"The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants and externals cooperate." (1)

How often I quoted this bit of Hippocratic wisdom to interns and residents through the years! But how does the young physician determine "what is right himself"?

Before being engulfed by the jealous vocation of medical practice, many physicians of the past were privileged during undergraduate training, at least at Jesuit Universities of the time, to be exposed to the philosophy of being human. Whatever the ultimate calling, it was hopped, the student would formulate "right reason." Ethical principles were to be applied to the student's newly discovered humanity through willful and reasoned action. All students, including the hapless premedical candidates, were required to have core foundation in apologetics, logic, metaphysics, natural theology and principles of ethics followed by social ethics; taught in the scholastic tradition. Many students succumbed to the search for Man as Man, (2) sometimes contrary to the wish of basic science faculty. Aquinas, Augustine, the Ancient Greeks and modern existentialists provided material for debate both in and out of the lecture hall. While providing relief from the rigors of biology, chemistry and physics, the profound effect on future behavior often lay unrecognized until ensuing years. Internship, residency, fellowships and, for some, military service were inevitably influenced intellectually and affectively by that early undergraduate experience. Once in practice or involved in medical education the need to properly form conscience in choice of human behavior in the presence of good and evil became all too evident. The transition from study and debate now evolved into action: performance of the human act in medical practice.

"Human acts, that is, acts that are freely chosen in consequence of a judgment of conscience can be morally evaluated. They are either good or evil." (3) It may be that the bulk of human behavior could be categorized as morally neutral. However, the performance of a human act requires knowledge of the purpose or object of the act, the deliberation or intention and the choice of means to the end. The act is good if all conditions are met; the act is evil if any condition is defective. Assuming recognition of the norms of morality being formed by God, we must willfully deduce that which is good (that to be sought), that which is neutral (that which is allowable) and that which is evil (that which is allowable) and which is evil (that which is forbidden). To reemphasize, the act is good if the entire means, intention and object are good or at least morally neutral. An act is evil f any of these conditions are willfully evil. As a respected professor of ethics, capsulized this concept: Bonum ex integra causa; malum ex quolibet defecto--- Every part is bad which is not conformed to the whole." (4) Goodness generates from integrity to the norm of morality, be it is the object of the act, the intention of the agent or the intrinsic nature of the means to the end.

There are many examples in current medical practice that can be recognized as fundamental (intrinsic) evil. Reason can recognize and judge whether the object of an act is good or evil. It is evident that one cannot intend an evil nor can one perform an evil that good may result from it. Inherently or intrinsically evil acts include:

- Acts which necessarily frustrate the supreme purpose of life (e.g.) embryonic stem research, human cloning; - Acts which necessarily lend to destruction of innocent human life (e.g.,) abortion, euthanasia, assisted suicide; - Acts which violate another's natural rights (e.g.) over billing, uninformed consent, breech of privileged communication; - Acts that endanger the common good of the profession (e.g.) fee splitting, abandonment, unnecessary pharmacologic, technologic or consultative usage.

In light of the above it is evident that any direct intention to cause an evil is unjustified. Though knowledge of an evil is not of itself evil, the willful choice of this intention is evil. Therefore, even if a good should result from an evil intention, the act itself is evil. Further, though the intention may be perceived as laudable but the result is inevitably evil (as in alleviation of patients suffering be euthanasia), the act is defective.

Secondly, it follows that just as a good cannot be done to achieve an evil, the converse is also true. Evil cannot be performed to obtain a good end, even though the intention may also be good. We cannot willfully choose to commit an evil action.

Though the moral implications of behavior are modified by invincible ignorance, by threat of serious physical or psychological violence, habits and cultural mores, the nature of the act as good or evil remains unchanged. Responsibility may be modified by these other factors, but the principles of natural law and the duty of the individual still require honest commitment to do what we must within a faithful intellectual and physical capacity.

But how does one approach the apparent and not uncommon dilemma of the need to perform an action which as both a good and an evil effect resulting from the action taken? Here the application of the principle of two-fold or double effect must be understood.

A. The initial voluntary act must itself be good. The will can never choose evil directly. B. The good effect must follow as directly as the evil effect. The evil effect cannot be the cause of the good effect. C. There must be a proportionately grave reason for placing the act and permitting the evil effect. It would be unreasonable to allow a grave evil for a relatively insignificant good. D. The evil effect must never be directly intended. The will may never intend evil. (5)

To reiterate: Neither means, intent nor object of an act can be willed as evil. Envision embryonic stem cell research, abortion following rape or incest, or artificial contraception. It could be argued that the gravity of illness or social needs justify radical intervention. However, in each instance the good effect necessarily propagates from the evil action of destruction of innocent human life or interference with the natural purpose of a human act. The will cannot choose an evil even to reach a laudable object. This reassuring is used not uncommonly in this modern era of medicine with the highly sophisticated technological, pharmacologic, surgical and research capabilities existing in the medical armamentarium.

Finally, the human act in medicine faces another challenge from the secular and pragmatic modern society that claims recognition of the right to withhold participation in acts felt to be contrary to conscience. In the same breath that same society insists on the obligation to refer to competent practitioners of the desired service. Even the highly regarded American College of Physicians states in its Code of Ethics, "A physician who objects to abortion on moral, religious or ethical grounds need not become involved either by proffering advice to the patient or by involvement in the surgical procedure. The physician does have a duty to assure that the patient is provided the option of receiving competent medical advice and care from a qualified colleague who does not impose his or her personal convictions upon the patient." (6) It follows that it is expected and often demanded that Catholic hospitals when merging with secular institutions provide a separate facility where patients may receive "Reproductive services" such as contraception, abortion or certain proscribed fertility services. Too often the Catholic interest in the merger will skirt the moral issue by arranging a financial separation despite geographic convenience.

The concept that voluntary acts proceeding from the will together with knowledge of the purpose of the act leads to more than accompaniment. It becomes a co-cause of action that must be recognized as morally repugnant by the referring physician or hospital. As Thomas Higgins stated so clearly in his text Man as Man. Man must avoid evil as far as he can and the specific law of charity bids him to prevent his neighbor from doing wrong to the best of his ability." (7)

Medical education currently ignores Hippocratic principles and minimizes the philosophical foundation for bioethics. Graduates today rarely are philosophically literate beyond a vague awareness of a desire to do that which is good. It is urgent to restore the guidelines of the principles of ethics in medical education.

"Life is short, and Art Long: the crisis fleeting; experience perilous, and decision difficult." (8) The physician has need for guidance in the decisions.

The Hippocratic Oath is the best summary of medical ethics thus far articulated. A tradition which should be exemplified by every physician. Articles concerning appication of the Hippocratic Oath: Is There A Catholic Medical Ethic? The Human Act and Medical Practice Is Medical Ethics Sectarian? Other Articles on Cathlic Medical Ethics