A Biblical Model for Medical Ethics
Dr. Heimburger is Assistant Professor of Nutrition Sciences and Medicine in the University of Alabama at Birmingham.
In the March 24, 1983 issue of the New England Journal of Medicine, Dr. David Hilfiker describes the case of a woman named Elsa Toivonen. Eighty-three years old, she had been confined to a nursing home since a stroke three years earlier had left her hemiplegic and aphasic. She had wasted to 69 pounds and developed decubitus ulcers on her back and hip. Dr. Hilfiker very honestly chronicles his struggle over the best course of action when she develops a fever of 103.5°, probably due to pneumonia, at 3 a.m.
"There in the middle of the night I consider `doing everything possible' for Mrs. Toivonen: transfer to the hospital, intravenous lines for hydration and antibiotics, thorough laboratory and x-ray evaluation, twice-daily rounds to be sure she is recovering, more toxic antibiotics, and even transfer to our regional hospital for evaluation and care by a specialist. None of it is unreasonable, and another night I might choose just such a course. But tonight my human sympathies lie with Mrs. Toivonen and what I perceive as her desire to die."1
He laments the facts that his medical training did not address, and physicians do not discuss, the large issues involved in these decisions; and that old, chronically ill, debilitated persons generally receive a lower level of care than do the young, acutely ill.
He feels as though he is "flying by the seat of his pants" - alone. He describes this sort of situation as "awesome," and his decisions as often being "irrational."
In the first article in this series, we examined the influence one's worldview exerts on the questions one asks of life and the kinds of answers that are logically entailed. We documented how one's presuppositions about the nature of the universe, the origin and verification of knowledge, the nature of man, and the destiny of the universe and of man serve both to direct and to limit one's basis for meaning and value, man's place in the cosmos, the possibility for universal ethical principles, and the significance of illness, death, and medical care.
In the solution of particular ethical problems such as Mrs. Toivonen's, there are three key considerations to be made, which can be illustrated as three "angles" on medical ethics:
First: we need a standard of right and wrong.
What is the summum bonum or greatest good to be pursued? In medical ethics these normative questions include: What determines the value of a person's life? Is it intrinsic or determined by level of function? Is preservation of life always paramount, or is relief of suffering more important? What is the meaning or significance of death? Is killing ever justified? What rights do persons have, and how are they defined, derived, and protected? Can they be lost or forfeited? Who has the prerogative to determine the course of action? Does the patient, family, doctor, hospital administrator, or society? What is to be done when the parties disagree? Does the patient have absolute autonomy? What responsibilities do we have toward one another, and how are they enforced? What should be our motives in approaching difficult problems?
Second: we must understand the situation that faces us.
What exactly is the nature of the dilemma? What is the patient's prognosis without treatment? What treatment is available, and what are its risks and benefits (how will it influence the prognosis)? What importance do the supply of resources and the cost of therapy have?
Third: what is the personal (existential) investment of each of those involved?
What are their desires? What are their motives? These three aspects of ethical problem-solving give rise to three major schools of thought, with different goals to be accomplished, and differing strengths and weaknesses. TheNormative perspective focuses on the need for a standard of right and wrong, the Consequentialist seeks to establish goals for each situation, and the Existentialist cares only that individual wishes be carried out. Each of the three emphasizes one of the important aspects of the problem at issue, but generally excludes the other two, and thus fails to integrate the analysis fully. Our discussion of these perspectives will follow the outline of the Table on page 26.
The essential element of the Normative perspective is its emphasis on an "ought" that transcends particular situations and personal wishes. It is based on principles considered to be universal and absolute, applying to all people, independent of time, geography, culture, or individual concerns. The normativist, citing the principle of the sanctity of life, might insist that Mrs. Toivonen's life be preserved regardless of cost or other considerations. After all, it might be argued, nothing is more valuable than life itself, so all other factors are subordinate when life is at stake. Immanuel Kant, a proponent of the Normative perspective, considered his "categorical imperatives" to be unconditional. Among these were truth-telling - one should never, under any circumstances, tell a lie - and the maxim that persons should always be treated as ends and not just as means. He considered them to be logically obvious. He appealed to a god of practical necessity, not the Judeo-Christian God, to establish them.
Christianity is generally thought of as a Normative perspective since it is based on absolute principles communicated by God. Indeed, if it must be classified as one of the three perspectives, it fits best here.
Any Christian ethical analysis must place heavy emphasis on Christian norms in order to be faithful to the Lord. But, as we will discuss below and in subsequent articles, an approach which places exclusive emphasis on norms is less than fully Christian. It is a truncated Christian approach because it does not integrate the sovereignty of God with the situation, or the immanence of God with our personal concerns.
The obvious strength of the Normative perspective is its provision of a firm standard of right and wrong, and of a definite goal toward which to direct ourselves. The situation is not expected to provide its own goal in some intuitively obvious manner, and the wishes of individuals are not simply granted without regard to broader considerations.
However, as with each of the perspectives, there are obstacles to the establishment of the correctness of the Normative perspective:
As Christians, of course, we appeal to the omniscience and revelation of the sovereign God to answer the first question. All the principles of apologetics are brought to bear on the unbeliever; but finally, only by faith can one acknowledge that what God has said is normative and universal. The second obstacle is hurdled by the fact that we are ultimately accountable to God himself rather than to any human authority; God's law is morally binding because he is the Lord and we can never escape His scrutiny.2 Apart from this, there are no satisfactory answers.
Each of the perspectives also presents certain pitfalls if it is emphasized exclusively and the other two aspects of ethical analysis are ignored. When norms are all we can use to guide us, our solution lacks immanence; the Normative perspective becomes a body of ethereal principles with vague applicability to real-life struggles. Which norms apply in which situations? Is one to preserve Mrs. Toivonen's biological life at all costs, or to have a sense that "her time has come"? Would it be more merciful and respectful of life to try to cure her pneumonia, or to allow her to die in relative peace (after all, pneumonia has been called "the old man's friend")?
What is to be done when it appears impossible to avoid violating one of two norms? If one is sheltering Jews, what is one to do when the Nazis knock on the door? Should one lie in order to avoid harm to the Jews, or allow harm to come to them in order to avoid lying?
Often the normativist creates a hierarchy of norms in order to solve these dilemmas. When two are in conflict, the lower norm is violated in deference to the higher. Some Christian ethicists attempt to resolve moral conflicts in this way. However, this is not entirely satisfactory because, in creating true "tragic moral choices" it appears to make God the author of evil (which He is not3) by putting us in situations in which it is impossible to be faithful (which He has promised not to do4). The fact that He says His law is perfect5 surely means that it is not contradictory. Indeed, we will see that a fully Christian ethical model avoids placing the law in conflict with itself.
The Consequentialist approach to ethics, as the name implies, maintains that the consequences of an action judge its rightness or wrongness. There is no universal standard of good to be applied in all situations. Rather, each situation is expected to provide its own ought, so the goals of two situations might differ greatly.
Whereas the standards of the Normative perspective are unconditional and "categorical," those of the pure Consequentialist perspective are entirely conditional, relative, or "hypothetical."
If any of the three perspectives prevails in modem ethics, it is this one.
Situationalism is consequentialism on a small scale. It is concerned mainly with the consequences of an action on those who are directly affected by it, and not on the community, nation, or world as a whole. Its most well-known proponent is Joseph Fletcher who, though an ordained minister, has very little to do with biblical Christianity. In his Situation Ethics he holds as binding only the principle of "love," taken from the "greatest commandment" to love one's neighbor as oneself. He insists that we abandon all other norms in order to do the "loving" thing. We can morally do anything we can justify as being "loving." In one situation it might be loving to save a life, in another to end it. In general, marital fidelity is useful; but if a situation arises in which infidelity satisfies someone's need, it is "loving," and therefore not only permissible but desirable.
Situationalism in medicine is typified by the "risk-benefit" analysis.6 In the case of Mrs. Toivonen, Situationalism would ostensibly not be bound to a certain agenda, but would evaluate her "quality of life," taking into account her debility and pain, the discomforts as well as the potential benefits of treatment, her previous attitude toward medical care (which Dr. Hilfiker indicates was not very positive), and any other relevant factors. The situationalist would not consider "cost-benefit" analysis improper, either; Mrs. Toivonen's financial assets and her net usage of resources vs. her contribution to society can all permissibly enter into the decision.
Utilitarianism is consequentialism on a large scale. For its proponents, the collective is preeminent, and the consequences of an action on the individual are of secondary importance. It seeks to calculate the sum total of good and bad effects produced by an action, and to maximize the former and minimize the latter. This, it is believed, would produce the "greatest good for the greatest number," and allow for public policy decisions to benefit an entire community or nation, or the whole world.
Utilitarian arguments are often used in medicine during discussions of the allocation of expensive therapies. For instance, these therapies may not be made available if the beneficiaries are few and the burden on society's resources great. Mrs. Toivonen would undoubtedly be the casualty of a utilitarian analysis: she is consuming a great deal more than she is producing, and her demise would liberate resources for use by others. It may not only be acceptable, but mandatory that she be put out of her misery.
The strength of the Situationalist perspective is fairly obvious. It is sensitive to situations, ostensibly without having preemptive formulas for the right thing to do. It fits into the relativism of the prevailing naturalistic worldview, while allowing for a sense of compassion. Utilitarianism's potential advantage is its broad, even global assessment of resources, needs, and other factors relevant to social justice.
However, the weaknesses of this perspective are also obvious. The most serious relates to the definition of the good. How does one establish what consequences are desirable? Why is one result preferred over another? In order to answer these questions, appeal must be made to at least one non-consequentialist principle, such as Joseph Fletcher's "love." Some consequentialists argue that we all have an inherent notion of good and evil. Not only is this not true, but it is not enough, for it assumes that our notions are correct, which they may not be.
For instance, in medicine, a strict risk-benefit analysis without clear standards for the just treatment of persons is dangerous. As an example, many of the arguments advanced in favor of abortion on demand are consequential. Justification of legalized abortion in order to make it available to rape victims or to avoid the complications of "back-alley" procedures is thoroughly situational. Arguments that genetically defective children should be aborted are often utilitarian. By defining the fetus as nonhuman, a selfish modern value, personal convenience, is allowed to usurp the universal right to life.
Attempts to judge the quality of a peron's life such as Mrs. Toivonen's are meaningless without a standard to indicate what kind of quality is acceptable and what is unacceptable, and whether there is some level of quality at which life is not worth living. Yet such a standard cannot come from a purely consequentialist framework.
Therefore, consequentialism cannot stand on its own, without appealing to a value system; by itself it falls for lack of norms. At best, it borrows norms from a general consensus or a heritage such as Christianity; at worst, subjective rules and agendas are passed off as situational imperatives.
Beyond this, utilitarianism has the added problems of justifying the preeminence of the collective and of calculating, much less accurately predicting, good and bad outcomes. Why should Mrs. Toivonen's fate be determined by an impersonal computation of costs and benefits? If an individual or minority group must be disenfranchised in order to produce even a slightly better effect for society, a pure calculus might demand that it be done, without helping determine when doing so is blatantly unjust. It falls into the trap of ignoring personal concerns.
The Existential perspective, on the other hand, cares only for personal wishes; it seeks only the autonomous fulfillment of individual goals, so it is also called the Egoist perspective. The egoist considers all ethical decisions to be private matters, and rejects accountability to any other persons, norms, or consequences. While ethical Egoism as a philosophy is less common than utilitarianism, in practice it is quite pervasive in American society.
If Mrs. Toivonen were an egoist and were able to express her wishes, she would demand that it makes no difference what anyone else says, she wants this or that done. If Dr. Hilfiker were an egoist, he wouldn't care what Mrs. Tolvonen said! He probably would have stayed in bed.
Ethical Egoism is more realistically illustrated in modern medicine by the abortion ethic: at least 97% of abortions are performed purely for personal convenience (not for the consequentialist reasons cited above), and most are likely justified by this perspective. The assertion, "It's my body, and you can't tell me what to do with my body" is (often unwittingly) solid ethical Egoism. The Hemlock Society, which exists solely to aid persons in committing suicide with few questions asked, is likewise largely in this camp. If one signs a Living Will only to maintain one's autonomy and to eliminate dependence on or accountability to others, again the Existential perspective is at work.7
The Existential perspective is attractive because it maximizes personal freedom. It is relativism in the extreme, insisting that one need not be accountable even to do what is in one's own best interest. In rejecting the subordination of the individual to the collective, it is suspicious not only of social planners, but of any outside constraints.
The establishment of this perspective as the correct one is no easier than is that of the other two perspectives. Egoists assume that because we are innately self-centered, we should be free to pursue our self-interest without impediment.
However, in assuming this, it commits the "is-ought" fallacy. The fact that we are egoists does not justify promoting Egoism. The existentialist's problem is the opposite of the consequentialist's: why is the individual preeminent, and collective concerns impermissible?
Exclusive emphasis on the Existential perspective is subject to two major pitfalls:
It is clear that each of the three perspectives is of crucial importance but also has serious shortcomings. None by itself provides a sufficient basis for morals. By ignoring the other two, each will miss important elements of any ethical dilemma. Integration of the three is clearly needed; yet none of them has an adequate way of accounting for the others.
Christianity is generally placed in the Normative camp. God in his authority,8 omniscience,9 and relevation10 of the Truth has provided us with absolutes that inform all of life. His Word is the standard by which all our actions are judged.2 But this is not all Christianity provides. Because God is sovereign, "working out everything in conformity with the purpose of His will,"11 the situations we find ourselves in have meaning and should be considered carefully. He does not require that we apply His norms in a vacuum, but sovereignly places us in circumstances where they will apply. By His grace, He does not make faithfulness to His perfect laws impossible at any time, but promises to "provide a way out." 4 Thus Christianity accounts well for the situation.
Further, our personal concerns are of interest to God. This is demonstrated by the fact that He is always present with us, in every situation we encounter.12 He has asked us to cast all our cares on Him, '3 and gives us discernment through spiritual maturity14 and prayer." Thus, He does not scorn our deepest desires and needs like a detached lawgiver. Also, He cares not just that we apply His Truth mechanically, out of duty alone, but instructs us to do so with the right motives. 16 The maker of our innermost being dwells with us, and we abide in Him.'? In Christianity, existential concerns find a solid foundation.
The triangle used earlier might now be expanded to illustrate the metaphysical basis that the Bible provides for each angle:
A biblical approach to problems such as Mrs. Toivonen's will be elaborated in future articles. However, in brief, it is obvious that norms such as the intrinsic value of life apply. She is still a creature of God, made in His image, and precious to Him. Yet we cannot assume that for this reason every available medical resource must be marshaled to save her life. In the perspective of eternity, our life on earth is not all there is. It is also clear that, appearances notwithstanding, her situation is not "hopeless." Though our understanding is cloudy, there are reasons for her and Dr. Hilfiker's predicament. Further, since there are many options available, is it possible that there is not one, and only one, that is correct?
After carefully analyzing her overall situation, remembering her attitudes when she was competent, evaluating all possible courses of action and their benefits and risks, and committing decision to prayer, we might find any of several options is acceptable. A biblical model for medical ethic quires that we take into account whole counsel of God as revealed Scripture so that we faithfully discharge the responsibilities He has given us, do not violate any clear biblical norms, and choose and carry out a contextually appropriate course of action with the proper motives.
1. Hilfiker D. Allowing the debilitated to die: Facing our ethical choices. N Eng J Med 1983;308:716-9.
2. Heb. 4:12-13, "The word of God is living and active. Sharper than any double-edged sword, it penetrates even to dividing soul and spirit; joints and marrow; it judges the thoughts and attitudes of the heart. Nothing in all creation is hidden from God's sight. Everything is uncovered and laid bare before the eyes of him to whom we must give account. "
3. Jas 1:13, "When tempted, no one should say `God is tempting me.' For God cannot be tempted by evil, nor does he tempt anyone."
4. I Cor 10:13, "No temptation has seized you except what is common to man. And God is faithiful; he will not let you be tempted beyond what you can bear. But when you are tempted, he will also provide a way out so that you can stand up under it."
5. Ps 19:7-9, "The law of the Lord is perfect, reviving the soul. The statutes of the Lord are trustworthy, making wise the simple . . . The ordinances of the Lord are sure and altogether righteous."
6. Used daily by all physicians in making treatment decisions, this method is vital to good medical practice and is not necessarily an expression of Situationalism. But as we will elaborate, risk-benefit analysis by itself is insufficient for ethical decision-making without a normative context.
7. Note, however, that Living Wills can also be an expression of consequentialist concerns: the situationalist emphasizes that under certain circumstances dying is preferred to living; and the utilitarian may promote living Wills to avoid burdening society with chronically-ill persons who require active care.
8. Lv 18:2-5, "Iam the Lord your God. You must not do as they do in Egypt, where you used to live, and you must not do as they do in the land of Canaan, where 1 am bringing you. Do not follow their practices. You must obey my laws and be careful to follow my decrees. 1 am the Lord your God. Keep my decrees and laws, for the man who obeys them will live by them."
9. Is 46:9,10, "Iam God, and there is none like me. I make known the end from the beginning, from ancient times, what is still to come. 1 say: My purpose will stand, and I will do all that I please. "
10. 1 Pet 1:20-21, "No prophecy of Scripture came about by the prophet's own interpretation. For prophecy never had its origin in the will of man, but men spoke from God as they were carried along by the Holy Spirit."
11. Eph 1:11, Also Is 45:5-7, "Iam the Lord, and there is no other; apart from me there is no God... I form light and create darkness, I bring prosperity and create disaster; I, the Lord, do all these things."
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."
12. Mt. 28:20, "Surely I will be with you always, to the very end of the age. "
13. I Pet 5:7, "Cast all your anxiety on him because he cares for you. "
14. Heb 5:14, "Solid food is for the mature, who by constant use have trained themselves to distinguish good from evil."
15. Jas 1:5, "If any of you lacks wisdom, he should ask God, who gives generously to all without finding fault, and it will be given to him. "
16. II Cor 9:7, "Each man should give what he has decided in his heart to give, not reluctantly or under compulsion, for God loves a cheerful giver."
17. Jn 15:5, "1 am the vine; you are the branches. If a man remains in me and I in him, he will bear much fruit; apart from me you can do nothing."
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