A Biblical Model For Medical Ethics
Dr. Heimburger is Assistant Professor of Nutrition Sciences and Medicine at the University of Alabama at Birmingham.
In the last article in this series it was pointed out that while Christian ethics has a normative base, an abstract understanding of this base is not sufficient to make one's approach to ethics Christian. Although God has given us absolute principles or norms to guide us, their proper application in real life contexts is not always obvious; knowledge of the principles must be followed by discussion of how they are to be used. To do this, we must consider seriously both particular situations in question and the motives and personal (existential) investment of each of the parties involved. In the last article this was illustrated by a triangle, with norms as the peak, and situational and existential concerns as the other angles. The biblical basis for these was illustrated with a second triangle, in which God's authority establishes the norms, His sovereign control of history gives meaning to situations, and His presence with us judges our motives. He does not abandon us to be faithful to His norms in a vacuum, but lovingly places us in situations in which they apply, and walks through our trials with us, enabling us to be faithful through the power of His Spirit.
We might now add a third triangle to show how these concepts apply to our daily decision making. This triangle indicates what questions we as Christians are responsible to ask ourselves each time we approach an ethical dilemma. (Much of the confusion in ethical discussions results from lack of clarity regarding the proper questions to ask, not to mention the right answers to them). At the top, since God has revealed His standard of right and wrong in the Scriptures, we must first ask, "what does God say?" or, "which of God's norms apply to this situation?" The second angle gives us the questions related to the situation, mainly "what is the nature of the situation?" (e.g., the prognosis of the patient with and without treatment, what treatment is available, etc.) and "How can the situation be changed in order to effect righteousness?"
So far, these questions are familiar. As Christians we often focus on normative questions, though we often define them too narrowly. And everyone is accustomed to asking how tough situations can be changed (although we often phrase it differently, such as "let me out of this!" and we often forget to be concerned about righteousness!) However, the third type of questions, the existential ones, are rather foreign, maybe because they get under our skin. In this angle we should ask, "what about me (or the others involved) must change in order to effect righteousness?" Very frequently, especially in difficult cases of suffering, this is the only real possibility left open.
The triangles are only a procedural model, and should not be construed to imply coequality of the three angles. God's authority is at the pinnacle, and informs the situation and the existential concerns. Without His spoken truth we would be left on our own to formulate goals, and would be in the dark about proper motives. To explore this further, in this article we will outline the biblical norms that apply to medical ethics. If we are to be faithful to the Lord we must grasp them before proceeding to analyze cases. Although the listing will be incomplete and the discussion sketchy, the principles should form an adequate basis for consideration of particular situations and motives in future articles.
The broad categories that will be discussed include epistemology, or the basis of what we know; Scriptures on who God and man are, including the basis of man's value and how he relates to God; a biblical view of health, disease, suffering, and death, and of how our earthly life relates to eternity; what sorts of rights we have; and what God provides us and expects of us when we honestly don't know what to do. In part, it represents a synopsis of the principles in the Westminister Confession of Faith that relate to medical ethics.
What is the source of truth? As biblical Christians our most fundamental assertion is that the Word of God, as revealed in the Scriptures of the Old and New Testaments, is the sufficient and final arbiter of truth in medical ethics as in all of life (2 Tim. 3:16,17; Heb. 4:12). From this most basic point we diverge from all other worldviews and ethical systems. What God has disclosed propositionally in the Scriptures is absolutely true, and is a revelation of His character. He tells us we are to obey His law simply because He is the lord our God (Lv. 18:2-5), to be holy because He is holy (Lv. 19:2), and promises that through obedience we will be blessed (Ps. 119:1-16).
Obviously, modern medical situations are not explicitly dealt with in Scripture. But this does not make God's word any less relevant to our current dilemmas, since the foundation it gives us is sufficient to inform any age in history. Principles not expressly stated in Scripture can and must be deduced from Scripture, but should not be given the same authoritative status. Rather, where Scripture does not speak explicitly, we are free to make decisions based on its counsel as a whole. Recognizing that they are "disputable matters", these decisions should tempered by a desire for peace and mutual edification (Rom. 14, esp vv. 1-6 and 19).
Some of the most frequent and divisive errors Christians in all ages have made relate to how they perceive ethical principles derived from but not unambiguously dealt with in Scripture. Apparently fearing uncertainty, we have an urgent need to portray each judgment as definitive. We extrapolate maxims from Scripture and (often unwittingly) elevate them to equal authority with Scripture. Like the Pharisees we become legalistic, taking ourselves too seriously and our limitations too lightly. This attitude promotes confusion because our dilemmas seem to match biblical statutes against each other; and it is divisive because we pit ourselves against others who haven't fit the issues into the same neat categories. If, on the other hand, we develop both an appreciation for the unfailing trustworthiness of God's word and an awareness that we can't resolve every contingency, we will find peace in our hearts and mutual edification of the body of Christ more easily achieved. Put in another way, Christians often agree on the norms but work through the applications in different ways. When this occurs we must be careful not to cast unfounded aspersions on each other's motives; we should strive for unity in principle and charity in application.
God is the creator and sovereign ruler of the universe (Gen. 1:1; Ex. 3:14). He is totally self-sufficient, needing no one's assistance. He works all things according to His good pleasure, and need not give account of His actions to anyone (Ac. 17:24-25). He intervenes in the courses of our lives so as to determine the means that are conducive to His ultimate purposes and to the ultimate blessing of His people (Rom. 8:28; Eph. 1:11, 12). This includes bringing calamity into our lives: "I am the Lord, and there is no other; apart from me there is no God. I will strengthen you, though you have not acknowledged me, so that from the rising of the sun to the place of its setting men may know there is none besides me. I am the Lord, and there is no other. I form the light and create darkness, I bring prosperity and create disaster; I, the Lord, do all these things" (Is. 45:5-7). "See now that I myself am He! There is no god besides me. I put to death and I bring to life, I have wounded and I will heal, and no one can deliver from my hand" (Deut. 32:39). These disasters and wounds are not to be confused with sin and evil, of which He is not the author (Jas. 1:13). However, if we remain in the illusion that God hands out only pleasant experiences and Satan doles out all the painful ones, we have a caricature of God and not a true understanding. We will be unable to integrate the existence of suffering with God's promises of blessing, and will find ethical dilemmas very difficult to reconcile. This will be discussed further in the section on suffering.
We are creatures, belonging to God and under His control. "He determined the times set for [us) and the exact places where [we] should live ...For in him we live and move and have our being" (Ac. 17:26-28). "Nothing in all creation is hidden from god's sight. Everyting is uncovered and laid bare before the eyes of him to whom we must give account" (Heb. 4:13; Rom. 14:12). He is not here to serve us, but we him. We are to be holy, because that is the way He is (1 Pet. 1:15,16), and are to have His glory as our chief end (1 Cor. 10:31). The very definition of our being is established by God, and we should be satisfied with that definition. God is God, and we are creatures.
Man is made in the image of God, and declared by God to be unique (Gen 1:26,27; 5:1-3). As such man's life, beginning at conception, is intrinsically valuable; his worth is not dependent on his age, form, attributes, independence, function, or station. "You created my inmost being; you knit me together in my mother's womb. I praise you because I am fearfully and wonderfully made" (Ps. 139:13-16). Because we are special to God, He says, "for your lifeblood I will surely demand an accounting" (Gen. 9:5,6), making us answerable for our own welfare and that of others.
Disease, Suffering, and Death
Disease and death entered the world as a result of the sin of man ("sin entered the world through one man, and death through sin, and in this way death came to all men, because all sinned", Rom. 5:12; also Gen. 3:1619). Since disease and death were not part of the original creation, when we fight them we are not fighting God. Rather, when as medical practitioners we strive to prevent and heal diseases, we are working against the effects of the Fall and are functioning within God's overall plan for the redemption of His creation ("He forgives all my sins and heals all my diseases", Ps. 103:3). The supreme example of this is Jesus himself, who "went through all the towns and villages, teaching in their synagogues, preaching the good news of the kingdom and healing every disease and sickness" (Mt. 9:35). In announcing the kingdom Jesus combined deeds of healing with words and acts of redemption, thus not just "saving souls" but bringing wholeness out of brokenness in spiritual and physical dimensions. When we as His disciples do similarly, we are likewise engaging in "kingdom activity," not just using care for physical needs as a way to gain entrance to the soul, but bringing wholeness where there was brokenness.
Sin is not only the ultimate cause of disease and death. Sometimes it is also the direct and proximate cause ("if you do not obey the Lord your God ... the Lord will afflict you", Deut. 28:1-68, esp. 27-8), such as when injury results from drunkenness or AIDS follows a promiscuous and deviant lifestyle. In these cases, we should not fall into our culture's self-flagellating confusion of discernment and judgment. We can, in fact we must, discern the biological and epidemiological causes of afflictions such as AIDS, and not flinch from pronouncing them even when to do so is socially sensitive. However, this is not to say that our role is to be the instruments of God's judgment, for it is not. On the one hand, if we do not say very clearly that healing requires repentance, we are not being His agents for healing. But on the other hand, we must guard ourselves carefully from smugly calling another person a sinner, as though we were otherwise. or as though that disqualified him from our care.
Further, such connections between sin and disease are the exception rather than the rule. It is most often not our prerogative to distinguish the causes and purposes of particular instances of suffering, so unlike Job's "friends" we must not infer that they represent the judgment of God (Job 40:1-8).
In fact, there is much more to affliction than whether it represents the judgment of God. A biblical view of suffering is one of the most pivotal and pervasive elements in our approach to medical ethics. For instance suffering, whatever its cause, is always used by God to accomplish His purposes. The psalmist said, "before I was afflicted I went astray, but now I obey your word" (Ps. 119:67). When Jesus was asked why a man was born blind, He said "neither this man nor his parents sinned, but this happened so that the work of God might be displayed in his life" On. 9:1-3). God tells us to "endure hardship as discipline; God is treating you as sons ...God disciplines us for our good, that we may share in his holiness" (Heb. 12:5-11). "Though now for a little while you may have had to suffer grief in all kinds of trials, these have come so that your faith ...may be proved genuine and may result in praise, glory and honor when Jesus Christ is revealed" (1 Pet. 1:6,7). He sometimes uses affliction to reveal His power and to witness to others ("we always carry around in our body the death of Jesus, so that the life of Jesus may also be revealed in our body", 2 Cor. 4:7-12).
In any given instance God may not intend to relieve our suffering in order to accomplish His purposes. "For Christ's sake I delight in weaknesses, in insults, in hardships, in persecutions, in difficulties. For when I am weak, then I am strong" (2 Cor. 12:7-10). However, whether it is relieved or not, He always intends to bless us and others through it, and our response to it influences whether this blessing is realized. "If your law had not been my delight, I would have perished in my affliction" (Ps. 119:92).
Mortality (the perishable, infirmity, death, etc.) is conquered by being clothed with the imperishable (unity with Christ). It is in this way that "death is swallowed up in victory" (1 Cor. 15:42-57, especially vv. 50,53,54). However, this will be fully realized only in eternity, when "he will be fully realized only in eternity, when "he will wipe every tear from their eyes. There will be no more death or mourning or crying or pain, for the old order of things has passed away" (Rev. 21:4).
Although modern technology sometimes allows us to exercise prerogative in the mode and timing of our death, we should never play God. Rather, such choices should always be considered in an attitude of submission to the will of God, since in all matters related to life and death, we belong to the Lord. "For none of us lives to himself alone and none of us dies tohimself alone. If we live, we live to the Lord; and if we die, we die to the Lord. So, whether we live or die, we belong to the Lord" (Rom. 14:7,8).
Although health was the norm in God's original creation, it is now marred by the effects of sin. Optimal health cannot be attained by the patching of the body alone, but requires a spiritual and physical wholeness attainable only through repentance, regeneration, and humble submission to God. "If my people, who are called by my name, will humble themselves and pray and seek my face and turn from their wicked ways, then will I hear from heaven and will forgive their sin and will heal their land" (2 Chron. 7:14). "Do not be wise in your own eyes; fear the Lord and shun evil. This will bring health to your body and nourishment to your bones" (Pr. 3:7,8). God is the one who heals our diseases (Deut. 32:39; Ps. 103:3); health care workers only participate in this process.
Life in the Perspective of Eterminty
Our present life is not the totality of our existence, and should not be treated as such. That is, preservation of biological life is not the "bottom line" for the Christian health care worker. "Do not be afraid of those who kill the body but cannot kill the soul. Rather, be afraid of the one who can destroy both soul and body in hell" (Mt. 10:28). In Heb. 2:14,15 we are told that Christ "shared in [our! humanity so that by His death He might destroy him who holds the power of death--that is, the devil--and free those who all their lives were held in slavery by their fear of death." How helpful and comforting this look at the "forest" can be to doctors and patients who are lost in the "trees".
All of this is predicated upon choices made during this life, since they have eternal consequences. "Man is destined to die once, and after that to face judgment" (Heb. 9:27). God distinguishes between believers and unbelievers ("my people" and "not my people", Hos. 2:23), and our approach to the two can rightly be different. While the one is "dead in transgressions and sins", the other has been "made alive with Christ" (Eph. 2:1-10).
Because our moral rights are derived from God, they serve only to guard our relationships with other men, and cannot be claimed against God. "Will the one who contends with the Almighty correct him? Let him who accuses God answer him! ...Would you discredit my justice? Would you condemn me to justify yourself?" (Job 40:1-8). In fact, we have no rights over against God. "Who are you, O man, to talk back to God? Shall what is formed say to him who formed it, `Why did you make me like this?" (Rom. 9:21; also Is. 29:16 and 45:9).
One of our rights is the right to life. Directly granted by God and protected by his law ("whoever sheds the blood of man, by man shall his blood be shed; for in the image of God has God made man," Gen. 9:6), it is foundational to medical ethics. However, it is not absolute, but can be forfeited righteously ("greater love has no one than this, that one lay down his life for his friends," Jn. 15:13) or unrighteously ("Saul died because he was unfaithful to the Lord ...The Lord put him to death and turned the kingdom over to David," 1 Chron. 10:13,14; also Gen. 9:6). The right to life only protects us against other men. It is not something we can hold against God, since "whether we live or die, we belong to the Lord" (Rom. 14:7,8).
The association of rights with health matters, such as a right to health care, or a right to die, is a very modern phenomenon. Prior to the last two decades there was no mention of such a concept in the ethics literature; people did not consider themselves to have a "right" to health. In fact, Scripture does not define a right to health or health care. "Who gave man his mouth? Who makes him deaf or dumb? Who gives him sight or makes him blind? Is it not I, the Lord?" (Ex. 4:11; also Deut. 32:39, above).
However, Christians are account able to a deeper principle than the maintenance of rights; in fact, we are bound to honor the morals that are often at the root of the rights debate. We are called by God, not by other men, to approach health care as an exhibit of grace, administered with a concern for justice and righteousness. "I was sick and you looked after me . . . Whatever you did for one of the least of these brothers of mine, you did for me" (Mt. 25:31-40). Scripture gives us the responsibility to care for and protect the poor and the powerless, and makes such activities an integral part of discipleship. "Is not this the kind of fasting I have chosen: to loose the chains of injustice and . . . to set the oppressed free? ... If you spend yourselves in behalf of the hungry and satisfy the needs of the oppressed, then your light will rise in the darkness, and your night will become like the noonday" (Is. 58:6-12).
We are valuable to God as individuals. "Even the very hairs of your head are numbered. So don't be afraid; you are worth more than many sparrows" (Mt. 10:29-31). However, God does not see us only as individuals, but places us in families, and refers to us as "a chosen people, a royal priesthood, a holy nation, a people belonging to God" (I Pet. 2:9-10). He also says "the body is a unit, though it is made up of many parts; and though all its parts are many, they form one body . . . There should be no division in the body, but its parts should have equal concern for each other. If one part suffers, every part suffers with it" (I Cor 12:12-26). Therefore, the concerns of the individual and of the collective are both represented in Scripture, and neither is preeminent; both must be guarded so that one does not eclipse the other. Since persons are created by God as individuals, their needs should not be ignored for collective, utilitarian purposes. But on the other hand, we are not required to consider only how an action will affect the individual, but can and should consider the wider context, such as the family and community.
God is always present with us, giving us the power to become holy. "I will be with you always, to the very end of the age" (Mt. 28:20); "you will receive power when the Holy Spirit comes on you" (Ac. 1:8). This is as true when our choices are difficult as when they are easy; even when he seems most distant He is with us, and His power can work in us. He never places us in a situation in order to abandon us or to force us to choose evil. "God is faithful; 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" (I Cor. 10:13; also Jas. 1:13).
Therefore, there are no moral dead ends or "tragic moral choices" in which we must choose the least sinful among evil options. The situations in which we find ourselves are never meaningless or hopeless. There is probably always more to the situation than we can appreciate, such as the spiritual battle in the unseen world. This was vividly illustrated when the Israelites were surrounded by the Aramean army and "the Lord opened (Elisha's) servant's eyes, and he looked and saw the hills full of horses and chariots of fire all around Elisha" (2 Ki. 6:17). We have the same power available to us, and our most formidable dilemmas can find some reconciliation through the application of the Word of God and prayer. "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" (Jas. 1:5).
Finally, it is important to remember that God weighs motives, not just outward appearances or consequences, in determining the rightness or wrongness of our actions. He knows that we sometimes do things that appear right, but do them for the wrong reasons; and He does not approve. On the other hand, when attempting to be faithful to Him we sometimes make wrong choices guilelessly, and He understands. This is very comforting in those times of uncertainly when we honestly don't know what is best and must do what seems best. God "does not take pleasure in burnt offerings. The sacrifices of God are a broken spirit; a broken and contrite heart, O God, you will not despise" (Ps. 51:16,17; also I Sam. 15:22,23; Pr. 21:2,3; Hos. 6:6; Mt. 9:12,13). "A man is not a Jew if he is only one outwardly, nor is circumcision merely outward and physical. No, a man is a Jew if he is one inwardly; and circumcision is circumcision of the heart, by the Spirit, not by the written code. Such a man's praise is not from men, but from God" (Rom. 2:28-29). "Each man should give what he has decided in his heart to give, not reluctantly or under compulsion, for God loves a cheerful giver" (2 Cor. 9:7). The rightness of an action turns upon whether we use the right standard (the Word of God), the right goal (the glory of God), and the right motive (love for God and fellow man).
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