‘A Knife into My Heart’: Cries, Compassion and Ethical Life

Abstract

The subtitle to the conference upon which this journal issue is based invited us to ‘follow Crowter’. This paper does so primarily by following the person and only thereby attends to the legal judgment. In particular, it will attend to her comment that When mum told me about the discrimination against babies like me in the womb, I felt like a knife had been put into my heart. It made me feel less valued than other people. The argument is that (I) there are strong reasons for such an approach from the field of theological ethics and that this is valuable for pastoral theology and for bioethics. With this case made, the argument proceeds (II) by following and building on three elements of Heidi Crowter’s words concerning (a) the knife (b) the heart and (c) the person. The argument concludes (III) with theological reflection and deliberation regarding institutions, practices and actions which will make for ‘ethical society’, principally focussed on ecclesial life.

KEYWORDS:

• Compassion
• pre-natal testing
• abortion
• Down’s syndrome
• persons
• church

I. Hearing cries wisely

The subtitle to the conference upon which this journal issue is based invited us to ‘follow Crowter’. This paper will do so primarily by following the person and only thereby attend to the legal judgment. The argument will, therefore, proceed from what may be heard from Heidi Crowter, focussing on her feeling that a ‘knife had been put into [her] heart’, upon learning about how some people like her are treated. There are, of course, other voices to which Heidi Crowter’s is joined, not least those of her fellow claimants in the relevant case. Even amongst those whose voices are suppressed or whose societal presence is relatively invisible, some are more visible or audible than others.¹

There are three kinds of reason, from within the discipline of theological ethics, for ‘following Crowter’ in this way.

First, theological ethics should be done close to and attentive to the cries of people for justice and recognition. Jewish philosopher Peter Ochs describes a cry as ‘an indexical mark that there is a pain there, somewhere’. Cognition of pain ‘is not the cognition of any quality but, rather, the registration of some event: that there has been some interruption, the shock of some No!’ Ochs claims that to ‘hear a cry … and then to move toward it is … to represent the cry as a sign, or as something that has some meaning for us’ (Ochs 2006, p. 473). So when cries become signs they become shareable – they are ‘for us’. They bear meaning for more than the one who cries out – meaning within which I can plot my own agency in hope that justice might be done. In Augustinian terms, there are ‘things’ (res) and there are things which become ‘signs’ (signa), referring beyond themselves to still other things in instructive ways, ultimately pointing to God (Augustine 1997, book 1). In this way, a shocking event may become theologically meaningful not just to an individual who cries out but for a community of listeners, who have ears to hear.

Second, the version of theological ethics proposed here is committed to attending to cries for moral psychological reasons. The claim is that affections – inhering both within one crying out and the hearers of cries are the beginnings of understanding, whether personal, social or political. When affections become shared – when loves become common – such affections can forge an intersubjective, inclined understanding, which in turn can be a powerful engine of societal agency (Hordern 2013, p. 78–81, Hordern 2020a, p. 81–88). David Ford writes:

Christian wisdom is discerned within earshot of such cries, and is above all alert to the cries of Jesus. Doing justice to diverse cries is at the heart of this theological wisdom. The insistence of the cries lends urgency to the search for wisdom. The persistence of the cries, together with the diversity and, often, novelty of their challenges, constantly expands the search and refuses to allow it to rest in any closure. (Ford 2007, p. 5)

On this view, an affectively laden ‘cry’ does not suggest non-rational communication. When Jesus cried out ‘My God, my God why have you forsaken me’ (Matthew 27:46; drawing on Psalm 21:1) this was not without reason. When Martin Luther King cried out ‘I have a dream’, this was hardly because he lacked insight. Regarding the treatment of unborn persons, including those with Down’s syndrome or other genetic conditions identifiable by prenatal testing, there is clearly a persistence of diverse cries. All of these, including surprising ones, must be attended to in order that insight may be gained and justice, mingled with mercy, may be sought and done.

Such attentiveness to cries, remembering our focus upon ethical society, locates the theological ethical enquiry in the sphere of political theology. In particular, cries indicate some deep diversity in society signalled in what the court, in the Crowter case, called ‘sincere differences of view about ethical and religious matters’ (Crowter v SSHSC 2021, §5). Sorting and adjudicating between such differences in ways which organize societal life is a task for politics. Such sincere differences of view do not simply differentiate individuals but rather cluster around communities and institutions. Of particular relevance to ‘following Crowter’, as I shall show, are ecclesial organizations – the communities and institutions called ‘churches’.

For to speak of an ‘ethical society’ is not to speak of one thing but many different things which go to make up the complex of social interactions and communications we call ‘society’. By those interactions and communications things which are loved as valuable may be widely shared – and argued about. But which society is in view in a discussion of an ‘ethical society’? For Augustine, two groups who share a set of institutions in a territory may be distinguished by the nature of their loves – by what they agree to love and share in common, albeit for diverse reasons. Equally they are distinguished by what they do not love in the same way and so do not share in common (Augustine 1972).

Thirdly, theological ethics is committed to engage critically in an activity which is related to but distinct from that which ‘applied’, ‘pastoral’ or ‘practical’ (APP) theology thinks of as ‘theological reflection on experience’. Experience might include hearing a cry; or a face-to-face encounter with one who cries out such as I had with Heidi Crowter when we met at the conference which was the occasion for this journal issue. Just what should be gained for bioethics from a critical engagement between theological ethics and APP theology will be one aspect of this argument and therefore deserves some further space. Exploring this disciplinary question seems fitting to the subject matter which inevitably touches very sensitive areas.

In a seminal article on practical/applied theology, Stephen Pattison explores the meaning of ‘theological reflection on experience’ or ‘theological reflection on practical contemporary situations’. Conscious that he is offering a limited model, he conceives it as a certain kind of ‘contemporary enquiry’ which is ‘active’ – ‘a learning experience’ which ‘deepens our experience of the world and of our own assumptions’, ensuring that theology does not get ‘cut off from the experience of everyday life’. The aspiration is that ‘faith remains relevant to experience’, able to address ‘questions which come out of contemporary experience’. In sum, ‘Theological reflection on experience can make both experience and theology come alive in a new way’. Pattison imagines this activity as a critical conversation in which ‘the beliefs, assumptions and perceptions provided by the Christian tradition (including the Bible)’, ‘contemporary reality and a [person’s] assumptions are all questioned in turn by each other’. One of the advantages which Pattison sees for this way of conceiving reflection is that ‘participants in a conversation are changed, both by what they learn and by the process of conversing with other participants’ (Pattison 2000, pp. 137–141).

What might theological ethics – of the kind endeavoured here – learn for the purpose of ‘following Crowter’ from this account of ‘theological reflection’? One of Pattison’s assumptions is that ‘there are some enormous gaps between some situations in the contemporary world and the religious tradition’ (Pattison 2000, p. 140). Such situations might include, one might imagine, that between the science and practice of pre-natal genetic diagnosis and the life of the Christian church. The kind of Augustinian theological ethics which I have described above would see matters somewhat differently. For such ethics, as a form of moral realism, theological reflection has to do with understanding the ‘moral field’ or ‘moral order’ (O’Donovan 1994, pp. 211–213) by means of traditions of theological interpretation – most notably the interpretation of Scripture. The goal of such reflection is that the nature of any situations in the contemporary world may be described and charted in the moral field as accurately as possible. The gap is not then a gap between an older world and the contemporary world as if they occupied a genuinely different moral field. The gap instead lies, standardly, in the agent’s imagination (and perhaps will) to identify a novel challenge in terms of the moral field. What follows from such reflection is deliberation about what to do (or not do) in relation to the challenge, leading to decision that resolves on action.

In regard to Scripture’s place in theological reflection, O’Donovan observes that we ‘will read the Bible seriously only when we use it to guide our thoughts towards a comprehensive moral viewpoint, and not merely to articulate disconnected moral claims’ (O’Donovan 1994, p. 200). Such a position, however, does not at all suggest the conversational process which Pattison recommends in which – so it would seem – Scripture itself might be changed by conversation with an individual’s experience. This matters for what we understand ‘theological reflection on experience’ to be and therefore what ‘following Crowter’ in the sense I have suggested might mean. When one pastoral theologian, Schlauch, remarks that ‘experiencing, occurring as a gestalt, is difficult to parse into patterned and pattern’ (Schlauch 2000, p. 218), he may, read charitably, be heard to be signalling the benefits of resolving ambiguities within patterns. He thinks of ‘experiencing’ as ‘registering information’ and is conscious of the ‘categories through which one registers information’ whereby similar objects are perceived similarly over time (Schlauch 2000, pp. 214–215). Moreover, he observes the importance of ‘reconstructing experiencing’ by which he means, in terms of pastoral theology, ‘a project of deepening faith, of fuller love and service to the neighbour, of augmented sight, hearing, understanding’ (Schlauch 2000, p. 217). Such a process, one supposes, will not give ‘slick and unrealistic answers to complex modern situations’ (such as pre-natal testing), a concern – presented as pastorally motivated – which characterizes Pattison’s proposals (Pattison 2000, p. 142).

Theological ethics has not been fond of explaining its own activity in the ways that Pattison and Shlauch commend. By contrast, the language of ‘moral learning’ has a simplicity to it. It does not consist in constantly adding pieces of new knowledge in response to new situations faced as if there was no standard against which our prior perceptions of experience should be judged. Rather it presents the interlinking of pastoral and moral theology in the form of humble repentance of false perceptions of the objective moral order in order to learn something new. This frees the way to locating an encounter or novel challenge properly in relation to what God has said and done, filling in the outline understanding of the moral order with detail (O’Donovan 1994, p. 188).²

With this said, there are important insights to be gained for ‘following Crowter’ from the interconnection between theological ethics (or moral theology) and pastoral theology. These insights may be fed precisely by the emphases of ‘applied’ or ‘practical’ theology on sensitivity to the event(s) in which I – an ethicist – have participated. In particular, conscious of its inseparability from pastoral theology, moral theology should begin reflection in the company of others, something to which Pattison’s conversational model points. Precisely as a discipline which supports pastoral formation, theological reflection – as a kind of informed self-consciousness – has to do with recognizing the relevance of a new experience to one’s own way of life: for example, of being at once an ordained minister, a parent, a brother to other members of Christ’s family. How might the experience of encountering Heidi Crowter in person alert me – and thus others like me in the moral field – to insights I could only have known in the form I have received them by reflection on that personal encounter? In light of the account of the intersubjective, affectively formed theological ethics given above, emphasis properly falls on reflecting on our affective responses in the company of others’ affective responses to experience: their beginnings of their understanding of what has occurred. For discerning and evaluating what people sorrow over, care about or rejoice in – often the very same things evoking differing or conflicting affections from different people – provides an important entrée into pastorally engaged, ethical reflection.

Such a way of understanding bioethics makes ‘following Crowter’ in the way I have suggested immensely important. Heidi Crowter’s reflective articulation of her life’s experience – of what she thought about how she felt – gives us an ‘indexical sign’, showing a way to enter the moral field.

II. The cry

With all this said to prepare ears to hear, here now are Heidi’s Crowter’s words:

When mum told me about the discrimination against babies like me in the womb, I felt like a knife had been put into my heart. It made me feel less valued than other people.

How may these words be heard with ethical discernment and pastoral wisdom? My theological reflection falls initially into three parts determined by three elements of Heidi Crowter’s words: (a) the knife (b) the heart, and (c) the person. Reflecting in this way will allow for section III’s deliberation regarding institutions, practices and actions which will make for ‘ethical society’, principally focussed on ecclesial life.

(a) The knife

First, consider the knife. More precisely, reflect on the experience of being knifed. Martha Nussbaum has described emotions (or affections) as upheavals of thought – kinds of cognition by which people interact intelligently with the often threatening world. She describes the cognitive emotional encounter with certain events or situations which are outside a person’s control as being like a ‘knife’, plunged into that individual’s underlying wounds. The world is a uncontrollable place which, with tectonic motions, heaves up and strikes us. Individuals are ‘in the hands of the world’ – vulnerable to the world’s sharp movements as they are to a knife. In short, humans are routinely knifed by the world. For Nussbaum, this focusses on the event of her mother’s death, a death which left an incisive mark in her life (Nussbaum 2001, p. 75).

The difficulty with Nussbaum’s account, from the perspective of theological (bio)ethics, is that it lacks a sense of how individual experience may be charted in a unified moral field (Hordern 2013, p. 51). Nonetheless, her thought may be deployed, following Crowter, by construing the knife put into the heart in terms of a species-wide or genetic cohort-wide imagination – that is, in a series of generically similar events. By this imaginative move, one which Pattison might resist but to which Schlauch seems more open, a feeling of being attacked is not a knife simply in one’s own individual wounds related, perhaps, to close significant others – one’s mother perhaps, in Nussbaum’s case. Rather, in being knifed, one may grasp, following Crowter, the way that the same knife strikes against people ‘like me’ – understood in species-wide terms. Such a work of moral imagination alerts us to our kinship and concern for a particular genetic cohort – the ‘babies like me’ of which Crowter spoke.

In this way, the experience of the knife in ‘me’ is associated with the suffering and needs of a group of others who are relevantly similar to ‘me’. Being knifed, an experience engaged through our affections, is not concerned with a risk to my flourishing alone or those closely associated with me; rather it has to do with all people like me. It is not a knife in an individual narrative. It is a knife in a generic human nature; or, in sharper focus, an instantiation of that human nature in those who share, for example, trisomy 21.

This species or cohort wide experience of being knifed, brought to consciousness through affective response and then intersubjectively shared (with those supporting the moral vision of Crowter’s legal cause), shares features with Nussbaum’s account: a cognitive quality to the understanding constituted by the affection; and the relatively uncontrolled quality of the events which occasion such cognition – that actions which feel discriminatory are protected by law make them by definition to some extent outside one’s control. However, the elements which qualifies Nussbaum’s account is the association of the emotional construal of being knifed oneself in relation to the experience of others who are both generically like the one knifed and are yet unborn and therefore incapable themselves of any species-wide affective construal of their experience. For those following Crowter, the experience of being knifed takes on a representative form – being assaulted affectively on behalf of those who, being unwanted on account of their genetic profile, are at risk of being terminated.³

This construal is an assertion of order in the face of uncontrol – that there is a generic intelligibility to the world and a horizon of justice against which being knifed, and crying out against it, is rendered intelligible. Being knifed – though itself a wrong – thus invites the recognition of the unity of born and unborn; the assault provides the opportunity for the born and the unborn to be construed together via the representative cry of the born. In Ochs’ terms, the cry has become a sign – a sign for all of us, whatever our genetic condition. Through the knife put into all one heart, there is in some way the possibility both of a knife into all human hearts which somehow unites those hearts with the hearts of those unborn for whom Heidi’s heart aches. But in what way and how?

(b) The heart

Second, to answer this, consider the double significance of Heidi’s heart into which the knife is put. On the one hand, there is the sense of the ‘heart’ as an enduring cultural symbol of individual interiority (Hordern 2020b): ‘as a symbol of feeling and emotion, the heart is unbeaten’ as the culturally accepted centre of affectivity and identity (Bound Alberti 2010, pp. 155–156). On the other hand, there is the heart as anatomical: ‘the heart of science that is a pump’ (Bound Alberti 2010, p. 166). Understanding the interaction between the two helps us to understand what it means to follow Crowter.

How so? Some doctors in London examined their late termination of pregnancy (TOP) procedure for foetuses, often with a genetic profile like Heidi Crowther’s, over a 5 year period. They report that ‘the main indication for late TOP was chromosomal abnormalities (24.3%), with trisomy 21 and 18 accounting for 56.4% of all cases’ and describe their procedure:

After aspirating 1 ml of fetal blood to confirm correct placement of the needle, strong potassium chloride (15%, 20 mM/10 ml; Phoenix Pharma Ltd, Gloucester, UK) was injected. In all cases, 2–3 ml of potassium chloride was injected first before a further dose (if necessary) to achieve fetal asystole. (Pasquini, L. et al. 2008, p. 529)

They conclude that ‘Potassium chloride injected directly into the left ventricle induces immediate asystole, and it is a safe and effective method of TOP. No maternal or fetal complications were associated with the procedure in our series’ (Pasquini, L. et al. 2008, p. 531).

We should pay attention to the mention of ‘fetal complications’. Unlike Crowter’s cry, which gives a sharp clarity to the ethical challenge to society, these words are more uncertain or ambiguous. For to note ‘fetal complications’ for a fetus being needled to immediate death bears witness to an intriguing kind of thoroughness. Moreover, this study has had some global impact and some similarly strange cries may be detected among those who have deployed similar techniques. A Taiwanese group reported their 10 year findings of fetal reduction in twin pregnancies. Their practice confirmed the findings of the London study. Their procedure is summarized thus:

the obstetrician utilizes a 22G × 150 mm needle (TOP Corporation, Japan) to puncture the left ventricle of the fetus and administer potassium chloride (KCl) to induce asystole. The first dose of KCl is 2–3 mL, and an additional dose (1–2 mL) could be given if bradycardia is not observed. (Sung, C-A. et al. 2022, 213)

The case of twins – of two hearts in one womb – raises an issue:

It is crucial to identify chorionicity in twin pregnancy. The placenta in dichorionic twin [sic] is separated that made it possible to perform intracardiac injection of KCl for inducing asystole. However, rich anastomosis in the placenta allows KCl to affect the other fetus. To avoid the effect of cardiotoxic agents toward healthy fetus [sic], selective feticide in monochorionic twin [sic] is suggested to be completed with radiofrequency ablation in the umbilical cord. (Sung, C-A. et al. 2022, p. 215)

Their conclusion is that ‘intracardiac injection of KCl was effective for feticide and safe for mothers and surviving fetuses’ (Sung, C-A. et al. 2022, p. 215). We may note especially the implied contrast between the monochorionic twins – with the one designated for survival deemed ‘healthy’ and the other, by implication deemed not healthy. This contrast points to important concerns about ‘disability’, health and the human person. The Taiwanese team’s choice to distinguish between the fetus with trisomy 23 and the ‘healthy’ fetus leads them, perhaps unwittingly, into what counts as normal functioning in disability ethics. Unfortunately, there is insufficient space to examine them in detail. Instead, the focus will be on the strange cry which follows these words.

For with respect to the fetus into whose left ventricle the needle is inserted, they say the following: ‘The comfort and dignity of the fetus count throughout the period of terminal care’ (Sung, C-A. et al. 2022, p. 215). If a hearer attends both to the Taiwanese teams’ report and to Crowter’s cry, she may be puzzled by this last sentence. For how could the comfort and dignity of the foetus count when a needle, effective for feticide, is being inserted into the foetus’ heart? Moreover, how does the comfort and dignity of the foetus to be needled count alongside the foetus who is not so injected? Read charitably, it seems as though a serious engagement in the moral significance of a foetus is being endeavoured by those responsible for the termination of its life.

Ford’s claim was that ‘Doing justice to diverse cries is at the heart of this theological wisdom’ (Ford 2007, p. 5). Here is one example of just such cries, in which the diversity takes the form of some strange admixture of conflict and concord as Crowter’s cry mingles with that of the London-based and Taiwanese doctors. ‘Doing justice’ in this case is hard. On the one hand, there is Crowter’s heart-cry, shocked that foetuses with a chromosomal profile relevantly similar to her, are judged acceptable targets for termination. On the other hand, there is the willingness to terminate such foetuses combined with belief in the moral significance of their comfort and dignity.

What matters for theological ethics, in the mode described above, is that cries may be in genuine conversation with one another precisely because they are responding not so much to the same single event but rather to classes or ‘series’ of generically similar events in a unified moral field, in which the standardized technique that the London group developed is repeatedly deployed. Here then is not a single ‘experience’ to be reflected on; but a set of events, experienced by people who may communicate with one other, involving multiple forms of ambiguity that require ethical clarification. What matters for pastoral theology should be reflection in relation to all the parties involved, avoiding arriving too quickly (or ‘slickly’ in Patterson’s terms) at a moral discernment which does not reckon with the complex networks of interest and vocation in which cries are uttered. For the clinicians too have vocations they seek to exercise, in which they understand themselves, to have important obligations even for the foetuses whose lives they seek to end.

This observation sheds light on what moral theological reflection on experience might mean for a bioethics applicable to an ethical society. Such bioethics requires noticing and problematizing different experiences of similar events, identifying the kinds of moral concern they signal, placing them in conversation with each other as important reference points for discerning both the right course of action and appropriate forms of ethically informed pastoral response. For Christian moral theology, the moral order undergirding the experiences under examination is what provides the unified moral field for ethical enquiry and pastoral care, both for those being knifed or needled in the heart (whether ‘symbol’ or ‘pump’) and for those, albeit concerned with comfort and dignity, who terminate foetuses which (or who) are relevantly similar to Heidi Crowter.

(c) The person

Third, consider the person. The London medical team wrote about certain unusual cases in their practice:

cases of failed feticide … have enormous emotional implications for women and significant financial consequences for the hospitals concerned. (Pasquini, L. et al. 2008, p. 530)

As with ‘comfort’ and ‘dignity’, so with these words. They bear witness to complex sensitivities and liabilities with which doctors work. They constitute a kind of cry, discordant amidst the procedure because occasioned by when the procedure has gone ‘wrong’. That cry attends to the person of a woman seeking termination whose desire is not fulfilled and who is then left with complex, perhaps ambiguous emotional debris in her life. It also attends to a certain kind of legal person, namely a hospital. What is missing, naturally enough for the doctors involved, is the person of a fetus.

Against this cry, Crowter’s cry sounds a discordant note:

It made me feel less valued than other people.

What then are the emotional implications for babies with trisomy 21, or some other genetic condition, who, for whatever reason, are not ‘screened out’,⁴ and come to birth and perhaps also to mature, reflective participation in society. For an individual person to feel less valued than others is sadly common. However, for this feeling to be applied to a whole group of people and then reinforced by a widely used procedure backed by the force of law and deeply embedded professional mores, cuts deep. That the law should permit the wielding of an emotional or affective knife in this way to an equal neighbour and citizen, Heidi Crowter, indicates a site of significant societal confusion and pain which needs therapy.

Crowter’s own statement provides the basis for weaving together her experience of the knife in the heart within a certain kind of therapeutic social theory. A theological resource will, I suggest, aid the bioethical imagination here. In Luke’s gospel, an older man, Simeon, encounters the infant Jesus at the Temple in Jerusalem with the words:

 for my eyes have seen your salvation

that you have prepared in the presence of all peoples. (Luke 2:30–31)⁵

He blesses the family, saying to Mary:

Behold, this child is appointed for the fall and rising of many in Israel, and for a sign that is opposed (and a sword will pierce through your own soul also), so that thoughts from many hearts may be revealed. (Luke 2:34–35)

Simeon’s cries have double significance interlinking heart, knife and person. First, there is the revelation of encounter made intelligible by placing this Lukan passage in conversation with John’s gospel (a subtly different kind of conversation, I note, than Patterson proposed). Spaemann remarks that the Johannine meaning of sin is found in the unwillingness of people to believe in Jesus – ‘they loved darkness rather than light’ (John 3:19) and ‘they do not believe in me’ (John 16:9). Spaemann observes that this orientation is set by ‘the heart [which] is always in control but makes its own decision as to who or what it will accept direction from’ (Spaemann 2007, p. 20).

A cry of ‘a knife being put into my heart’, set within this Lukan-Johannine conversation, invites a further question as to how the heart is already being directed, when knifed in this way. Spaemann explains that ‘in the New Testament evil is the basis of ignorance, not, as for Plato’s Socrates, ignorance the basis of evil … The term ‘heart’ underlies [this] development, and so amounts, more or less, to the discovery of the person’. Noting that it is encounter with Christ which, for John, reveals sin, Spaemann concludes that ‘Truth itself appears … as the unique countenance of another individual person’ (Spaemann 2007, p. 21). A person’s heart direction is determined by their orientation to the face of Jesus Christ.

Construing together Simeon’s encounter with the infant Jesus and Heidi Crowter’s experience of a knife in her heart, we observe that the revelation of Christ’s countenance and the experience of the world’s evil will both occupy the heart. Encountering evil in the light of the face of Jesus Christ means, for Crowter, the recognition of persons who, despite Christ’s countenance, were assigned lower value than other persons.

Second, there is a strange unity of persons made possible by encounter with Christ. Simeon’s words foretell Mary’s ‘soul’ uniting with her child’s future through a promised piercing. It is as if two persons were joined, heart and soul, by a single, straight skewer – fully aligned with one another through pain and sorrow. The sword which pierces Mary affixes her to this child. This image interprets the kind of interpersonal unity which Heidi Crowter’s words attest: a heart and soul unity between herself and those whose hearts (as pumps) are pierced by needles in utero. This strange, pierced unity in turn creates a division between herself – and those relevantly similar to her – and another section of society, the ‘other people’ with apparently greater societal value. Moreover, Crowter’s cry spotlights the strange thoughts of the heart, observed among doctors in London and Taiwan, revealed and available for charitable conversation.

What follows for a social theory of persons is this: a knife in the heart of one may, as with a single skewer, unite that person to the hearts of those yet unborn in such a way as to illuminate the somewhat conflicted thoughts of the hearts of many others. Just as Ochs, Ford and Augustine suggested, paying attention to cries provides bioethics with a sharp point, an indexical sign.

III. Remedy for a knife in the heart: compassion, ecclesial life and ethical societies

There is now a concluding ethical question requiring resolution: what remedy, if any, should there be to this knife in the heart, to a cry occasioned by needles in other hearts that are felt to sharply discriminate the worth of some from others on the genetic grounds?

An ethical society will attend to and discern the significance of cries. In so doing, it will give content to what is meant by ‘compassion’, understood primarily as a kind of social event (Hordern 2020a, chapter 2). Cries are not heard in a vacuum but in specific societal context. To identify how to understand Heidi Crowter’s cry, following our methodology, it seems right to pay attention to her own societal context. In a radio interview, she focussed examination of ethical society at the level of ecclesial life.⁶ She foregrounded the role of her pastor, as someone who accompanied her from just after her birth through her journey of faith through baptism, into marriage and into societal debates and law. Her account suggests a certain kind of covenantal, compassionate accompaniment beginning in the possibilities for ethical society which are found in the sacraments of the Christian church, developed in family and marriage and disseminated out in other aspects of political community. Through such ecclesial accompaniment the individual experience of being knifed may become a social experience: a knife in our heart – a first person, societal plural, a oneness of heart.

(a) Ecclesial life

Reflecting on Galatians 4:21–31, St. Augustine speaks of

a community, where there is no love of a will that is personal and, as we may say, private, but a love that rejoices in a good that is at once shared by all and unchanging – a love that makes ‘one heart’ out of many, a love that is the wholehearted and harmonious obedience of mutual affection.

This account of the ‘unum cor’ of an ethical society (the City of God) emerges from reflection on what Isaac, the ‘child of promise’, signifies (Augustine 1972, XV.3).⁷ The barrenness of Abraham and Sarah was a sign, Augustine says, of humanity’s lostness. But Isaac signifies the citizenry of a people who, by grace, dwell together in peace, are of one heart and share a wholehearted, obedient affection. Thus an unexpected, unusual child of grace prefigures the single unity of heart to which all people are called.

So integrated is this people – so interwoven are their hearts as one – that a knife, sword or needle penetrating one heart would be inseparable from a needle penetrating them all. This is the theological context for the social theory Crowter’s cry suggested, which construed on one ‘skewer’: first, the experience of heart-felt pain at unjust discrimination; second, the cultural symbolism of the heart; and third the foetal heart-as-pump into which needles are inserted. By this single, sharp, painfully united perception, for those pierced by it, the knife in one’s heart is about the needle put into a hearts of many.

With this in mind, two signs constituting two specific forms of personal encounter hosted in ecclesial life, indicate how life in ethical society should be. First, there is marriage, and by extension, vocation. Heidi Crowter’s church, through the accompaniment of her pastor and others, supported her marriage to the ‘most joyful person [Heidi] knows’, James, who shares with her not only marriage but also trisomy 21.⁸ This sign constitutes a specific context for intensification of personal encounter and the discovery of vocation. The Church of England categories vocation as relational, social and ministerial (Church of England Faith and Order Commission 2020, pp. 26–30). Crowter’s testimony indicates that the ministerial vocation fulfilled by her pastor, and by her wider family, has equipped her for both relational (marriage) and social (public advocacy) forms of vocation.

A major ecumenical statement on church and disability extends this microcosm of ethical society, observing that churches’

… guiding principle must be the conviction that we are incomplete, we are less than whole, without the gifts and talents of all people. We are not a full community without one another. Responding to and fully including people with disabilities is not an option for the churches of Christ. It is the church’s defining characteristic. (Ecumenical Disability Advocates Network, World Council of Churches 2003, §87)

Similarly, another ecumenical statement calls the church

to think not only of mission among those with a disability, but to recognize, affirm and facilitate the missional calling of believers with disabilities themselves as part of the Body of Christ. (Lausanne Movement 2010, §2.IIB.4)

What is seen in intensified form in Heidi’s Crowter’s marriage and vocation coheres with a total manifesto for vocation in ecclesial life.

Second, there are the sacraments of baptism and communion, signs to company-keeping with those threatened with knives and needles, places in which society encounters the full lives of those living with Down’s in the joyful community life that Augustine described: Crowter testifies that her church ‘loves [her] outlook on life’.⁹

By way of further theological reflection, consider communion (the eucharist) where we find a traumatic event – the death of Christ – given a liturgical form inclusive of all. The cries of Christ from the cross are brought to mind in the breaking of bread. They provide an acoustic space in which the cries of others can be brought into conversation – whether Heidi Crowter’s cries or those strange, ambiguous words of the London-based or Taiwanese doctors. Reconciliation is held out in Christ’s cries even amidst their discordancy. In the eucharist, hearts may be stitched together into the heart and whole body of Christ. Christ’s nailed hands and feet and Christ’s speared side are aligned on one ‘skewer’ with the knifed heart of those sorrowing over the termination of foetuses with trisomy 21; but also with the needled hearts of those foetuses and even with the confused thoughts of the heart of the clinicians. The same ecumenical statement cited above further observes that the ‘church is by definition a place and a process of communion, open to and inviting all people without discrimination’ (Ecumenical Disability Advocates Network, World Council of Churches 2003, §85).¹⁰

However, the public statements of churches are not straightforward in terms of how to guide ethical society. The Church of England general synod passed a motion concerning Down’s syndrome which was good in many respects.¹¹ However, in respect of pre-natal testing and termination, it seemingly spoke with a divided heart by seeking to ‘affirm the dignity and full humanity of people born with Down’s syndrome’ rather than that dignity and full humanity ‘before and after birth’ as some had proposed. Here then, no single skewer unites hearts; rather hearts are askew from one another. One observer asked:

Am I the only one finding it a bit odd that we want to make a wide statement in Synod about the inestimable value of people with Down’s Syndrome … as long as we don’t upset those who are happy to allow their pre-natal termination? (Paul 2018)

The challenge for the Church of England, which holds a clear position opposed to abortion, is how far it will follow the voice of people like Heidi Crowter in its public speech, while sensitive to communication challenges in a complexly plural society and to pastoral needs among both clinicians and those facing unexpected and difficult questions in pregnancy.

Crowter’s words summon churches into oneness of heart. To follow her cry is to extend self-imagination such that the single heart of the born who share ecclesial life is united – affixed and aligned as with a skewer or sword – to the unborn hearts at risk in utero. How the church construes the terms ‘comfort’ and ‘dignity’ should not display a divided heart but rather oneness. The comfort with which the church is concerned is achieved by the Holy Spirit precisely in the context of affliction (2 Corinthians 1; Hordern 2013, 277–279). When attentive to cries of affliction, ‘comfort’ or ‘dignity’ seem impossible to reconcile with the action of inducing asystole in a fetus; or of selecting one of two twins in which to induce asystole. In this sense, Heidi’s words invite an exegesis of Scripture and of the heart of ecclesial life in new and surprising ways. The summons to oneness of heart with her and with those unborn who are, in the relevant sense, like her, crystallises a vision of the church’s strange vocation to be an ethical society.

(b) Ethical society

In conclusion, these reflections suggest a substantive ecclesial meaning to ‘compassion’ as a societal event whereby hearts are aligned in affliction and comfort. This may be contrasted with Jonathan Herring’s account of the public good of abortion as a corollary to an ethics of ‘care’. What may be agreed between us is that ‘Law which ignores or undermines emotional values will be ineffective in seeking to promote’ (Herring 2019, p.3), either ‘care’ or ‘compassion’. Edmund Burke claimed that ‘public affections … are required sometimes as supplements, sometimes as correctives, always as aids to law’ (Burke 1999, pp. 77–78).

However, more generally Herring’s vision represents a vision of ethical society contrasting sharply with the one presented above. His analysis insists that what ‘will be caring, will depend on … particular individuals and their obligations. What will meet one person’s needs, cannot be generalized’ (Herring 2019, p. 5). This contextualizes his notion of ‘coerced care’, used to describe the circumstances of an unwanted pregnancy (Herring 2019, p. 10). His view is that ‘the ready availability of abortion’ enables women with an unwanted pregnancy to ‘meet the caring responsibilities they currently [or may] face … and to care for themselves’ (Herring 2019, p. 14). This view of care, he admits, is directly opposed to those who have argued that an ethics of care should emphasize the moral value of the corporeal and other forms of relationship that pregnancy enables.

What I hope that my analysis of the heart has shown is that there is a compelling way of understanding human interconnection which incorporates the arguments of those who adopt an ethics of care to argue against abortion as a legitimate practice (e.g. regarding the intimate relationality of foetus and mother); but which goes beyond that to explain the kinds of generic, cohort-wide relationships of care that Herring’s position occludes on account of his focus solely on the foetus’ relationship with the immediate would-be maternal carer. Herring’s position makes little sense of the kind of care relationships we have in society generally, and which he himself has paid extensive and illuminating attention: for example in care of the elderly or of children estranged from their parents. To render the moral significance of the relationship between mother and foetus as screening out all other relationships of care as less significant to the point of moral irrelevance seems implausible.

Herring is aware of the ‘wider societal factors influencing abortion’ and holds that abortion is a ‘public good because it is a way of responding to inequalities within society’ (Herring 2019, p. 12). But he gives no thought to the inequalities which arise on account of abortion between cohorts defined by their genetic profile. Admittedly, Herring’s argument is at a more general level and so his ethics of care might provide discerning attention to such relationships of care. However, although a focus on the caring relationships of a pregnant woman is reasonable, the neglect of other forms of caring relationships seems a serious and necessary side-effect of Herring’s position. For if the account of coerced pregnancy is simply that it is unwanted then his position would be impervious to the care that Heidi Crowter’s cry signifies, as someone biologically unrelated but genetically similar to an unborn foetus with Down’s.

In support of his defence of the obligations of caring relationships (and to self-care), Herring reports approvingly the words of a woman who, while wanting to maintain a pregnancy, says ‘sometimes what one wants isn’t right’ (Herring 2019, p. 14). However, compassion ought not to mean acquiescence to the perspective, the wishes, the wants of the other (Hordern 2020a, pp. 39–41). Thus there is some agreement here then, that wishes should not be acceded to just because they are the subject’s wishes. However, what Herring denies on the one hand he has already affirmed by untethering the ethics of care from any universal considerations and tying it solely to the needs of the individual, at least in the case of abortion. This is not at all the path of compassion, if one were to follow Crowter. For her cry identifies an objective wrong which is not tied to the needs of an individual but to humanity at a generic level. When such cries become signs, the possibility of a civically potent compassion arises. In such compassion, the intersubjective affections of those who utter and those who hear become united (Hordern 2020a, p. 301).¹²

So how might these reflections become practical, bearing upon what should be done to enhance a (bio)ethical society? Burke also spoke of the unity of the dead, living and the unborn in terms of a contract, whose terms may not be set aside by the mere fact that some parties to it have not yet appeared visibly on the scene as independent actors. Such an inter-generational vision can empower covenantal, compassionate accompaniment. Church life, marriage, sacramental practice and public speech are practical, concentrated, trans-generational forms of such accompaniment which witness to the equal value of all human life. They act as focal points whereby cries may become signs for ‘us’, a first person plural who share in them. Over time, it may be hoped that such cries, reflected upon and learnt from at an ecclesial level and in other forms of human community which constitute pluriform society, will permeate societal institutions.

If that were the case, then one might expect that an ethical society, which recognizes the dignity and full humanity, before and after birth, of people with Down’s syndrome will, for example, (i) enhance the quality and timely provision of educational plans that UK local authorities are required to draw up to support children and families living with Down’s; invest in ensuring the culture of schools and higher education is fully inclusive of such people and adress the stigma and discomfort which people with Down’s experience (ii) invest in supporting the vocation of people with Down’s syndrome (iii) tackle any culture in healthcare professionalism which systemically values the lives of those with Down’s syndrome as less than others (iv) reach court judgments, or changes to parliamentary legislation, or amendments to the regime of rights by which societal life is governed which attest the equal dignity and vocation of all people, including those with Down’s syndrome, and not forgetting those with other genetic conditions subject to pre-natal testing.

It seems reasonable to be sanguine about how long change in any of these areas might take. As Brian Brock notes, the human heart is profoundly resistant to being claimed and reshaped by difference (Brock, 2019). The length of a journey is a proper thought for the period of Lent when the conference which gave rise to this special issues was held. During Lent, the church reflects on how all Christian bodies are temples of the eternal Holy Spirit, places of living, blood-pumping physicality in which God incarnate kindly seeks to tabernacle, within and among us, which are vindicated by the resurrection of Christ, and which are now united in one heart to the Christ who was pierced for our transgressions.

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Notes on contributors

Joshua Hordern

Joshua Hordern is Professor of Christian Ethics at the Faculty of Theology and Religion and a Fellow of Harris Manchester College in the University of Oxford. He is author of Compassion in Healthcare: Pilgrimage, Practice and Civic Life (OUP, 2020). He is a former member of the Royal College of Physicians Committee for Ethical Issues in Medicine and co-author of Advancing Medical Professionalism (RCP, 2018).

Notes

1 I note especially the scholarship of Katrina Scior on this point. While I will refer to Down’s syndrome here in light of close attentiveness to Heidi Crowter, it is right to draw attention to other conditions similarly patent to screening, notably Edward’s, Patau and Turner.

2 It is striking that the first instance that O’Donovan gives of moral learning is ‘that a culture discovers for the first time the importance of treating human beings as “persons”’ (O’Donovan 1994, p. 118).

3 Nussbaum’s imagination does not run in this way, or so it seems (Nussbaum 2001, p. 417; cf. Hordern 2013, p. 62); nor apparently does the imagination of another lawyer who is attentive to the role of emotions in law (Herring 2019).

4 See https://dontscreenusout.org.

5 All biblical quotations are from the English Standard Version.

6 Accessible at www.premierchristianradio.com/Shows/Saturday/The-Profile/Episodes/Sir-Cliff-Richard-My-faith-has-never-been-stronger-Heidi-Crowter-The-Down-s-Syndrome-campaigner-fighting-for-a-change-in-abortion-law.

7 Cf. the relevant original Latin: ‘ … significat Isaac, per repromissionem natus, filios gratiae, ciues ciuitatis liberae, socios pacis aeternae … ’

8 Accessible at www.premierchristianradio.com/Shows/Saturday/The-Profile/Episodes/Sir-Cliff-Richard-My-faith-has-never-been-stronger-Heidi-Crowter-The-Down-s-Syndrome-campaigner-fighting-for-a-change-in-abortion-law.

9 Accessible at www.premierchristianradio.com/Shows/Saturday/The-Profile/Episodes/Sir-Cliff-Richard-My-faith-has-never-been-stronger-Heidi-Crowter-The-Down-s-Syndrome-campaigner-fighting-for-a-change-in-abortion-law.

10 Emphasis added.

11 www.churchofengland.org/sites/default/files/2018-02/Voting%20results%20-%20Item%2016%20%28February%202018%29.pdf.

12 The discernment of the cries of neglected, often invisible elderly may be applied similarly to the largely invisible people with Down’s whether born or unborn.