Counterpoint to Dr. Davis on the Brophy Case
Dr. Payne is Associate Professor in The Department of Family Practice at The Medical College of Georgia, author of Biblical/Medical Ethics, and an elder in First Presbyterian Church of Augusta.
It is with reluctance that I write the following counterpoint. Dr. Davis ranks near the top of my list of theologians and ethicists (he is both). His books have been invaluable to help structure and confirm my thinking in many areas. Any disagreement we may have is clearly one within the inerrant and authoritative Biblical system because we are both fully committed to it. Unfortunately, even with that commitment, on this side of heaven we will not all agree. Further, I believe that as Dr. Davis and I dialogue we will come closer in our relative positions. The goal of the Journal is to present both sides for the reader to arrive at his own Biblical position and even to contribute areas of omission or disagreement with either of our positions with their letters.
What is Health?
The problem with Dr. Davis' approach seems to be an elevation of the sanctity of human life above all other Biblical considerations. Now, I certainly agree that this sanctity is extremely important and have been active in writing and in other ways to move against what has been a degradation of human life in American society. The sanctity of human life, however, is only one of Ten Commandments. Further, other Biblical principles give us a more complete understanding of each commandment, especially in their application to specific situations. To raise one commandment above all others is to distort the unity of the whole and to lead to actions that are detrimental for God's people.
The necessary starting point is that health (and therefor, medicine as the preservative and restorative process of health ) is fundamentally determined by one's worldview. For example, the World Health Organization defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease." Christians recognize two states where this definition applies: the garden of Eden before the Fall (Gen. 1-2) and heaven (Rev. 21-22). Thus, the WHO definition could be used as a Biblical definition of health in these two realms.
Clearly, however, that definition of health is not applicable to the time between the first and last two chapters of the Bible. Thus, a Biblical application of the definition must be made to the time of man's earthly existence. In general, man suffers from his own sins and the sinus of others (Mark 7:21-23, Gal. 5:19-21). Thus, he can only experience relative health during his lifetime.
Man's nature is also different from what WHO would say that it is. Man is both body and soul.1 Because of the Fall, both body and soul are sinfully conditioned. Man is bent on self-destruction and the destruction of others because he is in rebellion against God (Rom. 5:10). The fact that he does some charitable acts and is not fully as evil as he could be is due to God's common grace (Mt. 5:45). But, for man's sin God has provided a remedy in Jesus Christ. Because of His sacrificial death and the regeneration of the Holy Spirit, some men are given a new heart (II Cor. 5:17, Titus 3:5). This transformation causes a two-fold division of the human race: the saved and the unsaved. This division has profound implications for health and medical concerns. First, this regenerate state is a prerequisite for health. Without being at peace with God, one can hardly be considered "healthy." Second, obedience is a prerequisite to maximal health even for the Christian. The New Testament is clear that some Christians are more obedient than others. Certainly, those who are more obedient will generally be more health.2 Thus, Biblical health consists of obedience to God's instructions to us through His Word.
Most simply, obedience is a life consistent with the
Ten Commandments. From the Sixth Commandment comes the principle of the sanctity
of life about which we are particularly concerned. Biblical obedience, that
is Biblical ethics, however, concerns all the Commandments and one is not to
be elevated above the others. Together, they form a whole, a unity that reflects
the unity of God Himself (Dt. 6:4). In philosophical terms they perfectly "correspond"
to each other and to Him. Then, all other biblical principles illumine and explain
these commandments within that unity. It is within this system that medical
ethics must be examined. This system as a whole is absolute, not any one commandment
The Eighth Commandment
The negative side of this commandment is, "You shall not steal (Ex. 20:15)." The positive side of this commandment is, to "labor, performing with his own hands what is good, in order that he may have something to share with him who has need" (Eph. 4:28b). The Parable of the Good Samaritan is an example of one who shared with another who had medical need (Luke 10:25-37). The Bible also limits those in "need." "...if anyone will not work, neither let him eat" (II Thess. 3:10b).
A text that concerns widows and the church further explains financial responsibility and giving (I Tim. 5:3-16). First, the principle of primary responsibility for needs lies with the person's family, if he or she has one (v. 8, 15). Second, like the passage above, "need" is not automatically the responsibility of others. A widow is not a responsibility of the church if she has family. She must be a "widow, indeed," that is she must be living a godly life (v. 5,10). If she gives herself to "wanton pleasure," she is not a responsibility of the church. She must be sixty years old (v.9). Younger widows are to marry (v. 11-15). Thus, "need" is not unconditional. Discernment is necessary in its distribution in all situations.
With this long introduction we can turn to the case of Paul Brophy. Who is financially responsible for his medical care? As we have seen, his family is primarily responsible, followed by his church or other voluntary, charitable organizations or people. From Dr. Davis' article and other information we do not know who was paying for his care. If his family was paying for it, then the situation would be consistent with biblical responsibility. More likely, his care was being paid for by Medicaid, a system of joint payment by the particular state of the patient's residence and the federal government because Medicare and private insurance will only pay for a few days of nursing home care. Thus, we must answer the question of whether government at any level is responsible to pay for the medical care of its citizens.
First, no texts in the entire Bible give the role of medical care (or welfare in general) to the government. Second, the explicit role of the state is to punish evil and reward good (Rom. 13:1-7). By extension the reward of good might apply to medical care, except that the government's application of medical payments nowhere considers right (what is good) and wrong as criteria for payment. It pays for the primary treatment and secondary complications of sexually transmitted diseases as readily as conditions unrelated to morality. Thus, even if this verse could justify government payment of medical care, (and I do not think that it comes close to doing so) then current practice is clearly unbiblical.
John Frame, a notable Biblical ethicist on the faculty of Westminster Seminary (West), believes that "society" does have the obligation to provide medical care for others, based upon both Old and New Testament principles, that is, to be charitable and to share what we have with those in need. But, "that is not to say that such benevolence is to be administered by the state; the tests don't say that."3 Later, he says, "I believe that the state has no role in welfare."4
Third, the government gives little consideration to fiscal responsibility. The federal deficit has exceeded two trillion dollars. State deficits also exist. A large portion of these deficits are related to medical care. For example, from 1970 to 1983 the expenditures for national defense increased a total of 9.9 percent while the expenditures for Medicare and Human Resources (of which the largest portion is for medical care) increased 236 percent and 142 percent respectively. (All figures are based upon 1983 dollars to factor out inflation.)5
The usual response to these numbers is that medical need justifies these expenditures. We have seen, however, that the government fails to determine Biblical need. Further, this irresponsibility of the government should be placed in its proper light. Is one Biblically justified to steal from your next door neighbor to feed your family, if they are starving? Further, is one Biblically justified to make counterfeit money in the same situation? I know of no Biblical ethicist that would begin to justify either means to this right end. So, one avenue that the government uses to provide for medical care, the creation of "new" money, is a form of theft because the money was not earned and the inflation that it causes, steals value from others.6 Further, taxation for programs that are not Biblically the responsibility of the government is theft, also.
An analogy may be helpful to understand this situation. A person who inherits several million dollars may begin to spend it for a large house, expensive cars, servants and other amenities consistent with his means. Initially, it seems that the money is almost inexhaustible. Sooner or later, however, he realizes that the implementation and maintenance of this lifestyle has consumed his resources. Now, who is responsible to pay for the maintenance of his lifestyle? Everyone would say that the responsibility is his own and no one else's. But, he would say, "I get such benefits from this lifestyle." You would say, "Such benefits are excessive and not essential to the basics of life."
This analogy is accurate for medical care. We have spent what we did not have (both in taxes and in "new" money). Now, because of the benefits of medicine, many clamor for its maintenance and continued expansion. But, the benefits are not clear (see above), and medicine fosters a lifestyle that ignores Biblical principles. Can we continue to subsidize ineffectiveness and immorality? An horrific example is the current AIDS threat. Medicine has supported homosexuality almost without hesitation. The advocacy of an "Alternate" (read healthy) lifestyle alone amy kill more than any plague in history and make the threat of nuclear war seem tame by comparison.
This "new" money has increased the overall cost of health care as well. New procedures and medications have been developed with this money. Anything "new" in medicine is almost always considerable more expensive. Again, theft does not justify the good that it may do. Further, as government ad private insurance restrict their payments (and they are doing so because of the rapid increase in medical costs), families are faced with a level of medical care that they cannot afford or that they too will go bankrupt or borrow heavily to finance the "latest and the best."
I am aware of the dangers of an approach that is solely concerned with economics. I am not arguing for cost as the only consideration. The Bible, however, clearly does not direct a blind fulfillment of the "needs" of others. Further, one cannot violate one Biblical standard in order to fulfill another. Payment of medical care by the government is wrong for at least the three reasons that we have stated. To justify this payment, a Christian must clearly violate the Eighth Commandment, as well as the explicit responsibilities stated in the Bible for the role of government. Evangelical Christians rightly proclaim and defend the sanctity of human life on the basis of the Sixth Commandment. But, in cases such as Mr. Brophy they violate another commandment. In so doing, they have elevated the sanctity of life above all other considerations.
We live in a world of limited resources.7 Decision must be made about the distribution of these resources, preferably according to Biblical criteria. God has delegated this primary responsibility to the family. Daily, all families make financial decisions that have life and death consequences for its members. Although they are usually less dramatic than these we are considering, they are no less life and death. As we have seen, the church is to supplement its own members under certain conditions. Further, Christians and others are to share and be charitable toward others. Thus, I advocate for medical care only what already is both Biblical and practical for families already.
Knowing the heart of man, I am aware of the potential "slippery slope" that a distortion of these principles can cause. It is possible for termination of life support and even less medical care to become based solely upon financial considerations. In fact, that scenario is likely, considering that the government now provides almost solely on the basis of financial need, rather than true medical need. They could deny for the same reason. This "slippery slope," however, does not negate the Biblical commandments and principles that we have examined. Rebellious man always stands ready to distort God's Word for his own fiendish needs. Biblical Christians, however, must apply the "whole counsel" of God's Word to situations.
Ordinary and Extraordinary
The categories of ordinary and extraordinary (p.3) are misleading and impractical. What is extraordinary today is ordinary tomorrow. For example, plastic feeding tubes were unknown prior to a few decades ago. Further, the initiative to insert and to maintain a G-tube without undue complications was extraordinary until even more recently. These categories are exactly the problems of "ordinary" air, food and water. Dr. Davis quotes the Larger Catechism of the Westminster Confession of Faith (to which I also subscribe) concerning the "lawful or necessary means of preservation of life."
To place air, food and water without further definition as "lawful and necessary means" is to conflict with his categories or ordinary and extraordinary. The artificial deliverance of any one of these means is extraordinary. Rarely can a respirator or feeding tube (whether through the nose or into the stomach) or simply intravenous fluids be maintained outside a hospital or nursing home. The former is a minimum of $400 per day and the latter is a minimum of $60 per day. Neither figures includes physicians fees or the cost of "tests." The latter amounts to $22,000 per year, a figure that is hardly ordinary for the budget of most families.
Further, there is now the availability of hyperalimentation by which complete nutrition can be maintained intravenously. This technology has only been available for the last few years. Prior to that time, a patient could not be given complete nutrition through a vein. The cost of hyperalimentation is $125-150 per day in addition to the $300-1000 per day for hospital costs, depending upon whether they are in a regular hospital bed or in the intensive care unit. If air, food and water are ordinary and obligatory, then hyperalimentation must be included for everyone, also. Thus, all patients can be kept alive a few days or weeks longer and the cost of medical care will be increased markedly.
The situation must be fully understood before artificial support is discontinued. The motive is all-important. Simply "unplugging" a respirator can be murder, if one's intent is to kill the patient. An example is the classical "plot" of the inheritor who does something to cause a "natural death." Further, with the intense emotions that can accompany these situations, motives can become blurred. I believe, however, that enough current safeguards exist with the routine oversight of nurses, other physicians, and family members as well as the medical-legal climate, that it would be extremely difficult to manipulate the system for one's personal motives.
The Golden Rule
And just as you want men to treat you, treat them in the same way.
And a second (commandment) is like it,
"You shall love your neighbor as yourself."
The Bible was written to give principles for every area of life, but it was not written to give complete casuistry, that is, to cover every possible situation that actually occurs or occurs in the imaginations of men. Also, Christians differ in their understanding, their reasoning, and in other ways that causes different decisions in similar circumstances. These two verses give more specific direction than might at first be apparent in the situation that we are considering. It seems that few people want "life-support" when recovery is very unlikely.
A recent Gallup survey supports this observation.8 Seventy percent of the respondents said that they would be "very willing" to have life-support disconnected and only six percent said that they would be "very unwilling." Also, supporting mine and others' observations, that when the same situation presents for a family member, decisions are much more likely to favor "everything" being done. Forty-six percent, however, said that they would be "very willing" to stop life-support for a relative, while twenty six percent said that they would be "somewhat willing" to stop life-support for a relative. This difference in application to self and to others is consistent with observations of patient care. When someone's relative is the one on life support, the family is more likely to ask that "everything" be done.
Other surveys and observations of patients generally fails to find people, especially the elderly, who want "everything" done for themselves. The Golden Rule states that the application of one's own desires is sometimes appropriate for decisions concerning others. In this situation the Golden Rule supports an almost universal consensus. Even though this application can be made apart from economic factors, financial limitations could further support a decision not to initiate or to discontinue life support.
Certainly the Golden Rule has a degree of subjectivity that could be abused. It is inconsistent with the unity of the Bible, however, to apply one Biblical principle to the exclusion of all others. Concerning terminally ill patients we find a distinct difference between Christians and non-Christians. The latter see no difference between discontinuing life-support and the injection of the patient with a lethal drug to end his life. In fact they support the latter as a means to relieve the patient's suffering. The Sixth Commandment, however, makes these two acts totally separate. Letting die in these situations has no necessary relationship to killing. John Frame makes the excellent point that for this reason the term passive euthanasia is totally inappropriate.9 The word euthanasia should never be applied to the decision not to implement or to stop life-support since euthanasia is an act where the primary intention is the death of the patient.
An analogy can be made with the situation (rarely necessary) in which a baby must be taken from its mother before it is able to survive outside her womb. Technically, this procedure falls into the general category of abortion. The intent, however, is not to kill the infant, but to save the life of the mother rather than lose both lives. With the terminally ill or otherwise severely debilitated patient the intent is not the death of the patient, but an acceptance that nothing effective can be done medically and either that the patient has expressed a prior desire not to have such life support or that the Golden Rule is applied by the person who has Biblical authority over the patient.
Initiation vs. Withdrawal of Life Support
An important question in these issues is whether any moral difference exists between the initiation of life support and its withdrawal. At first glance there seems to be a major difference. Failure to initiate allows an immediate situation to continue its course to the death of the patient. Withdrawal seems to cause the death of the patient. This distinction, however, is artificial.
In either case the disease process causes the death of the patient. The confusing factor is that life-support frequently is started in an emergency situation. Decisions must be made quickly, often before further studies can be made. The observation of the patient over time, however, gives information that could not otherwise be obtained and that is unavailable at the time of emergency decisions. Thus, the major difference between the failure to initiate and the withdrawal of life support is the extent of information available. The condition of the patient is often unchanged This latter fact is perhaps the most important in answering the dilemma. The patient has not changed, only his technical assistance and the knowledge concerning his prognosis. Thus, all concerned are better able to understand that the recovery of the patient is highly unlikely.
What might a scenario have been if these additional Biblical principles had been applied to Mr. Brophy's case? First, his wife has the responsibility and the authority to make medical decisions for her husband. She may (and probably should) consult her husband's physicians and other health care workers, other family members and the leaders of her church before making her decision. Second, the responsibility for payment falls first to her and the patient's family, second to her church and finally to other voluntary charity. The responsibility of her husband prior to his death would have included medical insurance to the extent that he and his wife wanted to be covered. We have seen that government payment systems are thoroughly immoral in their structure, even to encouraging sinful behavior.
Third, what would Mrs. Brophy want done for her (the Golden Rule)? Or, what were Mr. Brophy's desires about life-support systems? All husbands, wives and other relatives ought to discuss this matter at their earliest convenience. These decisions arise all too suddenly and unexpectedly.
Fourth, the withdrawal of life support has no moral principles that are different from those that govern initiation of life-support.
We not know Mrs. Brophy's motives, but from outward considerations her decision to stop treatment was consistent with Biblical principles. She may have desired to act upon her husband's prior wishes or the Golden Rule. She may not have had the financial resources to continue his required level of medical care and did not have the voluntary assistance of a church or other charity. Thus, there is considerable Biblical justification for her behavior, but not necessarily her motives because we do not know them.
1 Here, I skip over an area of debate with Christendom: whether man is dichotomous or trichotomous. I personally believe that the soul and spirit are one and the same. The two names denote its relationship to the body.
2 God calls some to unhealthy situations, for example, missionaries to backward countries where they are exposed to various diseases and other unhealthy situations. Generally, however, the obedient life will produce the maximal health available to use in this life.
3 Frame, John, Medical Ethics: Principles, Persons and Problems, manuscript being prepared for publication, p. 20.
4 Ibid., p. 39.
5 Carr, Albert C., "An Attack on Physician Services," The Journal of the Medical Association of Georgia, 74:142-52, 1985.
6 The tax money is also theft, but the government does have a right to tax (Rom. 13:6-7) and the refutation of that right is this land other instances is too long for this article. Also, I do not advocate tax avoidance for such immoral taxation, but we should strive to have it repealed and made consistent with Biblically legitimate taxation.
7 The earth' resources are far more abundant than the population planners consider that it is. The earth is capable of supporting several times its current population with a diet as generous as that of Americans. Nevertheless, on a day-to-day basis each family makes choices concerning its own limited resources.
8 "Survey Shows Most Americans Favor Ending Life Support," American Medical News, March 27, 1987.
9 Frame, Medical Ethics, pg. 54.
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