Bioethics is a blooming branch among academic disciplines, helping people to take moral decisions in health-related contexts and biological issues. People take decision either from the secular perspectives or from religious perspectives. On the one side, many of the secular approaches based their decision from quality of life arguments.1 On the other side, religions take their ethical decision from sanctity of life arguments; this means we have to respect the human being from the beginning to the end. Regarding bioethical issues, Catholic Church also takes decision from the sanctity of life arguments. This teaching can be seen from the scripture and the tradition of the Church, and the teaching is very clear. However, in certain circumstances, the theological concept of life is not enough to take decision when the life issues produces simultaneously good effect and bad effect. In this context catholic bioethical principles, based on the sanctity of life arguments, such as principle of totality and double effect, help the faithful to take the decisions in conflict situations. Many of the secular approaches, which are based on quality of life, are against these principles.
Moral theology clarifies the need of these two principles in catholic bioethics. For example, to justify the morality of mutilation of the human body, we need the principle of totality and the principle of double effect. We have to use both principles to justify mutilation outside the generative system and mutilation within the generative system. The principle of totality is considered to take mutilation outside the generative system. It is used as the general moral principle for determining the justification of all mutilations except those that suppress the generative function.2 Within the generative system, traditional teaching follows the principle of double effect. For instance, in order to justify the evil effect of the mutilation (e.g. sterilization), the principle of double effect is also taken into account.3 The generative organs have two separate functions and purposes, such as it exists 1) for the good of the body; and 2) good of the species. It must be seen under the principle of double effect. For instance, "in their existence as part of the whole body they may be removed or functionally suppressed, if they are destructive of the good of the whole body. This is indirect or therapeutic sterilization which is viewed in the light of the principle of totality. But since this will result in a limitation of the procreative faculty (the contraceptive effect of this mutilation) it must also be judged in light of the principle of double effect, for the contraceptive effect must not be intended but merely foreseen and permitted."4 In this context, we ask: are these principles relevant in bioethical issues? In this article, since the concepts of the two principles are vast, we try to evaluate only the relevance of the principle of totality in bioethics.
A simple expression of the principle of totality means, "the parts of the physical entity, as parts, are ordained to the good of the physical whole." From the medical perspective, the principle of totality would mean that "all the parts of the human body, as parts, are meant to exist and function for the good of the whole body, and are thus naturally subordinated to the good of the whole body."5 The term "totality" points to the duty to preserve intact the physical component of that integrated whole.6 In the following sections we will discuss the philosophical and theological foundations, different views, and the scope of the principle of totality.
The roots of the principle of totality are spread through the writings of Aristotle and Aquinas.7 St. Bonaventure and the Scholastic moral theologians also expressed the idea of the principle of totality.8 This principle has been used for many centuries as a justification for mutilation.9 Concerning the official teaching on the principle of totality, we find application of the principle very briefly in Casti Connubii (no. 23) by Pius XI and, in a wider perspective in the writings of Pius XII. Although moralists had incorporated the teachings of Aquinas on the subordination of the part to the whole, Pius XII made many official statements regarding the medico-moral application of the principle. He first named it as the principle of totality (13th September 1952, in his allocution to the Italian Society of Histopathologists).10 Our aim in this section is to present the foundation and the development of this principle of totality in moral theology, especially from the views of Aristotle and Aquinas, Pius XI, and Pius XII.
In this section, first, we discuss the theory of the principle of totality itself by clarifying terms from Aristotle and Aquinas; and secondly, we treat its Thomistic application with regard to mutilation; and thirdly, we see briefly the principle of totality and the justification of mutilation in moral theology.
a) Theory:
The principle of totality presupposes that "parts exist for the whole ... The good of the part is subordinated to the good of the whole; the whole is the determining factor for the part and can dispose of its own interest."11 Aristotle puts it briefly as totum quam parte, prius esse necesse est.12 The main notions on which the principle grounds itself are "the whole, the part, and their mutual relationships."13
Regarding the part, Aristotle explains it in the following manner: 1) A part denotes any portion of a quantum into which it can "be divided, for that which is taken from a quantum qua quantum" remains always a part of it. For example, two can be named "in a sense a part of three." There are two types of meaning for it. In the first place, part means "only those which measure the whole," which includes only two. In another sense a part cannot be considered as a "part of three." 2) Part can be understood as the constituent element of a dividable kind "apart from the quantity." For instance, "species are part of the genus." 3) Whole, which includes a part, can be divided. Here Aristotle uses the term 'whole' in the sense of "form or that which has form." He gives the example of the bronze sphere or bronze cube which is from bronze or it can denote a portion of material body which gives form to that. 4) Finally, the constituent "elements in the definition which explain a thing are also parts of the whole." Here, too, Aristotle gives the example of genus and species to substantiate his point. In this understanding "genus is called a part of the species," in another understanding "the species is part of the genus."14 In addition, H. Driesch understands a part as what logical nature-ness of a whole is with its constitutes.15
Concerning the whole, in a general understanding it is very difficult to define. However, in every day life we see whole things, either they are natural composites (plants, animals, human persons) or they are things made by a human person for his/her own use (machines, houses, ships). Here, the totality is seen as a harmonious development of a human person's powers in the psychological or ethical sense. So the notion is analogous in a restricted sense, and it is transcendental. In a limited sense "a whole is properly conceived in relation to its parts, and God has no parts. But even this limited transcendentality which it enjoys makes it impossible to be defined in the strict sense of the word, viz., through genus and difference, for it transcends them all."16 In general, a whole is in reference to parts and a part is in reference to a whole.
Aristotle explains the 'whole' in the following way. The whole is (1) "that from which is absent none of the parts of which it is said to be naturally a whole, and (2) that which so contains the things it contains that they form a unity; and this in two senses - either as being each severally one single thing, or as making up the unity between them."17 According to Thomas, Aristotle's concept of a whole includes two things: 1) "the perfection of the whole be integrated from the parts of which it is constituted;" 2) "that these parts form a unity."18 Without its parts, there is no ground for the whole. Hence, the concepts of part and whole are correlative.19
The idea of totality is closely related to the concept of unity. Unity does not include division, whereas there is a different intensity in the totality of a unity. Thomas makes a difference between unity as a 'simply so unity' (simpliciter unum) and as a 'unity in some respect' (secundum quid unum). A simple unity receives its species from some one element, it is the form or the composition or the order20 whereas a unity under one respect or other obtains its species from the multitude of its parts.21 For Thomas, the "substantial unity and totality comes first in order." It is also known as the natural unity.22
Thomas presents three types of ends or final causes for the parts in a whole. The first is the particular activity to which the individual part is oriented; for example, the eye is for seeing. The second considers the function as in an operation, a minor (less important) part gives service to a more important part. For instance, the veins serve the heart in the cardio-vascular system. Third, "the final cause of all the parts is the perfection of the whole that they comprise."23 This includes a person's overall well-being.24
Concerning the philosophical foundation for the principle of totality in Thomas' thinking, Martin Nolan presents that metaphysically the principle of totality is mainly concerned with the ordination of the parts to the overall perfection of the whole. This means, parts are integrated in the whole, which is a "perfect being." At the same time parts receive their own perfection as parts in the whole.25 Thus, parts are destined for the good of the whole. There is a mutual interrelation of parts and whole "being directed toward the perfection of totality."26
b) The Principle of Totality and the Justification of Mutilation by Thomas:
Moreover, with regard to the justification of mutilation, Thomas brings the principle of totality under the topic "injuries to the person." He raises the following question: "Is it ever legitimate to mutilate somebody?"27 Thomas answers from two perspectives, viz., penal and medical.28 With regard to medical mutilation, he observes:
an organ that is endangering an individual's whole body may legitimately be removed by his own consent for the sake of the well-being of the body as a whole, since each individual is responsible for the well being of his body as a whole. And the same reasoning applies where it is somebody else's responsibility to look after the person with the infected organ. In any other case it is wrong to mutilate another.29
Hence, one may conclude that mutilation is licit according to Thomas when it is necessary for the good of the entire body.30
Concerning penal amputation, Thomas never justifies mutilation against innocent persons.31 Thomas observes that individual life is greater than "any component good of that life" and hence the former should not be subordinated to the latter. So only those who are entrusted with the good of the community can deprive the individual of his life.32
Finally, there are three basic elements that justify mutilation in the teachings of Thomas. 1) Mutilation is justified for the well-being of the whole body. 2) It is not against the role of the human person as the protector of his/her body. This is done on the basis of a human person's limited power over his/her body for the betterment of whole body. 3) Mutilation in the form of penalty for a crime can be done by the state.33
As a whole, the application of the principle of totality by a human person depends on the principle of God's domination over man/woman. A person's right to mutilate parts of his/her body for the well-being of the whole is the protective responsibility of the human person over his/her life.34 Thomas did not develop particular limitations on human person's right to use his/her body or, more clearly, the right of the whole's domination over the part.35
c) The Principle of Totality and the Justification of Mutilation in Moral Theology:
The justification of mutilation on the basis of the principle of totality by moral theologians of the 17th century, viz., L. Molina, L. Leonardus, J. De Lugo, and P. Laymann followed the same reasoning as Aquinas without any difference.36 We do not find any new developments in their teachings. As well, moral theologians of the 18th and the 19th centuries accepted the conclusion regarding mutilation in the same manner as their predecessors.37 Again, the teachings of the theologians in the first forty years of the 20th century also continued in the same traditional direction.38 In addition, even though the scholastics unanimously accepted the justification of mutilation by Thomas Aquinas, there are differences in the application of these principles to particular issues.39 1) A diseased part is harmful to the whole body. All moral theologians unanimously agree upon a legitimate sacrifice of a part for the good of the whole. 2) Another question pertains to "the predicament of a person who was ordered by a tyrant to cut off his own hand." The scholastic moralists hold that the "self-inflicted mutilation was licit" when "the sacrifice of the part was" to safeguard the whole.40 3) Another case is "the necessity to amputate an extremity." The example is that "the foot of a person is caught in the railroad track as the train rapidly approaches." Traditional moralist justified "the subordination of the part to the whole."41
Above all, concerning the morality of mutilation, traditional moral theologians base their arguments on the fifth commandment, that man/woman has only a limited right over his/her body. More precisely, mutilation on the ground of the principle of totality is justified only by the physical good of the person. Further, we will see that the application of the principle of totality is considered more with medical issues during the period of Pius XI and Pius XII. In the following section we analyse the writings of Pius XI and Pius XII on the principle of totality.
The concept of the principle of totality is treated very briefly in the teachings of Pius XI. For instance, the encyclical Casti Connubii (Dec. 31, 1930), no. 23 states:
It is to be observed also that even the individual human being-as Christian doctrine teaches and the light of reason clearly shows-has no power over the members of his own body except so far as he uses them for their natural purpose; he cannot destroy or mutilate them, or in any other way render himself incapable of his natural functions, except where there is no other way of providing for the welfare of the body as a whole.42
The text justifies mutilation for the welfare of the entire body. Many argue that this paragraph is considered as the official position regarding the application of the principle of totality.43 G. Kelly says that Pope Pius XI presented the principle in the good composition.44 As one may notice Pius XI follows the teachings of Thomas.45 It is enough for us to say that Pope Pius XI accepts mutilation on the basis of the principle of totality in his encyclical Casti Connubii.
The real debate of the principle of totality can be seen in the writings of Pius XII.46 He bases his teaching on the principle of totality on the Aristotelian-Thomistic philosophical background.47 The official statement of the Church regarding the application of the principle of totality to medical problems can be seen mainly in the period of Pius XII. He reaffirmed, clarified, and applied the principle of totality to medico-moral questions in many addresses delivered from 1944-1958. According to him, "a part of the body has no meaning outside its reference to the whole, that as a part is to be thought of only in relation to the whole."48 He applied the principle of totality to the human person (physical totality) and the society (moral totality). In the following sections we describe these aspects of the principle of totality.
Pius XII explained the physical totality of the human person in the context of his discussion on 1) the human person and metaphysics, 2) the human person as an integral totality, 3) the well-being of the whole person, 4) the rights of the person and the principle of totality.
1) Human Person and Metaphysics: Pius XII does not limit unity and totality of a human being only to the physical organic unity but he discusses the principle in relation to the metaphysical foundations, which means it takes to the "plan of nature which is that of the Creator."49 On September 30, 1954, at the Eighth Assembly of the World Medical Association, he asserted that the foundation on which a medical ethics was to be built upon "being, reason and God."50
Pius XII further observed that a human person's totality comes from the essential nature of body and soul. It is the "substantial form" of the human body which makes a human being an integral whole. In the Congress of Psychotherapy and Clinical Psychology on April 15, 1953, he named soul the main constituent of human beings as "the substantial form of human nature." He also pointed out that the soul was the source of all human life activities and psychic forces.51 From a rational point of view, especially from the philosophical view, soul is the "substantial form of the body." This means that "the parts in this whole are determined in structure and estimated in value."52 Hence, totality does not depend on personal judgement, but it is pointed to the essence of the human being. Pius XII presents, "the essential man, the homo ut sic does not exist; only the existential man, the homo ut hic, is circumscribed in place and time."53 The structure of the personal ego, even in its minute state is characterized by the "ontological and metaphysical laws of human nature."54
The metaphysical aspect of the soul bestows on every human being, finally, his/her unity and totality. From womb to tomb a human being is a metaphysical personality. He/she retains his/her unity and totality irrespective of his/her physical and mental conditions and illness because this unity and totality belongs to his/her very nature.55 So Pius XII argues that a metaphysical personality has the right to life and also includes bodily integrity. Since one receives one's rights from God, one has a duty to protect oneself from danger.56
2) The Human Person an Integral Totality: In order to understand the human person as an integral totality, one has to understand Pius XII's text properly. He writes that "each of the members, for example the hand, the foot, the heart, the eye, is an integral part destined by all its being to be inserted in the whole organism. Outside the organism it has not by its very nature, any sense, any finality."57 Many understood this passage narrowly to mean the limited applicability of the principle of totality to a strictly physical wholeness.58 A correct reading of Pius XII's texts never limits the applications of the principle of totality to the physical perspectives of human life.59 Physicians and the surgeons are more interested in the organic nature of human body. But the body is dependent on the spiritual soul. The total harmony is seen as the togetherness of the body parts. This would mean that "[a]ll the members, faculties and functions fulfil their part for the good of the whole, and the value of each is measured by the good of the whole."60 So the unity between the parts is physical and "together with the soul one substantial whole" is formed. Furthermore, Pius XII stressed the priority of the soul in human beings who are a composite of matter and form.61 For him, the principle of totality includes the whole being of man/woman, not simply its physical side.62 This shows the integral totality of a human being, which is both physical and spiritual.
3) The Principle of Totality as the Well-being of the Whole Person: The principle of totality aims at the subordination of a part to the good of the whole: This means the good of the whole person "not with the extrinsic finality of the whole, but with the intrinsic or immanent good of the being in question."63 Totality leads to the attainment of God.64
One can find both the physical and spiritual good of the whole person in the concept of the principle of totality. In some addresses Pius XII refers the principle of totality to the physical well-being of the whole body. For instance, at the Italian Medical-biological Union of St. Luke (Nov. 12, 1944) his address reads as follows:
In forming man, God regulated each of his functions, assigning them to the various organs. In this way, he distinguished those which are essential to life from those which contribute only to the integrity of the body, however precious be the activity, well being, and beauty of this last. At the same time, God fixed, prescribed, and limited the use of each organ. He cannot therefore allow man now to arrange his life and the functions of his organs according to his own taste, in a manner contrary to the intrinsic and immanent function assigned them.65
Similar ideas can be seen in the first International Congress on the Histopathology of the Nervous System (September 13, 1952),66 the International Commission for the documentation of Military medicine (October 19, 1953),67 the allocution to the promoters of the Italian association of corneal donors (May 14, 1956).68 In all of the above referred addresses, Pius XII points out the principle of totality to the physical good of the whole body, which means the parts are aimed at the well-being of the whole organism.
However, Pius XII also mentions that the principle of totality includes both the physical and the spiritual good of the whole person. The person is not a mere thing but a whole person.69 At the International Congress of the International College of Neuro-Psycho-Pharmacology (September 9, 1958) he clearly expresses that a human person consists of a physical organism and an immortal soul.70 The point is that the principle of totality also describes the good of the whole person. Pius XII's idea of physical well-being is subordinated to the person as a whole.71 More concretely, it aims at the total good of the person. John Connery observes that the phrase 'total good of the person' is applied in the medico-moral use of the principle of totality.72 Similarly, Gerald Kelly observes that Pius XII was not simply concerned about the "physical organism" alone; rather, he had also spoken of the 'being as a whole' which is to be best understood as the person.73
The human being is seen in a broad sense of integral totality which includes both quantitative and qualitative parts. Pius XII, speaking to the Fifth International Congress of Psychotherapy and Psychology, explains: "[t]he various psychic faculties and functions form part of the whole spiritual being, and are at the service of its final purpose."74 He says that physicians and psychologists are more interested in the psychological personality of the human beings rather than in the metaphysical personality. Pius XII further remarks: "the psychosomatic unity of man in so far as it is determined and governed by the soul."75 So the human being is a psychosomatic unity. This means the "mutual influence of body and soul."76 To summarize, in the observation of Martin Nolan, Pius XII makes a harmonious union between the physical element and the spiritual element in the principle of totality, which points to the good of the whole person. To put it differently, the totality of the person subsists "as a spiritual-material entity,"77 which we can see in his allocution to the International College of Neuro-Psycho-Pharmacology.78
4) Rights of the Person and the Principle of Totality: Many addresses of Pius XII present the principle of totality in connection with the rights of the human person. There are two basic principles for this, viz., 1) the human person is only the administrator and God is the owner of the body; 2) the human person has the right to dispose of his/her organs for the well-being of the whole body.79 In his address to the Italian Medical-Biological Union of St. Luke (November 12, 1944) Pius XII reminds that since it is God who designed the organs with special functions and use, man/woman cannot rearrange them in such a way that these organs function in a "manner contrary to the original intrinsic" functioning.80
Regarding the right to remove the part for the good of the whole, he teaches in the First International Congress on the Histopathology of the Nervous System (September 13, 1952): "... [man/woman] does not possess unlimited power to allow acts of destruction or of mutilation of anatomic or functional character. But in virtue of the principle of totality, of his right to employ the services of the organism as a whole."81 Similarly, at the meeting of the Italian Society of Urology, on October 8, 1953 Pius XII speaks of the justification of the mutilation of an organ in the case of serious danger to the whole body.82
However, Pius XII also clarifies how one person can use his/her rights. He observes that doctors and nurses have no right to use patients for medical research and experimentation, when they create a serious danger to the person.83 He further observes, during the Allocution to the Sixteenth Session of the International Office for the Documentation of Military Medicine, that the patient does not have the right to cease either the integrity or the very existence of his/her own organism.84 Nor should he/she assume the right to remove his/her own organs except to the extent it is required for the good of the whole organism. The same argument is expressed in his allocution to the Urologists on October 8, 1953,85 and his address to the International College of Neuro-Psycho-Pharmacology, September 9, 1958.86
In simple terms, the teachings of Pius XII on the principle of totality can be summarized as follows: The principle of totality is seen in an integral manner, which includes spiritual and physical dimensions.
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