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Book Review

Medical Ethics: Principles, Persons, and Problems

Rev. Mitchell is the pastor of Middle Valley Baptist Church in Hixson, Tennessee and a Ph.D. student in Medical Ethics at the University of Tennessee.

Since the invention and proliferation of flexible plastic tubing (used on ventilators and for IVs), health care professionals and those whom they treat have had to make increasingly difficult ethical decisions. That such a minor technological advance could present such major ethical dilemmas is staggering, but only underscores the necessity of careful and constant analysis of the moral dimensions of high-tech medicine. Fortunately, along with the burgeoning medical technology there is a growing body of literature which addresses bioethical issues. Unfortunately, evangelicals are, perhaps, ten to fifteen years behind in the process. This recent contribution by John Frame, Professor of Apologetics and Systematic Theology at Westminster Theological Seminary in Escondido, California, is an effort both to "catch up" and to interact with some of the standard works in the field of biomedical ethics.

Frame's very helpful survey of medical ethics is divided into three major sections, each corresponding to his three major perspectives. He points out that every ethical decision is composed of three separate but related parts. The "normative" perspective focuses on the principles and precepts of Holy Scripture. The "situational" perspective takes into account the circumstances surrounding the decision. Focusing on the personal moral agent is termed the "existential" perspective. Frame believes that "this tri-perspectival ethical model is a distinctively Christian, indeed distinctively evangelical ethical approach" (p. 6).

The Normative Perspective

The first section lays the important theological foundations for doing medical ethics. "What saith the Scriptures?" is the compulsory starting point for Christian decision-making. "The Christian's norm -- his necessary, authoritative, sufficient, and clear standard -- is the Bible, the Scriptures of the Old and New Testaments" (p. 7).

The nagging question of "conflict of duty" takes up a major portion of Frame's discussion. Rather than opting for a "lesser-of-two-evils" approach to ethics in a fallen world, the author posits that the Scriptures contain a hierachy of moral/ethical commands. That is, since it is never right to disobey God, and since the Scriptures cannot be both trustworthy and contradictory; therefore, a Biblical ethic is one of non-conflicting absolutes which are presented in levels of priority. While this position is not without its difficulties and critics, it seems that Frame's approach compliments the unity and reliability of Scripture; the Person of Christ (who was "tempted like as we are, yet without sin"); and the promise of God always to provide a way of avoiding a sinful moral decision (cf. 1 Corinthians 10:13).

Ethical theory is always "complicated" by the necessity of applying the theory to concrete situations. But "after all, we are seeking an applied norm, that is situation-specific" (p. 19). Frame's priority-based ethic is applied to traditional biomedical issues such as, the principles of beneficence, non-maleficence, risk/benefit analysis, cost/benefit analysis, quality of life judgments, et. al. He successfully unravels several twists in applied ethics.

But how do we appropriate Biblical-ethical norms? What is the personal process of acquiring ethical knowledge? According to the author, conscience, as part of the imago Dei, plays a role in the process, as does vigorous analysis. But the bottom line is the "ethical knowledge . . . is not merely an academic achievement; it is a result of regeneration and sanctification; it is a product of the Christian life" (p. 28). Only those with a truly Biblical world-life view are genuinely equipped to do ethics. If the Biblical and Reformed world-view best explains the universe in which we live, and certainly it does, then Frame is right on target.

The Existential Perspective

The existential perspective focuses on the moral agent, the decision-maker himself. Here, the author examines the principle of autonomy and the concept of paternalism, especially as interpreted in the seminal work by Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics (New York: Oxford University Press, 1979). Frame rejects the word autonomy but accepts as Scriptural the idea "that competent persons under God have the right to make their own decisions about medical treatment . . ." (p. 38). Interestingly, based upon his "levels of priority" view, he argues that a physician has a right to overrule a Jehovah's Witness's refusal of a blood transfusion for his child on the grounds that the JW's spiritual competence is, at best, questionable. The physician's responsibility "to do good" (as a Good Samaritan) demands the transfusion. The judiciary, Frame contends, ought to make this possible without threat of litigation. Informed consent, confidentiality, and the principle of justice, are other areas that receive effective exposition in this chapter.

The Situational Perspective

Medical research, the criteria of death, and living wills are all problematic for medical ethicists as well as for patients and their families. Once again, Frame breaks some new ground for those evangelicals who find his method of doing ethics persuasive. In the case of medical research on the unborn, Frame perceptively concludes,

. . . unborn children, including fertilized eggs in vitro, have the same rights as children already born. If anything, such subjects should be treated all the more carefully since they are the youngest and least able to give informed consent and to communicate need (p. 57).

As for the criteria of death, Frame rejects the "definition" of death adopted by the Uniform Determination of Death Act, desiring a more comprehensive set of criterion.

It is better to define death as the irreversible loss of heart, lung, and brain function -- to make each a necessary criteria for declaring someone to be dead. This will mean, of course, that when someone is "brain dead" but supported by ventilators and so forth, he may have to be removed from those machines to determine whether he has died, or perhaps, if he is still alive, to "let him die" (p. 61).

Frame elaborates on his conclusions by adding an appendix (Appendix A) addressing recent critiques of the brain-death criterion. While it is true that his position is somewhat conservative, it will nonetheless inhibit the abuse of a brain death declaration in order to harvest organs, fetal tissue, etc.

The strengths of Medical Ethics are several. First, Frame establishes a viable ethical "theory" which may apply to all cases at all times. This is not to say that all bioethical dilemmas are easily resolved. The "stuggle of the soul" in ethical decision-making still remains. Second, he attempts to apply his ethic to concrete examples. This is no "ivory tower" treatment of the subject. Third, Frame interacts with some of the important literature in the field of biomedical ethics. Unfortunately, evangelicals sometimes ignore the arguments and contributions of those "outside the camp." This makes it appear that they have not done their homework. The book's importance and value is further buttressed by a lengthy appendix (Appendix B) on abortion which consists of the Report of the Committee to Study the Matter of Abortion, presented to the General Assembly of the Orthodox Presbyterian Church in 1971, of which Dr. Frame was a principal author.

While brief, Medical Ethics deserves a wide reading among evangelical health care professionals, pastors, counselors, and interested laymen. Seminarians should be exposed to the book as an introduction to the diverse, the often puzzling, issues they must face in ministering to families facing medical crises. The book is clearly written and guaranteed to stimulate one's thinking. In the rapidly changing world of medical technology, it is indeed refreshing to find, in what Carl F.H. Henry has called our "neopagan" society, another Reformed evangelical thinking deeply about life and death struggles in the arena of medical ethics.

[ JBEM Index / Volume 3 / Number 3 ]

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