración ética, y un conjunto de 4 principios prácticos destinado a guiar las decisiones éticas en el contexto biomédico. Los puntos claves del modelo personalista con fundamentación ontológica serán ilustrados también mediante la comparación de su valor teórico y sus principales implicaciones con las de algunas tendencias actuales en el debate bioético.

Introduction

My first aim in this essay is to present a personalist perspective which is ontologically founded, namely a bioethical approach rooted in the metaphysical tradition of Western philosophy that is well suited to address old and new problems arising from bio-medical developments.

My presentation consists of two parts. In the first part, I will introduce the theoretical framework of personalism, where the notion of person plays a crucial role. I will also compare the approach to the definition of person in ontological personalism with the definition of person in those perspectives that reject an ontological premise.

In the second part, I will outline how this personalist approach may apply to bioethical issues and concrete situations: I will do so by introducing a “triangular methodology” and four principles connected with this approach.

My second aim is to contrast this ontologically founded personalism and its notion of the human person with those perspectives in the bioethical debate that divide human lives between those that are “worthy” and those that are allegedly “unworthy”. Liberals, for instance, tend to follow subjective evaluations, with the consequence that decisions on life and on its value end up depending on individual choices. For utilitarians, the value of human lives is evaluated according to a vague standard of “quality of life” and to a set of abilities and functions that individuals may or may not possess.¹ Actually, the subject himself often assesses the “quality of life” and, therefore, expresses preferences on his/her life, or on the life of subjects that cannot express themselves (embryos, fetuses, the mentally ill, etc.). In this, utilitarianism is quite close to liberalism. On the contrary, personalist bioethics does not distinguish between human beings in terms of “worthiness” and value of life.

My claim is that, within this ethical scenario, ontological personalism corresponds to a non-discriminatory ethical approach to bioethical issues: since this perspective is based on firm and uncompromising premises, its anthropological and methodological structure leads to an ethics that is really fair toward the different subjects involved in medical decisions and social evaluations.

Historical and philosophical overview

Ontologically founded personalism belongs to the wider category of personalist philosophies which consider the person as the main epistemological and axiological starting point in philosophy.² In general, personalist perspectives emphasize such important traits of the person as relationality, subjectivity and moral freedom, in order to offer a strong foundation to the dignity of the person. However, individuals who might exhibit only few of such ‘personal properties’, or do not exhibit them at all, could not be considered fully persons from these personalist perspectives, or should even be considered non-persons. Evidence of this can be found in bioethical discussions, particularly on issues regarding the beginning of life (abortion, prenatal selection, pediatric euthanasia, etc., involving embryos, fetuses and newborn) and at the end of life (concerning the terminally ill or individuals with severe disabilities). Hence these human beings run the risk of being considered unworthy of being cured or of the right to live, precisely because they do not show some specific personal traits. From the bioethical debate, a clear need emerges to base the concept of person on a stronger foundation: this stronger foundation is found in the ontological foundation that defines the brand of personalism to which I am referring here.

Ontological personalism has to be distinguished from other forms of personalism (hermeneutical, existential, etc.) in that it focuses on the value of the person according to what the person is, and not merely on activities that people develop during their existence. Without reference to ontology – as I will discuss – individuals with no cognitive or relational abilities risk being excluded from ethical attention.

The theoretical foundation of ontological personalism entails its strongly applicative vocation, because it attempts to provide in every concrete situation the appropriate normative framework to the moral issues arising from biomedical applications to human beings, in issues such as abortion, assisted/artificial reproduction and genetics, euthanasia, organ transplantation, etc.

The concept of person in bioethics

To introduce personalist bioethics, it is appropriate to recall, however briefly, a few selected philosophical reflections on the concept of person.

The concept of person is one of the most frequently used and debated in bioethical discussions and in biolaw (Agazzi, 1993, p. 8; Spagnolo, 2012). The different approaches to human rights depend on their different concepts of person: according to the personalist approach, for example, human rights are grounded on the dignity of the person and are considered universal and inalienable, while other approaches build human rights mainly on the values of “individual freedom” or “quality of life” (according to the meaning they attribute to these expressions).

The concept of person is commonly used as the boundary line between what is licit and what is illicit in biomedical intervention on human beings. The term “person” in the common sense (and also in a legal context) means a subject worthy of respect and protection. However, even though there is broad agreement in considering the person on a practical level as a rights-holder worthy of maximum respect (the moral status of the person), there is fierce debate on the theoretical level. What or who is the person? There is a variety of theoretical approaches to the definition of the term “person”, and this in turn produces a variety of suggested solutions to the question of which individuals should be considered “persons”, first from the ontological point of view (“to be” persons), and second from the moral point of view (which rights and treatments have to be recognized for different individuals).

It is possible to classify the various theoretical perspectives on the notion of person under two main categories, and it is from these two perspectives that the different positions in bioethical debates originate.

The first one – which comprises various philosophical positions, both materialist and rationalist – affirms the separability in principle and separation in fact between the person on the one hand, and the human being and its life on the other hand (Palazzani, 2009). According to this approach, human beings “become” persons and cease being persons, not at the moment of conception and death, but only when certain–verifiable – conditions, or properties, arise: it follows that the respect for human life depends on the possibility of verifying certain empirical conditions, such as the presence of certain traits or capacities (individuality, ability of perception, self-consciousness, reasoning, autonomy, etc.).³ From this perspective, individuals not yet or no longer able to perceive, to be self-aware or autonomous as zygotes, embryos, fetuses or adults with disabilities (such as mental retardation, coma, etc.) are “non-persons”. Hence the moral status of the person depends on a number of functions of the subject (human or non-human), and not on the subject itself.

This anthropological and moral position is composite: the libertarian trend, for example, defines the “subject” – in its moral meaning – as individual self-awareness, ability to reason and to express moral judgments, while utilitarianism confers the anthropological and moral status of person on sentient individuals who possess the ability to feel pleasure and pain (Palazzani, 2009). This confirms the splitting between the two concepts of “person” and “human being” (Agazzi, 1994, pp. 222–226).

This splitting certainly calls for objections. Agazzi observes that this separation corresponds to an epistemological error, stemming from the abstract use of the nominal definition of person. Any nominal definition, in fact, elevates a singular property to determining artificially a class of things: in the case of person, this property could be, for example, consciousness. According to such nominal definition, only individuals with consciousness are persons. However, this is entirely unsatisfactory: definitions are meant to characterize in an abstract way what real entities are, instead of reducing their rich and complex reality to some property.

Some theories regard biological and cognitive functions as fundamental to considering individuals as persons. However, various functions depend on the subject itself as their ontological condition, or, in metaphysical terms, the condition for such accidents.⁴ When dignity and respect of the individuals depend on some properties – and not on their real referent – the practical consequence is that only few human lives are considered as worthy of respect in moral and legal terms, and this means substantial discrimination among human beings.

These objections come from a metaphysical matrix connected with a different approach in the debate on the person. This second approach descends from the Western philosophical tradition, in particular Aristotle and Aquinas, where the very concept of person took shape. This approach is not merely theoretical or “abstract”. On the one hand, the term “person” means something more than the mere expression “human being”: while human nature denotes an abstract essence, “person” denotes the subsistent individual that realized himself in the course of history with all the traits of personality. The person is the real human being, as stated by Thomas Aquinas, who defined the person as “individual substance of rational nature” (Seidl, 1987). Therefore the idea of personhood has to be related to reality, instead of adapting reality to any theoretical concept.⁵ The term “person”, on the other hand, is used to recall a moral status: referring to human nature, in fact, could look sufficient, but “person” indicates something more than the pure and simple condition of being a human being and refers to a moral status that requires maximum respect and the recognition of a maximum degree of dignity.

To recognize someone as a person only by observing some accidental functions or qualities implicitly refers to something (or someone) that comes before, and exists despite, those accidents. That existing individual is identified in the Aristotelian-Thomistic tradition with the term “substance”, as this term is used in Boethius's definition of person as “rationalis naturae individua substantia”.⁶ In metaphysics, substance is what does not belong to a subject but is the subject, and exists in itself and for itself, and not in something else, or for something else. Substance is what exists and persists, and, at the same time, develops itself over time through continuous changes.

From the very beginning of his/her existence at fertilization, the human individual shows substantial unity, which develops while maintaining this ontological unity at all stages, without interruptions. Here metaphysics meets biology: from the moment of fertilization, a new system arises, which works as a new individual, intrinsically finalized – if the necessary conditions exist – to achieve his/her specific final form according to the information contained in a single genome. The project included from the beginning in the new genome, which certifies both the individual identity and its membership in the human species, will develop throughout the individual's life according to a process that is coordinated, continuous and gradual (Bioethics Centre of Catholic University of Sacred Hearth, 1996; Pontifical Academy of Life, 1998; Palazzani, 2009, p. 32).

However, a human being is not just his/her body. According to the classical definition of person given by Boethius (which complements Aristotle's definition of human being as zoon politikon,⁷ and agrees with Aquinas's definition of “individual substance of a rational nature”),⁸ the body is the material principle of the person, while rationality is the nature (or “form”, in metaphysical terms) in it. The notion of rationality indicates the typical way of being for humans, who, by nature, are intelligent, have logos. But, of course, specific operating conditions are necessary for human beings to reveal fully what they are by nature. This is already contained in the genome's information since the very beginning of their existence.

The first perspective recognizes the person only when he/she shows cognitive functions: these abilities, which accidentally might or might not be manifest, are considered as essential properties of the person. However, because those properties are accidental, they cannot be regarded as essential requirements to define the moral status and dignity of a person. Contrary to this, rationality is an essential property of the person, and it belongs to the subject naturally, though he/she has to achieve a certain degree in his/her development to show it fully. When this development is interrupted, as in the case of interventions on embryos or fetuses that cause their elimination, the person cannot obviously reveal his/her full potentiality. In addition to that, if some properties, even essential, do not arise, this does not deny the existence of the subject that is in himself/herself worthy of rights and respect. (We do not respect properties but the subject that possess them.)

In summary, the concept of person expresses the way of being of the real subject, and the single human being persists as a substantial unity from fertilization to death. Hence every human being is, and must be considered, a person throughout his/her own life. The individual is a person, and does not become a person on account of the exercise of some functions or features. That is why we refer to an ontological foundation of personalism.⁹

Keeping an indissoluble relationship between the status of person and the existence of the individual – which is what is meant by the expression “ontologically founded” – prevents discriminations among human beings, which are brought about in the name of such different grounds as biological, social, psychological (as in the paradigmatic debate about when an individual begins to be a person).¹⁰ Thanks to these theoretical premises on the ontological equality among human beings, it is possible to affirm the equal dignity and value of every human individual.

From metaphysics of person to personalist meta-ethics

As mentioned above, the term “person” has a meaning that is both ontological and moral. This means that those who are persons should be treated as such, and the rights typical of their status must be recognized to them. The process of the person's recognition in the Western tradition was marked by Thomas Aquinas, who adds to his definition of person that a person lives in him/herself and for him/herself: in other words, person is an end in himself/herself, and cannot be considered as a means to something else. Kant later affirmed that the person requires the categorical imperative to treat him/her always as an end and never merely as a means.¹¹

There is therefore a general norm, which we could consider to be a first ethical principle, and which states that the human person requires unconditional respect, including inviolability of life and protection of the free expression of his/her way of being. As a consequence of this norm, there are specific “negative” ethical principles (Carrasco De Paula, 2004)¹²: respect for dignity in fact forbids to act against a human being mortifying his/her “personal” way of living, his/her autonomy and freedom. From this general principle, others follow: first, the prohibition of all forms of oppression against the person and the use of any human being for other purposes than the proper good of the same individual (thus prohibiting the exploitation of the persons); second, the prohibition of discrimination among subjects, i.e. treating human beings as things without value, or as insignificant specimens of the human kind, or as objects before they obtain the right to be recognized as persons.

These principles have general value in founding a broad ethics for the person. They do not have specific bioethical connotation, as they do not provide specific rules for the bio-medical context yet. However, it is possible to outline some applications of these principles. For instance, when human lives are exploited or assimilated to objects (such as in the case of embryo experimentation with non-therapeutic purposes for the involved embryos), or when they are underestimated because of an alleged “low quality of life”, as in the case of serious disability.

Moving from personalist meta-ethics to bioethics, the broad principle of inviolability and protection of the person's life is specified in the duty to safeguard his/her physical integrity through health care, and to promote the patient's global good. According to personalist bioethics, quality of life is not regarded as a criterion for assessing the value of human lives, but as a goal to be pursued through caring according to the integral good and the intrinsic value of the person.

A personalist bioethical model

Personalist bioethics aims to provide a normative framework for assessing actions in the bio-medical field. Therefore, starting from an anthropological-ontological foundation and meta-ethical framework, the personalist bioethicist Elio Sgreccia has developed a method of case analysis and principles guiding medical interventions on human beings and healthcare management (Sgreccia, 2012; Tarantino, 2016).

Personalism regards bioethical analysis as consisting of two phases. The first is descriptive, aimed at explaining the problem; the second is normative, leading to conclusions arrived at from meta-ethical premises.

Moving from the premise that, in bioethical reflection, bio-medicine, anthropology and ethics are closely inter-related, personalism has developed a “triangular method” (Gomez-Tatay, Hernandez-Andreu, & Aznar, 2016; Sacchini et al., 2008; Sgreccia, 2012, 247–248) involving three steps (or vertices of the triangle) in analyzing bioethical problems. The first vertex is the “scientific moment”, consisting of an in-depth study of all facts/data of the problem, including quantitative, qualitative and the relations between them. The second, and highest, vertex of the triangle is the anthropological understanding of the problem initially described in the scientific moment: this is the stage that takes into consideration the values related to life, integrity and dignity, which are at stake in the given problem. For example “experimenting on a conscious patient or healthy volunteer is one thing, whereas experimenting on a child, an embryo, or a mentally disabled person takes on an entirely different meaning” (Sgreccia, 2012, p. 248). The third vertex is the analysis of the problem, as described and studied in the two earlier phases, in the light of the ethical framework that allows to assess practical choices or judgments.

Moreover, a personalist approach to bioethics provides also practical principles to guide decisions on bio-medical interventions on human life and the human body. These principles are rooted in the Aristotelian-Thomistic moral tradition and in the philosophy emerging from the practice of medicine. Reflection on the purposes and nature of the health-care professions leads to well-founded ethical decisions. For example, the very raison d’etre of medicine forbids that a physician may deliberately kill a patient: this prohibition stems from his/her very role as a medical professional (Kass, 1992; Pellegrino & Thomasma, 1981).

The four principles of personalist bioethics (Sgreccia, 2012, pp. 176–183) are: (1) the principle of defense of physical life; (2) the principle of totality (the therapeutic principle); (3) the principle of freedom and responsibility; and (4) the principle of sociality and subsidiarity. These four principles are framed in an ethical theory founded on the key value of the good of the person. There is a hierarchical order among them.

The first principle, preceding the others, results from the fact that bodily/physical life is a fundamental dimension of the person, an ontological precondition for individual existence. Furthermore, body, as a “living lived body”¹³ is not something extrinsic to the person: in a dual (and not dualist) anthropological view, there are two dimensions, spiritual and physical. Thanks to this “unitotality” of body and spirit, I live in my personal body with my personal soul¹⁴ (Stein, 2002). Given the fundamental role of physical life for the person, it is forbidden to suppress human life, as in the cases of homicide, suicide, abortion, euthanasia, embryo selection, etc. This principle provides not only negative duties, but also an active defense and promotion of life as well as a moral obligation to defend and promote the health of all human beings in proportion to their needs. But this is not a matter of a “right to health”: no government can guarantee health, but rather a right to receive the essential means and treatments available for the defense and promotion of health. In addition, the right to life precedes the so-called right to health: for example, a pregnant mother's right to health does not justify abortion, which denies the child's right to life.

The second principle comes from the previous one, and is more practical: the principle of totality, or therapeutic principle, is used when it is necessary to intervene, also in a “harmful way”, on part of the body to save the whole of the person's life. Medical and surgical treatments are morally based on this principle: when the physician causes a “loss” by removing an appendix he/she is morally justified, and indeed obliged, because this partial “harm” is necessary to protect the whole of the subject's life. There are some corollaries to this principle: interventions have to be carried out both on the diseased part and on that part that causes illness¹⁵; there should not be alternatives to the interventions, such as less invasive treatments; interventions must be proportionate to the patient's situation and must have good prospects of success; and there must be the patient's consent.

This principle is linked to another practical norm defined as proportionality of treatments: medical intervention must be assessed taking into account the totality of the person, in order to avoid both an abandonment of the patient, or, conversely, overtreatments or futility (Calipari, 2006; Pellegrino, 2000).

In accordance with the third principle, persons are not merely “autonomous” but have to be responsible for their choices in order to pursue their global good. For instance, the value of life precedes that of liberty, so that everybody's acting must be guided by responsibility both toward his/her own life and that of others.

Both the physician and the patient are free and, at the same time, have the duty to be responsible. On the one hand, physicians are called to be responsible for their therapeutic choices and must respect the obligation of informed consent, since these choices should freely be accepted by the patient. At the same time, the patient's consent does not relieve the physician's duty to inform the patient about treatment progress and to ask the same patient for additional and explicit consent in case of unforeseen developments. On the other hand, the physician, in the name of freedom and responsibility, may – and sometimes must – refuse to agree to ethically unacceptable requests or patient expectations. The physician has to invite the patient to reflect more, and, if necessary, to consult other physicians or hospitals. The patient's conscience cannot be violated by the physician, and conversely the physician cannot be forced to carry out the patient's requests: both are in fact responsible for life and health as personal and social goods.

The last principle consists of “two principles in one”, and regards the field of healthcare assistance and the social dimension of health.

The principle of sociality commits each individual to participate in achieving the good of neighbors and society. It has to be applied for the protection of life and health, and it implies that citizens are engaged in the promotion of health and life, which are considered personal and social goods. On the one hand, the good of society is promoted when the good of each citizen is promoted, with the consequence that the community must ensure that everyone has access to necessary healthcare. On the other hand, this principle justifies organ and tissues donation (even when the explant involves some admissible damage to the donor), stimulates volunteering (for example voluntary participation in experimentation), and animates hospitals and care facilities.

The principle of subsidiarity states that the community must provide more resources where the needs are greater. Therefore, in the allocation of resources (including organs), economic utilitarian criteria, such as balancing costs and benefits (which can result in denying resources to those individuals who are not considered productive or are even regarded as “useless”), are not the only ones to be taken into account, precisely because healthcare must never be denied to those who have greater needs.

Conclusion

In this essay, I have outlined the theoretical framework and practical application of ontologically foundede personalism. “Personalist bioethics is a dynamically thinking enterprise, because it has to do with the scientific discoveries that are revisited from time to time […] [I]t also takes into account the various ways in which contemporary man perceives his own identity and values in general […] It has a critical and dialectical structure, which has its basis in a substantialist concept of the human person” (Sgreccia, 2012, pp. 67–68).

Personalist bioethics focuses on the real and historical human being, and it has to deal with new challenges, as scientific and technical applications emerge during the development of biomedical knowledge. An ethical reflection founded on the ontology of the person allows, especially in concrete cases, to put values in a hierarchical order: this approach is a response to contemporary ethical pluralism, which is often assumed as a kind of norm instead of a mere fact.

In contemporary bioethics, assuming substantial ethical positions is frequently ruled out (Pessina, 2013), with the consequence that ethical assessment ends up being reduced to complying with political or legal procedures. This is typical in liberalism or ethical subjectivism, for which individual choices are the only possible truths in ethics. However, it is a fact that liberalism is in itself a specific ethical view, with its particular truth, and therefore it does not really respect pluralism. According to liberalism, free and self-determining subjects are only those who can exercise freedom and autonomy thanks to some abilities, while other individuals without those abilities are not considered fully subjects. This is why ethical liberalism risks turning in an ethics of power: even though in principle single truths have equal value, in practice only the rights of some individuals prevail over the others. Contrary to this ethics of power, and thanks to its anthropological-ontological foundation, a personalist approach does not fall into this “paradox of pluralism”, and, at the practical level, offers a non-discriminatory normative framework that guarantees the right to live and to have healthcare to everybody in every state and at every stage of his/her existence.

Conflicts of interest

The author has no conflicts of interest to declare.