NOTE: Father Tad Pacholzcyk was in Dallas Nov. 8-10, 2003, to be the keynote presenter at the Catholic Pro-Life Committee of North Texas conference, “Do No Harm: Medical Ethics from a Catholic Perspective.” This interview was conducted the week before his visit.

By BILL HOWARD

DALLAS. He’s only 38, but Father Tad Pacholczyk has earned a doctorate in neuroscience from Yale University, four undergraduate degrees -- in molecular and cellular biology, chemistry, biochemistry and philosophy --and two degrees in advanced theology from the Pontifical Gregorian University in Rome.

Father Pacholczyk (pronounced pa-HOLE-check), ordained a priest for the Diocese of Falls River, Mass., in 1999, has spoken before state legislatures, at roundtables around the country and serves on the ethics committee at St. Anne’s Hospital in Falls River. [Editor's Note: He has since been named director of education for the National Catholic Bioethics Center in Philadelphia.]

Father Pacholczyk recently took time with Texas Catholic to examine some of the major bioethical questions.

1. What is the core issue with the Terri Schindler Schiavo euthanasia case in Florida?

It is relatively straightforward. It is a question of whether people who suffer significant brain damage, but are otherwise physically healthy, are entitled to basic nutrition and hydration. Terri Schiavo is essentially a healthy person apart from some brain damage. She does not have any diagnosed terminal disease and she is not, due to some pathology, about to experience a sudden and radical decline that would lead to her death. For all intents and purposes, if she is provided food and liquids through a feeding tube, it seems likely she could live for another 20 or 30 years or even longer with the appropriate care.

Part of the confusion around this case stems from the implicit assumption that if Terri's "quality of life" is not quite as high as most other people's, that means we can refuse basic care to her.

The distinction in my mind goes like this: One is not obligated to embrace excessively burdensome treatments. However, we shouldn't confuse this with the case of not putting up with an apparently "burdensome life," particularly when the means themselves are not heroic, such as feeding tubes. You see feeding tubes all the time in hospitals and nursing homes when you visit the elderly. In itself, it is not an unbearable or disproportionate treatment to have or to accept a feeding tube. It can be helpful to visualize a feeding tube as something like a very long spoon via which we help people who have trouble swallowing. In Terri's case there is the added suggestion that she may, in fact, be able to swallow a little bit on her own.

It is not an entirely futile exercise when something saves the life of a person, e.g., food and hydration to a comatose individual. Some would say that it is futile, when there is not any likelihood of the person ever waking up or ever doing anything remotely human again. But then one has to ask whether the person we love dies because of the course of their disease or illness, as they should naturally be allowed to do, or because we who are given charge of caring for them have failed to take the natural step of nourishing and hydrating them. Preventing someone from dying of starvation or thirst via a feeding tube does not seem to be extraordinary or heroic in most cases. This is not to say that there aren't cases where a feeding tube wouldn't be clearly futile. For example, if somebody has metastatic cancer that has spread all through the digestive tract, as a fellow seminarian friend of mine did several years ago, so that there is no longer a functional digestive tract, a feeding tube would be futile and morally contraindicated.

The other element I would mention about giving nutrition and hydration to the comatose is that such care is a strong indication of our bond with them, that is to say, our human solidarity with those we are related to. It also affirms their dignity as persons and retains some connection and semblance of human communication with them, even though they cannot respond in kind. These are real goods, and such care is a simple sign of our love towards them.

So the real moral question in Terri's case is very distinct from the case of a person who is terminally ill and is actively in the dying process. Such individuals can refuse disproportionate or extraordinary means of support that would only serve to extend their imminent dying process. This has been the teaching of the church in this area.

Terri's case, however, clearly does not come under this heading. What is being debated here is a question of active euthanasia under the guise of the intentional decision to withhold food and liquids.

Terri's case also raised some serious questions about the possibilities for her rehabilitation. Apparently, back in 1992, Terry was awarded about $1.3 million during a medical malpractice trial. Of that money, $750,000 was earmarked to be used for Terri's therapy. To that end it was put into a trust. Her husband received about $300,000, and various lawyers' fees were paid. However, of the $750,000 earmarked for her therapy, virtually none of it was used for her rehabilitation. Once the money was in the bank her husband ordered a "do not resuscitate" to be placed on his wife's chart and, within a few months of making the deposit, he also apparently refused to permit any more basic curative treatments like antibiotics. Had Terri Schiavo died during the early or mid-1990s, her husband would have inherited somewhere around $700,000. In the meanwhile it has turned out that money from her trust was actually being used to pay lawyers who were trying to end her life by pulling Terry's feeding tube.

Recently on Larry King Live, Terri's husband was interviewed, with attorney George Felos at his side. Mr. Felos has been paid over $350,000 from Terry's trust fund. Another attorney involved with the case has received about $90,000.

Clearly, Terri has gotten the short end of the stick here because money that was dedicated to her rehabilitation has never been used for that purpose, but has instead been used to pay for lawyers who are trying to pull her feeding tube.

2. What questions does this raise on Catholic teaching about how to decide when extraordinary means of life support is not required?  How do we define "extraordinary"?

First the church typically doesn't refer to extraordinary any longer, but rather to disproportionate means of support. And again, these would be means which would be considered excessive in a situation of imminent death, interventions which would in all likelihood only draw out the dying process unnecessarily.

As I mentioned earlier, these would not be morally obligatory under these circumstances. However, if there are certain medical indications that a particular intervention is very likely to be a bridge to healing, then it does become morally obligatory, generally speaking, because we do have a duty to take care of our health and to make use of the standard means that are available to us to do so.

Disproportionate means could also refer to highly experimental and exceedingly expensive types of intervention. At a certain point, if somebody has a disease or sickness, and one is attempting to begin an intervention of an experimental nature with only a rather limited likelihood of a positive outcome, and with huge expense and causing huge stress for the family and for the individual who is undergoing this experimental procedure, this might be legitimately considered an extraordinary or disproportionate intervention on their behalf, and again, not morally obligatory.

The general presumption in these cases is in favor of providing care, and this holds equally well for people who are in vegetative states. Simply because one's "quality of life" is not perfect does not diminish our moral obligation to reach out to and to take care of our brothers and sisters who are not as healthy as we are.

3. Regarding the elderly, what are the church teachings about DNR directives (Do Not Resuscitate if found unconscious)? How morally culpable are retirement home workers who work at places that encourage people to fill them out?

DNR, or do not resuscitate, directives, are a type of directive which should always be used with great caution. There should be indications that the person is in the terminal phases of their life, and there should be indications that resuscitation attempts would only extend an imminent dying process, and not that those resuscitative interventions would be a bridge to healing. Because if they were a bridge to healing, if someone needed to be resuscitated only so that they could survive and then be strengthened and rehabilitated and then get back on their feet, there would be an obligation to resuscitate them, and it would not be moral to insist on a DNR on their behalf.

So it is always going to be on a case-by-case basis where you decide whether a DNR is acceptable or not, based primarily on this question of whether this individual would in fact benefit from this. But a DNR could never be used, and should never be used, as a way either to commit suicide or to bring about the early and untimely demise of someone who is in our care.

4. What about advance directives?

Advance directives are generally morally problematic from the point of view that you never can know before you get into a particular disease or sickness exactly what your circumstances will be.  That's why it is far more preferable to have a health care proxy instead of an advance directive. A health care proxy is an actual person who you have designated to stand in your place and make a health care decision on your behalf. Such a person is able to assess the totality of your circumstances in "real time," in a way that is sensitive to all the particulars of your situation. This avoids the problematic situation trying to make blanket general statements about possible scenarios in the future as you attempt to do with an advance directive. You may specify that you don't want, for example, any tubes to be used. But such a statement is both medically and morally problematic because sometimes we do have to take tubes into our bodies so that they can provide us with particular nourishment or transfusions in order to serve as a bridge to healing.

So it is always going to depend on where a person is in their particular sickness that you then are able to make these decisions. That's why a health care proxy, an actual living person, is a much better way to go. Hopefully, a good health care proxy will have had discussions with the person they are representing at an earlier date, before that individual gets into life threatening circumstances. So, ideally, the health care proxy can, on a case-by-case, moment-by-moment basis, come to certain conclusions about what the appropriate approach from this point forward would be to provide the best heath care for the individual.

5. What are your thoughts on equal access to quality medical care?

The problem of equitable access to quality medical care is certainly a reality that our society faces. On the one hand, we have some of the finest medical facilities in the world in this country, but on the other hand there are many who find themselves in a situation where they cannot obtain insurance or other funds to cover the kind of desirable medical care that might be available. A number of Americans choose not to purchase insurance for medical coverage- perhaps because they feel they are low enough risk that they will take that chance and save some money. However there are others who genuinely are not able to get medical care and coverage. One of the premises behind medical insurance is that risk and cost should be distributed in a semiequal way over the entire society so that those who happen to be predisposed towards certain diseases will also be able to get reasonable medical insurance even though they will very likely end up costing the system considerably more than others who do not have the predisposition.

The real danger that I see in the future is that as genetic tests and other advanced diagnostic techniques become available to reveal which diseases we are likely to be susceptible to, that insurance companies may take this information and use it to deny coverage. And this does strike me as being morally problematic and certainly seriously objectionable.

The kind of care that is available in this country can be extremely expensive, and designing a medical insurance system that provides equitable access to all people who wish to participate is clearly a very significant moral challenge.

6. What are some of the most common moral pratfalls people fall into regarding stem-cell research and cloning?

There seems to be a general hesitation on the part of the scientists and the media to engage in a serious discussion about the intrinsic dignity and worth of the human embryo. There is a hesitation to acknowledge the very simple and basic biological truth that each of us was once an embryo and that embryos are already members of the human race, members of the human family, deserving of full and unconditional protection. Therefore embryonic stem-cell research that depends upon the intentional destruction of these defenseless and innocent human lives is intrinsically immoral and cannot be justified on any grounds.
 
Scientists find themselves unhappy with such a conclusion and often will argue that both embryonic and adult type stem-cell research should be carried out in parallel, in case it might be possible in the future to cure certain diseases only through the embryonic type of stem cells. My response would be that embryonic stem-cell research should only be carried out in animal models, never using human embryonic stem-cells from embryos. So first it would be necessary to show in those animal models that it is possible to cure certain diseases that cannot be cured using adult stem cells. If this were true, then one could proceed and obtain a small number of embryonic type stem cells in a manner that would not be morally objectionable. This would involve using miscarried fetuses - fetuses that are lost spontaneously, not electively. The parents would be able to donate the stem cells from their son or daughter in the same way that they could consent to an organ donation from their child on behalf of another.

It is unfortunate to see how the remarkable advances that are being made with adult stem-cell sources are not being systematically reported by the popular media. Rather there is a clear and at times intentional skewing of the message so that embryonic stem cells are being trumpeted and praised at every turn. But there has never been a single human being cured of any disease using embryonic-type stem cells. Meanwhile thousands of humans have already been cured of many different types of ailments using adult type stem cells.

Just to mention a few examples: One woman who had leukemia while she was pregnant decided to wait to be treated until she delivered her child. They were able to isolate stem cells from her daughter's umbilical cord and introduce them into the mother to cure her leukemia.

The bubble boy syndrome that we are all familiar with, where children are born without an immune system, can be cured by a stem-cell transplant, by a bone marrow stem-cell transplant.

There is another amazing story about an 11-year-old black boy named Keone Penn who was born with sickle cell anemia. He was cured using an umbilical cord stem-cell transplant. Following the transplant, his blood type changed from one type to another, and he is now considered cured of the disease.

There have also been a number of studies in this country and abroad which indicate that bone marrow-derived stem cells can be utilized in strategies and therapies to help the heart, so that the heart muscle does not become hardened in the usual way after a heart attack. Early treatment with adult stem cells seems to allow the heart to recover and to pump more effectively.

These are just a few examples of therapies that are already available and have been carried out successfully in humans using the morally acceptable alternative of adult stem cells. A great deal of hype is associated with the embryonic type stem cells, and this unfortunately is skewing the moral debate in a very serious way as people are being falsely told that it's necessary to destroy early embryonic humans in order to achieve cures.

The other myth that should be mentioned that many people fall prey to in the area of stem-cell research and cloning is the claim that the two types of cloning are somehow fundamentally different. The first type of cloning is cloning to make a baby while the second type is cloning for research. And many people have become convinced by rather smooth argumentation on the part of the proponents of research cloning that this second type of cloning is intrinsically different from the type of cloning that one would do to make a baby.

But the actual series of steps involved in both types are practically identical. The only difference is whether the cloned embryo that one ends up creating will be implanted into a uterus. If it is implanted into a uterus, it will cause a pregnancy and a live birth. But, if it is not implanted into a uterus and allowed to grow, then that early cloned embryo can be destroyed and strip-mined for the stem cells. Those stem cells will be genetically matched to the patient who was cloned and should be "rejection-proof" for that patient. In other words, in both types of cloning, you are making an identical twin. But in research cloning you are making the additional decision to violate the integrity of that identical twin to harvest his or her cells or tissues for the purposes of saving the already born twin.

So, this second type of cloning known as research cloning, is really, from the moral vantage point, far more objectionable than cloning to make a baby because it involves this premeditated decision to systematically create human life for its destruction and exploitation at the hands of eager embryonic stem cell researchers.

7. Regarding in vitro fertilization (IVF), how do you personally tell people who want to do God's work in having a baby (and who are adhering to church teaching and not contracepting) but need outside help and struggle with this teaching? What about people who say that this medical technology is a gift and is being used for life?

Sometimes relatives of IVF babies will say, "When I look into the eyes of my niece born by in vitro fertilization, I think to myself, 'How could anybody say she is not good, how could the church say she is not good, because of the way she was born? She is such a blessing!'"

Of course she is a blessing, and nobody, including the church, would ever say that she is "not good." However, just because a gift is good and precious, doesn't mean that the way that we obtained that gift was legitimate.

To reiterate, then, every child that is brought into the world, whether by IVF, cloning or the natural way, is to be esteemed and received as a precious gift from God. It is not in any way the child's fault how he or she came into the world. The moral responsibility lies rather with the parents, who have adverted to immoral means to achieve what is undeniably a good end. In parallel with this, it must be stressed that the intention of the couple is also likely to be a good intention. They desire to have a child of their own flesh and blood, of their own genetic constitution. They desire to end up with the blessing of a child of their own in their arms. Nobody is faulting the desire of the parents, at least in the most general sense, of desiring offspring of their own. But even very good desires and intentions cannot sanction immoral means.

A parallel example may be helpful in this case. One can imagine the scenario of a young girl in high school who decides she wants a child of her own flesh and blood, has relations with her boyfriend and becomes pregnant. Nine months later she delivers a child of her own. This child is without a doubt a blessing, a gift from God. However, the means which she used to bring that child into the world were clearly immoral. She should have waited until she was in a stable marital relationship with a man so that her child could have a true mother and father figure in his or her life. IVF is loosely analogous to this in that the gift of a child was realized through what are intrinsically immoral means.

8. What kinds of false assumptions underlie the widespread practice of in vitro fertilization today?

Many couples insist, that because they are married, they have a right to a child. None of us ever have a right to a child. Children are not property or a possession that we can claim a right to. A child is always a gift. Moreover, the child himself has his own set of rights that must be respected, including the right to be conceived as the fruit of marital love and to have a real mother and father. When we get married, what we in fact have a right to is those acts, those marital acts, which are in and of themselves disposed to the procreation of new human life. If those acts result in the procreation of a new human life, that is cause for rejoicing; if they do not, this does not throw open the door to making the use of any means whatsoever to obtain a child of one's own flesh and blood.

9. What are the specific reasons that in vitro fertilization is immoral?

First, IVF undermines the meaning of sex. It says that intimate sexual giving is not essential to creating human life. It says that it is simply OK to manufacture life in a laboratory as if it were a commodity, when it should be the result of human love. It turns procreation into manufacture.

Second, as an ancillary evil, you often cryopreserve embryos in liquid nitrogen and end up either abandoning them in this state of suspended animation or pouring them down the sink if they are not useful or donating them for research. Moreover, it doesn't take much reflection to realize that we shouldn't ever freeze other humans.

Third, IVF typically requires masturbation on the part of the man, which is an intrinsic violation of the gift of our sexuality from God.

Fourth, it can violate the exclusivity of the couple's marriage covenant, because it generally involves a third party, the laboratory technician, impregnating the wife, albeit artificially, in the place of her husband. The third party is really interposing himself in an intimate arena that is meant to be reserved exclusively to husband and wife. The ultimate criteria of whether a technical intervention over procreation is morally acceptable is whether one is assisting the conjugal act to achieve its end, or is substituting and replacing that act.

Fifth, because clinics are attempting to increase their success rates and generate more business, they implant multiple embryos, and there is an elevated risk of twins, triplets or quads. Those who become pregnant with multiple children are often encouraged to undergo "selective reduction." IVF is generally portrayed as a life-giving technology, but when we violate the moral law by adverting to it we quickly discover these other death-dealing dimensions of the technology as well.

Sixth, babies born via IVF have an elevated risk of birth defects. For example, studies have shown a six-fold elevated risk for IVF children contracting an eye disease called retinoblastoma when compared to normally conceived babies. IVF is a very unnatural process, which subjects ova and developing embryos to harsh and non-physiological conditions.

10. What are some morally acceptable alternatives for infertile couples?

First, the couple should diligently investigate the causes of their infertility. Often these causes can be remedied. For example, in the case of a blocked fallopian tube, it may be possible to surgically remedy an obstruction. This way, the woman could have marital relations and could conceive a child normally. If the man's sperm count is low, it may be possible to improve the count by simple measures such as changing the type of clothing that he wears to alter the temperature around the testicle. Sometimes the woman's cycle can be regularized via progesterone treatments or other means. All of these approaches should be investigated carefully in an attempt to resolve infertility.

If it turns out to be the case that the couple has genuinely irresolvable infertility, it is important to help them to realize that their fruitfulness as a couple is not simply exhausted by their biological fecundity, but that they can express that fruitfulness in other ways, such as becoming mother and father figures to others in the community. They should also be encouraged to consider the possibility of adoption.

To deal with the difficult and painful reality of infertility, a couple benefits greatly from lifting this up into a spiritual context. The decision not to turn to IVF can be a powerful sign to others of God's dominion over life and procreation.

11. What about Catholic couples who have adverted to in vitro fertilization?

IVF constitutes grave matter. Those who make use of or promote this technology would do well to bring the matter to proper resolution and find peace with God through means of conversion of heart and a good sacramental confession.