Biblical Reflections on Modern Medicine
Vol. 11, No. 1 (61)
Moral Issues Can/Should Dictate Medical Practice
I begin my 11th year of Reflections. I began my first issue in January 1990 by discussing the Nancy Beth Cruzan case. Nancy was one of the most publicized cases of persistent vegetative state over the past two decades. She had suffered brain damage from an automobile accident on January 11, 1983. Her parents went to court and won the right to have her feeding tube removed. She died on December 26, 1990.
The first year of Reflections, I also published, "The Rest of the Story." That article took to task many people in the pro-life group for going to extremes in prolonging death. One specific and central issue was/is feeding tubes. I contended then, and do so now, that feeding tubes (both nasogastric and gastrostomy) are medical procedures that are overused and have severe complications. As such, a decision not to insert them when a patient becomes unable to swallow is frequently within Biblical parameters.
With this position, I have been a voice crying in the wilderness of pro-life spokesmen. Others say that withholding food and water by not placing such tubes cannot be Christian! We must uphold the sanctity of life.
The October 13, 1999, issue of The Journal of the American Medical Association (pp. 1365-1370, 1380-1382) published a review of MEDLINE (an online medical database) from 1966 through March 1999 for articles on tube feeding in the severely demented.
Biblical ethics does not require empirical evidence for validation. (Some Christians contend differently, but they are woefully wrong!) However, if one has exegeted and deduced properly, and one has done good research, there should be considerable congruence.
This review destroys much of the position for those who contend that food and water by all routes is indicated. Granted, this study is limited to "severely demented patients." However, it is this group that comprises the large majority of patients with feeding tubes. Further, it is likely that many of the complications of tubes in these patients also occur in other patients, as well.
The principles that apply here are these. 1) Food, water, and air by natural routes should not be denied to anyone. (It amazes me that "air" is frequently omitted.)
2) Medical care that is not clearly effective or harmful may be refused. Tube feeding, as I have contended and this review points out, does not prolong life and brings its own severe complications.
One reason that pro-life writers and speakers make errors is that they make "sanctity of life" an absolute. It is a high Biblical principle, but not an absolute. For example, physical health and life may be placed at great risk to go to a third-world area to present the gospel of spiritual health and life.
Another example is more serious to a consistent pro-life and Biblical ethic. That is, there are three Biblical instances where life can be legitimately taken: self-defense from an enemy, officially declared war, and capital punishment.
Other principles supersede the "right to life" of others in these situations: the right to protect oneself from enemies, to defend one's country, and to punish those who commit capital crimes. I will not discuss these in detail. I have done so many times, and others who have discerned correctly may be consulted, as well.
There is one particular item that I would like to point out. Capital punishment actually elevates "sanctity of life" to a higher level than the position of those who are pro-life who deny its application. God said to Noah.
Whoever sheds man's blood,
In other words, one man's life is so valuable because he is made in the image of God that his murder requires the death of his murderer. The opposite position minimizes the value of man, and really of God Himself. It holds lesser values of man (as any unbiblical position does).
Another pro-life error is building one's position on falsehoods. Relative to tube feeding, the horrors of dying by dehydration have been overly dramatized. For example, sunken eyes, hollow cheeks, and loose skin are cosmetic effects that disturb the onlookers, but cause no pain or discomfort to the patient. Also, the admission of the complications of tube feeding have been rarely (if at all) discussed by those who contend for them.
The article, "The Rest of the Story" (mentioned above) was originally written for one of the leading pro-life publications. In it, I outlined the complications of feeding tubes and prolongation of death in severely and chronically ill patients. The article was intended to balance a strong, if not harsh, article against dehydration as a cause of death because of the withholding of feeding tubes. (I am not publishing names because I do not have the Editor's permission to publish his personal response to me.)
The Editor responded.
His position is dishonest. If there are problems with a position, it is wide open to attack. Open, honest discussion within one's own camp is not deleterious to one's position unless that position was vulnerable from the start. (To the above Editor's credit, he said at the end of the letter, "I want others here to read it" [your letter].)
It is possible that Christians have taken these unbiblical "sanctity of life" positions because of their alliance with non-Christians who cannot imagine that capital punishment could be consistent with a pro-life position. But, such nuances and distinctions are revelations by God Himself. God is God with His attributes of harsh justice of total annihilation of enemies in the Old Testament and eternal condemnation of unbelievers forever in the New Testament. Yet, He is the giver of eternal life at the very time that He condemns man to death and banishes him from His presence (Genesis 3).
Ultimately, wrong ethics come from a wrong view of Biblical truth which is a revelation of God Himself. The great message surrounding dying and death is not as much the horror of it, as the fact of it. We die because God condemned us after Adam and Eve's sin. Paul said that death is the "last enemy."
We let pictures and emotions color our ethics. For example, the death of a child is not worse than the death of an old person, but we discuss and act as though it is. The fact that death occurs to anyone is the horror, not the particulars. And, the character of God must be at the root of one's ethics to be fully and consistently Biblical. God is just and He is love. I am afraid that the pro-life camp has not been focused on these truths and has promoted errors on that basis.
I continue to be amazed with an attitude of worship at the congruency of Biblical ethics. Nuances, like those of truth-telling (elsewhere in this newsletter), fall into place like the pieces of a jig-saw puzzle. And, Christians who have never discussed such matters with each other find a harmony that could be explained only by the Spirit of God at work in them with His Word.
Again, empirical evidence does not determine Biblical truth. But, we must evaluate our understanding by comparison and contrast of both. Properly understood, they will be congruent. This review article concerning the realities of tube feeding roughly corresponds to Biblical truth. The pro-life movement would be well-served by a more logical and rational Biblical understanding of the issues and of God Himself.
"No man can serve two masters." Many physicians have tried to do just that in the form of serving their patients' interests, as well as the interests of insurors. More evidence of the vanity of this practice was published recently (Archive of Internal Medicine, October 25, 1999, pp. 2263-2270). "Many physicians sanction the use of deception to secure third-party payers' approval of medically indicated care" (p. 2263).
In some cases, more than half of the physicians would indicate that they would deceive the third party. Physicians whose practices were predominantly in managed care markets were more likely to practice deception. A minority of physicians would not practice deception in any circumstances.
Though it is much disputed among Christians, I take the position that not all untruth constitutes the sin of lying, just as not all killing is murder, not all sexual intercourse is incest, and not all taking is stealing. Old Testament "case law" helps us to understand the application of the statutory law. The sin of lying is withholding the truth from those who have a claim on it. This exception of an illegitimate claim would, it seems, be rather rare in medicine.
Perhaps, if a physician were captured by an enemy army and employed by his captors in the medical care of his fellow prisoners, it could apply. If his captors demanded that he identify all those prisoners who had emphysema, and he knew that those so identified would be executed as unfit for work, he would be sinning in identifying them. He would be justified in misleading his enemies. The New Testament praise accorded the Hebrew midwives and Rahab would constitute the core of the defense of my position.
This rare exception, however, will not cover lying to medical "third parties," however popular they are with physicians and patients. When a physician signs on with a third party, he is agreeing that the insuror has a legitimate right to know. If the physician does not agree, he may refuse to do business with that third party. Yes, there are very significant effects on his ability to practice his craft up to and including being effectively unable to practice medicine. Telling the truth is not necessarily the least expensive route to take!
Our nation may be posed a difficult decision, if and when the swelling government tyranny completely usurps medical care and transforms its every subject (no longer "citizen") into a medical slave. Physicians would then be in a position analogous to a slave who has been appointed to oversee a portion of the plantation's other slaves. Plans are already well afoot to make every encounter with any health practitioner a matter of federal record and potential scrutiny, without patient consent.
Every treatment would be subject to permission or denial. Physicians would have no legal "opt out" provision except to surrender their job entirely. This scenario may be a little different from options to contract or not contract with private "third parties," though I doubt it. By the premise above, one would have to conclude that the civil ruler had become no legitimate ruler and was instead an enemy in order to render untruths without sinning. If one had concluded that way, it would make more sense to turn in the medical license and practice without one, with all the risk that that entailed.
Dr. Terrell has pointed out an area that "is much disputed by Christians," but it ought not to be. The Bible is quite clear on the subject. I once struggled with this subject and eventually wrote a section for my first book. The subject is sufficiently important that I reproduce that section in this newsletter. See "The Importance of Truthfulness in Medical Care."
South Carolina's public health authorities have announced a federal grant from the Centers for Disease Control and Prevention to prepare for the covert, deliberate release of a biologic agent (Epinotes, Vol. 20, Nov. 1999, p. 5). Reading between the lines of the announcement, it appears that domestic "germ warfare"-type terrorism could be almost hopelessly difficult to recognize before it had caused considerable havoc. Physicians have no experience in recognizing some of the more fearful possibilities and the signs and symptoms of many are scarcely unique.
A reliable saying in medicine is that a particular set of puzzling findings is more likely to be caused by an uncommon manifestation of a common disease than it is to be caused by a common manifestation of an uncommon disease. For such infections as anthrax or smallpox, however, this aphorism would be exactly wrong.
If a terrorist managed to release a highly infectious agent into a closed space, such as a sports arena, there would be some hope of early recognition. On the other hand, a 5 percent infection rate from a continuous release in an air terminal could well go unrecognized for a long time until someone was astute enough to recognize the unusual ailment for what it was, look for other cases of rare infections, and then take steps to back-track to the common source. This kind of public health activity is a health activity which is Biblically legitimate for the civil ruler.
Infectious organisms, however, are likely to prove to be too difficult for "practical" terrorist use. More worrisome, albeit more recognizable, would be chemical toxins. I am glad that I have no interest in spectator sports.
Ed's note: The following is quoted from my book, Biblical/Medical Ethics, pp. 116-119, now out of print.
(Physicians) should not lie, it is a sin. "You shall not bear false witness against thy neighbor" was God's command from Mt. Sinai (Exodus 20:16). God's very nature is truth (John 14:17, 15:26, 16:13, I John 5:6). His Word is truth (Hosea 10:13, Amos 2:4, I John 2:4, 22). This realization prompted John Murray to conclude.
The Biblical position and goal for the Christian is truthfulness in thought, word, and deed in every area of life -- including the practice of medicine. Traditionally, lying to patients has been considered a prerogative of the physician for the good of his patient. Plato, in The Republic, wrote that the physician should embrace skillful deception, as a means of medical treatment (Steve Holve, "Truth Telling in Medicine: An Historical Perspective," Society for Health and Human Values, 925 Chestnut St., Philadelphia, PA 19107).
The Hippocratic Corpus (of which the Hippocratic Oath is a part) instructs the physician to reveal "nothing of the patients' future or present condition." Alexander Dumas was explicit in his Camille, "When god (sic) said that lying was a sin, He made an exception for doctors and gave them permission to lie as many times a day, as they saw patients." A trend towards candor is occurring, but regardless of the current non-Christian thought, Christians should tell the truth because the Bible is explicit in its command.
The manner in which truth is presented must be guided by the "fruits of the spirit." One would think that gentleness and kindness are obvious, but too many physicians seem to be ignorant or insensitive to patients. Instead of informing the patient of a serious problem in a clinical and curt fashion, the physician should set aside proper time to answer questions.
Later, followup would allow further questions and concerns to be voiced by the patient. Insensitivity to the confusion and mystery of medical terminology and medical milieu are frequent errors by physicians. The patient's concerns need to be anticipated, even actively sought, because strong emotions may prevent his ability to verbalize these concerns.
A second factor in truth-telling is its timing. Drugs, physical traumas, procedures, and other events may markedly reduce the patient's ability to concentrate and to remember. These circumstances are commonplace to the physician, but emotionally overwhelming to patients. The best time to inform a mother that one of her children has been killed in an auto accident is not in the emergency room as she is being stabilized for blood loss and injuries which she herself has sustained in the same accident (assuming that she is not consciously and continually asking about the child).
In another situation, a patient will probably recall nothing, if told the results of his surgery as he is awakening from anesthesia. Ideal situations are difficult to plan, but every consideration should be given the patient who receives bad news. An instance in which unnecessary delay should not occur is terminal illness and the spiritual urgency of such situations should not be overlooked.
After a lengthy discussion of several Bible instances, John Murray concludes that "the Scripture confronts us with difficulties," but it necessarily establishes the Biblical concept of truthfulness (Ibid, 146).
Two principles emerge. First, partial disclosure of truth may be appropriate, rather than untruth (Samuel at Bethlehem). Second, a concealment of truth is warranted from those who have no claim upon it (Joshua's deception at Ai).
These principles are essential to the truthfulness which may be complicated in medical practice. Partial truth is only permissible because of (the constraints of time), and medical facts exist as probabilities rather than unchanging truth. In any particular situation, all contingencies are too numerous to cover or even to predict! Thus, the physician must decide what he will (and will not) tell his patients.
Great latitude, in both the content of the information and its emphasized points, is possible for the physician. This complexity is illustrated by a study in which the method of presentation determined whether a patient would choose surgery or radiation for lung cancer (The New England Journal of Medicine, May 27, 1982, pp. 1259-1262). Another study on the avoidance of laryngectomy (taking the vocal cords out, leaving a person unable to speak) has shown that patients would choose a lessened chance of survival in order to preserve their speaking ability (Ibid.).
As early as 1903, a physician provided evidence that the truth did not harm the patient (Holve, "Truth Telling..."). In addition, real benefits have been found to occur: "pain is tolerated more easily, recovery from surgery is facilitated and compliance with therapy is markedly improved." Thus, empirical, medical evidence and Scripture agree that truthfulness is both influential in the patient's decision and that it positively affects his prognosis. A physician's concern ought to be, if medical disclosure is impossible, a partial presentation of truth which would most honor the God of truth.
The second principle, concealment of truth, has no application in medical practice. In Scripture, each situation involves concealment from an enemy. Clearly, the physician is not the enemy, rather he is the patient's advocate. The patient is responsible for his body and should seek knowledge of his health. Physicians are wrong to withhold information. The patient should know at least as much as any family member (emphasis not in original). Although pragmatic value is not necessary to validate Biblical truth, a benefit of this principle is that no family member need be concerned about information that the patient might hear inadvertently.
A method that would facilitate patient and family understanding would be to assemble all concerned. The patient would have to give permission since only the spouse or parents have the moral and legal right to access the patient's medical information. Much time could also be saved by the physician.
John Murray has provided what may be the best and most thorough review of truthfulness and its nuances (as discussed above) that has been written. With emphasis that God is Truth, there are nevertheless situations in which partial disclosure or even deceit are ethically necessary. Readers are referred to that chapter in his book, Principles of Conduct (Wm. B. Eerdmans Publishing Co., also available from <amazon.com>).
(Ed's note. Both physicians and laymen use "flu" rather loosely to describe a host of conditions attributable to viruses, from "colds" or upper respiratory infections [URIs] to vomiting and diarrhea. However, the word "flu" comes from influenza, a specific viral disease that causes high fevers, chills, and upper respiratory symptoms [stuffy nose, post nasal drainage, hacking cough that may or may not be productive, etc.].
When the Centers for Disease Control and Prevention or physicians talk about the "influenza vaccine" or "influenza outbreaks" they are referring to this specific virus. If they are accurately quoted in the new media, the term "influenza" will be used. Often, however, "influenza" gets translated to "flu" by the news media, non-medical people, and even physicians.
However, a variety of viruses (parainfluenza, rhinovirus, adenovirus, and respiratory syncytial virus) cause symptoms similar to influenza, usually milder cases, but with a great deal of overlap. Thus, there may be a "flu" epidemic without the CDCP reporting an influenza epidemic. Then, there are other viruses, such as those that cause stomach and intestinal symptoms that may be epidemic, as "flu," but are not influenza. This loose use of the term "flu" is the primary reason that many who get the "flu" shot still get the flu -- it is another kind of virus causing similar symptoms.)
Two research articles espouse the addition of the influenza vaccine to children under the age of two years (The New England Journal of Medicine, January 27, 2000, pp. 225-231 and 232-239. The authors of these two articles chose a peculiar criteria: hospitalization of children with symptoms compatible with influenza, but who had none of the usual criteria (chronic and debilitating illnesses) for which the influenza vaccine is currently recommended. From these studies, the authors recommend that "normal" children (those without chronic, debilitating diseases) be considered for influenza vaccination.
An editorial in the same issue of the Journal concludes that much more evidence is needed before this vaccine is added to the growing list of childhood immunizations, now at 16 injections during the first two years of life!
Commentary: Hospitalization of anyone has both objective and subjective criteria. Objective criteria in these studies were cardiopulmonary, that is, compromised breathing in the airways or lungs or laboratory studies that showed evidence of heart or lung involvement. Subjective criteria would include the physician's concern for a worsening of the patient's condition or possible complications and the parents' concern and pressure on the physician.
Also, as I have explained above, there are many kinds of viruses that cause similar symptoms. In these studies, efforts were made to separate out influenza from the other "flu" viruses, but specific blood-typing studies were not done. Thus, there leaves some conjecture about which cases were specifically influenza.
Despite recent setbacks (see Reflections, September-October, 1999) on three vaccines, these studies show that the juggernaut of childhood vaccination is alive and well.
It is time to call a moratorium on new immunizations. 1) There is evidence that immunizations may be causing more harm than good. There is sufficient evidence that targeted diseases are less harmful than the immunizations!
2) In every area of medicine, there can be too much of a "good" thing. At 16 injections of a variety of foreign proteins in the first two years, on even a common sense level, there should be concern about adding other vaccines.
3) Adding new immunizations is becoming almost a whimsy in medicine. Any immunization that can be shown to have a little evidence of disease prevention is added to the formulation.
4) Evidence for immunizations increasing the health of a population is still lacking. (See Reflections cited above.) Even so, the quest for current immunizations is different. Whooping cough and diphtheria were widespread killers. Influenza (with the exception of severe epidemic outbreaks) and other vaccines currently being tested cause far less morbidity and mortality. Thus, there is a likely chance that the vaccine will cause as much disease and death as it prevents, because its targeted numbers are smaller and the effects of the actual disease are less.
5) With the advent of hepatitis vaccine for infants (and possibly HiB, as well), public immunization crossed a new threshold: social engineering. That is, vaccinations are forced on everyone to solve the unhealthy effects of an immoral society. (Again, see the Reflections cited above for more detail.)
Thus begins a disturbing article entitled, "The Virus and the Vaccine." Disturbing for at least two reasons. First, there is very good research that the virus causes cancer, particularly mesothelioma, "a deadly cancer" that affects the cells that line the inner chest wall and the lung.
Second, "officials" have covered up the association of SV40 with cancers from the beginning. In the early 1950s, Jonas Salk found that monkey kidneys could provide the quantity of polio virus to mass-produce a polio vaccine. In 1960, Bernice Eddy, a government researcher, discovered that hamsters injected with the kidney mixture developed tumors. "Eddy's superiors tried to keep the discovery quiet, but (she) presented her data at a conference in New York... and lost her laboratory" (p. 68)
The cover-up continues. While more than forty independent research papers have reported the presence of SV40 in human tumors, only two have reported negative results. Guess which most government "officials" give credence to, including the Centers for Disease Control and Prevention?
Get this article! Space does not allow me to explore it fully. However, you will: 1) get a great overview of the difficulties of viral science, 2) learn the vagaries of drawing any conclusion based upon such research, and 3) see biases within those "official" branches of government that are supposed to protect us.
At the 7th Conference on Retroviruses and Opportunistic Infections, Dr. Bette Korber "suggested" that the first case of HIV in humans occurred around 1930 in West Africa (from website http://avert.org/origins.htm).
Commentary: There is little doubt that HIV and rare cases of AIDS were present decades before the AIDS epidemic which began in 1981. It is likely that the current human form of HIV came from a monkey virus (SIV - simian immunodeficiency virus), somehow transmitted to humans. But, in the 1970s, "Patient Zero," a steward for a Canadian airline, implanted it into the homosexual culture,* and as they say, "the rest is history."
* It occurs to me that "culture" has a double meaning here. First, it refers to the sexual practices of homosexuals. Second, it refers to the growth of viruses and bacteria in "culture" media (materials that favor the growth of these organisms). Indeed, HIV grew like wildfire in the "body fluids" of gay men.
"Oral sex was probably the cause of 8 percent of recent HIV infections among a group of homosexual men examined in San Francisco." (The Augusta Chronicle, February 2, 2000, p. 10A)
Commentary: Let's see now. Way back in the mid-1980s, "officials" were warning homosexuals and advising them towards "safe sex." One of those methods was oral sex. Duh! Perhaps, 12 percent or one of eight transmissions is by this "safe" route.
Then, there is the "condom" fall back (as above) -- a flimsy, easily rent material that is often forgotten or omitted. Readers, do you see why I often place officials and experts within quotation marks? These people are willing to compromise rationality and scientific evidence and fall over backwards not to condemn homosexual practices and allow gays to practice immorality. In so doing, these "officials" and "experts" have promoted what they said that they wanted to prevent: further transmission of HIV/AIDS.
Causing what one is trying to prevent is the hallmark of anti-God, liberal ethics. Government education produces illiteracy. Government war on poverty actually entrenches it from generation to generation. Government provision of medicine increases its costs and promotes ill-health lifestyles by providing for the consequences of unhealthy lifestyle choices. Need I go on?
Commentary: Let's see what is going on here. This "diverse group" is saying, "You Americans rejected the Clinton universal coverage, but we know better than you, so we are going to stick it in your face whether you like it or not."
Meanwhile, they are thinking to themselves and saying behind closed doors, "Wow! What a chance to grab a large portion of the monetary pie. Under the facade of 'caring,' we will increase our fortunes greatly."
Enough said? Not yet! This attitude is hubris in the extreme. It is callous lying worthy of the Clintons.
As a still small voice, I want to ask this question, "Where is the evidence that these 44 million are suffering health-wise from being un- or under-insured? For that matter, where is the evidence that Americans in general benefit by full access to modern medicine?"
Oh, one more question. Medicare began small and has now become unaffordable by the tax schemes of our elected government. With that history, how can the provision of coverage to this 44 million, and then, universal coverage, not bankrupt the entire American economy?
The real problem here is that few, if any, politicians are willing to take the stand that the "poor" must fend for themselves. All want to be seen as compassionate, while they slowly bankrupt the greatest economy in the history of the world. How ironic it would be that this economy were destroyed in the name of compassion for a medical system that does more harm than good?
But, medical coverage is also about political power. The more the government controls, the more powerful politicians and bureaucrats feel. Democrats and Republicans are hardly different in this respect.
Unless understanding by the American public and many politicians change, we are going to get universal health care. Unbiblical policies for most of this century have allowed the erosion of freedoms along with heavy taxation. Karl Marx would be proud of the American political system for both its syncretism and growth of central power. Universal coverage may be the straw that breaks the camel's back of any concept of a free society and economy.
The AMA provides "leadership," again. They led us into Medicare, now they are leading us into universal coverage.
Enough said? No, but I am through on this subject for now.
In general, Christians, even those with theological and popular credentials, do not grasp the Biblical economic principles that apply to American medicine. They are confused on the notions of caring for the poor and unfortunate vs. individual and family responsibility.
Thus, one article in the January-February 2000 issue of Focus on the Family - Physician magazine was fresh breeze on an other foul landscape. The author, Glenn Pearl, is interviewing Barry Asmus, Ph.D., who begins this way.
Then, he becomes anathema to the commonly proposed "Christian" policy of health care.
And, there is much more (Biblical) meat in this article (an unintended pun on Asmus' example!).
Working with elderly patients in the office, nursing homes, and hospitals has been a significant part of my medical practice for 15 years. I have this impression, as perhaps many primary care physicians do, that most, if not practically all, elderly are "poly-pharmacy" (on many prescription drugs).
Not so. Thirty-nine percent take no prescription drugs. Twenty-five percent take one prescription drug. That is 64 percent, almost 2/3 who take only one drug or less. (Pharmaceutical ad by Novartis, with original citation of Family Medicine, 30:733-739, 1998)
To someone with a hammer, everything looks like a nail. To a physician taking care of elderly patients with more problems (on average) than younger adults, they all look poly-pharmacy. But, they are not. I find this news exciting and encouraging...
And, a warning. Let's keep the elderly unmedicated according to the best "evidenced-based" research that demonstrates a low (under 10? 5?) Number Needed to Treat (NNT).* In over 2000 years, "Primun non nocere" (first of all, do no harm) is still basic to good medical practice.
* Number needed to treat is the number of patients that must be treated for one to benefit. For example, the best NNT for the fad prescriptions of
fat-lowering drugs that physicians are placing virtually everyone on, have a best NNT of possibly 20 with most in the range of 40 or more. That is, 20-40+ patients must take the drug for one to benefit. That is NOT "primum non
nocere." And, it is also deceptive, expensive, and harmful.
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