Ethical Conflicts in Medicine
Dr. Davis is Professor of Systematic Theology and Christian Ethics at Gordon-Conwell Theological Seminary in Massachusetts. He is the author of numerous articles and several books, including Evangelical Ethics, Abortion and the Christian, and Your Wealth in God’s World.
The practicing physician can be faced with situations where one ethical obligation appears to be in conflict with another. Consider, for example, the following five cases that were mentioned to me recently in a personal communication from Dr. Ed Payne: 1) the case of a cancerous uterus during pregnancy or an ectopic pregnancy, when preserving the life of the mother will end the life of the unborn child. 2) Membership in medical organizations that endorse abortion, homosexuality, and other sinful practices. To leave the organizations means losing the opportunity to be “salt and light”; to remain in the organizations may appear to be endorsement of their policies. 3) What about medical students, interns, and residents whose training or career paths require them to participate in abortions? 4) Requests to prescribe birth control pills to an unmarried (teenage) woman. Should the Christian physician prescribe the birth control pills as the “lesser of two evils”? 5) Truth-telling and the doctor-patient relationship: Are there circumstances when the physician should lie to the patient, when in the physician’s judgment, to do so seems to be in the patient’s interests?
Before commenting on these specific issues in Christian medical practice, I would like to address the more general issue of a biblical perspective on situations of ethical conflict. Are there circumstances when the Christian is compelled to choose the “lesser of two evils.”? Is it always possible, in a sinful world, to find and follow a morally right, guilt-free course of action? Three possible ethical methodologies will be evaluated: the “situational” approach of Joseph Fletcher; the “lesser of two evils” position; and the author’s position of “contextual absolutism,” the meaning of which will be explained during the course of the discussion.
After these principal matters have been addressed, comments will be offered on the five specific cases in medical practice raised by Dr. Payne.
JOSEPH FLETCHER AND “SITUATION ETHICS”
In his widely read and debated book of 1966, Situation Ethics: The New Morality, Joseph Fletcher describes the following incident from the Second World War: A German woman, a Mrs. Bergmeier, is captured by the Russian army and sent to a prison camp in the Ukraine. She learns that if she is found to be pregnant, she will be returned to Germany as a liability, where she can be reunited with her husband and three children. She decides to ask a prison camp guard to impregnate her, and the camp guard complies. She becomes pregnant, is sent back to Berlin, where here family welcomes her, and later gladly accepts as a family member the little baby Dietrich who was conceived in the prison camp. Fletcher poses the question, “Had Mrs. Bergmeier done a good and right thing?” Is this so-called example of “sacrificial adultery” justifiable under the circumstances and perhaps an acceptable way of dealing with the conflict between wanting to be reunited with one’s family on the one hand and, on the other, the prohibition against committing adultery?
Fletcher tells us that there is only one moral absolute — to do the most “loving” thing in any and every situation. “The situationist,” he says, “holds that whatever is the most loving thing in the situation is the right and good thing.” Moral rules and principles should be discarded if they conflict with the good of human persons and the loving course of action. All moral rules and principles — whether derived from scripture, reason, experience, or culture — are to be treated as “love’s servants and subordinates to be quickly kicked out of the house if they forget their place and try to take over.” Given this approach, Fletcher concludes that Mrs. Bergmeier’s decision to become pregnant by the prison guard was not morally wrong and not even the lesser of two evils but, in fact a positive good because it served the good of her family and was the “loving’ course of action.
What are we to think of Fletcher’s approach and his analysis of the case of Mrs. Bergmeier? However much human sympathy one might have for Mrs. Bergmeier and her family and however pleased at the apparently happy outcome, one must nevertheless be troubled with this analysis on biblical grounds. An obvious question for Fletcher’s situational methodology is, “Given my fallen human nature, and capacity for self-deception and rationalization, and given the complexities of life in a sinful world, what is my ultimate standard for defining the “loving” course of action?” Jesus Christ said, “He who has my commandments and keeps them, he it is who loves me” (Jn 14:21). A New Testament ethic does not dichotomize “love” and obedience to the moral law but, in fact makes obedience to the moral commandments of Christ the concrete test of Christian love. The word used here (entole, Jn. 14:21) for “commandment” is used elsewhere in the New Testament to refer to the Ten Commandments (e.g., Lk 18:20, Jesus to the rich young ruler, “You know the commandments…”).
Further, we all recognize that a good and “loving” intention does not guarantee a good and desirable outcome. As the proverb says, “The road to hell is paved with good intentions.” In the early 1960’s physicians who prescribed thalidomide to their pregnant patients no doubt intended to do so in their patients’ best interests, but the results, as we now know in hindsight, were tragic. Finite and sinful human beings acting on finite and imperfect knowledge cannot infallibly predict the long-term consequences of their actions. We recognize the wisdom of following the revealed moral principles of an infinite and omniscient God who can predict the outcome of any given course of action — rather than making our own personal moral calculus the final court of ethical appeal.
“Why not do evil that good may come?” is a question rhetorically posed and then rejected by the apostle Paul in Romans 3:8. This is the Pauline way of saying that right actions require not merely right intention, but right means as well. The ends do not justify the means, or any means at all; right intention and right ends must be accomplished by morally right means. “Loving” family values are not to be achieved by committing adultery. Worthwhile medical information is not to be obtained by any means — through force, coercion, deception, or torture — but only through morally acceptable means that acknowledge the values of informed consent and the sanctity of human life.
Fletcher’s situational methodology is further flawed in that it calculates the “loving” outcome and the “good of persons” only in the shorter-term, temporal perspective. There is no place in Fletcher’s Situation Ethics that seriously addresses the biblical reality of eternity, of heaven and hell, and the Last Judgment. From a New Testament perspective, many short-term “benefits” will in the last analysis turn out to be long-term and eternal disasters.
THE “LESSER OF TWO EVILS”
Another perspective on situations of ethical conflict could be called the “lesser of two evils” approach. For example, consider the dilemma faced by Rahab the harlot, who hid the Israelite spies from the king of Jericho (Joshua 2). To protect the spies, Rahab deceived the king’s soldiers, stating that the spies had left the city (v. 5), when in fact they were hidden on the rooftop of her house. Was she justified in lying in order to save lives? One might think of the similar dilemma faced by Corrie Ten Boom during the Second World War, who hid Jews in her home from the Nazi soldiers.
According to this approach Rahab chose the lesser of two evils by lying to the soldiers in order to save the lives of the Israelite spies. From this perspective Rahab’s actions were understandable and even excusable, but nevertheless objectively sinful — and hence cause for subsequent confession and repentance.
Various arguments are advanced in favor of this perspective. It is said, for example, that tragic moral choices are inevitable in a complex, fallen, and sinful world — a world where individuals and institutions and nations all bear the obvious stains of sin. Assassinations, “dis-information,” and covert actions by the C.I.A., for example, would not be necessary in a world where everyone plays by the rules; but the tragic reality is that we live in a world where evil exists and where many of the players do not respect the rules. Could one condemn, it might be asked, Dietrich Bonhoeffer’s participation in the plot to assassinate Adolf Hitler? Even though perhaps in itself an evil, would not the assassination have been justified in terms of a greater good?
Proponents of this view would seek biblical justification for the position. Is it not the case, they might argue, that the Lord’s Prayer itself teaches that the Christian stands in daily need of forgiveness (“Forgive us our debts,” Matt. 5:12) even as we stand in daily need of bread and the other necessities of life? Does it not say in 1 Jn. 1:8 that ‘if we say we have no sin, we deceive ourselves”? Does the believer ever reach the point this side of heaven where we are completely free from personal sin and the sinful circumstances that provoke such unfortunate choices?
Not all Christians would agree, of course, with the foregoing line of reasoning. In the situations faced by Rahab and Corrie Ten Boom, for example, there are those who would say that lying is never justified, even to save life. The well-known Reformed scholar John Murray believed that while Rahab’s action of hiding the spies was commendable, the particular method used — lying — was not. He also suggests that God could have perhaps saved the spies apart from lying on Rahab’s part. I personally find this separation of the intention (to save life) and the action (hiding, deception) somewhat artificial, especially in light of the specific commendation of James 2:25: “Was not also Rahab the harlot justified by works when she received the messengers and sent them out another way?” Was her deception not one of her “works” and an integral link in the action of “receiving” and “sending out?”
There would appear to be several serious objections to the “lesser of two evils” framework. First, there is the Christological problem. The New Testament presents Christ as the moral model for the believer. According to the writer of the epistle to the Hebrews, “We have not a high priest who is unable to sympathize with our weaknesses, but one who in every respect has been tempted as we are, yet without sin” (4:15). Jesus Christ, like we, was called to live in a sinful world, was truly faced with temptation and hard testing, and yet in every circumstance was able to do that which was well pleasing to God. The example of Jesus Christ, with the reality of temptation yet the record of a sinless life, argues strongly against the conclusion that some circumstances compel the believer to sin. Obedience may be costly, and discerning the will of God may be difficult, but nevertheless it is possible.
In the second place, the lesser-of-two-evils approach appears to be contrary to the Pauline teaching that “No temptation has overtaken you that is not common to man. God is faithful, and he will not let you be tempted beyond your strength, but with the temptation will also provide the way of escape.” (1 Cor 10:13). In some cases the way of escape could mean martyrdom for the sake of Christ, but however hard the circumstances, the apostle does indicate that there is a “way of escape” that does not compel the believer to commit sin.
The author has previously argued for the position known as “contextual absolutism.” This terminology is intended to suggest that the moral rules of scripture are “absolute’ in that they reflect the absolute and unchanging moral character of God, and not merely the changing perceptions and conventions of human culture. The term “contextual,” however, recognizes that in some circumstances our normal duties are suspended in light of a higher obligation. For example, we normally are obligated to obey the civil authority (Rom. 13:1). When, however, the civil authority commands that which is contrary to scripture, that obligation is suspended, for “we must obey God rather than men” (Acts 5:29). So-called prima facie obligations yield to actual obligations, that is, obligations when all things are considered.
In the case of Rahab, it would be argued that in this wartime circumstance the obligation to save the lives of the Israelite spies superseded the normal obligation to tell the truth. Rahab’s words were deceptive; but in this case, it is argued, she had no obligation to tell the truth.
As Charles Hodge stated this approach, “… in criminal falsehoods there must not only be the enunciation of what is false, and an intention to deceive, but also a violation of some obligation … a general is under no obligation to reveal his intended movements to the enemy.” The obligation to tell the truth presupposes the normal covenant of trust between person and person. This covenant of trust breaks down in wartime situations such as that faced by Rahab. A mother is under no moral obligation to disclose the whereabouts of her daughter to a crazed criminal intent upon murder and rape.
This recognition of a hierarchy of obligations is supported by Christ’s references to the weightier matters of the law (Matt. 23:23) and the greatest commandment (Matt. 22:36). It is consistent with Christ being the believer’s ethical model, and with his finding and fulfilling the will of God throughout his earthly life — a life of conflict, temptation, and suffering. It is consistent with 1 Cor. 10:13 and the Pauline teaching that in times of severe testing the believer need not be compelled to sin, but that God will provide a way of escape.
Such a “contextual absolutism” can be found in rabbinic Judaism. The Sabbath was held in very high regard, but the rabbis taught that “if a man is pursued by gentiles or robbers, he may desecrate the Sabbath in order to save his life.” Echoing the saying of Jesus that “the Sabbath was made for man, not man for the Sabbath,” the rabbis held that the obligation to keep the Sabbath was superseded by the obligation to preserve life in circumstances where the two were in conflict.
SOME PRACTICAL APPLICATIONS
An attempt will now be made to apply these more general principles to some of the specific cases mentioned at the beginning of the discussion. The first case involves truth-telling and the physician. Is the physician ever justified in lying to the patient or in withholding important medical information? What about the apparent reluctance of some physicians, for example, to fully disclose a diagnosis of cancer to the patient out of concern for possible adverse psychological effects such as depression or even suicide? Could one argue from analogy to the Rahab case — that for some cancer patients, one is justified in suspending the normal obligation to tell the truth out of concern for a higher obligation to preserve life? In my judgment, this comparison is faulty and invalid. The relationship of Rahab to the soldiers was an adversarial one in time of war; the relationship of physician to patient is a “peacetime” covenant of trust. The patient should expect and receive truthful information from his or her physician. The paternalistic attitude possibly implied by a “let’s withhold information for the patient’s own good” policy treats the patient as a child rather than as an adult, is inconsistent with the growing respect for patient autonomy, and could possibly provide grounds for a malpractice suit in today’s litigious society.
What about situations where residents or nurses may be required to perform abortions or assist in abortions as a condition of employment or training? Hopefully, the Christian physician or nurse will be able to appeal to institutional conscience clauses that apply in such cases. If not, the choice seems clear: with the early apostles and disciples, in such conflict situations “we must obey God rather than men” (Acts 5:29). Like Daniel and his friends, we know that a sovereign God may deliver us from the fiery furnace, but if God chooses not to resolve the conflict, then “…be it known to you, O king, that we will not serve your gods…” (Dan. 3:18). The honor of God and the sanctity of innocent human life cannot be sacrificed for reasons of personal or professional advancement. The third case involves the Christian physician or nurse and membership in professional organizations that advocate or permit abortion and other unethical practices. Should, for example, the Christian refuse to participate as a member in a professional society that supports legalized abortion? Here a distinction should be made between what policies an organization may advocate and what policies and practices it requires the membership to personally maintain. In 1 Cor. 5:9-13 the apostle makes a distinction between contact with immoral persons in society and close fellowship with immoral persons in the church: “I wrote to you in my letter not to associate with immoral men” — and clarifies this by writing, “not at all meaning the immoral of this world … since then you would need to go out of the world. But rather I wrote to you not to associate with anyone who bears the name of brother if he is guilty of immorality … not even to eat with such a one.” The apostle brings a healthy realism to the discussion. To avoid all contact with evil in the world, one would need to leave the world entirely — and then how could the Christian be “salt and light” in the social order? Lines must be drawn, but Paul draws the line in the Christian fellowship, and it is here that discipline must be maintained, not only for the sake of the purity of the church but for the sake of the honor of the name of Christ as well. A Christian physician might choose for various reasons not to participate, for example, in the membership of the American Medical Association, but such a choice, in my judgment, would be made on prudential grounds rather than being compelled by explicit biblical teaching.
The fourth circumstance involves abortion to save the life of the mother in the case of ectopic pregnancy or cancer of the uterus. As we know, such cases involve only a miniscule proportion of the abortions performed in America today and are quite rare, yet nonetheless they do occur. Most Christians would accept the permissibility of abortion in such cases, yet the ethical justification may not be immediately obvious. If both mother and child are innocent human beings, how can it be right to choose one innocent life (the mother’s) in preference to another? Would such a decision represent a form of favoritism and partiality that scripture condemns? Is abortion in such cases consistent with the basic ethical principle, derived from the sixth commandment (Ex. 20:13), “You shall not murder”), that the direct, intentional killing of an innocent human being is always wrong?
In the case of an ectopic pregnancy the argument has been made that this circumstance is analogous to self-defense. The embryo developing in the mother’s Fallopian tube is an “aggressor’ whose continuing growth and presence threatens the life of the mother. In such a case, it is argued, the person being assailed has the moral right to repel the attacker, even with deadly force if necessary.
The weakness of this argument is apparent. The analogy between the case of a woman being assailed by a murderous rapist or other vicious criminal and the “attack” by a developing human embryo is rather weak. Both circumstances involve a threat to the life of the woman, but conscious intent and moral culpability can hardly be ascribed to the embryonic human life.
A better argument for both this case and the case of the cancerous uterus is the so-called “triage” analogy. A physician arrives at the scene of a catastrophic train wreck. Time and medical resources are limited. He quickly mentally categorizes the victims according to a three-fold division: those with minor injuries who will survive without any attention or medical treatment; those whose injuries are so massive that they have little or no prospect of survival even if treated; and those with substantial injuries, but with a reasonable prospect of survival if promptly treated. The physician wisely and ethically decides to devote full attention to those in the third category and to pass by the rest. In the case of ectopic pregnancy or uterine cancer during pregnancy, if no intervention is made, there is real risk that both mother and child will perish. The abortion is performed to save the life that can be saved — the mother’s — in recognition of the tragic fact that the life of the unborn child, given the present state of medical technology, is doomed in any case. The abortion is related to the death of the child in an indirect and unintended manner, and hence can be ethically justified. It is somewhat like the physician at the scene of the train wreck moving aside the body of a fatally wounded victim in order to reach a victim whose life can be saved if promptly treated. This argument from the “triage” analogy may not be without its limitations, but it does seem to provide a more convincing justification for intervention than does the self-defense argument.
The final issue concerns the dispensing of contraceptives to unmarried teenagers. Should the Christian physician attempt to “impose” Christian and biblical standards of sexual chastity on a teenager who does not share those values? Would prescribing the birth control pills for the teenage girl who intends to engage in premarital sexual activity be a “lesser evil” than pregnancy out of wedlock?
A decision to prescribe the birth control pills in such a case may be done with a good intention, but good intentions do not guarantee good results. “Common sense” and the “conventional wisdom” hold that greater availability of and information about birth control devices will reduce out-of-wedlock pregnancies among sexually promiscuous teenagers. The empirical data, however, challenge this widely held belief in American society. One study based on the experience of a Detroit clinic found that girls who were given the pill increased their sexual promiscuity, having sexual intercourse on the average of 4.3 times per month before admission to the clinic and 6.8 times a month one year later. Other studies have shown that as sexual activity increases, the probability of pregnancy increases, even when contraceptives are used.
Abstinence from fornication is a moral obligation not merely for Christians and Jews, but for “Gentiles” (“pagans,” “unbelievers”) as well (cf. Acts 15:28,19). Violation of basic moral principles that are known through creation and conscience trigger the wrath and judgment of God (Rom. 1:18-32; 2:14-16). Persistent, unrepentant fornication is a serious sin that can exclude the one who practices it from God’s eternal kingdom (1 Cor. 6:9,10; Rev. 22:15). The Christian physician is called to bring salt and light to a dark and morally rotten world — not merely to “throw contraceptives” at the problem of out-of-wedlock pregnancy.
“Notwithstanding the protestations of patients and colleagues,” writes Barrett Mossbacker, “the Christian physician will provide … the most compassionate care” to sexually promiscuous teenagers not by accommodating their sin but by “seeking to persuade them to abstain from spiritually and physically destructive behaviorSuch a course of action may be neither professionally nor personally easy, but then again, whoever said that following Christ in the sacrifices of faith and obedience would always be easy?
2. For the author’s position, see John Jefferson Davis, Evangelical Ethics: Issues Facing the Church Today, Presbyterian and Reformed, Phillipsburg, N.J., 1985, pp. 12-16. For a similar position, called “graded absolutism,” see Norman Geisler, Options in Contemporary Christian Ethics, Baker, Grand Rapids, 1981, pp. 81 – 101.
15. Cf. chapter XXX.III, Westminster Confession of Faith: “Church censures are necessary for the reclaiming and gaining of offending brethren … for vindicating the honor of Christ, and the holy profession of the gospel …’
This article is taken from Dr. Davis’s presentation at the First Northeast Medical Ethics Conference, held in Philadelphia on April 28, 1990.[ JBEM Index / Volume 4 / Number 4 ]