Medicine and The Third Commandment
Dr. Pomerantz is a 1986 graduate of the School of Osteopathic Medicine of the University of Medicine and Dentistry of New Jersey. He is currently a resident in Family Practice and lives in Glassport, Pa.
In an age of easy divorce, prenuptial agreements, lying public officials, and a general separation of rights and responsibilities, a comprehensive look at the Third Commandment is certainly overdue. Although its immediate concern is the sanctity of the Name, a study of Scripture shows the commandment to be concerned with oaths and vows (see Westminster Confession, Larger Catechism, Questions 111-114).
Promises, contracts, oaths, vows, covenants (contracts) and other forms of agreement are both necessary and required in ecclesiastical spheres. The Westminster Confession of Faith, Chapter 22, provides a powerful statement on the seriousness with which God has taken the word of men throughout Scripture. Medicine, as a secular calling, is also intimately involved with formal and informal contracts, particularly with third party payers (medical insurance, health maintenance organizations, Medicare, Medicaid, etc.). As Christian physicians, an appreciation of the Divine perspective on lawful oaths and vows is incumbent upon us.
A simple place to start is God's prohibition of sinful oaths and vows. When physicians guarantee desired results (whether explicitly stated or implied), we sin in our promise to do the impossible. Therapy confers no grace ex opere operato. Patient compliance and responsibility, as well as the condition being treated, are major factors in therapeutic outcome. Only God can guarantee healing. If physicians insist on playing God, then they must deliver accordingly or at least be held liable for breach of promise' (of which many are in the courtroom).
To promise the unknown is also contra Deum (Lev. 5:4). For example, treatments with unproven efficacy may be used without the full disclosure of this information to patients. Also, some practices of "holistic" medicine, such as mega-vitamins, amino acids, herbs, minerals, special diets and massages, fall under this condemnation. What you do not have is documentation of efficacy; what you do have is a growing literature on vitamin intoxication and plant poisoning. The proper knowledge of these "therapies" would be to educate our patients about such false claims and their potential for harm. Doctor, after all, means teacher.
The Third Commandment also covers the promising of the unlawful. The communication between physician and patient has historically been compared with the sanctity of the Roman Catholic confessional. That is, absolute confidentiality has been applied to both. As I pointed out in a previous article,' Scripture does not warrant this restriction to either one. The sword has been placed in the hand of the civil magistrate (Rom. 13:4) and physicians are nowhere authorized to stay his hand. As Gillon1 pointed out, the need for chart review by various personnel along with individual circumstances has dictated the posture of relative confidentiality by the British Medical Association. In the United States the increasing number of persons, with more or less valid reasons to have access to medical records, makes this position de facto . Regardless, physicians should clearly inform our patients that a) confidentiality is not absolute, particularly for brief, initial visits ("gate-keeping" is the word in vogue today); b) confidentiality will be broken where illegal activities are revealed; and c) the prohibition of "unnecessary discovering of infirmities"' (that is, the unnecessary revealing of the problems of others) will be observed (Gen. 9:22; Prov. 25:9,10). Communication is thus privileged and confidentiality subject to conditions appropriate to the circumstance.
Another ancient and questionable practice is the taking of the Hippocratic Oath. Although this oath often has the swearing to false gods omitted, the Christian should only make oaths by the Triune God. To swear by the generic god of ecumenicity is to take the Lord's name in vain. The oath, however, is still binding, if it is not made to a sinful purpose. For example, the physician who does abortions, yet swore not to abort under the traditional form of the oath (this clause has been removed since Roe vs. Wade), makes his own condemnation greater because he adds covenant-breaking to fetacide (murder).
Perhaps the sin most intrinsic to medicine (second to quackery) is the false assumption of expertise. The physician-patient relationship has always been founded upon trust and honesty. Modern medicine seems to impure omniscience via the rigorous training, licensing, and certification to the physician. Yet, medical expertise in one area does not automatically transfer to other areas. All physicians have their "cognitive windows." These gaps in their knowledge and skills clearly demonstrates that this omniscience has not been imparted.4 Thus, the physician must recognize his limitations and honestly convey them to his patients. He must not promise more than he can deliver.
Medical expertise does not automatically transfer to realms outside of medicine either. Gordon Clark states that ostensibly scientific enterprises cannot address the metaphysical issues.' Since medicine is founded upon the natural sciences, the physician who uses his medical credentials to speak authoritatively on non-medical topics represents himself falsely and presumptively, albeit sincerely. He violates the Third Commandment by his making a false contract. Often, he does not present himself in this way, but patients seek him because of the "omniscience" that seems to have been given to him for the above reasons. Examples include child-rearing advice, competence of criminals to stand trial, and the probability that some patients or criminals will or will not be violent in the future. Such categories lie wholly outside the pale of medicine. Therefore, pediatricians who pose as child psychologists, forensic psychiatrists, and other public "authorities" contract under false premises.
The Bible speaks clearly on such issues, so there is no need to enlist these physicians who are thus incapable to render sound advice here. As Thomas Szasz has adroitly discussed ,b the problems of living are not problems of medicine. Thus, physicians should not collect fees for ostensibly providing medical services to patients who seek medical expertise where none exists.
On this subject I find myself a bit at odds with Ed Payne, as I have stated elsewhere in a review of his tome.7 The Christian physician, even as an ordained elder with training in Biblical counseling, must still be wary of overstepping his bounds. Those patients who are not members of his church are outside the authority of his church office, if not his expertise.
The four means of grace are prayer, the Word, the sacraments, and church discipline. They are Biblically administered under church aegis (the "keys" of Mt. 16:88ff), not by free-lance physicians. The concerned Christian must respect the governing body of the believer-patient's church. If the church is apostate, then affiliation with an orthodox church should be discussed. Otherwise, the physician should consult this governing body for their permission and advice, prior to any prescriptions for psychotropic medication and/or counseling. He must keep them informed periodically, as well. For a physician to assume (in effect) pastoral oversight without the consent of that patient's church is to meddle in the covenant that he established by his church membership. In so doing, both physician and patient violate the Third Commandment.
Failure to keep lawful vows is equally sinful, particularly in organized medicine. Medical boards, societies, academies, and hospitals have not fulfilled their covenantal obligation to safeguard the common weal by the police of their members. For example, "Double O Privates"8 with a license to kill are protected by the "Old Boy System" and the frantic efforts of residents on night call. Physicians who serve as licensed "pushers" are usually known within a community, but they are not disciplined by the Organization until the Drug Enforcement Administration (DEA) and other police become involved. If the public is to consider Medicine's plea for tort reform seriously, it will have to demonstrate its own house-cleaning ability.
One cannot forget the hue and cry, raised over the start of Medicare and Medicaid, that subsided when physicians began to appreciate their profitability. To allow abortionists to remain in good standing in the medical community further shows the public that medicine is a vested interest which will readily abandon principles and patients for the sake of profit. As Rousas Rushdoony stated, " . . . . every doctor is hurt by that recognition. He who recognizes murder as legitimate is classed with the murderer." Less severely, he could be classed with the other prostitutes and mercenaries. Surely, the medical community has broken covenant with the public that it swore to serve.
I cannot end without a criticism of third-party medicine, such as the health maintenance organization (HMO) and preferred provider organization (PPO). Business and medicine have become involved in an entangling alliance that is disguised as maximum care at a minimum price. Yet, this arrangement often seems to help neither the physician nor the patient. When a physician is financially rewarded for non-intervention and penalized by a corporate bureaucrat for inappropriate intervention, the physician-patient relationship is changed from a therapeutic alliance to an adversarial contest. The only result can be compromised care. If this situation is combined with forced in-house (those contracted by the third-party) referrals to specialists who are not competent physicians, then the Sixth Commandment is transgressed. (Some might add that the physician has also violated the premise primum no nocere, "first of all do no harm".)
Medical training produces physicians, not "gate-keepers." "Holding the line" can be medically unsound and invite a medical-legal disaster. While the third-party may limit the options to a physicians, his liability does not have similar limits under the principle of caveat emptor.
The business principles of the third party are open to serious questions, as well. The physician is probably "unequally yoked" in this humanistic arrangement (11 Cor. 6:14). In short, involvement with such aspects of third party medicine is at best gray. The Christian physician would do well to avoid it.
To be properly focused, we should reflect upon the Old Testament where one's word was sacrosanct and sealed symbolically with anointed pillars, cairns, salt, and blood. The old adage that a man's worth is measured by the fidelity to his word is sound Biblical truth (Psa. 15:4). With its "right hand of falsehood" (Psa. 144) modern society illustrates the "love of death" in those who flee God's law and follow humanistic law (self-law). As Christians, we should be salt to preserve covenants (Num. 18:19; 11 Chron. 13:5) and to be mindful of God's requirements regarding oaths and vows.
1. Pomerantz, J.D., "The Practice of Medicine and the First Commandment," Journal of Biblical Ethics in Medicine, January 1987, pp. 11-13.
2. Gillon, R., "Confidentiality," British Medical Journal, December 7, 1985, pp. 1634-1636.
3. This phrase is quoted from the Answer to Question 145 of the Larger Catechism. For those not familiar with Reformed and Presbyterian churches, their most common theological documents are the Westminster Confession of Faith and the Larger and Shorter Catechisms. The latter are framed as questions and answers to central matters of belief. Question 145 asks, "What are the sins forbidden by the ninth commandment?" There follows an answer that requires a half page of fine print
4. God imputes Christ's perfect righteousness to believers, but He does not impart it immediately. That is, God accounts believers as perfectly righteous (the requirement of salvation), but He does not give it to them personally. He imparts it partially upon initial belief, progressively through sanctification, and finally in heaven.
5. Clark, Gordon C., The Philosophy of Science and Belief in God, Jefferson, Maryland: Trinity Foundation, 1964, p. 113.
6. Miller, Jr., "The Myth of Mental Illness: A Conversation with Thomas Szasz," The Sciences, July-August 1983, pp. 22-23.
7. Pomerantz, J.D., "Biblical/Medical Ethics" (book review), Covenanter Witness, March 1987, p. 13.
8. In the James Bond series, certain special agents are "licensed to kill." Their designation is a "00" number. The application of this "license to kill" comes from: Shem, S., The House of God, New York, Dell Publishing Company, p. 426.
9. Rushdoony, Rousas J., "The Criticism of Medical Practice by Doctors", Chalcedon Medical Report, no date given.
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