A Biblical Model for Medical Ethics
Part 1. Worldviews, Presuppositions, Logical Conclusions
Dr. Heimburger is Assistant Professor of Nutrition Sciences and Medicine in the University of Alabama at Birmingham.
In discussions of ethics, particularly in the courses provided in American medical schools, it has long been in vogue to invite individuals from varying viewpoints to make presentations. This way, it is reasoned, the student can weigh the options and decide for himself or herself what is right and what is wrong. This approach is thought to do justice to the pluralistic nature of our society. All sides of the argument are heard. Even the most extreme opinions are not excluded. All will be "fair."
The resulting curriculum then becomes something resembling both a circus side show and a smorgasbord. As in the circus, grossly perverse behaviors and outlooks are paraded before the class, and the eyes of many are opened to "alternative" lifestyles they never before dreamed existed. In the interest of fairness the coursemaster often invites a Christian to make a presentation, rounding out the complement of (extreme!) viewpoints aired. And of course, there are discussions of what might be called "mainstream" modem viewpoints, often cast as more "reasonable" and therefore intellectually more defensible, even if somewhat eclectic.
The students are then invited to draw their own conclusions, with the coursemaster presenting some of the ramifications of the various choices but maintaining a noncommittal, "neutral" stance. However, whether intentional or not, the context in which this is done is often subtly manipulative, because of the "smorgasbord" effect and undisclosed assumptions.
As we all know, a smorgasbord is a feast in which we can choose whatever we want to eat, with the only constraints being our own. None are imposed upon us from the outside; we are autonomous. And all the choices have virtually equal ultimate consequences. According to the ground rules, it makes little difference what we choose as long as we ourselves are satisfied. Just as we may choose lean or fat, and take or leave the desserts in a gastronimcal smorgasbord, so may we choose, to name two examples, chastity or promiscuity, individualism or collectivism in the moral smorgasbord. We will reap whatever temporal consequences are entailed, but no one can impose his mores, any more than his food choices, upon us while we feast at the smorgasbord. In this setting, distinctions among the choices seem small, and Christianity is seen as only one of the many choices open to us.
At first blush this may not seem unfair to Christians. After all, we can't exactly force people to think as we would like. But when examined more closely, the deck has obviously been stacked. The very assumption made from the beginning, whether openly stated or not, that we must not accept any mores "imposed" (read pejoratively) from the "outside," if inviolate, precludes a choice for Christianity. For to be a Christian is specifically to choose to submit oneself to the authority of another. If we decide at the outset not to do so, then we have a priori excluded Christianity and are left with the remaining choices. Though there are many options still open to us, they are all of a certain type. All the theistic cards have been removed from the desk, so we can be assured that we won't find that tyrant God popping up somewhere - not so much because the Christian position has been rejected as mistaken as because it has dismissed as meaningless. The framing of the discussion has rendered not only God's demands irrelevant, but his existence for all practical purposes impossible.
The argument to be made here, then, is that to be truly fair, discussions of ethics must begin with systematic examinations of more primitive concepts. The most basic assumptions for ethical dialogue must be clearly stated, and their ramifications lucidly portrayed, so that divergences of opinion can be seen all the way back to their origins. We've got to talk about worldviews, presuppositions, and logical conclusions.
A worldview is a belief-ordering framework which each of us has and uses; it might be said, in fact, that we each inhabit a particular worldview. Our worldview is not only a conceptual framework, but profoundly influences our daily actions. It is through our worldview that we answer such questions as where did we come from, why are we here, and where are we going. It further gives us a grid for judging right from wrong, good from bad, better from best - for establishing values. It tells us what to expect from the world, and provides a means for us to integrate (or discard) ideas or phenomena that don't fit our expectations. It has been said, for instance, that we have a great ability to admit the evidence that fits our preconceived ideas and an amazing capacity to be unaware of the rest! Partly through communally-held values (the church!), our worldview also provides psychological, emotional, and practical reinforcement. Last, it determines whether we can or should adapt to the world as it changes.
Stated another way, our worldview provides us with the first principles, assumptions, or presuppositions, for beginning an investigation of the world, and a discussion of ethics. Beginning from these presuppositions, we make observations of the world around us which are both directed by and limited by our overall framework. To a certain extent, we look where we expect to find answers. And then we draw conclusions which, no doubt, are backed up by the observations, but sometimes so strongly reflect our presuppositions as to cast doubt on the sincerity of the observations "my mind is made up, don't bother me with the facts"! (Vide supra re: the stacked deck). As Michael Polanyi stated, though there is a "desperate craving to represent scientific [or other] knowledge as impersonal, . . . into every act of knowing there enters a tacit and passionate contribution of the person knowing what is being known, and this coefficient is no mere imperfection, but a necessary component of all knowledge."
The discussion of these presuppositions, and of the questions, what can we know? how do we come to know it? and how do we substantiate it? It is called epistemology. A second branch of philosophical dialogue equally important to a just treatment of medical ethics is that of metaphysics or ontology. This asks such fundamental questions as, what is the nature of the universe? what distinctions are normative, and on whose authority? do our choices have more than temporal significance? and, to whom are we answerable for our actions? The more specific field of philosophical anthropology asks, who is man? what distinguishes him from other animals? how is-he to be treated? etc. Once these questions are answered, we have a clearer idea whether we're beginning at the same point in our discussion on medical ethics.
Already it is obvious that the biblical answers to these questions, the biblical presuppositions for all of life's endeavors, are vastly different from those used in most classrooms. As an illustration of this, and to point out the differing logical conclusions that ensue, let us compare and contrast the presuppositions regarding the universe, knowledge, and man and his destiny that belong to the Christian worldview vs. what we will call the naturalistic worldview. We will then point out the profound implications that these presuppositions have for ethics their logical conclusions. These are summarized in Tables 1 and 2 on the next page.
Two Worldviews Contrasted
1. The Universe
The divergence of the two worldviews is obvious from the outset. The Christian worldview asserts that the universe was created by God, and that it is therefore ultimately personal. Furthermore, it is not the world of the deists which was created and then left alone, but is ruled by his sovereignty. He has created it so that our actions have real consequences, both temporally and eternally.
To the philosophical naturalist (or humanist), materialist, agnostic, or other non-theist), the universe is entirely the product of chance. Composed only of matter and energy, everything it contains is a pure accident. There is therefore no room for personality or "spirit," since these lack a metaphysical base. The universe is ultimately impersonal. At best, the personality that we exhibit :s considered a scientific epiphenomenon, but philosophically it is an anomaly. At worst, in fact, it is a mirage. E.O. Wilson represents this viewpoint, more forthrightly than most authors, at the beginning of his book, On Human Nature .
. . . If the brain is a machine often billion nerve cells and the mind can somehow be explained as the summed activity of a finite number of chemical and electrical reactions, boundaries limit the human prospect - we are biological and our souls cannot fly free. If humankind evolved by Darwinian natural selection, genetic chance and environmental necessity, not God, made the species . . . No way appears around this admittedly unappealing proportion. It is the essential first hypothesis for any serious consideration of the human condition. . ."
Wilson thus dearly lays out his presuppositions at the beginning of his treatise on man. If all discussants did likewise, the points to be argued would be far clearer.
With regard to knowledge, Christianity affirms that the fact that God knows everything (omniscience)2 and has spoken to us in propositional terms (revelation)3 provides a basis for us to say that we know some things to be absolutely relied upon, because he cannot be mistaken as we so often are. This is what Francis Schaeffer called "true truth", to contrast it with the assertions of the naturalist who simply uses tools of observation to gather information and draw conclusions. Such empirical assertions must always be considered tenuous because of the constant possibility that some as yet unknown perspective or piece of data lurking around the comer will negate them. In this sense, then, all of the naturalist's knowledge is relative. Of course, the Christian has no comer on truths which are not revealed (e.g., most scientific observations) and is no less subject to distorting the truth than is the naturalist, but he can be confident that what God says is truth.
One important thing that God has communicated is that He is reasonable, and does not play whimsical tricks on us, chaotically changing the fundamental nature of the universe from one day to the next.4 On the other hand, the naturalist has only its apparent empirical improbability to assure him that the fundamental principles governing the universe will not change at some point in time.5
Another reassuring thing that God has told us is that His ultimate intentions towards us are good, even when the appearances are contrary.6 That is, the principles which govern the universe are finally good and not diabolical. However, this assurance has teeth: we are answerable to the One who rules the universe. Our moral choices have real consequences.7 For all he knows, the naturalist has no such answer to give to anyone outside himself; but neither does he have assurance that the universe does not finally work against him.
Some might insist, as did the positivists of old, that the nature of scientific knowledge is such that it can provide us with values adequate for moral living and decision-making. However, the words of Gordon Clark prove the absurdity of such a hope.
What then is the scientific argument against
the proposition that just one minute ago the universe sprang into being, trees
complete with rings, human beings with navels, and scientists with those ideas
we call memories? At any rate, 1 cannot imagine any empirical observation that
contradicts this exceedingly peculiar hypothesis. To dispose of it, something
other than science is needed. Much less can physics demonstrate the non-existence
of a Supreme intelligence who ... directs the whole universe for his own purposes.8
The next major group of presuppositions relates to the nature of man. For the Christian, man is created in the image of God; in so creating him, God declared man to be unique.9 Though he has striking similarities to other animals, by virtue of his bearing God's image, man is, to use Mortimer J. Adler's phrase, "radically different in kind" from other animals. This provides grounds for treating man and animals differently.
The naturalist cannot assume such a radical difference between man and animals, regardless of the amount of evidence to the contrary.10 For him, man is simply an advanced animal whose essence is no different from that of other animals. Both are simply matter and energy, and no more. If God does not exist, there is NO possibility that man and animals are radically different in kind. Their apparent difference is simply a colossal chance occurrence, an incredible play of the Monte Carlo game.
Last, the two worldviews diverge further with regard to their treatments of the ultimate future. In the Christian worldview, when one passes from this life as we know it, that is not the end. One continues to exist either in a life of eternal bliss or in eternal judgment.
Either case involves eternal significance, based upon the choices made in this life. The universe continues to exist eternally, though with major changes. Contrarily, for the naturalist, each human's life is entirely ended at death, and one becomes worm food. The universe is doomed to die a cold entropic death, barring reversal of the second law of thermodynamics.
The differences in the conclusions that logically proceed from these two worldviews are profound. To state them, however, does not mean that all Christians or all naturalists are consistent in ascribing to these logical conclusions. None of us is pure of understanding or of motive. We all make alterations, even distortions, as we go, and are often eclectic in our approaches, borrowing where convenient from another worldview in order to make life tolerable or manipulate it according to our wishes. The nature of the fallacies we commit is telling. For if the world truly is that described by one worldview, it should be impossible to live consistently in the other.
1. Basis for meaning and value
By virtue of God's having created the world, and man in His image, and being a "reasonable" God, the Christian worldview provides an epistemological basis for the meaning that we attach to our lives. When we make choices and act into the world, the significance with which we would like our actions to be endowed is explicable beyond mere mechanical cause and effect. There is also value to our lives as a whole, which inheres in who we are as image-bearers of the Creator rather than in what we do (or do not do). These concepts of meaning and value are rooted in the character of God Himself, who does not change.
For the naturalist, there is no such epistemological basis for meaning or value. The nature of the universe only provides for chance occurrences, so what happens to us carries no special import, and the choices we make will finally be lost in the cold universe. The only meaning our actions have is what we invest in them, and such meaning is bounded by the portals of time. Life has no ultimate value or purpose.
But to the extent that the
new naturalism is true, its pursuit seems certain to generate two great spiritual
dilemmas. The first is that no species, ours included, possesses a purpose beyond
the imperatives created by its genetic history . . . If the brain evolved by
natural selection, even the capacities to select particular esthetic judgments
and religious beliefs must have arisen by the same mechanistic process . . .
The first dilemma is the one under discussion here. But in passing, one is tempted to say that if the second dilemma is true, then Wilson's thoughts themselves evolved as instinct, and why should one concur with them rather than reject them? Consistency at this point would reduce all persuasion to utter absurdity. If Wilson were fully consistent, he would not have written the book.
2. Respect for life
The Christian worldview requires that we treat all of God's creation, particularly living beings, with respect, since all of creation belongs to God. Yet, since only man bears the image of God, he is to be treated differently from the rest of creation, with more "dignity" or "sanctity" in the traditional sense. Since the image of God in man is present by virtue of God's creative fiat and is not simply descriptive of some function man performs, the rights to life and to respectful treatment are not subject to revocation due to deformity or disability any more than to race, social station, or other descriptive characteristics. In the naturalistic worldview, a basis for treating man differently from lower animals can be found only in man's more advanced capabilities. Yet, the moral relevance of such a distinction is quite tenous, leaving for the consistent naturalist no real reason to give man more respect than other living beings. This is clearly articulated by Peter Singer, who says,
Whatever the future holds, it is likely to
prove impossible to restore in full the sanctity of life view. The philosophical
foundations of this view have been knocked asunder. We can no longer base our
ethics on the idea that human beings are a special form of creation, made in
the image of God, singled out from all other animals, and alone possessing an
immortal soul. Our better understanding of our own nature has bridged the gulf
that was once thought to lie between ourselves and other species, so why should
we believe that the mere fact that a being is a member of the species Homo
sapiens endows its life with some unique, almost infinite, value?
3. Moral sanctions
Based on these distinctions and on the revealed law of God, the Christian has moral sanctions with teeth. The law of God represents the norms for all of human thought and behavior, and thus Christian ethics has a universal normative base. Our moral choices are judged by God Himself, in accord with His law, thus giving those choices eternal significance, for better or for worse. God's norms are therefore not simply wishful platitudes. Since their consequences cannot be escaped, they are binding.
Having no universally applicable norms and no one who will require an answer of him, the naturalist has no binding moral sanctions. Morever, the naturalistic worldview provides no ultimate reason even for making one mundane choice over another, since it affirms that one's choices do not change the final destiny of any individual or of the universe as a whole. This reduces the options available for deriving moral principles to the following:
a. INDIVIDUAL WISHES, where one simply makes up one's own mind, either with or without regard to broader consequences. This might be described as the existential approach.
b. CONSENSUS, the most popular tool currently for articulating moral guidelines for the community. The consensus could be arrived at by referendum or by a representative body such as Congress, but efforts to date have been invested in groups of experts such as The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.
c. AUTHORITARIAN pronouncements determine public morality in many countries of the world.
It is obvious that all of these methods are subject to individual, cultural, and political whims. They provide only descriptions of what the individual, the group, or the elite considers appropriate at the time, and will never provide binding moral precepts. They can all be finally reduced to expressions of sentiment or intuition which, though they may be invested with legal power, lack morally compelling significance. In fact, ethical statements are totally meaningless if they are, as Wilson insists, merely the product of our genetic makeup. No more can be said in favor of any of them than "it seems reasonable." Worse yet, ethical prohibitions run the risk of impeding the "inevitable" process of evolution.
4. Significance of Illness and Death
For an overall perspective on medical ethics, perhaps second in importance to one's view of the meaning and value of life is the significance one's worldview gives to illness and death.
In the biblical worldview, the fall of man gives Christians a means to integrate the abhorrence we feel toward illness and death with the fact that God is sovereign and loving. Since the world as He created it was perfect, there was initially no such thing as illness and death.
Man brought these upon himself as a result of his rebellion against God. For this reason, we can justifiably treat illness and death as our enemies without acting as though they are the final enemy. The reason they are hateful and ugly to us is that they are not part of God's original design for the world.13 But because God has provided a way of salvation, death cannot finally defeat us; in fact, for the believer, "death is gain."14 And illness, though also a result of the fall, is used by God to accomplish His purposes in our lives.15
In the naturalistic worldview, death is simply a point in the continuum between being and nothingness. As such, it has no particular ontological, much less moral, significance. Therefore there is no metaphysical rationale to explain why we hate it so. On the one hand, for the living, death is the final enemy. Yet, the thorough-going naturalist must say that man's universal hatred of death is due either to a universal illusion that life has abiding value or to a simple relational attachment to the deceased. Since both death and illness are part of the essential order of things, there is no fundamental philosophical basis for considering them enemies.
It can be seen from the foregoing that the two contrasting worldviews provide very different backgrounds for medical practice. The Christian worldview is responsible for the high view of man which has driven the development of science and medicine in the western world. It fits life into the wider purposes of the universe and endows man with special significance extending beyond the portals of time. It offers directives for moral conduct which are not dependent on the limited knowledge or mixed motives of man himself. It supports a vigorous battle against illness and death but casts both in the light of unseen realities and eternal priorities.
The naturalistic worldview, on the other hand, erases distinctions which are vital to society's moral categories. It does not consider life to have ultimate value, undermines moral distinctions between man and other species, offers ethical guidelines based finally on mere individual sentiment, and does not support man's inherent hatred for and battle against illness and death. In short, if applied consistently, it is destructive of ethics and gives no real foundation for medical practice as we know it. The impossibility of living consistently in this worldview calls its validity seriously into question.
Future articles in this series will examine in greater detail the biblical foundation for medical ethics and offer a biblical model for ethical decision-making.
1. Wilson, E.O., On Human Nature. Cambridge, MA: Harvard University Press, 1978, pp. 1-3
2. Rom. 11:33, "Oh, the de. pth of the riches of the wisdom and knowledge of God, How unsearchable his judgments, and his paths beyond tracing out:"" Ps. 147:5, "Great is our Lord and mighty in power; his understanding has no limit:"
3. Is. 45:19, "1 have not spoken in secret, from somewhere in a land of darkness; 1 have not said to Jacob's descendants, `Seek me in vain.' 1, the Lord, speak the truth; l declare what is right." I Jn. 5:20, "We know that the Son of God has come and has given us understanding, so that we may know him who is true."
4. Mal. 3:6, "1 the Lord do not change. So you, O descendants of Jacob, are not destroyed " Gen. 9:15,16, "Never again will the waters become a flood to destroy all life. Whenever the rainbow appears in the clouds, 1 will see it and remember the everlasting covenant between God and all living creatures of every kind on the earth. "However, we do know that one day things will change dramatically, when "He who [is] seated on the throne [says], `I am making everything new;" Rev. 21:5
5. In fact, most naturalists postulate just such an occurrence in the history of the universe in order to reconcile its present existence with the law of entropy. This is a sort of "it must have happened, therefore it did happen" reasoning, with no firmer evidence to establish it. But they don't often talk about such possibilities when discussing day-today realities!
6. Rom. 8:28, "And we know that in all things God works for the good of those who love him, who have been called according to his purpose. " Jer. 29:11, " `For 1 know the plans 1 have for you,' declares the Lord, `plans to prosper you and not to harm you, plans to give you hope and a future.' "
7. Rom. 1:18,19, "The wrath of God is being revealed from heaven against all the godlessness and wickedness of men who suppress the truth by their wickedness, since what may be known about God is plain to them, because God has made it plain to them." Jn. 3:35, "Whoever believes in the Son has eternal life, but whoever rejects the Son will not see life, for God's wrath remains on him."
8. Clark, G.H., The Philosophy of Science and Belief in God. Nutley, NJ: Craig Press, 1964, p. 94.
9. Gen. 1:26, "Then God said, `Let us make man in our image, in our likeness, and let them rule over the fish of the sea and the birds of the air, over the livestock, over all the earth, and over all the creatures that move along the ground."
10. After eloquently amassing this evidence, Adler rightly admitted that if man actually has some immaterial (spiritual) aspect to his being, which he concluded he must if a "Turing machine" which can converse intelligently with him cannot be designed, this "might even lead to a new proof of the existence of God." Adler, M.J. The Difference of Man and The Difference It Makes. New York, World Publishing, 1967, p. 292.
11. Wilson, E.O., Ibid. pp.3,5.
12. Singer, P., Sanctity of life or quality of life? Pediatrics. 72:128-9; 1983.
13. This probably was why Jesus wept at the tomb of Lazarus. Jn 11:35)
14. Phil. 1:21, "To live is Christ, and to die is
gain." I Cor. 15:54, "Death has been
15. Heb. 12:10, "God disciplines us for our good, that we may share in his holiness."
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