Our People

'From good doctor to Dr Evil: when should a doctor cooperate in evil?'

University of Sydney Catholic Chaplaincy

By Most Rev. Anthony Fisher OP
Auxiliary Bishop of Sydney
17/8/2007

1. What is cooperation in evil?
To modern ears talk of ‘co-operation in evil’ may sound rather sinister and abstract. In fact, I would suggest, it is a much more everyday problem for healthcare professionals than are the headline gabbers such as cloning. Let me begin with an ostensive definition. Over the years I have done a lot of talking at bioethics conferences, nursing colleges and so on. Commonly, I am approached after my lecture by someone, especially a young doctor or a nurse. They will have a hard question which is troubling them. It will be something like: “I would never do an abortion. But I am part of a team or an institution that mostly does good work, but that sometimes does unethical things like abortion. How involved can I be before I am really part of the problem? Can I prep the patient or assist in the surgery or give aftercare?” The list can go on and on, and often does....

Notice a few things about this situation. First, this is a hard question. There does not seem to be a single, simple, black or white answer — even for someone with sound moral principles and a respect for moral absolutes (such as never directly killing the innocent). The person posing the question accepts that certain things like abortion, sterilization, and violent or exploitative medicine of any kind, are out of bounds, or at least very morally troublesome.

Secondly, the context is some kind of co-operative venture, some kind of team-work. This is essential to community and to any human life. We live and work with others, for particular projects and for the common good, in relationships of equals, or of authority and obedience, each person making a distinct and appropriate contribution in pursuit of common ends. Difficulties regarding co-operation often arise because one is asked or expected to help family, friends, employers, fellow-workers, government or others toward whom one already has duties, a history and a future of relationship.

Thirdly, though co-operating in the project, the agent in question is not the one most directly involved, conceiving, instigating, directing, co-ordinating and actually engineering the operation or whatever. Rather he or she is in a secondary or subordinate rôle to the principal agent(s) and contributes something which facilitates the wrongdoing of the principal agent(s). What he wants to know is how close he can properly get to taking part, without becoming, as it were, an accessory, a conspirator. How involved can she be without becoming tainted by it?

Fourthly, the work of the person in question, and the team of which he or she is part, is in general good work. It is not the gas chamber of a concentration camp, or a clinic devoted to killing unborn babies. No, it is a hospital or medical practice or course of medical study which engages in all sorts of medical procedures, most of them good, but some of them morally dubious.

When should I co-operate with someone who is doing something wrong? The simplest answer would be: never. As the Scriptures exhort me, I should maintain ‘clean hands and a pure heart’; I should ‘scorn the company of evil-doers’ and never take part in their wickedness. I should set a good example. So it is that some people went to the death camps rather than collaborate in any way with the Nazis. And some people have quit jobs in particular healthcare institutions or even left the profession, rather than have anything to do with some practice which they cannot condone. Others have taken a courageous stand in some other way, perhaps at great cost to their relationships with fellow health professionals or to their career path. These people are either martyrs or fanatics. Those who are martyrs deserve our admiration and respect. But not everyone is called to be a martyr, or at least not all the time. And none of us is called to be a fanatic.

Paradoxical as it sounds, God and his saints and all those who live ‘in the world’ must, in fact, cooperate with evil from time to time; sometimes it is their duty to do so. Even Christ’s little band paid taxes some of which were predictably used for wicked purposes by the government of the day. Despite his entreaties, when Jesus cured the sick some of them went on to sin some more and so in a sense he was complicit in that. After repeatedly evading his persecutors, Christ eventually allowed himself to be arrested, thereby occasioning his false trial and terrible execution. Almost anything we do, no matter how good it is in itself, can be an occasion, opportunity or means for someone else to do something wrong. To avoid all cooperation in evil would require that we abandon almost all arenas of human activity – such as family, workplace, government, health system, Church – and could well constitute a sin of omission.

Reflection upon cooperation in evil begins, therefore, with some commonplace human experiences:

• we are all involved in webs of relationships which enable people (including ourselves and others) to achieve both their good ends and bad ends whether by good means or bad means; in this context our actions inevitably affect others
• which ends and means those other people choose are often beyond our control or influence
• sometimes we choose to involve ourselves in other people’s bad ends or means, by seduction or conspiracy or deliberate cooperation in that evil, making at least part of their bad willing our own;
• at other times we make no such choice, but the otherwise good things that we do foreseeably assist others to achieve their bad purposes;
• this is an example of an act with a double effect – one good and intended; the other bad, not intended but foreseen – and so the principles of cooperation are really expressions of the principle of double effect;
• accepting the bad “side-effects” of cooperation has implications for those who perform the act of cooperation, those who are assisted by it in performing their evil act, and other parties who may be affected; it is sometimes reasonable and sometimes unreasonable to engage in an act foreseeing and permitting such side-effects; and so
• people in this situation must decide whether to go ahead with their contemplated action despite its connection with the morally objectionable action of another, or alter their plans, thereby possibly foregoing achieving whatever good they had proposed.

2. Some traditional distinctions and examples
I will not rehearse the history, similarities and differences between different expositions of the principles of cooperation in the Catholic moral-theological tradition or in the broader tradition of Hippocratic and other bioethics. Suffice it to say that by cooperation in evil traditional authors meant performing an act which in some way assists the evil activity of another agent. This could be either by act or omission, it may be a major or a minor contribution to the principal agent’s wrongdoing, it may be more or less indispensable, and the cooperator may or may not be under considerable pressure to take part.

Some authors distinguished immediate from mediate material cooperation on the basis of the degree to which the cooperator’s act forms part of or physically overlaps with or is essential to the act of the principal agent, as opposed to being merely an occasion of or assistance to it. Some distinguished proximate from remote material cooperation on the basis of how closely the cooperator’s action “joined” or “touched” upon the principal’s action, geographically, temporally or causally.

But the most important distinction traditionally made was that between formal and material cooperation. Formal cooperation is where the cooperator not only does something that foreseeably helps the principal agent do wrong, but the cooperator does so while sharing in the wrongfulness of the principal agent’s act — his/her wrongful end or intention or will. Material cooperation, on the other hand, foreseeably helps the principal agent do wrong, but the cooperator honestly does not want to help that wrongful act to occur.

Lets look at a few examples of formal cooperation and material cooperation in evil found in traditional Catholic bioethics books. Examples of formal and therefore forbidden cooperation included:

• a doctor or nurse assists in an illicit procedure such as an abortion or sterilisation, physically supporting every step of the principal surgeon, performing an essential part of the procedure and/or being ready to take over in case of necessity;
• a person volunteers his/her services to an abortion clinic, helping people fill out forms in order to help women seeking abortions to get them;
• a hospital administrator decides that the obstetrics department will offer sterilization and sees to it that all patients about to be sterilized fulfil the usual consent requirements;
• a physician or counsellor refers someone for abortion;
• an agency (e.g. the army, a prison) distributes or disseminates contraceptives;
• a counsellor encourages a person to engage in non-marital sexual activity or to take illicit drugs in the hope that this will lead to the client’s psychological growth, or to engage in contraception, sterilization or abortion because this is “the lesser evil”.
  Amongst the examples of what some traditional authors regarded as permitted material cooperation were:
• a physician gives merely passive assistance at the preliminary instruction and preparation for an illicit operation, remaining aloof from every appearance of approval of the procedure;
• an intern or nurse in an operating room performs the usual duties, such as the preparation of instruments, drugs and patients, but sometimes finds him/herself caught up in immoral procedures;
• an assistant likewise administers anaesthesia or hands over instruments during an immoral operation, if this is an accidental and quite exceptional part of the cooperator’s routine work and there is a risk to the patient or to the assistant’s employment if the assistant refuses;
• an engineer keeps utilities working in a hospital where abortions are done, only to make a living and further the other good activities carried out there;
• a doctor or agency distributes medicine for healing a sexually transmitted disease, taking care that this is no inducement or invitation to engage in a sinful practice;
• a company manufactures a drug or device which has good uses but which the company knows some people will abuse;
• a legislator who, having tried and failed to exclude abortion funding from a general appropriation bill, then votes for the bill only to bring about the good things it will fund.

3. All formal cooperation in evil is unethical
Let us examine formal co-operation in evil a little more closely. Sometimes cooperators clearly share in some or all of the principal agent’s bad purposes or ill-will, and then it will be a clear cut case. At other times, the cooperator might deny he or she shares in the principal agent’s object, but no other explanation suffices to distinguish the cooperator’s object from the principal’s. Sometimes the cooperator wants the same wrongful object that the principal agent wants; in this case, the cooperator’s proposal, what he chooses to do, includes something (and perhaps everything) objectively wrong in the principal agent’s action. An example would be when a pro-abortion health professional takes a job in an abortion clinic in order to help women seeking abortions to get them. At other times, the cooperator might say he or she does not share in the principal agent’s goals precisely, but there are an essential means to the cooperator successfully carrying out his or her own project. An example would be someone who owns and operates abortion clinics for profit. In all these cases the cooperator is engaging in formal cooperation in evil and this is always unethical: he or she is choosing against the good and acting unreasonably. And this is so, as in the rest of the moral life, even if one could achieve some great good by acting unethically.

The moral theologian Germain Grisez points out that sometimes people formally cooperate in things they don’t like or agree with themselves. A hospital administrator, for instance, might say she does not like or approve of sterilization. But, for whatever reason, she decides that her obstetrics department will offer this ‘service’ and she sees to it that all patients about to be sterilized fulfil the usual informed consent requirements. In doing so, Grisez argues, the administrator formally co-operates with immoral sterilization and may well be more guilty of what occurs that those ‘on the ground’ who are reluctantly assisting in the procedure.

We might note a few points about formal co-operation here. First, it is very much a matter of what one chooses, what one makes one’s own purposes or means to those purposes, and thus what one makes oneself. The self-creative effects of choices, which are central to the whole moral life, are crucial here: what is what I am doing making me and what is it saying about me?

Secondly, even a person who finds the whole business repugnant, disapproves of it, tries to dissuade people from getting involved in it, can nonetheless choose to co-operate formally and in such a case he or she engages in an unethical act.

Thirdly, the claim that one does not approve of the procedure oneself, but that one wants to respect the consciences of others who think it is OK, is no justification for acting untruly with respect to one’s own conscience. Neither is the cooperator’s claim that he or she was simply doing as he was told an excuse.

4. Material cooperation in evil is sometimes OK
There are lots of good reasons to cooperate materially in any particular evil. While the principal agent may have an evil object, the cooperator may very well have a good one in mind, and that good object is a reason to do what the cooperator is planning. There may also be various good spin-offs, such as keeping one’s position and the opportunity it brings to do other good things; income to support a reasonable life-style for oneself and one’s dependents; friendship with the others with whom one works; and so on. So, when considering whether to engage in an action which has the foreseeable effect of assisting someone else’s wrongful purposes, we must ask ourselves: how important are the benefits expected from this action, how probable, how lasting, how extensive and for whom? What kind of loss or harm would result (and how serious, and for whom…) from foregoing this proposed action? If there are real and important and lasting benefits I may well have a strong reason to go ahead with my action even if I foresee that it will materially help someone else to do wrong.

On the other hand, there may be strong reasons not to cooperate. I must ask myself honestly how grave (and probable, lasting, extensive, preventable…) is the evil of the principal agent’s act which I will, however unintentionally, be helping. How grave (and probable etc.) will the harm be to the principal agent, e.g. by helping and even apparently encouraging him/her to engage in a wrongful act and possibly further wrongful acts, with all the moral and spiritual consequences of that for the principal agent? How grave (and probable etc.) will the harm be to third parties, especially the innocent, e.g. by assisting the principal agent to do something which damages third parties or their interests, or gives others the impression that the cooperator approves? How grave (and probable etc.) will the harm be to the cooperator him/herself, e.g. by inclining the cooperator to do similar acts in the future and worse or by gradually corrupting him/her or by compromising the cooperator’s ability to give witness to true values? How hard would it be to protest the evil and/or to avoid or minimize scandal? How easy would be for the principal agent to proceed without the cooperator’s involvement?

These are the sorts of considerations we must have in mind if we are contemplating doing something that materially cooperates in another person’s evil. There is no simple calculus to be applied here, but obviously the graver the evil at issue or the that will predictably result to those affected, the stronger the reason would have to be to take such a course. After prudent reasoning and discernment, two people of good will and right reason might come to a different judgment.

5. Different worldviews
Disagreements about the application of the principles of cooperation may serve to highlight a difference in moral worldview. For some people observing the moral law is the way to true freedom and authentic happiness. For them there are some clear moral absolutes, such as that against formal cooperation, which cannot be compromised even to achieve some great good. Morality on this account is part of the vocation to human perfection or holiness under grace, and the presumption is against cooperating even materially, unless there is a sufficiently strong reason to warrant proceeding.

At the opposite poll are those who like “tax-lawyers” view the moral law not as a map to human freedom and happiness but rather as a series of constraints on human freedom and happiness. Real happiness is about getting our own way, fulfilling our preferences, and going with the flow, being socially acceptable; conversion and self-sacrifice have little place here. On this view we should sail as close to the wind as possible, avoiding doing really bad things unless there are great benefits to be gained, but not be over-scrupulous about things like material cooperation in other people’s evil actions.

I do not mean to suggest that there are the only two moral worldviews or that everyone (or anyone) fits neatly and clearly into one or the other. Rather I am suggesting that two polarities are particularly evident when people ask whether they should cooperate in evil and help to explain why they might come to such different conclusions.

6. Why it matters
I want to conclude this paper tonight by suggesting three reasons why the question of the permissibility of cooperation in evil matters so much and why one would be reluctant to engage in even material cooperation in serious evil unless there were very persuasive reasons to do so.

First, we must love the Lord our God with all our minds and wills. The goal of human life is the pursuit of holiness – becoming lights to the world, images and likenesses of God, more and more conformed to Christ, living stones of God’s house, temples of his Holy Spirit, perfect like our Heavenly Father. We should become Gospels in which people can read God’s story. As John Paul II wrote in Veritatis splendor:
The new evangelization will show its authenticity and unleash all its missionary force when it is carried out through the gift not only of the word proclaimed but also of the word lived. In particular, the life of holiness which is resplendent in so many members of the People of God, humble and often unseen, constitutes the simplest and most attractive way to perceive at once the beauty of truth, the liberating force of God’s love, and the value of unconditional fidelity to all the demands of the Lord’s law, even in the most difficult situations. For this reason, the Church, as a wise teacher of morality, has always invited believers to seek and to find in the Saints, and above all in the Virgin Mother of God “full of grace” and “all-holy”, the model, the strength and the joy needed to live a life in accordance with God’s commandments and the Beatitudes of the Gospel… The life of holiness thus brings to full expression and effectiveness the threefold mission of every Christian to be priest, prophet and king…

Yet so often we don’t even try to pursue such a lofty goal. Instead of offering a distinctively Christian form of witness to the life of God’s kingdom, even to the point of martyrdom, we settle for more comfortable collaboration with the fashions of the age, the current mores, the expectations of others, whatever is easiest for us. As Paul puts it so graphically, rather than lifting up Christ and his Church up to God we take them down into the bed of the prostitute. In so doing we damage our relationship with God, making God a cooperator in evil, for it is only by God’s power that we are supported in being and by God’s permissive will that we are free to do what ill we do. We also compromise our ability to give witness to the true and the good as alteri Christi, and so undermine the progress of the Gospel. A keen sense of the privilege that it is to be apostles and prophets, saints and even martyrs, and a deep commitment to the new evangelisation, will give us a greater sensitivity to the issues of cooperation in evil than any purely secular account which sees the principles of cooperation as, at best, useful action guides and, at worst, hindrances to human freedom and happiness. In this respect, believers will have additional reasons to care deeply about this matters.

In addition to and as an expression of whole-hearted love of God we must love our neighbours. This is a large part of the reason for the presumption against material cooperation in evil. Out of love of our neighbours we desire to help them and to help them do good. We need a very serious reason indeed to do anything that foreseeably helps them to do serious evil, given the potential moral and spiritual consequences for them. But cooperation in evil, especially by “good” people and especially when “successful”, can reassure sinners and encourage obduracy. Innocent third parties such as unborn children can also be harmed. And onlookers can be misled. What we do will inspire and educate or else mislead others; it will encourage those who imitate us to acquire virtues or vices. The example that healthcare administrators and senior clinicians give to juniors can, for example, elevate or corrupt those juniors. Thus Eleazar declared in the Book of the Maccabees that he would rather die painfully than lead the young to disobey God’s holy law, Our Lord inveighed against those who corrupt others and St Paul counselled caution lest we scandalise our brothers even at table.

All these concerns, it seems to me, depend for their bite upon two things. First, a strong sense of moral solidarity with others: that we are, contrary to Cain, our brothers’ and sisters’ keepers; that our example does, as the Maccabean heroes saw, impact upon those around us; that as Jesus commanded we must always be lights to the world, trying to draw people into the life of God’s kingdom and wary of ever being an obstacle to their entry; that our actions, as Paul insisted, do affect the whole body of Christ. Furthermore, these concerns depend for their piquancy upon a high sense of the moral possibilities of one’s neighbour. All too often “harm minimisation” approaches seem to me, at least implicitly, to give up on the other party as beyond anything better. We see them as inevitably inclined to do wrong or what harms themselves and others, and that the best we can do is help them to do wrong more safely. But people of faith should hold out more faith and hope in others, and reject cooperation in activities which ultimately demean them and ensure they do, in fact, perform according to our low expectations.

Third and finally, Christ commands that we love our neighbours as ourselves. Appropriate self-love includes an abiding concern for the kinds of persons we become as a result of our choices. Good ethics requires an awareness of the reflexive effects of human choice and habit (what it makes us), and of how corrupting even material cooperation can be. This consciousness of the self-creative effects of choice and thus of the burden of personal responsibility and integrity helps explain Christ’s apparently extreme exhortations – to cut off limbs that might cause us to sin and enter heaven disabled, rather than go to hell with all our limbs in tact; to avoid sexual promiscuity, violence and acquisitiveness not just of action but even of the mind; and to be ever-conscious of that which emerges from the deepest recesses of the human heart. A keen sense of who we are, of our Christian identity and vocation, is essential to moral discernment in all difficult cases. But a healthy resistance to occasions of, temptations to, and habits of sin is especially necessary when discerning whether to cooperate materially in evil. Sometimes this will require sacrificing our personal preferences, our desire to get on well with others, our institutional commitment, or even the great goods that our actions might otherwise achieve. But in the process we may become images of God, true keepers of our brothers and sisters, and the saints which each of us are called to be.