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Eternity In Our Hearts:  Revelation Confronts Medicine

Dr. Duffee is a fourth-year medical student at East Tennessee University in Johnson City, Tennessee, pursuing a residency training program in Internal Medicine. He received his Master of Divinity degree from Golden Gate Baptist Theological Seminary in California in 1989 and has served in various ministries.


THE NECESSITY FOR A REVELATIONAL APPROACH TO ETHICS

Setting the Scene

There is an attitude among medical students today which suggests that serious ethical discussion is peripheral and bothersome to the practice of medicine. As medical mercenaries waging war on disease, we are armed with the weaponry of exalted empiricism. This weaponry, best described as an application of the scientific method (with its reliance on repeatable and verifiable sensual phenomena) coupled with the emerging tools of molecular biology (unlocking the pathophysiologic principles of disease), allows the formulation of a diagnosis and treatment plan based on "the facts." Young physicians are well equipped in the advancing science of medicine. We are students of fact.

However, like mercenaries, young physicians often lack a moral impetus in waging this war. While the science and technology of medicine are increasingly able to fight disease in an empirical sphere, this same science and technology are unable to extend their answers to questions in a relational sphere.1 This is illustrated most profoundly in the case of Mrs. Toivonen presented in a previous issue of this Journal.2 This 83 year old woman, institutionalized with severe senile dementia, is hospitalized with pneumonia. "Why does Mrs. Toivonen have a fever?" is a question readily answerable by empiricism. A sputum gram stain and culture and sensitivity will demonstrate the causative pathogen in her pneumonia and allow the proper choice of an antibiotic for treatment. However, the question "Why should Mrs. Toivonen be allowed to die?", an option implied by the author of this case scenario (originally presented in the New England Journal of Medicine), is a question unanswerable by empiricism, extending beyond simple fact into an ethical sphere. For the field of medical ethics steps beyond the sensual when questions regarding the quality, value, or ending of life are added to the basic questions of physiology. These are questions whose answers lie beyond our senses, beyond our ability to objectively analyze and make reasonable our data. These are questions that deal with personality, family, relationships, and the soul. This is the point at which medical practice leaves the realm of the sensual situation and becomes a theological pursuit.

Thus, young physicians, trained to manage the weapons of empiricism, are often unprepared when confronted by ethical questions. When presented with issues of an ethical sort the usual response is an apathetic "it is a matter of one's own opinion." In service to the god of empiricism (in spite of its strength in its proper sphere) and blinded to its limitation in an ethical sphere they respond, as characterized by Carl Henry, "granting to reason a pragmatic significance in this world of physical events [while cutting reason off] from any ontic relation to universal essences and absolutes and indeed denies the very reality of such."3 This nihilism creates a moral bankruptcy, hampering the caring side of medicine, while producing a new generation of physician-scientists in search of their professional soul. In fact, it may be too optimistic to imply that there is even a search for a soul. Many, rather than seeking to understand the relational sphere and its application most notably seen in primary care medicine, opt for careers in procedurally-oriented sub-specialties which operate within the comfortable environs of empiricism.4

THE LIMITATIONS OF MEDICINE

In theory, that empiricism alone can and/or should inform our actions in an ethical sphere exclusively is argued by relatively few. While nonrevelational ethical approaches, characterized as "speculational" by Carl Henry, use varying degrees of human empirical and rational reasoning, very few (exceptions are pragmatism and logical positivism) argue that empiricism and the scientific method alone can be used to build these principles.5 It is clear to most that the "tools" used to answer the question "Why does Mrs. Toivonen have a fever?" are different from the "tools" used to answer the question "Why should Mrs. Toivonen be allowed to die?"

In practice, however, modern physicians trained as biological scientists do not always realize the limitations of empiricism in an ethical sphere. Consider for a moment the family of Mrs. Toivonen. While the principle of patient autonomy is certainly the most important ethical principle in doctor-patient-family relationships, families (in the absence of advance directives and patient coherence and sometimes even competent patients themselves) often turn to physicians to inform their autonomy. While in this situation the empirical medical status and prognosis of the patient is crucial information, the family is also concerned about issues of life, death, loss, guilt, or even the hereafter. These are issues whose answers lie beyond a scientific capacity to inform them. Trained purely as biological scientists and informed only by opinion, conscience, or common sense, young physicians lack a moral authority to share relationally with their patients in these matters of the soul.

The limitations of empiricism were demonstrated early on in the philosophy of Descartes. In Meditations on First Philosophy he implies that while sense perception is adequate for "things near to us" (for example things in an empirical sphere), the senses are unable to inform reality in "things very far away" (for example things in an ethical sphere).6 Scripture confirms this limitation of human reasoning by showing that while man is an empirically reasoning being and held responsible for what that reasoning deduces,7 his reasoning ability is limited in its capacity to know God fully on its own. Thus a dilemma is present. Human beings are built to function in an empirical sphere but are unable on their own to gain total insight into the ethical sphere. This is the source of frustration for empirical young physicians confronted with ethical questions. The result is an apathy toward ethical discussion so common in today's student-physician.

THE NECESSITY FOR REVELATION

What knowledge source should inform decision making in an ethical sphere? Descartes' rationalism confirms that sense perception alone has no foundational role in answering this question. These answers must come from beyond our sensory understanding of the situation. This source for Descartes was "first principles" or "objects of intuition."9 Hume went even further in showing that not only was empirical reasoning inadequate for answering questions of an ethical sort but so was Descartes' rationalism. Others have offered alternative explanations for this knowledge source.10 These alternatives fall short because they are fundamentally bound by the use of human deductive reasoning in a non-deductive sphere. When an empiricist or rationalist confronts an ethical situation, pragmatism, agnosticism, or subjective value systems are the only logical solutions.

However, a revelational knowledge source claims to provide insight from beyond the empirical sphere into the ethical sphere. This is the fundamental task of revelation.11 This is not to imply that revelational truths are irrational, only that their source is not limited by empirical sense or rationally derived. John Baillie describes revelation as a revealing from divine subject to human subject truths that were previously a mystery (i.e., beyond our ability to deduce them). Further, he states, "the mystery described is nothing less than God's own will and purpose."12 In fact, the application of revealed principles in ethical situations, their call on us to decision and response,13 their reliance on faith rather than deductive reasoning for their reception and the hope this faith creates in a Revealer form the core of our relationship with God.14 This is what fulfills the search for a soul. God in His infinite wisdom has gifted humankind with the ability to empirically reason and rationally deduce. But in His infinite wisdom He has also seen fit to limit the capacity of this reasoning ability so that a faith relationship can be fostered with Him through encounter with His revelation. It is through this relationship that revelation regarding Himself and the beyond can occur. It is through this relationship that our lives can attempt to imitate His revelation alone that provides answers for the relational question of life, death, family, and the hereafter. Thus "Revelational ethics" are necessary to inform the answers to questions such as "Why should Mrs. Toivonen be allowed to die?"

Difficult questions arise from this approach to medical ethics when applied within the broad context of the whole of the medical profession as there are many and diverse belief systems within our profession. What constitutes a revelational principle? What individual or body of revelational norms are true and appropriate for use in the ethical sphere? How are these revelational truths applied to specific situations? The epistemological task of Revelational ethics is to evaluate and apply revelational principles through:

(1) A Phenomenologic theological method.15
(2) An appropriate hermeneutic.16

As the above tools are applied to this approach to ethics, we as Christians are convinced that the source of revelation will be seen as:

(1) The personal revelation of God
    (a) General ionl7
    (b) The person and work of Christ18
    (c) The work of the Holy Spirit,19 and
(2) The propositional revelation of God through the infallible and inerrant words of Scripture.20

THE APPLICATION OF A REVELATIONAL APPROACH TO ETHICS

The imago Dei as a Point of Contact

How then is a revelational approach applied generally to the field of medical ethics and specifically to the doctor-patient relationship within which a diversity of people and belief systems will be encountered? Christian revelation states that human beings are created in the image of God (imago Dei).21 Dr Franklin Payne offers a solid explanation as to the nature of this image of God in man from a survey of scriptural references and Reformed theology. He states 'The image of God in man consists of man's righteousness, his mind (intellect and will), his assigned dominion over the animals and the earth, his 'in-created' (Kuyper's term) knowledge and possibly his ability to communicate and have fellowship with others and with God."22

However, the application of this revelational principle to medical ethics has historically been unclear. This lack of clarity is due in part to the question of the presence of the imago Dei in unregenerate man. If the image is not present in unregenerate man, the universality of a revelational approach to medical ethics is lost.

The classic debate as to the presence of the image in unregenerate man is seen in a dialogue which took place between two neo-orthodox theologians in the first half of the twentieth century. In his essay entitled "Nature and Grace, "23 Emil Brunner states that part of the image remains in unregenerate man. He calls this the "formal" part consisting of man's "humanness" and dominion over creation. But he also claims that a "material" part of the image consisting of God's original image in man (justitia originalis) which formed the basis of fellowship with God before the fall is completely destroyed.

On the other hand, Karl Barth, initially in his commentary on Romans24 and later in his reply "No!" to Brunner,25 claims that the image of God is completely destroyed in unregenerate man. This "divine no" produces a barrier between man and God making man unable to understand anything of the divine nature or existence. He states that man's rational nature is only capable of bringing him into a "krisis," in which he comprehends this barrier and his need for revelation from God in breaking through it.

Dr. Payne suggests that the image of God is present in unregenerate man albeit in a markedly distorted form.26 The extent of this distortion is the crucial question. Is unregenerate man capable of any spiritual longings or insights? Brunner, in his concept of responsibility implies he is. Barth in the "divine no" states he is not. Both Barth and Brunner cite Calvin in support of their positions.27 Calvin himself seems to suggest a capacity for unregenerate man to have insight into spiritual matters while not denying that in his total depravity humankind's inability to relate to God without divine revelation and response.28

Two passages of Scripture seem to shed light on this question of the presence and nature of the imago Dei in unregenerate man. Ecclesiastes 3:11 supports that a spiritual dimension exists in all. In fact, it is possible that this "eternity in our hearts" is placed there by God in every person so that we can find His plan for our lives (or at least bring us into divine Krisis ).29 Further, Romans 1:18-23 shows that a rational nature capable of perceiving the uniqueness and existence of God by our senses through creation exists in all and which makes us responsible before God in our response to Him.30 This seems to imply that a common aspect of the imago Dei exists in both the regenerate and unregenerate seen as spiritual longing and empirical rationality. There is a likeness of God, given from God, to and in every person. This is a core revelational principle.

The centrality of this principle to revelational ethics is two-fold. As God's likeness is somehow present in every person, every person has an inherent worth and value. Brunner, citing Calvin, emphasizes this point.31 It also provides for every person a point of contact with the revelational source. This allows a universal applicability of the revelational approach to medical ethics. At some level true revelation can speak to every person. As Christian physicians discuss options or even pray with patients for wisdom in ethical situations or as they inform a patient's autonomy in dealing with questions of life and death, revelation can speak to the "eternity in their hearts." The revelation may be rejected by patients in their autonomy, may simply satisfy the ethical question at hand or, by God's sovereign guidance and the power of the Holy Spirit in the situation, may lead them to the point where they "find out the work which God has done from beginning to end" (Eccles. 3:11) and enter a saving relationship with Jesus Christ. The phenomenological theological method introduced above safeguards the evaluation of other viewpoints in this revelational process. Thus young physicians in search of their professional identity and soul need not fear informing eternity in their own or their patient's hearts. We are not being academically dishonest as we utilize revelational principles and step beyond empiricism when justified. We have come back to our roots as spiritual image-bearing people when we can do so.

The trappings of casuistry versus the freedom of the Spirit

In a prior issue of this Journal, Dr. Douglas Heimburger presents an integrated approach to ethical problem solving.32 He incorporates the strengths of three historical approaches. He states that the normative approach provides "a firm standard of right and wrong"33 "from a revelational source"34 "adhered to out of the Lordship of Christ."35 With respect to a consequentialist approach he incorporates the freedom it provides to make decisions in specific situations controlled by a sovereign God.36 An existential approach also preserves freedom in a more personal sense.37 He integrates the strength of these three approaches as equal factors in ethical decision making, illustrated as the three corners of an equilateral triangle.38

Dr. Heimburger importantly sees the necessity for biblical propositional revelational norms in informing ethical decisions. Furthermore, he senses a need for freedom of application of these norms personally and situationally because of God's involvement with us in every situation.

However, he chooses to integrate the normative approach with the situational and existential in an Hegelian fashion due to a limited application of the whole spectrum of Christian revelation. He implies, to the exclusion of God's personal revelation, that normative action in an ethical sphere is informed only by propositional truths.39 While he does see a role for the Holy Spirit in "enabling us to be faithful to these [propositional] norms,"40 he does not give the Holy Spirit a personal or corporate revelatory role in the life of an ethical decision maker. This eliminates the freedom the Holy Spirit provides in the choosing and applying of revelatory principles in specific situations.41 Furthermore, if not accepting in total, he must now deal with the differing presuppositions that situational and existential approaches bring to ethical decision making, namely, the rejection of revelational absolutes and the elevation of empirical reasoning in informing the ethical sphere. A revelational approach as opposed to a normative or integrated approach preserves the strength of revelational absolutes in informing the ethical sphere while providing the freedom for individual families and physicians to apply these principles in difficult situations by the power of the Holy Spirit through discussion and prayer.

Dr. Heimburger also presents a powerful criticism of the classical normative approach to ethics (and in so doing incriminates the revelational approach) for its application of ethical principle irrespective of situational factors and in a "vacuum."42 Ultimately this type of approach denies the freedom and break from the law provided by the ministry of Christ and the Holy Spirit.43 This casuistry robs people of their freedom rather than leading them to be free in their Christianity. Helmut Thielicke further characterizes the danger of this application of revelational norms.44 Heimburger states that strict application of normative laws to ethical situations actually runs counter to the sovereignty of God to act in ethical situations. Heimburger thus feels obliged to offer an integrated approach to ethical problem solving incorporating situationalism and existentialism.

Revelational ethics actually preserves the freedom of individuals to act in ethical situations. Through prayer and an expanded understanding of the ministry of the Holy Spirit, people can be guided by His supernatural power to apply revelational norms rightly in any ethical situation. This approach often is shunned due to the "perceived uncertainty" of what the Holy Spirit may be guiding us to do in any situation. Revelational principles are numerous and ethical situations are complex but God is faithful and will provide a genuinely seeking individual, asking for wisdom, the wisdom to choose appropriately in any given situation.45 Our faith requires this confidence in us. Revelation provided by the Holy Spirit individually through Scripture study and prayer or corporately through correction by the church creates our freedom to choose in an ethical situation. It is prayer, study of the scriptures, and faith in light of situational factors and not situations informing our principles that create freedom to decide in ethical situations. This may be a matter of semantics, but the revelational approach guides one to prayer and scripture study in informing ethical decision whereas the other guides one to study the intricacies of the situation at hand. An integration of the normative and situational approaches with their differing presuppositions is not needed to preserve freedom in ethical decision making.

Dr. Theilicke refers to Matthew 10:19-20 in support of this ministry of the Holy Spirit in providing insight into ethical situations.46 In emphasizing supernatural inspiration within the ethical situation, he preserves true Christian freedom. He also insists that true Christian freedom is done away with wherever the assistance of the Spirit is lacking.47

Thus an application of revelational principles to medical ethics is made possible by that part of the image of God present in every person. The freedom in applying revelational norms is seen in the ministry of the Holy Spirit. Prayer is the vehicle by which the Holy Spirit, as "its object and acting subject"48 empowers us to make ethical decisions and frees us from the trappings of casuistry.

CONCLUSIONS

1. Empirical ethical reasoning, as used by speculative approaches to ethics (e.g., situationalism, existentialism), is inadequate in informing decision making in an ethical sphere. The answers to ethical questions lie beyond our empirical rational capacity.

2. The source for informing ethical questions is thus by necessity revelation. Revelational sources are understood as both personal and propositional.

3. The pursuits of a phenomenological theological method, hermeneutics, and correction by the church are essential in determining the truth character of supposed revelational principles from numerous belief systems and the legitimacy of applying these principles to ethical situations.

4. The part of the imago Dei present in every person provides a point of contact for revelational principles. This part of the image seen as eternity in our hearts" and our empirical rational capacity makes revelational principles potentially applicable to and understandable by all people.

5. The ministry of the Holy Spirit in all ethical situations preserves human freedom. We can trust the Holy Spirit to perceive the complexity of the situation and to inform our response to the situation. Even the unregenerate have the capacity to be informed by the Spirit in a limited way.

Endnotes

1. Thielicke, H., Theological Ethics, vol. 1: Foundations, Grand Rapids, Eerdmans Publishing Co., 1979, p. 465. Here Thielicke emphasizes the necessity of human relationships as the sphere within which ethical decision making takes place.

2. Heimburger, D.C., "A Biblical Model for Medical Ethics, Part 2: Three Ethical Perspectives - A Biblical Integration," Journal of Biblical Ethics in Medicine, Vol. 1, No. 2, April, 1987, pp. 22-27.

3. Henry, C., Christian Personal Ethics, Grand Rapids, Eerdmans, 1957, p. 148.

4. CoIwill, J.' "Where Have All the Primary Care Applicants Gone? New England Journal of Medicine, Vol. 326, No. 6, 1992, pp. 387-393. Here Colwill suggests that a decreased interest amongst medical students of developing a meaningful philosophy of life is at least one factor in decline of interest in primary care.

5. Henry C., op. cit., pp. 23ff and 97ff. Here Henry divides speculational ethical approaches into Naturalistic (similar to situationalism) and Idealistic (similar to existentialism).

6. Descartes, R., Meditations on First Philosophy, trans. by Laurence I. Lafleur, Indianapolis, Bobbs-Merrill Educational Publishing, 1980, p. 18.

7. Romans 1 :20, "For since the creation of the world His invisible attributes, His eternal power and divine nature, have been clearly seen, being understood through what has been made, so that they are without excuse.

8. I Cot. 1:20-21, "Where is the wise man? Where is the Scribe? Where is the debater of this age? Has not God made foolish the wisdom of the world? For since in the wisdom of God the world through its wisdom did not come to know God, God was well-pleased through the foolishness of the message preached to save those who believe."

9. Schouls, P., The Imposition of Method, New York, Oxford University Press, 1980, pp. 33ff.

10. Henry, C., op. cit., pp. 22-23.

11. Gal. 1:11-12, "For I would have you know, brethren, that the gospel which was preached by me is not according to man. For I neither received it from man, nor was I taught it, but I received it through a revelation of Jesus Christ."

12. Baillie, J., The Idea of Revelation in Recent Thought, New York, Columbia University Press, 1956, p. 28

13. Henry, C., op. cit., p. 132.

14. Rom. 8:24-25, "For in hope we have been saved, but hope that is seen is not hope; for why does one also hope for what he sees? But if we hope for what we do not see, with perseverance we wait eagerly for it."

15. This is my term for an apologetic theological method suggested by Carl Henry in Volume 1 of his systematic theology, God, Revelation and Authority, Waco, Word Books, 1976. In chapter 14 (pp. 225-244) he presents specific verifying principles for analyzing alternative revelatory claims. In chapter 3 (pp. 44-69) he presents principles for determining revelation from socio-religious myth. An interesting example of the application of this method is seen in the writings of Albert Schweitzer, Christianity and the Religions of the World, London, George Allen and Unwin, Ltd., 1923, and Indian Thought and its Development, New York, Henry Holt and Co., 1936.

16. Hermeneutics is the study of applying biblical principles from an original historical context appropriately into our modern day context through consistent methodology. For an Evangelical example, see Grant Osborne's text, The Hermeneutical Spiral: a Comprehensive Introduction to Biblical Interpretation, Downers Grove, Intervarsity Press, 1991.

17. see Rom. 1:18-23 and Acts 17:15-34.

18. Matt. 11:27, Luke 10:22, and John 12:38 show a role of Christ as revealing the Father.

19. John 16:13-15 and Gal. 5 show both the revelatory and "Helper" role of the Holy Spirit in the life of the believer. John 16:7-11 shows the revelatory role of the Holy Spirit in the life of the unbeliever.

20. II Tim. 3:16-17, "All Scripture is inspired by God and profitable for teaching, for reproof, for correction, for training in righteousness; that the man of God may be adequate, equipped for every good work."

21. Gen. 1:27, "And God created man in His own image, in the image of God He created him; male and female He created them."

22. Payne, F., Making Biblical Decisions, Escondido, Hosanna House Book Publishing Co., 1989, p. 114.

23. Brunner, E., and Barth, K., Natural Theology, London, The Centenary Press, 1946, pp. 22-23.

24. Barth, K., The Epistle to the Romans, trans. from 6th ed., by Edwyn C. Hoskyns, Oxford University Press, 1933, pp. 42-48.

25. Brunner, E., and Barth, K., op. cit., p. 71.

26. Payne, F., op. cit., p. 114.

27. Brunner, E., and Barth, K., op. cit., pp. 94ff.

28. Calvin, J., Institutes of the Christian Religion, I., Library of Chnstian Classics, Vol. XX, Philadelphia, The Westminster Press, 1960, pp. 56-57.

29. The Hebrew phrase mibli asher in Eccles. 3:11 may suggest a translation such as "without which" yielding a rendering as "God has given eternity in their heart without which man will not find out the work which God has done." This suggests a purpose relationship between eternity and plan. The NASB and NIV imply that in spite of eternity in our heart, man still can not find out God's work. In any case, these translations do not deny the fact that eternity is present in the heart of all. See Brown, Driver, and Briggs, Hebrew and English Lexicon of the Old Testament, Oxford, Clarendon Press, p. 115, for discussion of bli as an adverb of negation.

30. See Romans 1

31. Bnmner, E., and Barth, K., op. cit., p. 42.

32. see footnote 2.

33. Heimburger, D., "A Biblical Integration," p. 23.

34. Heimburger, D., "A Biblical Model for Medical Ethics: Biblical Norms for Medical Ethics," Journal of Biblical Ethics in Medicine, Vol.2, No.1, Jan. l988,p. 11.

35. Heimburger, D., "Biblical Norms for Medical Ethics, p. 11.

36. Heimburger, D., "A Biblical Integration," p. 24.

37. Heimburger, D., "A Biblical Integration," p. 25.

38. Heimburger, D., "A Biblical Integration," p. 22.

39. Heimburger, D., "Biblical Norms for Medical Ethics," pp. 10-11.

40. Heimburger, D., "Biblical Norms for Medical Ethics," p. 10.

41. In addition to the revelatory and "Helper" role the Holy Spirit provides as cited above, Romans 8:26 suggests that the Holy Spirit will help us even when we do not understand the situation we are in or what to pray for regarding its decisions and outcomes.

42. Heimburger, D, "A Biblical Integration," p. 25.

43. This is a central theme in the book of Galations.

44. Thielicke, H., op. cit., pp. 456-457.

45. James 1:5-6, "But if any of you lacks wisdom, let him ask of God, who gives to all men generously and without reproach, and it will be given to him. But let him ask in faith without any doubting, for the one who doubts is like the surf of the sea driven and tossed by the wind."
46. Thielicke, H., op. cit., p. 651.

47. ibid., p. 652.

48. ibid., p. 660.

[ JBEM Index / Volume 7 / Number 1 ]

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