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MORAL PRINCIPLES AND MEDICAL PRACTICE.

INTRODUCTORY--THE FOUNDATION OF JURISPRUDENCE.

Gentlemen:--1. When I thoughtfully consider the subject on which I am to address you in this course of lectures, i.e., Medical Jurisprudence, I am deeply impressed with the dignity and the importance of the matter.

The study of medicine is one of the noblest pursuits to which human talent can be devoted. It is as far superior to geology, botany, entomology, zo?logy, and a score of kindred sciences as its subject, the body of man, the visible lord of the creation, is superior to the subject of all other physical sciences, which do so much honor to the power of the human mind; astronomy, which explores the vast realms of space, traces the courses and weighs the bulks of its mighty orbs; chemistry, which analyzes the minutest atoms of matter; physics, which discovers the properties, and mechanics, which utilizes the powers of an endless variety of bodies--all these noble sciences together are of less service to man than that study which directly promotes the welfare of his own structure, guards his very life, fosters the vigor of his youth, promotes the physical and mental, aye, even the moral, powers of his manhood, sustains his failing strength, restores his shattered health, preserves the integrity of his aging faculties, and throughout his whole career supplies those conditions without which both enjoyment and utility of life would be impossible.

Wages may be measured by the time bestowed, or by the effect produced, or by the wants of the laborer to lead a life of reasonable comfort; a salary is measured by the period of service; but an honorary is not dependent on time employed, or on needs of support, or on effect produced, but it is a tribute of gratitude due to a special benefactor. Whatever practical arrangements may be necessary or excusable in special circumstances, this is the ideal which makes the medical profession so honorable in society.

Your career, gentlemen, to be truly useful to others and pursued with safety and benefit to yourselves, needs to be directed by a science whose principles it will be my task to explain in this course of lectures--the science of MEDICAL JURISPRUDENCE.

In such a land, the lecturer on Medical Law would have nothing to explain; for there would be no human laws and law courts with which a physician could come in contact. But the lecturer on Medical Jurisprudence proper would have as much to explain as I have in this country at present; because he treats of the Ethics or moral principles of Medical Practice, he deals with what is ever the same for all men where-ever they dwell, it being consequent on the very nature of man and his essential relations to his Maker and his fellow-man. Unfortunately the term "Medical Jurisprudence" has been generally misused. Dr. Ewell, in his text-book on the subject, writes "While the term 'Medical Jurisprudence' is a misnomer,--the collection of facts and conclusions usually passing by that name being principally only matters of evidence, and rarely rules of law,--still the term is so generally employed that it would be idle to attempt to bring into use a new term, and we shall accordingly continue the employment of that which has only the sanction of usage to recommend it" .

I prefer to use terms in their genuine meaning; for misnomers are out of place in science, since they are misleading. Yet, to avoid all danger of misunderstanding, I will call my subject "Moral Principles and Medical Practice," and distinctly style it "The Basis of Medical Jurisprudence."

On what lines will my treatment of the subject depart from the beaten path? On the same lines on which most other improvements have been made in the science of medicine. Science has not discovered new laws of physical nature that did not exist before; but it has succeeded in understanding existing laws more perfectly than before, and has shaped its practice accordingly. So, too, the leaders of thought among physicians, especially in English-speaking countries, now understand the laws of moral nature--the principles of Ethics--more thoroughly than most of their predecessors did, and they have modified their treatment so as to conform it to these rules of morality. Hitherto Medical Jurisprudence had regulated the conduct of practitioners by human, positive laws, and sanctioned acts because they were not condemned by civil courts. Now we go deeper in our studies, and appeal from human legislation to the first principles of right and wrong, as Jurisprudence ought to do; and, in consequence, some medical operations which used to be tolerated, or even approved, by many in the profession are at present absolutely and justly condemned. The learned physician these days is no longer afraid to face the moral philosopher; there is no longer any estrangement between Ethics and Medical Practice. Medicine, sent from Heaven to be an angel of mercy to man, is now ever faithful to its beneficent mission; it never more performs the task of a destroying spirit, as--not in wantonness, but in ignorance--it did frequently before.

On these lines, then, of the improved understanding of first principles, I will now proceed to develop the teachings of Medical Jurisprudence.

From this principle it follows that a physician is not responsible to God or man for such evil consequences of his prescriptions or surgical operations as are entirely beyond his will and therefore independent of his control. If, however, his mistakes arise from his ignorance or want of skill, he is blamable in as far as he is the wilful cause of such ignorance; he should have known better; or, not knowing better, he should not have undertaken the case for which he knew he was not qualified.

But it often happens that the best informed and most skilful practitioner, even when acting with his utmost care, causes real harm to his patients; he is the accidental, not the wilful, cause of that harm, and therefore he is free from all responsibility in the matter.

The practical lessons, however, which all of you must lay to heart on this subject are: 1st. That you are in duty bound to acquire sound knowledge and great skill in your profession; since the consequences involved are of the greatest moment, your obligation is of a most serious nature. 2d. That in your future practice you will be obliged on all occasions to use all reasonable care for the benefit of your patients. 3d. That you cannot in conscience undertake the management of cases of unusual difficulty unless you possess the special knowledge required, or avail yourselves of the best counsel that can reasonably be obtained.

The goodness and the evil of human acts is not dependent on human legislation alone; in many cases the moral good or evil is so intrinsic to the very nature of the acts that God Himself could not change the radical difference between them. Thus justice, obedience to lawful authority, gratitude to benefactors, are essentially good; while injustice, disobedience, and ingratitude are essentially evil. Our reason informs us of this difference; and our reason is nothing else than our very nature as intelligent beings capable of knowing truth. The voice of our reason or conscience is the voice of God Himself, who speaks through the rational nature that He has made. Through our reason God not only tells us of the difference between good and evil acts, but He also commands us to do good and avoid evil;--to do certain acts because they are proper, right, orderly, suitable to the end for which we are created; and to avoid other acts because they are improper, wrong, disorderly, unsuitable to the end of our existence. There is a third class of acts, which, in themselves, are indifferent, i.e., neither good nor evil, neither necessary for our end nor interfering with its attainment. These we are free to do or to omit as we prefer; but even these become good and even obligatory when they are commanded by proper authority, and they become evil when forbidden. In themselves, they are indifferent acts.

I will not examine this important matter in all its bearings at present; I mean to take it up later on in our course, and to lay before you the teachings of science on this subject, together with the principles on which they are based. For the present I will confine myself to the point we are treating just now, namely, the existence of a higher law than that of human tribunals, the superiority of the claims of natural to those of legal justice. Some might think, at first sight, that this needs no proof. In fact we are all convinced that human laws are often unjust, or, at least, very imperfect, and therefore they cannot be the ultimate test or fixed standard of right and wrong; yet the main argument advanced by one of the advocates of craniotomy rests upon the denial of a higher law, and the assertion of the authority of human tribunals as final in such matters.

Dr. Kearney's doctrine of the existence of a higher law, superior to all human law, is the doctrine that has been universally accepted, in all Christian lands at least, and is so to the present day. Froude explains it correctly when he writes: "Our human laws are but the copies, more or less imperfect, of the eternal laws so far as we can read them, and either succeed and promote our welfare or fail and bring confusion and disaster, according as the legislator's insight has detected the true principle, or has been distorted by ignorance or selfishness" .

How admirably is this order displayed in the material universe! The more we study the sciences--astronomy, biology, botany, physiology, medicine, etc.--the more we are lost in admiration at the beautiful order we see displayed in the tiniest as well as in the vastest portions of the creation. And shall man alone, the masterpiece of God in this visible universe, be allowed to be disorderly, to be a failure in the noblest part of his being, to make himself like to the brute or to a demon of malice, to waste his choicest gifts in the indulgence of debasing pleasure? The Creator is bound by His own wisdom to direct men to high purposes, worthy of their exalted intellectual nature. But how shall He direct man? He compels material things to move with order to the accomplishment of their alloted tasks by the physical laws of matter. He directs brute animals most admirably to run their appointed careers by the wonderful laws of instinct, which none of them can resist at will. But man He has made free; He must direct him to do worthy actions by means suitable to a free being, that is, by the enacting of the moral law.

He makes known to us what is right and wrong. He informs every one of us, by the voice of reason itself, that He requires us to do the right and avoid the wrong. He has implanted in us the sense of duty to obey that law. If we do so, we lead worthy lives, we please Him, and, in His goodness, He has rewards in store.

But can He be pleased with us if we thwart His designs; if we, His noblest works on earth, instead of adding to the universal harmony of His creation, make monsters of ourselves, moral blots upon the beautiful face of His world? It were idle for Him to give us the knowledge of His will and then to stand by and let us disfigure His fairest designs; to bid us do what is right, and then let us do wrong without exacting redress or atonement. If He is wise, He must not only lay down the law, but He must also enforce it; He must make it our highest interest to keep His law, to do the right; so that ultimately those men shall be happy who have done it, and those who have thwarted His designs shall be compelled to rue it. He will not deprive us of liberty, the fairest gift to an intelligent creature, but He will hold out rewards and punishments to induce us to keep the law and to avoid its violation. Once He has promised and threatened, His justice and His holiness compel Him to fulfil His threats and promises. A man can commit no rasher act than to ignore, defy, and violate that higher law of which we are speaking, and which, if it must direct all men, especially requires the respect and obedience of those into whose hands he has placed at times the lives of their fellow-men, the greatest of earthly treasures.

I have insisted so much, gentlemen, on the existence of the higher law, on its binding power and on the necessity of observing it, because it is the foundation of my whole course of lectures. If there were no higher law, then there would be no Medical Jurisprudence, in the true sense of the word. For Jurisprudence studies the principles that underlie legal enactments, and if there were no higher law, there would be no such principles; then the knowledge of the human law would fill the whole programme. This in fact is the contention of the defendant of craniotomy to whom I have referred; and he boldly applies his speculation to a matter in which the physician has the most frequent opportunity to exhibit his fidelity to principle, or his subserviency to the requirements of temporary expediency at the sacrifice of duty.

A. The matters entrusted to their keeping are the most important of all earthly possessions; for they are life itself, and, along with life, health, the necessary condition of almost all temporal enjoyment. No other class of men is entrusted with more weighty earthly interests. Hence the physician's responsibility is very great; hence the common good requires that he be eminently faithful and conscientious.

B. With no other class of men does the performance of duty depend more on personal integrity, on conscientious regard for the higher law of morality than with the Doctor. For the Doctor's conduct is less open to observation than that of other professions. The lawyer may have many temptations to act unjustly; but other lawyers are watching him, and the courts of justice are at hand to check his evil practices. As to the judge, he is to pronounce his decisions in public and give reasons for his ruling. The politician is jealously watched by his political opponents. The public functionary, if he is unjust in his dealings, is likely sooner or later to be brought to an account. But the physician, on very many occasions, can be morally sure that his conduct will never be publicly scrutinized. Such is the nature of his ministrations, and such too is the confidence habitually reposed in his integrity, that he is and must be implicitly trusted in matters in which, if he happens to be unworthy of his vocation, he may be guilty of the most outrageous wrongs.

The highest interests of earth are in his hands. If he is not conscientious, or if he lets himself be carried about by every wind of modern speculations, he can readily persuade himself that a measure is lawful because it is presently expedient, that acts can justly be performed because the courts do not punish them; and thus he will often violate the most sacred rights of his patients or of their relatives. Who has more frequent opportunities than a licentious Doctor to seduce the innocent, to pander to the passions of the guilty, to play into the hands of greedy heirs, who may be most willing to pay him for his services? No one can do it more safely, as far as human tribunals are concerned. As a matter of fact, many, all over this land and other lands, are often guilty of prostituting their noble profession to the vilest uses. The evil becomes all the more serious when false doctrines are insinuated, or publicly advocated, which throw doubt upon the most sacred principles of morality. True, the sounder and by far the larger portion of medical men protest against these false teachings by their own conduct at least; but it very frequently happens that the honest man is less zealous in his advocacy of what is right than is the propagandist of bold speculations and dangerous new theories in the spreading of what is pernicious.

The effect thus produced upon many minds is to shake their convictions, to say the least; and I need not tell you, gentlemen, that weak convictions are not likely to be proof against violent and repeated temptations. In fact, if a physician, misled by any of those many theories which are often inculcated or at least insinuated by false scientists, can ever convince himself, or even can begin to surmise that, after all, there may be no such thing as a higher law before which he is responsible for even his secret conduct, then what is to prevent him from becoming a dangerous person to the community? If he see much temporal gain on the one hand, and security from legal prosecution on the other, what would keep him in the path of duty and honesty? Especially if he can once make himself believe that, for all he knows, he may be nothing more than a rather curiously developed lump of matter, which is to lose forever all consciousness in death. Why should he not get rid of any other evolved lump of matter if it stand in the way of his present or prospective happiness? Those are dangerous men who inculcate such theories; it were a sad day for the medical profession and for the world at large if ever they found much countenance among physicians. Society cannot do without the higher law; this law is to be studied in Medical Jurisprudence.

It is my direct object, gentlemen, to explain this law to you in its most important bearings, and thus to lay before you the chief duties of your profession. The principal reason why I have undertaken to deliver this course of lectures--the chief reason, in fact, why the Creighton University has assumed the management of this Medical College--is that we wish to provide for the West, as far as we are able, a goodly supply of conscientious physicians, who shall be as faithful and reliable as they will be able and well informed; whose solid principles and sterling integrity shall be guarantees of upright and virtuous conduct.

That this task of mine may be successfully accomplished, I will endeavor to answer all difficulties and objections that you may propose. I will never consider it a want of respect to me as your professor if you will urge your questions till I have answered them to your full satisfaction. On the contrary, I request you to be very inquisitive; and I will be best pleased with those who show themselves the most ready to point out those difficulties, connected with my lectures, which seem to require further answers and explanations.

CRANIOTOMY.

Gentlemen:--In my first lecture I proved to you the existence and the binding power of a higher law than that of human legislators, namely, of the eternal law, which, in His wisdom, the Creator, if He created at all, could not help enacting, and which He is bound by His wisdom and justice to enforce upon mankind.

We are next to consider what are the duties which that higher law imposes upon the physician. In this present lecture I will confine myself to one duty, that of respect for human life.

A duty is a bond imposed on our will. God, as I remarked before, imposes such bonds, and by them He directs free beings to lead worthy lives. As He directs matter by irresistible physical laws, so He directs intelligent and free beings by moral laws, that is, by laying duties or moral bonds upon them, which they ought to obey, which He must require them to obey, enforcing His commands by suitable rewards and punishments. Thus He establishes and enforces the moral order.

Now the duties He lays upon us are of three classes. First, there are duties of reverence and honor towards Himself as our sovereign Lord and Master. These are called the duties of Religion, the study of which does not belong to Medical Jurisprudence. The other classes of duties regard ourselves and our fellow-men, with these we are to deal in our lectures.

This is what reason teaches concerning our status in this world; and this teaching of reason is confirmed by the convictions of all nations and all ages of mankind. The oldest page of literature that has come down to us, namely, the first chapter of the first book of Holy Writ, lays down this same law, and no improvement has been made in it during all subsequent ages. Whether we regard this writing as inspired, as Christians and Jews have always done, or only as the testimony of the most remote antiquity, confirmed by the acceptance of all subsequent generations, it is for every sensible man of the highest authority.

Here is the passage: "God said, Let us make man to our image and likeness; and let him have dominion over the fishes of the sea, and the fowls of the air, and the beasts, and the whole earth, and every creeping creature that creepeth upon the earth." And later on in history, after the deluge, God more explicitly declared the order thus established, saying to Noe and his posterity: "Every thing that moveth and liveth shall be meat for you; even as the green herbs have I delivered them to you." But He emphatically adds that the lives of men are not included in this grant; they are directly reserved for His own disposal. "At the hand of every man," He says, "will I require the life of man."

All things then are created for man; man is created directly for God, and is not to be sacrificed for the advantage of a fellow-man. Thus reason and Revelation in unison proclaim that we can use brute animals as well as plants for our benefit, taking away their lives when it is necessary or useful to do so for our own welfare; while no man is ever allowed to slay his fellow-man for his own use or benefit: "At the hand of every man will I require the life of man."

Thus it is apparent that rights and duties suppose free beings, persons; now an irrational animal is not a person; it is not a free being, having a destiny to work out by its free acts; it is therefore incapable of having duties. Duties are matters of conscience; therefore they cannot belong to the brute animal; for it has no conscience. And, since rights are given to creatures because of the duties incumbent on them, brute animals are incapable of having rights. When a brute animal has served man's purpose, it has reached its destiny.

That all men are equal in their essential rights is the dictate of common-sense and of sound philosophy. This truth may not flatter kings and princes; but it is the charter of human rights, founded deeper and broader in nature and on the Creator's will than any other claim of mankind. As order requires the subordination of lower natures to higher, so it requires equality of essential rights among beings of the same nature. Now all men are of the same nature, hence they have all the same essential rights.

So far we have chiefly considered murder as a violation of man's right to his life. We must now turn our attention to God's right, which the murderer violates. It may indeed happen that a man willingly resigns his right to live, that he is tired of life, and longs and implores for some one to take it away. Can you then do it? You cannot. His life does not belong to him alone, but to God also, and to God principally; if you destroy it, you violate God's right, and you will have to settle with Him. God wills this man to live and serve Him, if it were only by patient endurance of his sufferings.

For a man may be much ennobled and perfected by the practice of patience under pain and agony. Some of the noblest characters of history are most glorious for such endurance. The suicide rejects this greatness; he robs God of service and glory, he rebels against his Creator. Even Plato of old understood the baseness of suicide, when he wrote in his dialogue called "Phaedon" that a man in this world is like a soldier stationed on guard; he must hold his post as long as his commander requires it; to desert it is cowardice and treachery; thus, he says, suicide is a grievous crime.

This being so, can a Doctor, or any other man, ever presume to contribute his share to the shortening of a person's life by aiding him to commit suicide? We must emphatically say No, even though the patient should desire death: the Doctor cannot, in any case, lend his assistance to violate the right and the law of the Creator: "Thou shalt not kill."

I have no doubt, gentlemen, that some of you have been saying to yourselves, Why does the lecturer insist so long upon a point which is so clear? Of course, none of us doubts that we can in no case aid a patient to commit suicide. My reason for thus insisting on this matter is that here again we are dealing with a living issue. There are to-day physicians and others who deny this truth, not in their secret practice only, but, of late, to justify their conduct, they have boldly formulated the thesis that present apparent expediency can lawfully be preferred to any higher consideration. Here is the fact. At a Medico-Legal Congress, held in the summer of 1895, Dr. Bach, one of its leading lights, openly maintained it as his opinion that "Physicians have the moral right to end life when the disease is incurable, painful, and agonizing."

What his arguments were in support of his startling proposition, I have not been able to learn. But I know that a cry of horror and indignation has gone up from many a heart. Many have protested in print; but unless, on an occasion like this, moralists raise their voice against it with all the influence which sound principles command, the saying of Dr. Bach may at least shake the convictions of the rising generation of physicians. The only argument for Dr. Bach's assertion that I can imagine--and it is one proceeding from the heart rather than the head--is that it is cruel to let a poor man suffer when there is no longer hope of recovery. It is not the Physician that makes him suffer; it is God who controls the case, and God is never cruel.

He knows His own business, and forbids you to thwart His designs. If the sufferer be virtuous, God has an eternity to reward his patient endurance; if guilty, the Lord often punishes in this world that He may spare in the next. Let Him have His way, if you are wise; His command to all is clear, "Thou shalt not kill."

One rash utterance, like that of Dr. Bach, can do an incalculable amount of harm. Why, gentlemen, just think what consequences must follow if his principle were, admitted! For the only reason that could give it any plausibility would be that the patient's life is become useless and insupportable. If that were a reason for taking human life away, then it would follow that, whenever a man considers his life as useless and no longer supportable, he could end it, he could commit suicide. That reasoning would practically justify almost all suicides. For, when people kill themselves, it is, in almost all cases, because they consider their lives useless and insupportable. Whether it results from physical or from moral causes that they consider their life a burden, cannot, it seems to me, make any material difference; grief, shame, despair are as terrible sufferings as bodily pains. If, then, we accept Dr. Bach's principle, we must be prepared for all its baneful consequences.

But it may be objected that no evil act may be done to procure a good result, that a good end does not justify a bad means. That is a correct principle, and we will consider it carefully some other day. But my act of necessary self-defence is not evil, and therefore needs no justification; for the means I employ are, under the circumstances, well-ordered and lawful means, which violate no one's rights, as has just been shown. Of course the harm I do to the aggressor is just only in as far as it is strictly necessary to defend the inalienable right I have to life or limb or very valuable property. Hence I must keep within the just limits of self-defence. To shoot an assailant, when I am in no serious danger, or when I can free myself some other way, or when I act through malice, would not be self-defence, but unjustifiable violence on my part.

Now the only case in which the need of medical treatment against unjust aggression could become a matter for discussion in Jurisprudence is the case of a mother with child. Is the child under those circumstances really an unjust aggressor? Let us study that important case with the closest attention. Let all the rays of light we have gathered so far be focussed on this particular point. Can a physician ever be justified in destroying the life of a child, before or during its birth, by craniotomy or in any other manner, in order to save its mother's life, on the plea that the child is an unjust assailant of the life of its mother? Put the case in a definite shape before you. Here is a mother in the pangs of parturition. An organic defect, no matter in what shape or form, prevents deliverance by the ordinary channels. All that medical skill can do to assist nature has been done. The case is desperate. Other physicians have been called in for consultation, as the civil law requires before it will tolerate extreme measures. All agree that, if no surgical operation is performed, both mother and child must die. There are the Caesarian section, the Porro operation, laparotomy, symphysiotomy, all approved by science and the moral law. But we will suppose an extreme case; namely, the circumstances are so unfavorable for any of these operations--whether owing to want of skill in the Doctors present, or for any other reason--that none can safely be attempted; any of them would be fatal to the mother.

In this extreme case of necessity, can the Doctor break the cranium of the living child, or in any way destroy its life with a view to save the mother? If three consulting physicians agree that this is the only way to save her, he will not be molested by the law courts for performing the murderous operation. But will the law of nature and of nature's God approve or allow his conduct? This is the precise question under our consideration. We have seen that the infant, a true human being, has a right to live, as well as its mother. "All men are created equal, and have an equal right to life," declares the first principle of our liberty. The Creator, too, as reason teaches, has a clear right to the child's life; that child may answer a very special purpose of Providence. But whether it will or not, God is the supreme and the only Master of life and death, and He has laid down the strict prohibition, "Thou shalt not kill."

Will any one object that the infant has no right to be there at all? Who put it there? The only human agents in the matter were its parents. The mother is more accountable for the unfortunate situation than the child. Certainly you could not, to save the child, directly kill the mother, treating her as an unjust assailant of her child's life? Still less can you treat the infant as an unjust assailant of its mother's life.

The plea of self-defence against unjust aggression being thus ruled out of court in all such cases, and no other plea remaining for the craniotomist, we have established, on the clearest principles of Ethics and Jurisprudence, that it is never allowed directly to kill a child as a means to save its mother's life. It would be a bad means, morally evil; and no moral evil can ever be done that good may come of it; the end cannot justify an evil means. In theory all good men agree with us that the end can never justify the means. But in practice it seems to be different with some of the medical profession. Of late, however, the practice of craniotomy and all equivalent operations upon living subjects has gone almost entirely out of fashion among the better class of physicians.

Allow me, gentlemen, to conclude this lecture with the reading of two extracts from articles of medical writers on the present state of craniotomy in their profession. You will find them in accord with the conclusions at which we have arrived by reasoning upon the principles of Jurisprudence.

Even if a liberal deduction be made for unfavorable circumstances and deficient skill, the results, gentlemen, will still leave a wide margin in favor of Cesarian section. My second extract is from an article of Dr. M. O'Hara, and it is supported by the very highest authorities : "Recently the British Medical Association, the most authoritative medical body in Great Britain, at its sixty-first annual meeting, held at Newcastle-upon-Tyne, definitely discussed the subject before us. In the address delivered at the opening of the section of Obstetric Medicine and Gynecology, an assertion was put forth which I regard as very remarkable, my recollection not taking in any similar pronouncement made in any like representative medical body. The authoritative value of this statement, accepted as undisputed by the members of the association, which counts about fifteen thousand practitioners, need not be emphasized.

ABORTION.

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