Kevin P. Doran

Much of the current interest in Medical Ethics seems to focus on a few specific areas, notably the areas of human reproduction and organ transplantation. Although many other branches of medicine are occupied with the task of healing, preventing illness and prolonging life, these two areas seem to capture the imagination of many as concrete examples of medicine pushing back the frontiers of science-fiction, and opening up all kinds of new possibilities. They purport to offer us the possibility of creating new human beings, and of providing replacement parts for those who are already in existence. Development in these areas of medicine seems to take place at a phenomenal rate, in a way which is scientifically exciting and which, from a human point of view, gives rise to a mixture of hope and apprehension.

Medicine is in a very interesting and sensitive position, delicately balanced as it is between the natural sciences and the human sciences. It has to answer questions which relate to both - questions about what is possible and about what is appropriate, about 'can' and 'should'. Is it possible to take human gametes, to develop an embryo and to transplant it successfully into the womb, and is it appropriate? Can I successfully graft a portion of brain tissue from one person, into the brain of another; should I? Indeed, one aspect of decision making in medical ethics, which tends to add considerably to the confusion, and to render many ethical decisions suspect, is when the acceptability of a procedure is made to follow from the fact that it is possible to carry it out 'successfully', rather than from any consideration of what is actually involved in human terms. Personhood, then, is a key question for medical ethics. If we are to have any possibility of dealing with the ethical questions which are posed by human fertilisation in-vitro, organ transplants, and many of the other developments of modern medicine, we need to be able to answer the question about what is in the test-tube or on the operating table. We need to be able to recognise what is a person from what is not. We need to have reliable criteria for determining when a person begins to be and when one ceases to be present.

The purpose of this paper is to examine the concept of 'person' as it has developed since its origins as a theological term in the early centuries of the Christian era. It will become clear that on-going development is not a denial of completeness as a person, either in philosophical or biological terms. The relationship between personhood and the right to life will be discussed in the context of in-vitro fertilisation and the use of embryos.

The first systematic definition of 'person' is the definition of Boethius: "Person is an individual substance of rational nature". This definition is the subject of discussion by Aquinas in the first book of the Summa Theologica (Aquinas, 1964/6, 1ae.,29 ). It is a definition which Aquinas broadly accepts, with one particular reservation. The term 'substance', as earlier generations of philosophers had also noticed, is ambiguous. Sometimes it is used in a way which means simply "essence". At other times it is used in a way which is synonymous with "hypostasis" or "subsistens", implying an actual reality and not just an essence. What is at the heart of the problem here is whether Boethius uses the term 'substance' in the sense of something which actually exists, or only in the sense of the concept. It is possible to have a concept of 'doctor' (let us call it 'doctorhood') but the concept is not the reality. Doctorhood cannot perform surgery, or write a prescription. To do these things we need to have an actually existing doctor.

Aquinas' objection, then, is not that Boethius definition is wrong, but that it is open to misinterpretation. Because of his use of the word 'substance', it is not sufficiently clear whether he considers 'person' to be a reality, existing in its own right, or just a concept.

In his earlier works (e.g. Summa Contra Gentiles and the first part of the Summa Theologica), Aquinas makes regular use of the term 'subsistens' to express a distinct entity which stands firm by reason of its own separate existence. Separate existence is the characteristic of an entity which is complete in itself, and distinct from anything else.

When we go on to the third part of the Summa Theologica we find Aquinas referring explicitly to being as a constitutive element of a person.

In the third part also he demonstrates an obvious preference for describing a person as a "subsistent in an intellectual nature", precisely because the term 'subsistens' incorporates the notion of separate existence. By using the term 'subsistens' in his definition of 'person', Aquinas is expressing his understanding that a person is

a) an entity, and not just a concept

b) a whole and not just a part.

The fresh insight which Aquinas brings to the question of personhood is his explanation that separate existence and intellectual nature (essence) together are constitutive of persons. He also makes the important point that the activity of a person is not constitutive of the person, but rather consequent on its being a person (Aquinas, 1964/6, 3ae, 19, 1 ad 4). In other words, I am not a person because of what I do, but rather I can do what I do because I am a person.

In conclusion, then, for Aquinas, a person cannot be which lacks its own separate existence. On the other hand, a person can exist without necessarily performing all, or indeed, to be logically consistent, any of the activity appropriate to a rational nature.

Aquinas' understanding of person is conditioned by the fact that he admits the possibility, indeed the reality, of a world mediated by meaning, and not just the inner world of immediate experience. By immediate experience I mean consciousness which has no reference to anything outside the self.

For Aquinas, experience leads to reflection and insight, and to judgments about the truth of reality. For Empiricists such as Locke and Hume, the only reality is that of immediate experience. Hume is convinced that there cannot be identifiable things because, in reality, everything is composed of successive and closely related parts, and these only appear to our minds as if continuous.

Such a view of the world, of necessity, conditions the empiricists' understanding of what a person is. If there is only the appearance of unity and identity about things in general, and they do not actually exist as concrete entities outside the consciousness of the observer, then the same must be true of the 'Self'. Continuity as a Self, or personal identity, is dependent on continuous self-consciousness. Locke would describe a person as:

Hume takes Locke's idea one step further in that he chooses to recognise 'person' as 'just a train of consciousness' and sees even the unity of consciousness as purely circumstantial.

The legacy of the empiricists is to be found, alive if not well, in the writings of people such as Peter Singer, Michael Tooley and John Harris, on such topics as the treatment of the handicapped newborn. Each of these writers defines personhood in terms of the immediate experience of a person as consciously self-aware, as having desires and interests. What they are in effect saying is that we can only experience ourselves and others as persons by the actual exercise of rationality, and that beyond that experience, we have no grounds for asserting the existence of a person. Singer, an Australian philosopher teaching at Monash University, concludes:

The failure of the approach of Locke and Hume, and more recently of the school of thought represented by Singer, Harris and Tooley is that, in basing personhood on the ability to desire, to have a continuous consciousness, to achieve a certain distinctly human level of performance, they overlook the fact that all this presupposes a being who desires, is conscious and performs at such a level. They place considerable stress on the actuation of an aspect of the human essence and fail to take account of its continuous existence as a distinct human entity.

Hume denied personal identity because he experienced change, but the concept of identity is meaningless without the possibility of change. To express this in another way, it is only in the midst of change that we can relevantly attribute any significance to what remains the same. If we translate Hume's problem into the modern

idiom and the modern context, we find that what Singer et al. have done is to confuse the concept of 'personality', something which is variable and non-essential, with the concept of 'person' which is invariable and essential. To exercise personality on must first be a person.

(2) Utilitarianism

We have seen already that there is a close correlation between the recognition of a person and the acceptance of personal rights, such as the right to life and to medical treatment. While realists and empiricists differ as to the criteria which are appropriate for recognising a person, both viewpoints do have their criteria, and in each case, what ought to be done is based initially on a judgment of fact about personhood. There is a direct link between what something Is and how it Ought to be treated.

Utilitarians are not prepared to allow that rights are based on objective criteria, and this has implications for the way in which they deal with the question of personhood. The basis of Utilitarianism is to be found in the idea that what is good consists in the creation of happiness and the avoidance of unhappiness. John Stuart Mill, probably the best known exponent of Utilitarianism, concedes that there is a scale of human pleasures and happiness, such that not all pleasures are equally valuable or desirable. Mill maintains that Justice is a central element of the Utilitarian code, but admits that Justice is liable to be a subjective concept in that it involves both a rule of conduct and a sentiment of justice. The sentiment of justice in his understanding is

Mill uses the example of the debate about the morality of slavery to illustrate how moral decision making tends to be influenced to a considerable extent by what is expedient, rather than by objective criteria. He takes this as sufficient evidence to demonstrate that expediency or the principle of utility is a kind of law of nature.

To the extent that the sentiment of justice is based on expediency, it is certain to be subjective, and not a reliable indication of what is truly just or good. Just as any decision about the rights of a slave, according to this view, will depend on how useful slavery is perceived to be in any given society; so the rights of an embryo, or a neonate, would depend on what view society had of their usefulness (e.g.; for the preservation of the species, or for research). However Mill presents it, the Utilitarian view of rights depends on a subjective balancing of the pleasure of one person or group and another. The criterion is one of expediency and the question of personhood doesn't enter into it.

We are all familiar with the classic examples of expediency (the eskimo grandfather left to die on the ice, the passengers thrown out of the life-boat so that it will continue to float etc.). The reality of Utilitarianism in the modern context is to be found, for example, in the report of the Warnock Committee on Human Embryology.

Mary Warnock, who chaired this British Government committee, expresses unease at the idea that the life or death of a child should be decided simply on the basis of the parents' attitude. Yet she says that nothing is settled by our deciding to call a newborn infant or an embryo a 'person'.

What Warnock seems not to take into account is the fact that when we prescind from the question whether the infant or the embryo is or is not a person, we are left with no option but to make the decision about rights or about treatment depend on the preference of some other party. Without the question about personhood, the objective basis for any decision is removed.

So, while the empiricists narrow their consideration about personhood to one aspect of the essence of a person, and ignore the continuity of existence; the Utilitarians, ignoring any objective consideration of human existence or essence, make personhood a non-question and, in so doing for all practical purposes decree that no one is to be considered a person except for reasons of expediency.

The attempt to deal with moral questions without some kind of objective base is doomed to failure. We have seen that any attempt to by- pass the person or to see the person purely in terms of function or activity (essence) is inadequate.

Bernard Lonergan, the distinguished Theologian and Philosopher who has taught at Harvard, in Rome and at Boston College, re-affirms the basic principle of realism, that all things (including persons) are constituted by both essence and existence. He makes a distinction between what we know by common sense through perception, and the underlying reality which we judge to be (exist) on the basis of our perceptions. The data which we perceive and even the concepts which we form are objects of experience, but cannot properly be called things.

With an object of experience (e.g.; a landscape) the aggregate of data changes from time to time, but such change is possible only because there is some entity, underlying the data, in which the change takes place. This is what we mean by a thing, and Lonergan describes it as an "intelligible concrete unity". By a process of elimination he concludes that the basis for this unity is not to be found in accidents, principles, parts, potencies or essence. There is only one possible explanation for the transcendent unity which is the hall-mark of a thing, and that is the having of its own separate existence. It is in a distinctly existing entity that accidents, principles, possibilities and essence are all brought together. (c.f. Lonergan, 1964a, p.21).

The principal fact worth noting at this stage is that a thing is strictly one while, at the same time, our sense experience reveals the possibility of change in things. It follows that being and change, far from being in conflict, are related. Being is a pre-condition for change.

While separate existence is the ultimate basis for recognising a thing, the things which exist are seen to differ according to essence, and it is on this basis that we classify them according to species. A person is defined as a thing the essence (or nature) of which is to be rational. The term has been classically used to refer to God, to angels, and to human beings. To be a thing involves completeness, distinctness and internal unity. But what exactly does it mean to be 'of an intellectual nature'?

Lonergan defines intellectual nature as "nature which can operate over the whole range of being by understanding and willing (c.f.; Lonergan, 1964a, p.24). The whole range of being includes the metaphysical; the transcendent. But it is precisely here that the empiricists and their heirs run into trouble. For them, a nature which can operate over the whole range of being by understanding and willing must be experienced as so acting in practice and, failing to experience this activity, they conclude that there is no person.

Lonergan introduces an important distinction into the debate about being, and so into our understanding of personhood. This is the distinction between Central act and potency, and Conjugate act and potency. 'Act' is a technical term which implies completion, while 'potency' implies openess to change or development. Anything which exists is in central act, but it is invariably in potency to a further actuation (i.e.; conjugate potency and act).

The act of being is basic and prior to all other acts, but it is not isolated from potency to various other developments.

So it can be said of all things, and of persons in particular that their essence or nature is a potency for any actuation beyond the act of being itself. While the potency is not the thing itself, a thing on the way to fulfillment is no less a thing simply because all its potential is not yet realised. Indeed, common sense tells us that no thing can realise all of its potential, because the actuation of some of that potential might actually preclude the actuation of some other.

In so far as persons are concerned, intellectual activity is second or conjugate act, while an intellectual nature is the potency for this act. Intellectual activity therefore is not the nature of a person, but only an expression of that nature. No human intellect can know everything perfectly. No human potential is ever fully realised, and therefore lack of perfection, far from being an indication of inhumanity or sub-humanity, is in fact a characteristic of being human.

Since being is a pre-condition for change, and both things and, specifically, persons, while centrally in act have a potency to further or conjugate act, it follows that to be is not necessarily to be static. This metaphysical insight of considerable importance seems to hearken back to the comment of Heraclitus, the pre-Christian Greek philosopher, that the universe is in a state of flux. Perhaps in attempting to express the centrality to 'being' of unity and continuity, the Scholastic concept of 'being' conveyed too great a sense of rigidity and inability to change. But for Lonergan,

and finality,

So the law of being is one of immanent finality - a process of becoming more completely what one already is, in response to an end which is written into one's essence, rather than exerted from without. An external finality is certain and inescapable, whereas an immanent finality opens up possibilities and provides the means for their fulfillment.

Biology and embryology cannot account for the coming to be of a person, because the reality of personhood goes beyond the limits of biology. However it is important to note that the concept of a 'person' who is and is yet becoming, and who may never reach activity of a recognisably human kind, is not in conflict with the laws of biology.

While life is cyclical, animal organisms are distinct and entire in themselves and have an identifiable moment of origin. As an entity, genetically related to but distinct from both its parents, the human embryo is complete by the time of the first mitotic division.

If all the genetic information pertaining to the new organism were not contained in the first embryonic cell, then it could not be replicated throughout the organism as it developed. The new organism is, in the terminology of Lonergan, "a distinct subsistent". It is not a part of something else, nor is it just a collection of cells without any internal unity.

But to be complete is not necessarily to be static. The human organism contains within itself a finality - a tendency to develop certain perfections which are in keeping with its nature. There is no way, however, of predicting all of the factors which may, at any subsequent stage, contribute to or interfere with the development of the organism. As Lonergan has reminded us above, finality is expressed in failure as well as in success. Apple trees bear fruit or do not bear fruit, they flourish or they die, they spread their branches to varying degrees, yet we never question the fundamental fact of what they are.

It is not sufficient, of course, that the human organism subsists distinctly. It is that fact that it subsists precisely in an intellectual nature, which is a potency for all kinds of activity including knowing and willing, that is significant. This is what makes it possible for us to recognise the human embryo as a person from the time when it begins to exist as a new genetic and spiritual entity, until it ceases to be.

Many of the reasons which are presented for respecting the right to life of persons derive from the Judaeo-Christian tradition. The first chapter of the book of Genesis suggests that human beings, the final stroke of God's creative genius, made in his own image, are of special value. To be made in God's image has nothing to do with appearance or performance, but implies the potential for relationship with God. The birth of Jesus Christ and his human life establishes a new intimacy and a permanence in God's relationship with the human race. For those of us who are Christian, these reasons are perfectly valid for recognition of the right to life of all persons, because they form part of what we believe, and our ethical judgments must be based on what we believe.

The Vatican Instruction on Human Life in its Origins expresses the Church's understanding of personhood as a criterion for the right to life, as follows:

But, even outside the context of Christian or other religious belief, personhood is no less significant as a criterion for the right to life. The fact that personhood can be attributed in the same measure to an embryo, to a neonate, to a mature adult and to a geriatric patient, does not mean that they are all 'the same', but it does mean that there is no basis in reality for distinguishing between them in so far as the right to life is concerned. Persons are defined in terms of what they are, not in terms of how fully they have actuated their potential. A person, by definition, is being-for-and-in-itself, irrespective of what or even whether someone else wants it to be. In simple terms, what it is determines how it ought to be treated. The right to life either applies to all persons or it does not apply to any of them. One person cannot decide that the life of another is disposable, without logically deciding the same about his own.

'In-vitro' fertilisation as a process for by-passing human infertility, involves the aspiration of mature oocytes (eggs) in large quantities from the mother-to-be, and their fertilisation with treated sperm provided by the male. This fertilisation takes place in a dish (the 'test-tube') and the embryos thus produced are 'grown on' in the dish and monitored for a few days, after which some or all are transferred to the mother's uterus. Those which remain, if any, may be frozen and stored for further attempts during a later cycle, used for research purposes, or disposed of.

Since embryos actually subsist, and are of an intellectual nature, it is appropriate that we ask "what are the implications of IVF for these persons?"

The practice of using two or three embryos on any one occasion is designed to increase the possibility of pregnancy. It has, however, been shown to reduce the chances of survival of each individual embryo. (c.f. Luno and Mondejar, 1986, p.48). Thus the acceptance of this practice involves the implication that it is expedient that a person or persons should die so that others may be parents. It places the right to parent-hood above the right to life.

This process has been shown greatly to reduce the chances of survival of the individual embryo. (c.f.; Senate Select Committee, 1986, p.129). It does provide more chances of pregnancy without the need to multiply the number of laparoscopies. As in the case of a. (above) it implies that human convenience is the primary consideration. It could be said that the embryo becomes the ultimate in frozen consumer products.

The Vatican Instruction, referred to above, states that:

Under present conditions, research on human embryos is inevitably destructive. It is undeniable that much valuable knowledge about genetic disorders can be achieved by means of this research, but only at the expense of the individual embryo, on whom the research is carried out. The Declaration of Helsinki makes a distinction between biomedical research which may be of benefit to the patient / subject and research which is non-therapeutic. It states that :

Th Warnock committee approves even the production of embryos specifically for research (Warnock, 1985, p.69), while the Australian Senate Committee, in line with the Helsinki Declaration, rejects experimentation on an embryo which is "invasive and destructive of that embryo". (Senate Select Committee, 1986, p.16). It is significant that, although the Australian Senate Select Committee approves In-Vitro fertilisation, its rejection of any form of experimentation on embryos is based firmly on a particular understanding of the nature of the embryo.

Unfortunately, this very positive view of the embryo, held by the Select Committee, does not lead the Committee to reject other procedures which frustrate the healthy development of the embryo, e.g.; frozen storage and disposal.

Oliver O'Donovan, an Anglican priest/philosopher, points out that it is not really possible to condemn research on embryos and yet accept IVF because, irrespective of where and when the research took place, it was and remains a necessary pre-condition of the sccess of IVF. "Our view of IVF", he concludes, "is necessarily determined by our view of non-clinical research on early embryos" (O'Donovan, 1984, p.80).

The implication of research on embryos is that a person can be a means to an end. Her value is to be found in what I can achieve through her use, not in what she is or can be in herself. This is a common enough pre-supposition also in relation to born persons (e.g.; in attitudes towards labour, economic policy, and military strategy).

Some embryos are disposed of because they are not needed, others are rejected because they are seen to fall short of the required standard. In either case, the human significance of the disposal of embryos is that persons are of no intrinsic value. It is not uncommon to meet adult products of the same attitude, people who are left to one side because they are surplus to requirements, or because they don't measure up.

e. Re-implantation:

The 'lucky' embryos are those which are sucessfully transferred, anything between 2% and 10%. But even in success there are important human implications. The question has been raised, not unreasonably, as to how an embryo who is manufactured by a process of modern technology, rather than begotten of a loving embrace, can be understood as being-for-and-in-itself. This is not to suggest that parents of IVF children love their children any less than other parents, but simply a reflection of how intrusive technology can be. The parent who lives out his own dreams and ambitions in his child is a well known stereotype. Could IVF represent the ultimate in being-for-another?

I conclusion, In-Vitro fertilisation, of its very nature, has depended and will continue to depend on embryo research which is invasive and destructive. The conditions and assumptions which offer the greatest possibility of successful in-vitro fertilisation are those which require that the embryo be regarded as disposable, and of no value in itself.

Medicine is directed towards the well-being of persons, through the prevention and healing of sickness and disease, the alleviation of pain, and the care of those who are suffering. in-vitro fertilisation does not fall into any of these categories, and is found to be implicitly and explicitly in conflict with the respect due to the embryo as person. It cannot, therefore, be considered to be ethical.

'In-vitro' fertilisation is but one of many aspects of medical practice and bio-technology, about which an appropriate ethical judgment can be made only in the light of an adequate concept of 'person'. Others would include pre-natal diagnosis, our treatment of handicapped newborn, geriatric, psychiatric and comatose patients, as well as decisions about resuscitation after cardiac arrest. Attempts to make such judgments, while by-passing the judgment about personhood, or while confusing 'person' with 'personality', lead only to failure and confusion.

Aquinas,T (1923-1928).The Summa Contra Gentiles, three volumes in four, Burns Oates and Washbourne, London.

Aquinas,T (1964-1966). Summa Theologica, sixty volumes, Blackfriars / Eyre and Spottiswoode, London.

Balinsky, B.I. (1981). An Introduction to Embryology, C.B.S., New York.

Congregation for the Doctrine of the Faith, (1987). Instruction on Respect for Human Life in its Origin, and On the Dignity of Procreation, Vatican City.

Hume,D. (1888). A Treatise of Human Nature, Clarendon Press, Oxford.

Kuhse,H. and Singer, P. (1985). Should the Baby Live?, Oxford University Press, Oxford.

Locke, J. (1975) An Essay Concerning Human Understanding. Clarendon Press, Oxford.

Lonergan, B.J. (1958) Insight, Darton, Longman and Todd, London.

Lonergan, B.J. (1964a) De Constitutione Christi, Ontologica et Psychologica, Gregorian University, Rome.

Lonergan, B.J. (1964b) De Verbo Incarnato (thesis altera ad decimam), Gregorian University, Rome.

Luno,A.R. and Mondejar,R.L. (1986) La fecondazione in-vitro, Citta Nuova, Rome.

Macintyre, A. (1981) After Virtue: A Study in Moral Theory, Duckworth, London.

Mill,J.S. (1962) "Utilitarianism" in Utilitarianism, (M.Warnock), ed., Collins, London.

O'Donovan, O. (1984) Begotten or Made, Clarendon Press, Oxford.

Senate Select Committee (1986) Human Embryo Experimentation in Australia, Australian Govt. Publishing Service, Canberra.

Warnock, M. (1983) "In-Vitro Fertilisation: The Ethical Issues", The Philosophical Quarterly, Vol 33, No.132, July 1983, pp.238-249.

Warnock, M. (1985) A Question of Life, Basil Blackwell, Oxford.

World Medical Association, (1975) Declaration of Helsinki (Revised), Ferney-Voltaire, France