October 31, 2006 12:57 PM
A HISTORY OF EXTRAORDINARY MEANS
Scott M. Sullivan, M.A.
This is the third and concluding section of our three-part series on ordinary and extraordinary means. Please see the September and October issues for the first two parts - Ed.
St. Alphonsus Liguori
Doctor of the Church and the patron saint of confessors and moral theologians, St. Alphonsus Liguori (d. 1787), while asserting the priority of his own judgment over prior moralists, also agreed with his predecessors on ordinary and extraordinary means. It is not necessary that a man take expensive medicines, nor must he relocate to a healthier environment to prolong his life, “for it suffices to make use of ordinary means.”1 This means that it is not necessary to undergo a painful amputation.2 Normal medical procedures and medicine are required when there is hope of recovery, yet interestingly Liguori also puts forward the possibility of certain psychological factors that constitute what is extraordinary. 3 A consecrated virgin is not obligated to be seen by a male doctor, if being touched by a man is more psychologically repugnant than death.4
Liguori emerged as the recognized authority on the subject. Most follow him on the distinction between ordinary and extraordinary means. Later, theologians further develop the notion of extraordinary financial concerns relative to one’s status and also give weight to the hope of recovery. They, however, also had to deal with the advances in modern science. Operations could be performed with less pain and greater success, as the use of chloroform lessened pain and thus anxiety to a certain extent. Also in this period, moralists begin to consider the implementation of prosthetic limbs and similar devices. Anesthesia made its first successfully demonstrated appearance in Boston in 1846.5 Yet these later moralists still emphasized the intense subjective horrors of such operations, which play a role in questions of obligation. Even with the progress of modern techniques, procedures like amputation were still considered by moralists to be extraordinary. As Augustino Lemkuhl writes:
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I think scarcely is a mortal sin committed by the one who, terrified of an amputation, refuses to submit to it … one should not omit the fact that not the torments alone, which partly can be deadened now, but also great horror can be the reason why it would be licit to refuse a great operation— I am not speaking now, e.g., of cutting off a finger at its joint.6
Later theologians thus developed the notion of the subjective aversions or “horror” of a given means. Adolphe Tanquerey notes that one does not need to conserve one’s life through gravely inconvenient means—whether they are very painful or very distasteful.7
While this list of moralists (continued from parts 1 and 2 of this article) is not in any way exhaustive of all the moralists, it is representative of the most noteworthy. From the examples cited thus far, one gathers a set of general criteria for what constitutes extraordinary means. Means become extraordinary when they constitute a certain impossibility (quaedam impossibilitas). Either this impossibility is physical (something simply cannot be physically done), or some circumstance (such as extreme fear, danger, or grave inconvenience) makes the means a moral impossibility . A moral impossibility is “a proportionately grave inconvenience which excuses from the present observance of the law.”8 Thus, when a means of conservation is a proportionately grave inconvenience, and it is morally impossible, then it is extraordinary. The four categories below are causes of “something impossible.”
1. Great effort (summus labor). The duty to conserve one’s life does not entail exerting a tremendous amount of effort. The most commonly cited example is that one is not required to move to a location where the air is cleaner or to eat only the healthiest of foods.
2. Enormous pain (igens dolor). The presence of an unreasonable amount of pain in a remedy is universally recognized as extraordinary by the moralist tradition. The most common example is amputation, yet we should consider that what used to be extraordinarily painful without anesthesia may not be so anymore. However, not only are there still other painful and uncomfortable procedures in practice today (perhaps a case of aggressive chemotherapy) that may constitute a grave inconvenience, but there are also psychological factors to consider (see 4, below).
3. Exquisite means and extraordinary expense (media exquisita et sumptus extraordinarius). The moralists have always accounted for extreme expenses and excellent or fine sorts of treatment. One is not obligated to spend an exorbitant amount of money to conserve one’s life. This criterion becomes more complex and crucial today with rising healthcare costs and uninsured patients.
4. Severe dread (vehemens horror). This is an intense fear or very strong repugnance toward a certain means. Many moralists state the case of a religious virgin not being obligated to undergo treatment by a male doctor. Vitoria mentions that even food may be repulsive to some who are particularly ill. Other moralists have suggested this factor as operative in the case of amputation. But while severe pain is perhaps no longer an issue in the present age, one could still argue that there may be a reasonable repugnance toward living with a mutilated body. Moreover, one can imagine other examples—if cannibalism were the only available form of sustenance, perhaps, or if a man were trapped in a cave where the only source of food was maggots or something similar. Judging from their writings, it seems that moralists readily categorize cases like these as extraordinary, by the criterion that a particular procedure or means can be so feared or subjectively repulsive that it constitutes a grave inconvenience or moral impossibility.9
We must note the relative nature of the standards for both ordinary and extraordinary means. The age of an individual can be a determining factor in deciding whether the benefits will be greater than the means or risks. One’s financial status is certainly an important factor in determining relative difficulty. One’s physical and psychological condition, as well as one’s geographical and temporal situation, are also relative factors that prohibit the establishment of an absolute standard for determining ordinary and extraordinary means. The more difficult a means becomes, the less ordinary it becomes. There is no a priori mechanism to determine where to draw the line in all cases. As in other areas of ethics, there is no replacement for prudential judgment, and hence there will always be some degree of inherent ambiguity in norms such as these. The best that can be done here is to establish general principles.
From the prohibition against suicide to the recognition that one is not required in every case to fulfill positive precepts like the duty to conserve one’s own life, we see the origins and increasingly maturity of the distinction between ordinary and extraordinary means, which later becomes the magisterial teaching of the Church. For example, in his address on November 24, 1957, to an international congress of anesthesiologists, Pope Pius XII responded to three questions regarding resuscitation and the validity of extreme unction, stating that people have a duty to conserve their lives out of charity and justice:
But normally one is held to use only ordinary means— according to the circumstances of persons, places, times and culture—that is to say, means that do not involve any grave burden for oneself or another. A stricter obligation would be too burdensome for most men and would render the attainment of the higher, more important good too difficult. Life, health, all temporal activities are in fact subordinated to spiritual ends. On the other hand, one is not forbidden to take more than the strictly necessary steps to preserve life and health, as long as one does not fail in some more serious duty..10
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Scott M. Sullivan, M.A.
The Center for Thomistic Studies
University of St. Thomas
Houston, Texas
6. Notes
7. 1 “Nec aliquem alium uti pretiosa et exquisite medicina ad mortem vitandam; nec saecularem, relicto domicilio, quaerere salubriorem aerem extra patriam … Sufficit enim uti mediis ordinaries.” St. Alphonsus Liguori, Theologia Moralis, Lib. III, Tr. IV, Cap. 1 (New York: Benzinger Brothers, 1890), 371.
2 “Non teneri quemquam mediis extraordinariis et nimis duris, v. gr. abcissione cruris, etc., vitam conservare.” Ibid., 372.
3 “Ubi dicit infirmum in periculo mortis, si sit spes salutis, non posse medicamenta respuere.” Ibid.
4 “Non videtur tamen virgo aegrotans (per se loquendo) teneri subire manus medici vel chirurgi, quando id ei gravissimum est, et magis quam mortem ipsam horret.” Ibid. Liguori adds however, that if a female doctor were available, the virgin would be obligated to undergo treatment.
5 This was done with ether, as any textbook on the history of medicine attests. “On October 16, 1846, William T. G. Morton, a Boston dentist, demonstrated the use of ether during surgery, ending the indescribable pain—and the overwhelming dread—that had been associated with the surgeon’s knife … News of the discovery spread quickly, and within months it was hailed as the ‘greatest gift ever made to suffering humanity.’”Massachusetts General Hospital Web site, at http://neurosurgery.mgh.harvard. edu/History/gift.htm.
6 Augustino Lemkuhl, Theologia Moralis, I (St. Louis: B. Herder, 1898), 345.
7 Adolphe Tanquerey, Synopsis Theologiae Moralis et Pastoris, III (Paris: Desclee and Socii, 1953), 248.
8 Ibid., 100.
9 It should go without saying that an unreasonable fear (for example, a fear of needles) does not qualify. Again, prudential judgment is as applicable here as in other areas of ethics.
10 Pius XII, “The Prolongation of Life”(November 24, 1957), quoted in Daniel A. Cronin, Conserving Human Life (Boston: Pope John XXIII Center, 1989), 315.
