10.1. The nurse

There are certain special issues that concern other health-care providers than physicians; and I am going to take them up here in relation to the providers that are most concerned with them. First, let us consider nurses.

Obviously, a good deal of what was said in the two preceding chapters will be of interest to nurses, since they deal with the patient's life and physical integrity.

There is a view of nursing that says that nurses have a kind of specialty of their own: that of the "whole patient," meaning the patient's physical and mental and social and spiritual health and their interrelation. I could stand corrected on this, but it strikes me that in order to make this more than nice-sounding palaver, the nurse who was competent in this "specialty" would have to have an M.D. and Ph.D.'s in psychology, sociology, and Theology; and I know of no one, let alone most nurses, who actually has these credentials. A little learning is a dangerous thing; and people who think they know something because they've had a couple of undergraduate courses in something (or a couple of graduate ones, for that matter), can be a menace when treating people unhealthy in these various ways. And you can bet that someone who had all those Doctorates wouldn't want to be called "nurse."

This is not to denigrate nurses; but let's not pretend that things aren't what they are. Basically (or at any rate for our purposes),

DEFINITION: a nurse is someone who is an assistant to some other health-care provider.

This may involve considerable knowledge and skill, of course. If you're going to assist a physician, for instance, he's not going to want you to be asking him what he means every other sentence; and so he's going to assume that you have enough of a background to be able to interpret him correctly. And you have to know enough to be able to spot difficulties that need to be reported to the doctor; and so on.

But these are medical details, however important they may be, and don't of themselves have ethical overtones. The main ethical issues involve what it means to be an assistant.

DEFINITION: An assistant is one who places himself under the authority of another person.

DEFINITION: Authority is the right to command someone else.

DEFINITION: A command is a statement that has a sanction attached to it.

DEFINITION: A sanction is a threat of punishment (or the punishment threatened).

If there is no sanction, you are making request or offering a suggestion or advice, of the form, "It would be nice if you would..." This sort of thing means that the person will be better off if he does it; and so it gives a person the choice of adopting it as a goal or not. On the other hand, when you command someone, you are telling him that he's going to be worse off (because of what you are going to do to him or withhold from him); and since people have a moral obligation to avoid choosing their harm, you leave him "not free." That is, he's free in the sense that he can choose to disobey and harm himself, but he's not morally free because he can't morally choose to harm himself.

Note that when you engage the services of someone, you do not put him under your authority, because you can't tell him how to perform the service. What you've done is enter into a contract with him, saying, "I want to get rid of my infection, and I'll pay you thirty dollars to free me of it." So it's a mutual give-and-take, with benefits on both sides.

But the person in authority can tell you not only the final result, but how to accomplish it, and also it is irrelevant whether you benefit from the command or not; he's just going to see to it that you suffer if you don't do it. So when your mother told you as a child to take out the garbage, included in this was not simply getting the stuff out to the curb, but going around to the various waste bins, in what order, and emptying them into the bag, and when the bag was to be placed on the curb, and so on; and the fact that you found this procedure less than "fulfilling" made no difference whatever. You did it or faced a week without dessert.

But then why would anyone voluntarily put himself under authority, and "give up his own will" to someone else? Ordinarily, it is done because something that needs to be done can't be done by any single individual, or even by a bunch of individuals each of whom has his own idea on how to go about it; only a coordinated effort of everybody will get the job done. (Think of how a football team would fare if in the huddle all the players had to "come to a consensus" on how to run the play.) This means that one person has to be picked out to say, "This is what is going to be done," and the rest have to say, "Yes, sir!" and do it.

Cooperation among individuals (many acting as a unit) implies commands with their sanctions and authority.

So if something can't be done by just one person, and people have to cooperate to do it, then authority is necessary, and the assistants have to be willing to be commanded. Thus, if nurses don't do what they're told, they can expect to be punished--to have privileges taken away, to have their pay docked, to be fired. That's what you agree to when you agree to be someone's assistant.

10.1.1. Immoral and unjust commands

Obviously, the treating of a patient, especially in a hospital, has to be a cooperative venture; the main health-care provider has to have assistants. But note that these assistants, particularly nurses, often have more contact with the patients (whom the doctor is serving) than the doctor; and so they might well have information that the doctor lacks.

Since nurses are cooperating with doctors in treating patients, then the patients' benefit is the primary goal of the cooperative venture, and so this gives the nurses more of a moral obligation than simply that of following orders blindly.

First of all,

A "command" that is beside or contradicts the purpose of the cooperative venture is a null command, because the commander has exceeded his authority.

That is, assistants do not turn their whole lives over to the commander, but only that part of their lives that deals with the purpose for which they are cooperating. Hence, when the commander proceeds to tell them what to do outside the "common goal," as it is called, this is not a true command, and need not be obeyed. But let me spell out the moral implications of this a little more clearly.

DEFINITION: An unjust command is one that goes beyond the authority of the commander.

DEFINITION: An immoral command is one that commands the subject to do what [his conscience tells him] is morally wrong.

Remember, conscience is the factual knowledge you have about the moral status of the act in question; it's not just your feeling or opinion. It's obvious that an immoral command contradicts itself, because the commander expects you to obey basically because it's inconsistent with you to put yourself under authority and then not do what you're told. So he knows it's immoral for you to choose to disobey; but then if he commands you to do something morally wrong, on what grounds can he expect you to obey the command?

An assistant must always disobey an immoral command. Any command that will harm the patient is ipso facto immoral.

You are never permitted under any circumstances to choose what is morally wrong, and especially to choose to harm the patient; and so you can't hide behind, "But he told me to." It's still your choice, and you knew it was wrong.

But of course, the commander may not think there's anything wrong with what he's telling you to do; and your conscience is not his.

Furthermore, in the case of the doctor and the nurse, he is the expert and you are the assistant, who doesn't know as much as he does, at least as far as medicine is concerned. So we have to make some qualifications here.

First of all,

If you think a command is immoral, you must consult with the commander to see if he has reasons why the act would not be morally wrong; and if you still know that he is telling you to do what is wrong, you have to tell him you cannot obey and give your reasons for it.

Remember, this is a cooperative venture, and so you can't simply disobey and leave the doctor thinking that you've done what he told you. But if you say that you can't obey, and he tells you to go ahead and do it anyway, you still have to disobey, even if it gets you fired.


In the case of a doubt after consultation as to whether the act commanded is wrong or not, then the morally safest course, ordinarily, is to do what is commanded.

The reason for this is the following: You're not sure that what you're told to do is wrong, but you think it is. The doctor has heard you out and he says, "I know what I'm doing; there's nothing wrong with this; just go ahead and do it." The doctor is the expert in medicine and you're not, and you have no right to presume that he's a moral idiot (unless, of course, you have reason to believe this); and so the presumption is that he's more likely to be right than you are. Hence, the morally safest course is to do what he says.

This is one of the cases where the doubt of conscience often can't in practice be removed by consulting an ethical expert, because you very often have to obey or disobey before you can trot off to your local parish for an interview. So in general, you can only disobey if you know the command is immoral or unjust.

Now then,

An unjust command may be obeyed when the Double Effect applies.

In this case, you're not being commanded to do something wrong. It may be perfectly all right in itself to do what the doctor wants you to do; it's just that it's not part of your job description, and so he has no right to command you to do it. For instance, a doctor has no right to command a nurse to write the thank-you note to his host for the party he attended last night.

Now there's nothing wrong with doing this for him; it's just that he's not asking this of you as a favor, and is expecting you to do it because he's your boss and he thinks of you as his servant. But you're a nurse, not a secretary.

In general, what should be done in a case like this (if you can get away with it) is make it clear that you'll do it as a favor, but it's not part of your job description, and not something he has a right to expect of you. On the other hand, in the real world, this might have the bad effect of his thinking of you as uncooperative, and making your working for him miserable enough so that it offsets the bad effect of doing as if you were commanded something that was an act of generosity. So the Double Effect can allow you to do it.

In general, you should disobey (politely, and telling him you're not going to do what you're told and why); but you don't have to if it's more trouble than it's worth. The reason why it's preferable not to obey is that "obedience" to this non-command gives the person the impression that he can command others to do whatever he wants, and so it can have rather far-reaching implications.

Remember, "Give him an inch, and he'll think he's a ruler."

10.1.2. Morally correct commands

All, however, is not necessarily perfectly straightforward if the command is neither immoral nor unjust. It is conceivable that there is nothing morally wrong with it, but it is still not a wise command. Do you have to obey it anyway?

If you know that a command is unwise, you have an obligation to inform the commander of the facts you know that make it unwise. Then if after receiving the information he still issues the command, you must obey.

The reason you have to inform him is that he's not omniscient (even if he thinks he is), and might change his mind based on the information you give. If you don't inform him, you are willing that the unwise act be done, because you have a chance of preventing it and you refused to take it. Note that all you have an obligation to do is provide information he might not have, not to persuade him to rescind the foolish order.

There's nothing wrong with trying to persuade him, because, after all, stupid actions can do harm, and certainly don't do good. But you have to beware of being insubordinate here. He's the boss and the expert, and you're the assistant.

And if he hears the information and still tells you to do the unwise thing, you have to do it. Otherwise, you're in effect saying that you'll "obey" (i.e. do what you're told) when it seems good to you to do it, and not otherwise. But in effect that means that you'll do just as you would if you were not under orders. But this is clearly inconsistent with the fact that you are under orders.


If you know that your commander is prone to issue unwise orders, and he has a superior, then you have a moral obligation to document this and inform his superior, so that steps can be taken.

If you don't, then once again you're willing to have these unwise things done, because you know they're unwise and you might be able to prevent them by giving information to the people who can do something about it.

So yes, you do have an obligation to be a "whistle-blower," in spite of your early training not to tattle on people. Once again, however, beware of becoming a person who nit-picks what his commander is doing and runs to his superiors with the news that he's not perfect. The Double Effect allows for a good deal of human frailty before taking action against it is required.

Can you ever disobey legitimate orders? In general, No, of course; but there are exceptions:

You may disobey the letter of the command when you are clearly doing what was intended by it.

Obviously, you are to do what the commander wants you to do. If he tells you to do something, he presumes you are intelligent enough to realize what he wants; and so sometimes the literal thing he commanded doesn't exactly express his intentions. In that case, you do what he wants, not what he said. Be careful of this, however. At times, what seems like an "obvious misspeaking" is an unconventional order that was intended as stated. It is better to make the commander clarify himself and become annoyed with you than to presume that he doesn't "really mean" what he says.

A nurse, for instance, who is told to administer an intravenous injection of sodium bicarbonate in cardiac arrest, knowing that this can be dangerous to the patient, interprets the command as due to fatigue on the doctor's part and doesn't administer it. It turns out that the doctor was not giving the conventional treatment, and due to the lack of this injection, the patient dies.

Where this rule generally applies is not in individual commands, but in cases where there is a standard procedure that is in place, and you know that the situation is inappropriate to the procedure. In the obvious cases of this, you don't have to go running to the doctor and say, "I really shouldn't be doing this to this patient, should I, Doctor?" when both you and he know darned well that you shouldn't.

And with an individual command when the situation changes between the time when the command was issued and the time you are to carry it out, and it is no longer appropriate, and the doctor is not there to be consulted, you may do what it is obvious he would want you to do. But you must tell him afterwards that you did it, because he is the one primarily responsible for what is done, and so should have control.

And for this same reason,

A person under authority must not act on his own initiative in anything substantive, unless the Double Effect demands it.

That is, in the case where taking matters in your own hands is the way to avoid considerable harm, then you can interpret the intention of the commander's "first, do no harm" as paramount. So the Double Effect can allow you to do something on your own.

I had an actual case reported to me before I wrote the first version of this book. Nurses are (wisely) forbidden to prescribe medicine without a doctor's orders. A nurse in an emergency room had a patient dying of poisoning brought in, but there were no doctors available at the moment. She called the poison control center and was told to administer ipecac (something that makes you throw up). She asked for a doctor's orders to do this, and was told that there were no doctors in the poison center either. While she dithered, the patient lost consciousness--after which you couldn't administer the ipecac, and ultimately died of the poisoning.

In minor matters, however, in day-to-day details, the assistants may carry out their duties as they see fit, without asking for orders on how to do them. They may presume that everything is fine in these cases unless they are told differently.

Doctors are not going to bother themselves with details of how nurses go about the ordinary business of nursing, even though the doctor, as commander, is primarily responsible for what they do. You can assume that he wants the standard things done by the mere fact that he hired you; and if he wants something non-standard, he'll tell you. The point is that you don't have to force him to be explicit.

In other words, use your head in all of this.

One final point about the obligation of an assistant:

Assistants have a moral obligation to speak well of and even think well of their commanders, as far as this can be done without being untruthful.

I'm not saying here that you have to close your eyes to the obvious, or pretend that your commander is a paragon when he isn't. But you do have an obligation to look on him and what he says and does in the most favorable light possible, for the simple reason that it is a good deal harder to obey a person you despise. And if you talk badly about him, then you are encouraging others to despise him and so disobey him.

This is obviously a moral obligation that is one of the most ignored of all. Keep it in mind.

Now then,

Insofar as an assistant is an expert in his own right, such as an anesthesiologist who is helping a surgeon, the commander must defer to the assistant's area of expertise, and cannot simply command as if he (the commander) knew best.

This type of assistant has a kind of counter-authority over the commander in his field of expertise, because he is more like someone the commander is engaging the services of rather than hiring to be under orders. True, he is assisting the surgeon during the operation, and what he does is secondary to what the surgeon is doing; but he is really performing the service of administering anesthesia for the surgeon, and it just happens that it is to be done under these conditions. The point is that it is the anesthesiologist who makes the decisions about the specific anesthesiological issues, not the surgeon.

10.1.3. Responsibility of the assistant

You will (I hope) remember that, back in Chapter 4 I discussed responsibility, and said that it came after the act, as accountability for what you had control over.

We now have the situation where a person under orders is not morally in control of some of the things he does, and has control (in the sense of could prevent) things that other people do. So let us spell out what the responsibility here is.

First of all,

Assistants are not morally responsible for what they do in obeying legitimate commands, even unwise ones (provided they have informed the commander). The reason is that they cannot morally not do the act, and so the control is in the commander's hands, not theirs. (Yes, you can say, "It wasn't my fault; he told me.")

In this case, the commander and only the commander, is responsible for what you do.

Assistants are responsible for

Any act of disobedience, even a legitimate one, because they could prevent the act by obeying. Notice, when they legitimately disobey, they are responsible for what they do, but not guilty of it, because the act was a good act.

Any act of obedience to a foolish command when the commander was not informed, because the command might have been rescinded if the commander was told what he was doing. Hence, the control is in the hands of the assistant. Of course, in this case, both the commander and the assistant have joint responsibility, since either could have prevented the act.

The interesting thing here is that you are responsible for what the commander does in this case, because your giving or withholding the information affects his choice and his act.

Any act of obedience to an immoral or unjust command. In this case, you can morally disobey, so you are morally responsible for obeying. If the command is immoral, you are also morally guilty, even when the commander (by ignorance) is not. So here you can't hide behind, "I was only obeying orders." You had an obligation not to obey this one.

In the case of an unjust command, you are responsible for the obedience whether or not the Double Effect allows it, because the command always could have been obeyed; but you are not morally guilty, because by the supposition, it is not morally wrong to do the act (otherwise the command would be immoral, not simply unjust).

In both of these cases, you are also responsible for what the commander commands if you don't inform him of the immorality or injustice of his command.

Any act done not under explicit orders, but done while under orders, even when interpreting what the commander "obviously" wants. Since the commander didn't actually tell you to do the act, even if it's what he would have wanted, you are the one in control, because you are actively interpreting him. So if you make a mistake and don't do what he would have wanted, you can't blame him.

Any harm to the commander that comes or might come from thinking or speaking badly of him. Since you're the one with the nasty thoughts or words, then the consequences of these thoughts or words are yours. Now of course, if his bad conduct forces you to recognize it, you are not responsible for harm that comes from the conduct; it isn't your recognizing the truth that did him damage, but what he's doing himself.

Obviously, if you tell the truth to his superior, you are responsible for the consequences of what you say (which may harm him), but not morally guilty of the harm, because you had to tell on him to avoid the harm that he was doing.

10.1.4. Cooperation in evil

I also said as far back as Chapter 3 that basically, morality commanded you not to be willing to do what is morally wrong. You may be in a situation where you are an assistant to someone you know is doing wrong. To what extent can you even be his assistant without going along with the wrongness, and so being willing that it be done?

If the moral wrongness is not simply something that is inconsistent, but is something that violates a right of another person, you may not even be an assistant of the perpetrator.

The reason is that in this case, you have an obligation to prevent the violation of another person's right or you are willing to allow the violation which is, of course, the same thing as to will to violate it. But if you assist a person who is violating someone else's right, even though he doesn't think he's violating any right of anybody, you can't be unwilling to allow the violation. You are at the best indifferent to it, not opposed to it.

Think of it this way. Suppose you were hired by a slave-owner, and were helping him, even if not directly, with his oppression of the slaves. Obviously, you are making life easier for him, and so easier for him to continue oppressing the slaves, and so you are indifferent to the fate of the human beings he is using as animals, and conniving at making it easier for him to do so. You can't say, "I care about the slaves' rights."

So, you can't be an assistant of someone like Dr. Jack Kevorkian, even if he thinks he's benefitting mankind by helping people kill themselves, and even if you're not directly assisting in that service. For instance, you can't be his secretary.

But the obvious application in our present day is to abortion. Anyone who assists in any way a person who performs abortions makes it easier for the person to perform the abortions. Therefore, the assistant is at best indifferent to the rights of the people being killed, and is conniving in abortion. This is true whether or not he assists in the actual abortion.

Also, no one who knows what the truth is may morally serve in any capacity in a hospital in which abortions are performed.

The Germans didn't have to serve in the death camps to be morally guilty of what was done to the Jews; by simple complacency and indifference, they made it possible for the horrors to be performed.

And, propaganda by the "pro choice" people to the contrary, a worse than Hitler is here.

But suppose the doctor performs vasectomies to sterilize men who want to be sterilized. He's doing what is morally wrong, but he's not violating a right of the other people, because even though he's doing objective harm to them, they want the harm to be done. Further, neither he nor they think that they're doing harm.

Note that in this matter

Not to do anything whatever to demonstrate your opposition to abortion is to be willing that it happen. You can't morally be indifferent to the violation of others' rights without conniving in the violation.

Now this doesn't mean that you have to go out and picket abortion clinics. But if the subject comes up, for instance, you can't just not say anything to show that you're opposed. Even if that's going to lose you some friends, not do so indicates that you're willing that lives be sacrificed to your convenience of having your friends not be uncomfortable.

After all, the fewer assistants and supporters abortionists find, the more difficult it will be for them to perform abortions. And let's face it; the indifference of the majority is the real support they have. Look at smoking, and how the lack of indifference on the part of many has curtailed it.

But now, aside from a violation of rights, can you be an assistant of someone who does morally wrong things? Suppose a person who performs vasectomies, which sterilize men, wants an assistant. Can you take the job?

It depends. If the person does for practical purposes nothing but vasectomies, or if he makes this his main business, then if you worked for him at all, you would be willing for these acts to be done, and would be an accessory to the wrong. So you can't assist a person whose main business is doing something that is morally wrong.

This is true even if he thinks it's morally all right, and even if his patients see nothing morally wrong with it. The fact is that it is wrong, and you know that it's wrong; and so even though they're not being immoral in doing it (because of their ignorance), you would be immoral if you helped in it.

Well now, suppose the physician is not a vasectomist, but every now and then performs vasectomies. What then?

You may assist a person who occasionally does what is morally wrong without being willing that the wrong be done, as long as you don't help in the act itself.

Obviously, if you assist in the actual act, then you're not unwilling for it to be done; your actual help shows your willingness that the act be done. That should be obvious.

But that's not the case if you help the person who happens to perform the act, because he's doing all sorts of other good things, and those you can morally choose.

You may even morally do things like sterilize instruments which may be used in the morally wrong procedure, as long as they aren't instruments that have no other use but this.

Obviously, if you're going to work for somebody like this, you have to come to an agreement with him. You have to tell him, "Look, I'll work for you, but I believe that vasectomies are morally wrong; and while I'm not trying to be your conscience and prevent you from doing them, my conscience won't allow me to help you do them. So if you'll exempt me from working on vasectomies, I'd be glad to be your assistant in everything else." If he agrees, then morally speaking you're home free.

Obviously, if there is some kind of emergency in your service, and people would be harmed unless you assisted at what in fact is a morally wrong act, the Double Effect would permit the assistance.

For instance, the doctor is performing another operation, and (forgetting that you have qualms of conscience about vasectomies) he decides that he's going to perform a vasectomy while he's at it, rather than schedule another operating time. If you walk out as soon as you discover what he's up to, then the patient may die or be severely harmed because the doctor suddenly has lost his assistant. Clearly, you are staying there not because you want the vasectomy, but solely to prevent harm to the patient.

Finally, as I said before in another context:

If someone wants a morally wrong procedure performed, you may not tell him that you (or this hospital) can't perform it, and then give him advice on where to go to get it done.

In that case, you are willing that the act be done, and so morally speaking, you might just as well be doing it yourself. This would apply to telling someone where to go to get advice on contraceptives, for instance, or abortion.

You can't hide behind "Well, it's a legal procedure, and he has a right to know." He has no right to know from you. No one can ever claim a right for anyone else to do wrong. Legally, of course, he might have a right (depending on what the laws are); and so you might have a legal obligation to inform him. But you have a moral obligation not to inform him; and so any law that would force you to do so is an immoral command, and must not be obeyed.

10.2. The psychologist

So much for nurses. There are a number of moral issues that are specific to psychologists also. Now first, a psychologist, medically speaking, is someone who doesn't have an M. D., and so who cannot prescribe medicine; only psychiatrists are also medical doctors and can prescribe drugs for treatment. But I am going to deal with both together, and I said "the psychologist" just for convenience. I am speaking of anyone in the field of mental unhealth, which, as I said in Section 6.2. is the inability to control one's actions by one's choice, or to have access to information one would be expected to have.

The first thing to do is be very clear on what we are talking about here.

The problem in mental unhealth is not bizarre behavior, or self-destructive behavior, or feelings of inadequacy or hopelessness, or not fitting into society, or unrealistic views of life, or unhappiness. The problem is lack of conscious control over one's acts or one's information.

All of the above may be signs of mental unhealth; but there are eccentrics who could perfectly well do what normal people do and simply choose not to; there are people who do themselves damage and know they are doing so and don't care; there are people who feel inadequate because they recognize that they are inadequate, and hopeless because in fact there is no hope; there are people who don't fit into society because society refuses to accept them; there are people who are perfectly sane and simply aren't knowledgeable enough to think that life isn't what they believe it is (think of all the atheists, who believe that this life is the only one--and they call themselves the rational ones); and there are people who are unhappy because life has stepped all over them.

10.2.1. The mind

But obviously a person is not mentally unhealthy if he can't control his legs because he's crippled, but only if there's something wrong with his mind. But what is the mind, he asked, with another of those questions that have no answer. Oh yes, it does.

DEFINITION: The mind is the ability to be conscious.

It isn't consciousness itself, but whatever it is that makes us capable of being conscious. We are conscious at some times and not others (as when we're fully asleep and not dreaming); and when we regain consciousness, one and the same consciousness takes up where it left off, so to speak, so that we're not subjectively aware that there's been any break (we argue to breaks by external signs). Obviously, there has to be something there during the unconscious period, which can "turn on" again, so that consciousness can resume.

Not to make this into the long story that it should be if you analyzed it carefully, the mind is the brain. When the brain is active in a certain way, you are conscious; when it is inactive or active in other ways, you're not.

Note that the brain is not consciousness; it is a physical part of you which (a) enables consciousness to turn on and off, (b) selects which conscious act you have at any given moment (by which nerves are active), and (c) channels consciousness along various paths, and links it with behavior.

Note also that consciousness ordinarily has a good deal of control over these functions. You can keep yourself awake when you want to, you can fall asleep at a time (more or less) of your choosing; you can concentrate on what you want to concentrate on, and you can keep yourself from doing what you feel like doing if you choose. All within limits, of course.

Now then, the brain (the mind) functions as an extremely complex computer, with the nerves as the "bits" that are either on or off. Each act of every nerve (well, perhaps nerve-complex, and perhaps only certain types of nerve-complexes) has its own form of consciousness associated with it; even the act of the "operating system" itself has its own form of consciousness.

DEFINITION: Emotions are the conscious aspects of the various operations of the mind as it directs consciousness from the stimulus that caused it to behavior.

Mental unhealth, then, consists in a malfunction of these operations of the brain-computer, such that consciousness loses the ability to direct what the mind is doing.

You have "lost your mind"; and since what has got out of control is the mind's "operating system," it's not surprising that mental unhealth is called having an emotional problem. It isn't the emotions you have that are the problem; it's that the emotions are either inappropriate to the situation that caused them, or that they have so much energy to them that either you can't access the information that's there and waiting to be used, or that they take over control of your behavior contrary to your choice. Mental unhealth and immorality

The first issue to straighten out is one that we discussed in Chapter 4: the relation of mental unhealth and moral and immoral choices. Let me expand just a bit on it.

Choices are immoral insofar as you choose to do what you have reason to believe is wrong. Choices imply action: they are consciousness directing the energy-flow in the brain. "Choices" which you have no intention of carrying out aren't choices; they're daydreams. So if you actually carry a choice into action, the action merely confirms that it was a choice and not a daydream.

Now then, if some emotion is so strong as to blind you to the facts when you make a choice, the morality of the choice depends on the facts you actually have in your consciousness, not what you could have known. This should be obvious by now. Similarly, if an emotion is so strong that it's going to cause behavior whether you choose to do the act or not, the morality behind the action depends on whether you were willing to do the act or whether you chose to prevent it but couldn't.

It is this relation of lack of control between the choice and the information or the behavior that constitutes mental unhealth, not either the choice itself nor the information itself nor the behavior itself.

Let me illustrate the permutations of this by an example. Psychologists nowadays no longer say that homosexuals are mentally unhealthy. This is in part true, and in part it isn't.

A homosexual who is in control of himself and who sees nothing wrong with homosexual sex is neither mentally unhealthy nor immoral when he engages in homosexual sex.

In point of fact, the act is morally wrong, because obviously the act of homosexual sexual intercourse contradicts its reproductive dimension (the ejaculation of sperm shows that it has this dimension; but of course this makes no sense in the context of the act). So this homosexual has an intellectual problem, not a moral or emotional one (the same sort of intellectual problem that people have who see nothing wrong with contraception).

He may well also have a social problem which could amount to social unhealth, insofar as the people around him disapprove of his behavior, thinking it (rightly, in this case) morally wrong.

(a) This is society's problem when the disapproval extends to the disapproval of him as a person and people seek him out to "punish him for his perverted behavior," when that behavior is not in fact violating any right of any person (if he's not "recruiting" people into homosexual sex, but only doing it with people who want to), and he's not flaunting his conduct. People tend to disapprove (rightly) of heterosexuals who engage in foreplay in public too. People are not to be persecuted because they don't act according to others' moral standards, as long as no one's rights are violated.

(b) But the problem is his social unhealth if he wants the rest of society to accept his conduct as "equal" to theirs, just because he sees nothing wrong with it.

That is, the homosexual activist, who wants society to recognize homosexual sex as a "different lifestyle" is in fact doing to others what he wants them to stop doing. He is condemning others for thinking that it's wrong for anyone to engage in this activity (which he sees nothing wrong with). But that means that he's condemning them for disagreeing with his moral position on the matter. But clearly, he is disagreeing with their moral position on the matter; and so in condemning them, he's condemning himself. He won't tolerate their moral position, and he wants them to tolerate his. That is, his position is not one of "live and let live," because in fact he wants them to change their moral position of non-acceptance; and so he doesn't accept their position as morally valid, and wants it stopped.

This social dimension of homosexuality applies, mutatis mutandis, to all the variants of homosexuals I mention here.

A homosexual whose homosexuality blocks him from understanding that there is anything wrong with the act is mentally unhealthy, but has no moral problem. Here, he doesn't really have an intellectual problem either, because he's intelligent enough to understand the issue, but his emotional attachment to the act simply won't let him see it.

A homosexual who recognizes that homosexual sex is wrong and chooses not to engage in homosexual sex, and actually doesn't do the acts, is neither mentally unhealthy, nor is he immoral, nor does he have an intellectual problem. He may not be happy, but he's in control.

Now he may have an "emotional problem" in that he's attracted sexually to people he can't actually have sex with, morally. (That's why he's unhappy.) But he's not, strictly speaking, actually mentally unhealthy, because he can control himself. It might be that a psychologist may reorient him sexually (there's a question on whether, for a "true" homosexual, whatever that is, this is possible, but let that ride); but it's not, strictly speaking, curing his unhealth.

I should say that, insofar as he doesn't want to feel the emotion and feels it in spite of himself, he could be said to be mentally unhealthy, given that the tendency the emotion implies is toward a self-contradictory act (and so the tendency is "objectively disordered"). But this isn't mental unhealth in the strict sense, as can be seen from the following: It would be a little difficult for, say, a married man who has lustful urges (that he doesn't act on) toward other women to call himself "mentally unhealthy." Everyone else would call him "perfectly normal."

A homosexual who recognizes the act is wrong and says, "But this is the way I am, and so I'm going to do it anyway," when he could keep himself from having homosexual sex if he wanted to, is being immoral but has no mental unhealth. Indeed, he does not even have a problem with his emotions, because he wants to have them.

A homosexual who recognizes that the act is wrong and doesn't want to do it, and still finds himself doing it, is mentally unhealthy, but has no moral problem.

A homosexual who recognizes that the act is wrong and finds he can't help himself, and then says, "Well, I might as well accept myself for what I am," is both mentally unhealthy and immoral.

The point, of course, is that mental unhealth does not excuse you from being immoral; that depends on what your choice actually is, whether you are in control of the information or your actions or not. Implications for treatment

The case of the homosexual is instructive, because all of the examples given above actually exist, and some of them are mentally unhealthy in the strict sense, some are mentally unhealthy in a treatable sense, and some are not.

First of all,

Psychological treatment may not be given to people who are not mentally unhealthy.

Practically speaking, the treatment won't work, because the person isn't out of control, and so how can you get him back into control? But morally speaking, to treat someone for a "disease" when in fact all that's wrong with him is that he's doing something that "normal people don't do" is a morally wrong interference with a person's choosing his own goals: his own "lifestyle." It contradicts the essence of humanity.

Thus, it would be wrong to treat (as was done in the past) the "mental unhealth" of homosexuals who see nothing wrong with homosexual sex, or who don't care that it's wrong and want to do it. You can't hide behind, "They must be crazy, or they wouldn't want to do such a thing." They are in control.

By the same token,

Treatment must not be refused to those who are mentally unhealthy and want to be treated.

The exact opposite of what I just mentioned is being perpetrated on homosexuals now, in many cases. Since homosexuality is not any longer considered mental unhealth, some psychologists will actually resist allowing homosexuals who want to get rid of their orientation, or stop performing acts they don't want to perform, to receive treatment. "It's not a disorder; don't treat it." Well in this case it is mental unhealth; as much mental unhealth as the person who wants to be able to go into dark rooms and can't make himself do so.

The third point we can learn from the above discussion is this:

If the mental health of a person leads him toward behavior that is morally wrong, his treatment must not consist in getting himself to accept himself for what he is, in the sense of being willing to behave in the way in question.

This is another sin against homosexuals who are at war within themselves and go for psychological treatment. Very often the "treatment" has as its goal "coming to terms with yourself" and recognizing that this is the kind of person you are, and not feeling guilty when you act according to your nature.

Much, for instance, is made of any shred of evidence that homosexual tendencies are "innate," as if this made any moral difference. Actually, the jury is still out on this issue (if it ever will be in); but in fact it makes absolutely no difference whether you got your orientation from your genes or your early environment, or whatever. The fact is that it is a tendency to do what (in one respect) contradicts itself; and so it is "unnatural" in the moral sense, whatever it is in the biological sense.

That is, there are people who are genetically blind, genetically lame, genetically stupid. Suppose the genetically blind person's blindness could be cured, is the fact that it's genetic a reason you shouldn't cure him? That he should "accept himself for what he is, and rejoice in the way he goes around bumping into things"? He has to accept himself as blind, to be sure, but he certainly doesn't have to be satisfied with it, still less embrace it.

The homosexual is a sexual cripple, however he got that way. This is not to denigrate him, any more than it is denigrating the blind person to say that he's handicapped. And the homosexual has to accept the fact that he's homosexual (at least temporarily, if his orientation can actually be changed), but he must never be satisfied with the behavior that the tendency leads toward.

Put it this way: Suppose Jeffrey Dahmer's psychological need to cut people in pieces and have sex with the parts were genetic. Therefore, he should be counseled to accept himself and not feel guilty about his behavior?

Getting rid of guilt feelings can be a goal of psychological treatment only when there's nothing to be guilty about.

If the person is doing things that make him guilty, then obviously he ought to feel guilty. Too much of what goes on in our culture consists in the following reasoning:

I am doing something evil, and I feel guilty about it.

I don't like to feel guilty about what I am doing.

Therefore, I will define it as all right, and persuade myself (or psychologize myself) out of my guilt feelings.

And there are too many psychologists, infected with the theory that guilt is just guilt feelings, who are too ready to do too much of this to too many, for too great a fee.

Now then, one final point, before we go on to psychological methods:

A person whose mental health consists in inability to access information may sometimes be treated against his will.

The reason is, of course, that he doesn't (because he can't) have access to the information he can base a rational choice on. You can break down the barrier that is keeping information from his consciousness even if he doesn't want you to, using the Double Effect.

But here, you have to have reason to believe (a) that he actually is unaware of the relevant information; (b) that he's doing what he would not want to do if he had it; and (c) that he would want you to force the information upon him.

You have to be careful of this, because as I said, it's very easy to say of someone, "He must be crazy if he wants to do this kind of thing; he must not know what he's doing."

For instance, as I wrote the above, there was speculation that the person who bombed Centennial Olympic Park in Atlanta was the security guard who "discovered" the knapsack containing the bomb, and who saved many people from the blast. It seems as I now write that there isn't yet any evidence that he's actually the one. I certainly don't want, by this example, to imply that I think him guilty of the crime, or even that he's the type of person I'm going to describe. But to illustrate what I am saying here, let us suppose that the person who planted the bomb was a security guard who wanted the glory of being the one who rescued hundreds of people from a horrible death.

One would certainly think that a person who would set a bomb to blow up a place so that he could be a hero as he rescued people from being hurt, has to have no unavailability of loose screws that he could stuff the bomb with. So in all probability he's mentally unhealthy, and just pictured himself saving all those people and didn't really consider that he was the one who was blowing them up and that he might not save all of them and that he'd probably get caught and be even more despised and go to jail and all the rest of it--he probably had this heroic picture and "I'll show them!" so strong in his mind that it blocked out everything else.

But it's also possible that he realized the implications of what he was doing, and so did have access to the relevant information, and was or was not in control of carrying out the plot (in which case he either wasn't mentally unhealthy at all, and was simply depraved, or was mentally unhealthy in the behavioral but not informational sense).

In the first case, he could be treated against his will; in the second, he could be treated only if he wanted treatment.

(In any case, by the way, supposing the actual guard to have done the act, we must pray for him and help him; but we have to be protected from him and everyone else like him.)

10.2.2. Methods of treatment

A few remarks are in order about the moral implications of certain types of psychological treatment.

Treatment can be divided into two categories: psychophysical treatment, such as surgery, drugs, and the borderline cases of narcotherapy and hypnotherapy; then purely psychological methods of what is now called "counseling" or just "therapy."

As far as psychophysical methods of treatment are concerned,

Surgery, drugs, or shock treatments are morally legitimate, subject to the rules of the Double Effect.

Many of these things have serious, even drastic side-effects; and obviously if they do, then the harm that is to be avoided has to be that much greater. In all cases, you are fooling around with the brain, analogously to tinkering with the motherboard on your computer; and any time you do that, you had better know very well what you are doing, because tiny changes can produce enormous effects.

In my own case, for instance, I was in the experiment testing the antidepressant I took regularly for several years afterwards; and I discovered that as the dosage was increased, the depression was removed--up to a point. After that, a tiny increase brought the depression back with a vengeance. And at that point I was only at about a quarter of the normal dosage. An unwary psychiatrist, not knowing how sensitive his patient is, might prescribe the normal dose, and find that his patient has killed himself in despair.

This caution goes double for things like hypnotherapy, in which the doctor (by his words) takes over control of the "operating system" of the brain (what I in Living Bodies call the "instinct"), giving him a control over it that the person does not consciously have himself. The trouble is that if you try to treat someone this way, you might wind up by hypnotic suggestion "rewriting" part of the program of the brain; and when the person gets back into the real world, this might clash with something else he has there, making the last state worse than the first.

I heard a story (which may be apocryphal) about a man who quit smoking by being told under hypnosis that he couldn't stand it. It turned out that the reason he was smoking in the first place was that it was being used as an escape from his hatred for his wife--whom he then killed.

I may be going out on a limb in saying this, but many if not most psychological problems are a way of coping with a fear of one sort or another (at least, that's Freud's view): of avoiding something that you just can't stand to experience again. When the avoidance involves undesirable behavior, it is not necessarily desirable simply to correct the behavior.

Obviously, I'm not breaking any new ground here. The point is that you can use these things, but you have to know what you're doing, and you still have to be extremely careful, or you can be doing more damage than you're correcting.

As to psychological methods, the Freudian approach basically is that the brain has created a series of shunts around the horrible experience, which generally happened when very young; and so the behavior is a way of keeping it out of consciousness. His idea was that if you could get to reexperience it now in your adulthood, when you know that such things aren't the end of the world, you might be able to cope with it. You can't just be told (or know intellectually) what it was; you have to be able to get back "into" it, the way you get "into" a movie, and go through it emotionally again--which, of course, is the thing you're terrified of doing. If you can manage it, then you've broken down the barrier into that area of the brain, and can gradually get to use it again.

The approach itself is perfectly legitimate, and the therapy, though often extremely lengthy, is apt to work. The moral problem with this approach is that it could create a false conscience in a person, and leave him thinking that because his problem is psychological, particularly if it involves guilt, then guilt is just a feeling that can be psychoanalyzed out of you. But there is objective as well as subjective guilt, as I think I've shown in these pages.

Behavior modification, the other major theory of treatment, is not concerned with discovering the source of the mental unhealth; it takes the undesirable behavior and treats it like a bad habit that you can be trained out of. Situations with only a very few of the characteristics that trigger the behavior are introduced and you learn to cope with them; and as you learn, more and more of the characteristics are brought in until finally, you don't have any problem behaving the way you want in the original situation.

You don't necessarily need a therapist to guide you through this. If you find yourself trapped into undesirable behavior in certain situations, there's nothing to prevent you from devising your own pattern of gradual behavior modification, and taking step by step at your own pace. It's tough, but basically that's what we do whenever we want to get rid of a bad habit or acquire a good one.

Again, this method tends to work, and there's nothing morally wrong with it in itself. Its moral problem would come when the retraining would take the form of doing something morally wrong. The fact that you're trying to get out of a psychological difficulty is no excuse for deliberately doing something wrong as a means to get out of it.

I am a terrible subject of psychotherapy. At one time, I began by telling the therapist, "You're the psychological expert, and I'll do what you tell me, if I can. But I'm the moral expert, and I decide whether something is right or wrong, and if I think it's wrong, I won't do it." He said, "But that's going to tie my hands. Do you think I'd tell you to do wrong?" I said, "Maybe not what you think is wrong; but I know what's wrong. So that's the way it's going to be." He looked at me strangely, probably for daring to think that there was any right or wrong that you could know.

The last method I want to mention, group therapy, is extremely dangerous. Putting psychologically vulnerable people together and getting them to "be honest with the way they feel"--particularly about each other--can be absolutely devastating to them. No matter how much good it may do for a person to get his feelings for another out into the open, and no matter how much you might insist that these are "just feelings and not facts," it can be completely shattering to find out that someone you thought loved you and had high regard for you actually holds you in contempt. It takes a very strong psyche to be able to withstand that kind of assault; and very strong psyches are precisely what you don't have here.

I have heard from psychiatrists I respect that these things can do a great deal of good; but from my experience with them and just on common-sense grounds, my impression is that the Double Effect would not allow them. I would have to be thoroughly convinced that the dangers I see (and the terrible effects I have seen) do not occur before I would think that they could morally be allowed. One person's mental health is not to be sacrificed to another's.


There is a morally dangerous attitude underlying a good deal of psychotherapy: that we are not free, and that we are simply to be altered into behaving "acceptably," the way animals are trained.

Granted, the definition of "acceptable" behavior is generally left to the patient. But a patient, especially a vulnerable one, is not an animal to be retrained or a lump of clay to be remolded; he is a free individual, who isn't trying to get changed, but to get back into control, so that his choices once again govern his behavior.

10.3. The researcher

Strictly speaking, of course, a person engaged in medical or biological research is not a health-care provider; but he's in the health-care field, and his research leads to methods of health-care delivery.

I have already spoken of using people in experiments, in section 7.4.1. They have to know that they are in an experiment, and what risks they run in being in it, and so on, so that they can make rational choices of whether to run the risks. They have to receive standard treatment if they are in control groups, and no harm may be done to them in order to achieve the goal of the research.

But there is one "hot topic" that hasn't been treated: that of genetic engineering. Is it morally acceptable to fool around with the genes of any living thing? If so, can you morally fool around with human genes in the name of curing genetic defects, and so on?

First of all,

There is nothing morally wrong in itself with changing the genetic structure of a living organism. We do that every time we breed organisms--indeed, every time we have sex and have offspring ourselves. So the mere fact of creating an organism which has a genetic structure different from any other organism is morally acceptable.

True, this genetic manipulation is happening in the laboratory and not by grafting or breeding two different strains of the species; but in principle it's the same thing. So, certainly in the case of other organisms, there is no moral problem with genetic engineering in itself.

There is a danger in engineering the genes of microorganisms such as bacteria or viruses, however. A strain toxic to the organisms (including the human ones) could be produced, and if it gets out into the world, it could cause incalculable and unstoppable harm. Insofar as there is any real reason for thinking this might actually happen, the Double Effect would not allow it.

The reason, of course, is that this "Andromeda strain" could produce such destruction that the harm would vastly outweigh any benefit from the newly created beneficial organisms. Hence, unless there are safeguards such that (to those who know what the objective situation really is) there is no reasonable doubt at all that this could occur, it is immoral to choose to perform such experiments.

Let us suppose that there are such safeguards. True, if there's no reasonable doubt and you happen to be mistaken, then we're all doomed. But then, if an asteroid hits us, we're doomed. If some crazed bomber gets hold of some nuclear weapons and starts flinging them around, we're doomed. If the world warms up ten degrees or cools down ten degrees (which might happen if twenty volcanoes of a certain magnitude erupted in a year), we're doomed.

"Unless the Lord guards the city, it is a waste of time for the guards to stay awake." There is no way we can be safe. So it is perfectly moral to pursue these researches even if there is the theoretical possibility that we'll be bringing the Apocalypse upon us. Ultimately, the Lord is running the universe, and all he asks is that we be reasonable.

There is, however, one thing that is being done that must be stopped:

The practice of patenting of genetically engineered material, with the enormous economic rewards to be gained from the monopoly over the new organism, creates a morally unacceptable incentive to be careless in the race to be the first to get in the patent application. The law allowing patenting of these things must be rescinded--and as soon as possible.

It's just too much to ask of human nature for people to take all the necessary time to be meticulously careful if they know that someone else is on their heels in developing a certain useful new organism. It's a recipe for sloppy work. That's a real danger, no less real than the danger of getting lung cancer from smoking.

But now what about human genes? First of all, there is nothing wrong with studying and mapping the human genetic structure, so that we can know where genetic defects lie.

But this knowledge must not be exploited to the harm of anyone.

That is, finding out whether a fetus has a genetic defect so that he can be killed (pardon, aborted) is clearly morally wrong because the motive is evil. But also, if a person is known to have a genetic defect which will result in some serious disease twenty years from now, this knowledge cannot be used to deny him insurance; which would mean that he is to be harmed (denied treatment) because of the defect. This is also morally wrong.

But of course, if you have this knowledge, then steps might be able to be taken to head off the sickness (or even correct the genetic defect); and so the knowledge in itself is not an evil thing.

I will also go out on a rather thin limb and say:

There is nothing wrong with altering or manipulating human genes in such a way that the body's structure can be changed, as long as this does not involve doing harm to any human being.

What I mean is (a) you can't use human fertilized eggs or embryos for this purpose, because there are bound to be risks involved, and these human beings can't give their consent. You can use unfertilized eggs or sperm, because, of course, they aren't human beings.

I think the theory as it now stands is that it might be possible to put an altered human chromosome into a virus in such a way that when the virus is injected into a person with a chromosome with a defective gene on it, the virus will induce the cells to replicate themselves using the altered gene instead of the defective one.

For instance, if you could get a normal chromosome in a virus and infect someone who had sickle-cell anemia, then it might be that the infection would replace the defective chromosome, and the person's body would then produce normal blood cells.

Certainly, the effect of such experimentation is very good. The experimentation itself does not necessarily involve anything inconsistent (as I say, when two people have sex, they are "genetically engineering" the baby); the motive is not to create human mutants or monsters, but just the opposite, and so everything seems in place for the Double Effect.

The moral caution here is to be sure that the experiments leading up to the good results do not result in harm greater than the benefits to be envisioned--and that the persons running the risk of possible harm know what they are doing and are willing to undergo it.

--I could go on and speak of issues dealing with hospitals and veterinarians as well as unconventional treatments such as acupuncture; but I already mentioned in passing the main moral concerns here (e.g., the obligation of hospitals to cut down inefficiency and waste), and this book is too long as it is. So let this be the end of my pronouncements on ethical considerations in the field of health-care delivery.

Summary of Chapter 10

There are issues mainly of interest to other providers than physicians. A nurse is an assistant to another health-care provider. An assistant is under the authority of someone else, and authority is the right to issue commands, which are statements that have sanctions attached to them; a sanction is the threat of punishment if you don't do what you're told. People put themselves under authority when certain goals can only be achieved if many people cooperate; cooperation implies authority and sanctions.

A command that exceeds or contradicts the authority of the commander is null. It is immoral if it commands you to do what (your conscience says) is morally wrong, and unjust if the act is not morally wrong, but the authority has no right to tell you to do it. You must disobey any immoral command; but you may obey an unjust command if the effects of disobeying are worse than the effects of obeying. If you disobey, you must consult with the commander and give him your reasons. In the case of doubt whether the act commanded is morally wrong, the benefit of the doubt goes to the commander, and so the morally safest course is to obey.

If a command is not immoral or unjust, but simply unwise, you must inform the commander of your reasons for thinking so, in case he doesn't know the information; then if he issues the command anyway, you must obey. If you know he is prone to issue stupid commands, then you have an obligation to let his superior (if any) know, so that corrective steps can be taken.

You may disobey the letter of a command when you are obeying what is clearly meant by it; but you must be careful not to "interpret" commands to suit your own ideas, since this contradicts you as under authority. You may disobey if the situation changes, and it is clear that the commander would have rescinded the order. You must not act on your own while under orders, except (a) when the Double Effect applies, or (b) in minor, everyday duties that the commander assumes you know enough to do. You must speak and think well of your commander, insofar as it is possible consistent with the truth, because it is hard to obey when you despise the commander.

An expert assistant (e.g. an anesthesiologist) is really someone whose services are engaged; and so the commander can't really tell him what to do in his own field.

An assistant is not morally responsible for what he does in obeying legitimate commands, even stupid ones (if he has informed the commander), since he cannot morally disobey. He is responsible for: (he has moral control over) (a) any act of disobedience, even when he morally must disobey, (b) any obedience to a foolish command if he has not informed the commander, (c) any obedience to an immoral or unjust command, (d) any act not explicitly commanded, but by way of interpreting what the commander would want done, and (e) any harm that comes from thinking or speaking badly of the commander.

You cannot assist any person or group that violates the rights of another; thus, you cannot morally work in any capacity for an abortionist or in a hospital that performs abortions. This would be to facilitate (even indirectly) the injustice of killing someone. You cannot be simply neutral in such a matter. You cannot morally assist a person who makes as his main business services that are morally wrong, even if no one's rights are violated; but you may morally assist a person who occasionally does morally wrong procedures of this nature, as long as you don't help in the procedure itself, which would be being willing that the procedure be done. In an emergency, the Double Effect would allow assisting in the actual act. If someone wants something morally wrong (such as advice on contraceptives), you may not give it, nor may you direct him to somewhere where he can get it. To do so would be to be willing that the wrong act be done. You do not need to try to persuade him out of it, however (unless it involves a violation of someone's right, as an abortion). The fact that some of these things are legal is irrelevant; if the person has a legal "right to know" about them, he has no right to know from you.

The psychologist treats mental unhealth. This is the lack of conscious control over one's information or actions, not bizarre behavior or feeling bad. The mind is the ability to be conscious, and this is the brain; it is not consciousness, but what shuts consciousness on and off and what controls the flow of consciousness (when the consciousness is not controlling itself by controlling the brain). The brain acts like a complex computer, and emotions are the conscious aspect of its "operating system" at work. Thus, mental unhealth is a malfunction of the operating of the computer, and it shows up as an emotional problem.

Mental unhealth occurs when, because of a brain malfunction, consciousness either cannot access information that should be available to it, or cannot direct behavior. If the person does what is wrong and does not know it but, whatever his emotional state, is in control of himself, he has an intellectual problem, not a moral or mental one; if his lack of knowledge is due to inability to access information, he is mentally unhealthy, but not immoral. If he knows what is wrong but doesn't care, he is immoral, but not mentally unhealthy. If he knows it is wrong and can't help doing it and tries not to and fails, he is mentally unhealthy and not immoral; if in this situation, het "accepts himself" and is satisfied with doing it, he is both mentally unhealthy and immoral. All these combinations are possible.

Psychological treatment may not morally be given to people who are not mentally unhealthy, whatever their behavior may be, because this infringes on their control of themselves. Treatment may not be refused to those who are mentally unhealthy and want it. When treating someone whose unhealth leads him to morally wrong acts, the treatment must not consist in getting him to "accept himself" and think he is not guilty doing the acts. Feelings do not determine rightness or wrongness, and you can never be willing to do wrong. Ridding yourself of guilt feelings can be a goal of treatment only when there's nothing to be guilty about. A person whose mental unhealth consists in inability to access information may be treated against his will, if it is clear that this is what he would want if he could know the facts. But one must be careful in not "reading into" the situation.

As to methods of psychotherapy, psychophysical methods are morally acceptable, even drastic ones, when the Double Effect applies and the harm done is less than the harm avoided. Psychoanalysis is legitimate if it does not create the false conscience of thinking that because you are acting due to a psychological problem, this fact allows you to be willing to do wrong acts. Behavior modification is legitimate if the retraining process doesn't involve doing something morally wrong to get yourself out of the undesirable behavior. Group therapy, involving people with fragile psyches "getting things off their chest" about each other, is extremely dangerous, and may very well not be allowed by the Double Effect, because the harm can be very great. In general, the attitude that people are like animals to be trained, and whose behavior can be externally controlled and molded, is a morally wrong attitude. The object is not to change the person's behavior, but to get him in control of it.

The main problem of research not discussed is genetic engineering. This in itself is not morally wrong, since organisms naturally "engineer genes" every time they have sex. But there are dangers, which morally must be provided for. If there is any reason to believe that manipulation of genes might produce a toxic organism that could escape into the environment, the research must not be done; but there must be a real reason to believe that this actually can happen, not the mere theoretical possibility that it might. But since patenting such altered organisms encourages carelessness in the race to be first because of huge sums to be gained, this practice must stop. Even human genes may be altered, as long as no human being, such as a fertilized egg or embryo, is harmed, and those in the experiments know the risks and are willing to run them. Any genetic defects discovered by genetic mapping must not be used against a person.

Exercises and questions for discussion

1. Should communications between nurses and patients be privileged? Can a nurse morally keep information from the doctor?

2. May nurses form unions to see to their interests? Discuss the moral implications of this.

3. If patients are being treated by an incompetent doctor, and the nurse has told the administration to no avail, may she inform the patients that the doctor is incompetent and that they should find someone else?

4. If a psychologist sees that the treatment is not getting anywhere, should he tell the patient and let him go, or keep him in the hopes of a breakthrough later?

5. A judge has sentenced a homosexual caught violating the vice law to treatment. He tells you that he is only there because he was ordered to be, and has no interest in being "cured." But if you do not treat him, he will go to jail. What do you do?

6. A clearly psychotic patient protests violently against being sent to a mental hospital, which can help him. You see that his relatives want him sent there to get rid of him and for various selfish reasons. Should you have him committed anyway against his will?