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Chapter42
Rom an C at h ol i c
Perspect i v e s on
Psychiatri c Et h i c s
Emilio Mordini
Introduction
The Roman Catholic Church is the largest Christian community in the world. It includes
more than 1.2 billion believers worldwide, around 1.2million clerics, and consecrated people
(monks, nuns, etc.).1 Roman Catholics call themselves just Catholic, which comes from a
Greek word that means universal. The denomination Roman Catholic originated during
the seventeenth century within English speaking countries to differentiate Roman Catholic
from reformed Christian churches and, notably, from Anglicans.
Theologically speaking, Roman Catholics share with most other Christian communities and churches the so-called Nicene Creed,2 which is the profession of faith adopted at
the First Council of Nicaea (325 AD) by Christian clerics convened in Nicene, in Northern
Anatolia, by the Roman Emperor Constantine (Ratzinger 1968). The Nicene Creed includes
1<http://www.pewforum.org/2013/02/13/the-global-catholic-population/>.
2
The Creed includes seven original statements:(1)We believe in one God, the Father Almighty,
Maker of all things visible and invisible; (2)And in one Lord Jesus Christ, the Son of God, the only
begotten of the Father; that is, of the essence of the Father, God of God, Light of Light, very God of very
God, begotten, not made, being of one substance with the Father; (3)By whom all things were made
both in heaven and on earth; (4)Who for us men, and for our salvation, came down and was incarnate
and was made man; (5)He suffered, and the third day he rose again, ascended into heaven; (6)From
thence he shall come to judge the quick and the dead; (7)And in the Holy Ghost. In the First Council of
Constantinople (381 AD), this Creed was further modified, notably statement 7, and two new statements
(6bis and 8)were added. Consequently the Creed final statements read now:(6bis) Whose kingdom shall
have no end; (7)And in the Holy Ghost, the Lord and Giver of life, who proceedeth from the Father, who
with the Father and the Son together is worshiped and glorified, who spake by the prophets; (8)In one
holy catholic and apostolic Church; we acknowledge one baptism for the remission of sins; we look for
the resurrection of the dead, and the life of the world to come.Amen.
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14
Prohibition to marriage for Catholic priests is only customary. On the contrary, bishops cannot
marry because of doctrinal reasons.
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This creates a bizarre situation. On one hand Christian ethics is definitely an ethics of striving rather than an ethics of ought (Kramer 1992). The core of Jesus teaching, As Ihave
loved you, so you must love one another16 could be hardly considered a precept. On other
hand, the notion of natural law provides Catholicism with a strong normative framework.
The tension between these two poles is unavoidable. The notion of natural law includes,
however, at least two different concepts. First, the natural law could be understood as law of
nature, say, moral order grounded in the very nature of things. This approach has been often
mainstream in Roman Catholic moral teaching, at least from XIX century on. Yet the natural
law could be also understood as practical reason, say, as human capacity to conform to
Gods mind and cooperate to divine providence. In other words, moral norms could be said
natural either because they can be found in nature or because they are consistent with
human practical reason (Rhonheimer 2000). Ultimately, the idea that ethical norms could,
and should, be rationally justified (say, they are not Gods arbitrary commands and there is a
deep harmony between reason and revelation) is thus integral to Roman Catholic teaching,
but this does not imply that the moral law is written in the book of nature.17 Although the
physicalist doctrine of natural law may be prevalent, one could be Roman Catholic without sharing it (Antiseri 2003).18
15 Stoicism was a philosophical current, born in the Hellenistic milieu around 300 BC, which became
one of the most influential schools of thought of the Roman Empire. According to Stoics, the universe is
governed by rationale laws. The goal of a rational agent is to live in accordance with theselaws.
16 John 13:3435.
17 The Catechism define the natural law as the light of understanding placed in us by God; through
it we know what we must do and what we must avoid (art.1955), and John Paul IIs encyclical letter
Veritatis Splendor reads the light of natural reason (is) the reflection in man of the splendour of Gods
countenance this law is called the natural law:it receives this name not because it refers to the nature
of irrational beings but because the reason which promulgates it is proper to human nature (John Paul II
1993, n.42).
18 Roman Catholic teaching in matter of faith and morals obliges the believer to assent only when
it is extraordinary, say, when:(1)it is a specific, solemn, Popes declaration called ex cathedra; (2)it
is a doctrine formally endorsed by a General Council of the Church; (3)it is considered definitive and
absolute by all bishops, all over the world, without exceptions. In all other cases, Churchs teaching is
called ordinary, which is authoritative and demands hierarchic submission, but it is not a truth that one
should believe in order to define herself Roman Catholic. Finally, disagreement is always possible with
theologians teachings (magisterium cathedrae magistralis) no matter if it is the prevalent doctrine.
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Scriptural Sources543
Scriptural Sources
14When they came back to the disciples, they saw a large crowd around them,
and some scribes arguing with them. 15Immediately, when the entire crowd saw
Him, they were amazed and began running up to greet Him. 16And He asked
them, What are you discussing with them? 17And one of the crowd answered
Him, Teacher, Ibrought You my son, possessed with a spirit which makes him
mute; 18and whenever it seizes him, it slams him to the ground and he foams at the
mouth, and grinds his teeth and stiffens out. Itold Your disciples to cast it out, and
they could not do it. 19And He answered them and said, O unbelieving generation, how long shall Ibe with you? How long shall Iput up with you? Bring him to
Me! 20They brought the boy to Him. When he saw Him, immediately the spirit
threw him into a convulsion, and falling to the ground, he began rolling around
and foaming at the mouth. 21And He asked his father, How long has this been
happening to him? And he said, From childhood. 22It has often thrown him
both into the fire and into the water to destroy him. But if You can do anything,
take pity on us and help us! 23And Jesus said to him, `If You can? All things are
possible to him who believes. 24Immediately the boys father cried out and said, I
do believe; help my unbelief. 25When Jesus saw that a crowd was rapidly gathering, He rebuked the unclean spirit, saying to it, You deaf and mute spirit, Icommand you, come out of him and do not enter him again. 26After crying out and
throwing him into terrible convulsions, it came out; and the boy became so much
like a corpse that most of them said, He is dead! 27But Jesus took him by the
hand and raised him; and he got up. 28When He came into the house, His disciples
began questioning Him privately, Why could we not drive it out? 29And He said
to them, This kind cannot come out by anything but prayer.
New American Standard VersionMark9:14
The episode of the exorcism of a boy possessed by a demon, which is extensively reported
by Mark but is also reported by Matthew (17:1421) and Luke (9:3749), is one of the miracles of Jesus in the Gospels. The scene was vividly represented by Raphael in his last painting, The Transfiguration.19 The episode reported by Mark has always drawn attention of
scholars. On one hand the tale follows the standard plot of all Jesus exorcisms (Twelftree
2011), on other hand there are some significant particularities that make this exorcism rather
peculiar (Meier 1994). First, the whole episode is included between two explicit references
to Jesus disciple helplessness to heal the boy, which is uncommon in the Gospels. Second,
Jesus interlocutor is not the demon, as in all other exorcisms, but the distressed boys father.
Third, it is the sole instance in the Gospels in which Jesus conditions an exorcism to faith
and mentions his own faith as the source of his miracles. Fourth, the clinical description of
the boy possessed by a demon is an accurate picture of a neuropsychiatric disturbance, say,
epilepsy.20 Because of all these elements, and a textual analysis of Marks lexicon, most New
19
Intriguingly enough, this painting is mentioned by Friedrich Nietzsche (Nietzsche 1872) as the
highest plastic representation of the tension between the two primordial holy follies, Apollonian
possession and Dionysian frenzy.
20 Moreover, Mark uses a Greek word that literally means lunatic, which was often used in his epoch
to describe epilepsy.
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21
Of course recognizing the likely historical authenticity of an episode does not imply to accept also
its nature of miracle.
22 The notion of historical Jesus refers to the reconstruction of Jesus life based on historical
methods.
23 Some scholars have thought to find in this episode many elements that usually characterize
resurrection miracles in the Gospels (Meier1994).
24 The expression suspension of disbelief was coined by Samuel T.Coleridge in the context of poetry
(Cattorini2007).
25 Paul was a Hebrew Pharisee who converted to Christianity, and played a pivotal role both in the
theological systematization of Jesus teaching and in its diffusion in the Hellenistic and Romanworld.
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26 This concept is echoed by Dostoevsky The more stupid one is, the closer one is to reality. The more
stupid one is, the clearer one is (Dostoevsky 2007, p.258).
27 With the term Church Fathers, one usually refers to ancient Christian theologians who variously
contributed to the definition of Christian religion.
28 Augustine of Hippo (354430 AD) was a Latin philosopher and Christian theologian, who played a
pivotal role in the development of Western Christianity and philosophy.
29 Galen (129216 AD) was a Greek physician and philosopher in the Roman Empire. Galen
argued that the mental and the physical were the same and mental diseases had a physiological basis
(Hankinson1991).
30 Thomas Aquinas, (12251274) has probably been the most influential philosopher and Christian
theologian. In his encyclical of 4 August 1879, Pope Leo XIII stated that Thomass theology was a
definitive exposition of Catholic doctrine.
31 Sum III, q.15,a.4.
32 Sententia Ethic., lib. 7 l.1 n.45.
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33 Mais en Dieu, Frre, sache aimer comme toi-mme ton frre, et, quel quil soit, quil soit comme
toi-mme Tel est le commandement de lamour du prochain. Freud a raison de sarrter l (Lacan 2005b,
p.62).
34 La vrai religion, cest la romaine Il y a une vrai religion, cest la religion chrtienne (Lacan 2005b,
p.81).
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Psychiatric ClinicalEthics
The last part of this article will be devoted to Roman Catholic perspectives on some ethical
issues related to psychiatric clinics. In most cases, there are neither Catholic official statements nor established moral practices. The Roman Catholic teaching on mental health is
rather limited (Kehoe 1998) and the institutional Church tends to espouse traditional
medical deontological approaches to psychiatric ethics (Vanderveldt and Odenwald 1957,
pp.123155). There are, however, some cases in which ethical conflicts between Catholic faith
and psychiatric professional practices may occur. Iwill focus only on these occurrences,
while Iwill not discuss ethical conflicts that would not challenge a Catholic psychiatrist
as a believer. Iwill also mention some ethical problems that could arise when a patient is
Catholic and her psychiatrist isnot.
Psychiatric Diagnosis
The main ethical issues raised by psychiatric diagnosis are related to stigmatization and
psychiatrization.
Stigmatization:stigmatization refers to the process of attributing to an individual a stereotypical description, a behavior, or reputation which is socially demeaning (Goffman 1963).
This has been one of the main theoretical tools used by 1960s anti-psychiatric movements
to criticize official psychiatric theories and practices (Dain 1995). From a Catholic perspective, promoting, or not preventing enough, psychiatric stigma is one of the major unethical
behavior which a psychiatrist could incur, because it threatens the inherent human dignity
of the patient.
Psychiatrization:with this neologism, one refers to the process of labeling a behavior, or a
social fact, as an occurrence that pertains to psychiatrists. Although this process is habitually
justified by alleging a new scientific discovery, this is rarelyif everthe case. Usually the
process of changing label to a behavior is due to reasons that are more mundane and sometimes it is even used as a diagnostic cover for the introduction of, or new indications for,
drugs and treatments. Psychiatrization is always ethically questionable and it could become
a source of specific ethical conflicts for Catholic psychiatrists when it is used to justify serious
disregards of responsibility. If school teachers use the diagnosis of learning disability as an
alibi for neglecting problematic children; if public authorities use the label psychopathic
to avoid confronting social problems that they are unable to handle; if families delegate the
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Psychiatric ClinicalEthics549
management of rebellious adolescents to psychiatric agencies; in all these cases Catholic psychiatrists should refuse to participate into a collective system for discharge of responsibility,
which is definitely in contrast with Jesus teaching35 and the Churchs teaching on individual,
and professional, responsibility (Pontifical Council for Pastoral Assistance to Health Care
Workers 1994, n.57).
35
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38Mark2:27.
39Matthew23:4.
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Psychiatric ClinicalEthics551
religious marriage would be definitely unethical (American Psychiatric Association
2013b, sect. 2 and8).
(3)
Sexual orientation: both gender dysphoria (former gender identity disorders)
and homosexuality are usually expected to raise ethical problems to the Catholic
psychiatrist.
The main ethical conflict in the case of gender dysphoria is when a patient is seeking sex
reassignment therapy; because a Catholic psychiatrist could legitimately think that
individual sexual constitution is part of the whole Gods design40 and should be
respected by humans.41 The problem is very close to the one we have met discussing the notion of natural law, say, a misunderstanding between moral and scientific
norms. Ultimately, the concept of sex reassignment therapy is grounded on gender
theories. All gender theoriesalthough variedshare the conviction that gender
and sex are two different things (Butler 1990). This is a legitimate and interesting
point of view, which is not however a scientific theory, rather it is a philosophical
perspective. For the same reason, in clinical practice, a Catholic psychiatrist should
not confuse the natural law doctrine with scientific evidence; she (or any other psychiatrist) should not feel obliged to espouse gender theories, as they were the medical state-of-the-art. If a Catholic psychiatrist thinks that sex reassignment therapy is
unethical, she could simply refer the patient to a colleague. What is paramount is that
the psychiatrist always avoids criticizing or stigmatizing the patient, which is never
ethically tenable (American Psychiatric Association 2014, N.1.J).
Homosexuality is an over-debated issue. The Catechism reads homosexual acts are intrinsically disordered. They are contrary to the natural law (art. 2357). Once more, the physicalist
notion of natural law makes things, in my opinion, pointlessly complicated. Not only is it
highly debatable that homosexuality could be considered out from the natural order,42 but
any clinical psychiatrist knows that homosexual fantasies and desires (if not behaviors) are
part of normal human sexuality. ACatholic psychiatristbased on Pauls writings,43 the
Old Testament,44 and the Churchs moral teachingcould legitimately argue that homosexual acts are an execrable moral fault, but this does not make them abnormal or psychiatric
symptoms. When a patient asks to be helped to change sexual orientation, from homosexuality to heterosexuality, the psychiatrist (also the Catholic psychiatrist) should reject this
request, not only because this is the professional ethical standard (American Psychiatric
Association 2014, N.1.J), but also because for a Catholic physician it would be unethical to
treat conditions as medical when, in fact, they are not medical-health in nature. In this case
the person is not helped to perceive the exact nature of their problem, thus misleading them
(Pontifical Council for Pastoral Assistance to Health Care Workers 1994, n.57).
40Genesis1,27.
41
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Right toLife
The intrinsic finality of (physicians) profession is the affirmation of the right of the human
being to his life (Pontifical Council for Pastoral Assistance to Health Care Workers 1994,
n.48). Right to life is a well-established principle in Roman Catholic ethical teaching. It
is rooted in the Old45 and New46 Testaments, and in the Tradition. The Catechism reads
Human life is sacred because from its beginning it involves the creative action of God and
it remains forever in a special relationship with the Creator, who is its sole end. God alone is
the Lord of life from its beginning until its end:no one can under any circumstance claim for
himself the right directly to destroy an innocent human being (Catechism of the Catholic
Church 1997, art. 2258). Although non-violence appears to be almost an absolute principle in
Jesus teaching47, the Catholic Tradition has always accepted three exceptions, say, legitimate
defense, just (defense) war, and capital punishment, which is considered as a societal legitimate defense, whose necessity today is however very rare, if not practically non-existent
(Catechism of the Catholic Church 1997, n.2267). The Right to Life is relevant to psychiatric
clinical ethics mainly in three contexts:
(1)
Capital punishment: the WPA Ethical Standards for Psychiatric Practice reads,
Under no circumstances should psychiatrists participate in legally authorized
executions nor participate in assessments of competency to be executed (World
Psychiatric Association 2011, p. 3). This is definitely in line with Roman Catholic
moral standards. ACatholic psychiatrist should refuse to participate not only in the
execution but also in assessment of competency, notwithstanding the different opinion of the Ethics Committee of the American Psychiatric Association, which argues
that it is ethical to provide a competency examination (American Psychiatric
Association 2014, G.1.c).
45
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Psychiatric ClinicalEthics553
(2)
Euthanasia: Catholic moral teaching affirms that euthanasia, as well as medical
assisted suicide, is always unethical, while psychiatric professional ethical standards
are a bit more nuanced (World Psychiatric Association 2011, p.1). ACatholic psychiatrist should refuse to participate in, and actively oppose, any procedure, which
may lead to the decision to suppress the life of mentally incapacitated people, and
people suffering from mental disorders, who are unable to express a valid informed
consent. In addition, when a competent patient asks to be assisted to commit suicide,
a Catholic psychiatrist should refuse, as she should refuse to participate in any related
procedure. However, in the situation where a psychiatrist is requested to provide a
pharmacological treatment to a dying person in order to mitigate physical sufferance,
psychological distress, and make less painful the event of death, this kind of assistance is permissible. In so far as the procedures do not aim directly at the loss of
consciousness and freedom but at dulling sensitivity to pain, and are limited to the
clinical need alone, they are to be considered ethically legitimate (Pontifical Council
for Pastoral Assistance to Health Care Workers 1994, p.71).
(3)
Abortion:The Catechism (Catechism of the Catholic Church 1997) reads Life must
be protected with the utmost care from the moment of conception:abortion and
infanticide are abominable crimes (art. 2271). Catholic psychiatrists are requested
not to perform abortion, which would be, however, outside their professional competence. The Catechism also specifies formal cooperation in an abortion constitutes
a grave offense. The Church attaches the canonical penalty of excommunication48
to this crime against human life. (art. 2272). This means that a Catholic psychiatrist
should also avoid providing her expertise to medical teams that perform abortion.
This leads to a question, would a Catholic psychiatrist be morally allowed assessing mental conditions of a woman, in those jurisdictions where such an assessment
is legally mandated in order to terminate a pregnancy? When this procedure is a
mere legal formality, a bureaucratic green light before pregnancy terminationas
it often occursI think that the psychiatrist should decline. On the contrary, when
pre-abortion psychological assessment is a sincere social effort to assure that the
decision for an abortion is intellectually robust, Ithink that professional duties prevail and the psychiatrist should accept to visit the patient. The psychiatric interview
could also be one of the last opportunities offered to a woman to change hermind.
A difficult question concerns the way in which a Catholic psychiatrist should respond to a
non-Catholic patient who raises elective abortion in the context of therapy. From a Catholic
perspective, this is almost a Tarasoff-type49 situation. If abortion were (or is) a murder, one
would be (or is) confronted with same dilemma that arises when a patient shows homicidal
intentions, or acts out behaviors that could seriously damage other people. This ethical
dilemma is made still more complex by the fact that abortion is legal in most western jurisdictions, and this prevents the psychiatrist from relying upon a legal escape hatch. Actually
the psychiatrist is trapped in a Catch 22 situation; either she becomes morally responsible
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Psychotherapy
Ethical conflicts between Catholic faith and psychiatric professional practices could also
occur in psychotherapies. In the previous sections, Ihave briefly enlightened those issues
that are specifically related to psychodynamic psychotherapies and psychoanalysis. As per
ethical issues related to other kinds of psychotherapies, either they have been already discussed under sections 6.1, 6.2, 6.3, or they are not directly related to any specific conflict
between Catholic morals and psychiatric practice. There is probably only one issue missed
in ethical discussions raised by the situation in which a non-Catholic psychiatrist takes in
therapy a Catholic cleric. For instance, a priest could seek a treatment because of the occurrence of panic attacks or a monk, or a nun, could suffer from serious depressive disorders.
These symptoms could mask, or be related to, various psychological conditions, e.g. panic
attacks are often related to unconscious homoerotic phantasies, and depressive disorders
could hide deep, inhibited, aggressive feelings. The psychiatrist should respect patients,
notably she should avoid confronting them violently with their mental contents, particularly
when they explicitly contrast with patients moral and religious beliefs. 52 Of course respecting does not mean that one could not discuss psychological meanings, but this should never
be done in derogatory ways, or hurting feelings of modesty, or humiliating the patient. If
during the psychotherapy the patient experiences a priestly crisis, the psychiatrist should
become over-vigilant about her countertransference. Actually, this is a very delicate situation, both clinically and ethically, and it is paramount that the psychiatrist avoids either mitigating or intensifying the crisis, as it could happen if the psychiatrist is not fully aware of the
50
Matthew 23,27.
Luke 7,4447.
52 When Iwas a young psychoanalyst in training, my supervisor used to teach that disturbing mental
contents are like champagne corks, they must be eased out very slowly, with a gentle, almost silent thud.
He used to add that this was not only a technical rule but also an ethicalnorm.
51
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Conclusions555
anxiety that the patients religious crisis could generate in her.53 Moreover the non-Catholic
psychiatrist should respect confessional secrecy (a priest cannot divulge for any reason what
he has learned during a confession) although this could be problematic, notably in a psychodynamic psychotherapy (Gemelli 1955, pp.139140).
Conclusions
Religions are complex phenomena, which include doctrines, philosophies, ritual, structures,
communities, narratives, popular beliefs, power relationships, and so. By examining Roman
Catholic perspectives on psychiatric ethics, Ihave focused on official teachings, statements,
and scholarly debate. Is this enough? Probably it is not. Catholic culture (or cultures) is not
the same as Roman Catholic institutions and official documents. One should study, for
instance, Catholic popular piety and the role of popular practices in the traditional understanding of mental diseases. It would be interesting, for instance, to investigate the patron
saints related to mental illnesses in popular culture (Tomi and Salopek 2012) and the narratives that surround these saints, as in the case of Simeon the Holy Fool, a monk and hermit
lived in Syria in the sixth century AD, who is traditionally considered the patron saint of
fools and, with an intriguing association, of puppeteers as well (Krueger 1996). One could
also investigate healing miracles concerning mental diseases. Narratives about miraculous
healings very rarely concern mental diseaseswhy? What different religious traditions have
been incorporated by regional Catholic subcultures? How did these different, and oldest,
religions contribute to shape Catholic perspectives on mental health? Briefly, one should
face the richness and complexity, which characterize any religious phenomenon. Cultural
analysis is essential to understand the way in which ethical themes are presented in the real
world, notably addressing mental health issues. Unfortunately, this was not possible in a
short chapter of abook.
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