Discussion of Life on the Line
Dr Kenneth Feucht is a practicing surgical oncologist in Puyallup, Washington. His major interests include the development of a theology for the practice of medicine.
John Kilner has produced a thought-provoking text on medical ethics that is valuable in that it goes beyond most medical ethics textbooks by focusing on the basis for development of an ethic, rather than limiting discussion to particular contemporary ethical dilemmas. Kilner's text is heavily referenced and demonstrates a substantive reflection on critical issues facing physicians and health-care providers at the end of the twentieth century.
Life on the Line is divided into three sections. In the first section, Kilner develops his ethical system by establishing three guiding principles: Any ethical statement must be God-centered, reality-bounded, and love-impelled. Kilner feels that these principles best express the ethical system of Paul and Christ.
In the second section, Kilner applies the principles of the first section to the question of end-oflife issues, such as physician-assisted suicide, the termination of life, and the management of the critically ill. The final section is a discussion of how scarce medical resources are allocated, with a focus on renal failure and distribution of organs for transplant.
Kilner wishes us to perceive a love-impelled ethic as providing a superseding principle that governs our obedience to God's laws. An example that Kilner provides is the question of the Sabbath. To Kilner, the Scriptures seem to imply that keeping the Sabbath is not a moral imperative but a command to be exercised only as it does not interfere with the higher principle of loving others. To this end, he implies that principles, imperatives, and duties are not intrinsically binding on people, and thus, he argues against a deontological ethic. He supports his contention by arguing that since a deontologic ethic written in Bible times could never encompass all the moral dilemmas of modern times, another ethical principle, that of love, must be the guiding factor. Finally, because his ethic is act-based, Kilner feels that deontologic ethics are allegedly faulty for failing to take outcomes into consideration.
Kilner confuses several issues. First, the law, as explained by Christ in the Sermon on the Mount, if interpreted with the Pharisaical finesse of Kilner, must be interpreted by the letter rather than the spirit of the law. Even still, the law remains deontologic. Thus, a command not to kill implies far more ethically than simply not to murder. This is why David pled for understanding of God's law (Psalm 119:18). He knew that obedience to the law reached far deeper than a superficial obedience to the overt commands.
Second, the law of love does not provide a superseding principle to the legal demands of the law, as Joseph Fletcher and Kilner might suggest. Rather, deontologic ethics must be viewed through the lenses of love. This perspective can be provided only by the Spirit of God and would never contradict but only illuminate the deeper implications of the law.
The law of love provides for us not only the prohibitions of the law but demands far more of us, indicating that we are morally obligated to be our brother's keeper. The law of love thus does not grant us increased permissiveness, but rather, increased demands to maintain love toward neighbors and enemies as well as brothers. The deontologic demands of the "Great Commandment" do not relieve us from the moral obligations of the rest of Scripture. Without belaboring the point, it can be shown that while Paul's thinking was distinctly God-centered and practical, he also thought deontologically, just as Christ thought deontologically. Neither abrogated the law or in any way suggested that principles would now order or subjugate specifically stated commands. A love-based ethic opens insurmountable problems, as Joseph Fletcher has suitably demonstrate
d. How does one know whether a given action is morally acceptable?
God does not (usually) verbally communicate His will to us, and love is tainted by a fallen psyche. Our only hope in discerning God's will is to look into His Word as contained in the Holy Scriptures. His will in both the Old and New Testaments is manifested through ordinances, laws, principles, and commands.
It is impossible to have a strict deontologic ethic without postulating an infinite moral lawgiver. Any set of rules derived by man would either be random or arbitrary and thus irrational, or a set of rules derived to provide the greatest good for all or some, would in reality be a consequentialist ethic. The Judeo-Christian lawgiver has clearly stipulated laws for society. While we may disagree as to the extent or interpretation of this law, the entirety of the discussion centers around understanding the mind of God when He issued a given command. With David, we say, "Open my eyes that I may see wonderful things in Your law" (Psalm 119:18, NIV), and "Let me understand the teaching of your precepts..." (Psalm 119:27, NIV). Psalm 119 indeed reflects on even a teleological domain, a benefit from a deontological ethic. David Jones in Biblical Christian Ethics would argue also for the teleological domain of Christian ethics, while never succumbing to the notion that we base ethics on the "ends" but rather on the laws of God. The law provides illumination, joy, delight, strength, salvation, and life. It does so because it is based on a covenantal relationship with Godperfectly fulfilled by the active obedience of Christ, and obeyed by us as the servants of Christ.
Chapter 4 centers around the ethics of clearly eliciting and following a patient's wishes. A patient's decision, according to Kilner, can be moral only when necessary and sufficient information has been conveyed to the patient (pp. 84-85). Kilner omits the role of the moral physician in deciding what should be best, based on experience, for the patient. Any physician realizes the impossibility of completely informed consent; the patient rarely understands fully the implications of a decision, and it often would be harmful to the decision-making process to thoroughly inform a patient of all possible factors that may influence a decision. The moral approach to the mentally incapacitated patient, according to Kilner, is the living will (p. 88).
On the contrary, the living will is primarily a document intended to appease lawyers; it cannot and must not govern the physicianpatient relationship. If a given medical situation has a reasonable chance of a positive outcome, the living will does not give me, as the physician, the moral capacity to "pull the plug." Likewise, an unreasonable chance of success will of moral necessity get the "plug pulled" whether or not there is a living will.
Kilner argues (p. 92) that God has given us the freedom to make bad decisions. That is true, but that still does not make the decision a morally correct decision, which is what we are concerned with. Kilner seems preoccupied by the desire to know and grant to a patient free and autonomous agency to the extent that he will not include any substantive discussion of possible higher laws that govern physicians.
In chapter 6, Kilner muddies the already-difficult issue of withholding or withdrawing treatment. In Kilner's mind, one must soulsearch the reasons for an action of withdrawing or withholding treatment, resulting in probable death. Those are motives impossible for a physician to entirely ascertain, and the simplest recourse in thinking this way is to resort (often immorally) to maintaining treatment at any cost, lest the motive be blurred. Kilner recognizes this (p. 126) but fails to direct the moral physician in this issue. He vacillates, first stating that "death entails much more loss than gain" (p. 122), but then, "to die is gain'' (p. 128). Tentativeness and ambiguity do not help physicians in the trenches of medical care.
Kilner discusses allocation of resources in a manner that has little application outside of transplantation medicine. From my perspective as a surgical oncologist, issues of allocation of resources have been hypothetical rather than practical. For example, the unavailability of the drug Taxol and the morality of its fair distribution created much anxiety long before the drug had any proven efficacy. We now realize that Taxol is not the lifesaver it was billed to be, and pharmaceutical ingenuity has now made the drug readily available, albeit expensive.
On page 179, Kilner implies that a Biblical ethic dictates delivery to the person most in need. He is silent as to any references, because there are none. He never mentions disease as a consequence of actions. If a person develops liver failure from alcoholic cirrhosis, he should not necessarily be transplanted based on need. Kilner is very concerned about criteria for non-medical exclusion of the elderly but discusses matters mostly in hypothetical terms. Discussion of the care of the elderly supposes an extreme shortage of medicine and medical care, which simply isn't true. The only shortage is in the money to pay for medical care. Kilner offers no discussion as to the factors that drive up the cost of medical care, such as legal interference, governmental regulatory interference, and the societal attitude that medical care is a right that must be automatically provide rather than an honored privilege and responsibility.
Kilner thus imagines that inability to pay is an immoral criterion for denying medical care! But would he extend this attitude toward the other exigencies in life, such as provision of food, shelter, clothing, etc.? If an individual cannot pay, only four options exist:
1. The physician and the hospital must provide services free or at a discounted rate,
2. The church community must assist the patient,
3. The government must coercively tax the public to pay for the individual's medical care, or
4. The patient must go without medical care.
Kilner complains that the poor receive insufficient medical care, yet substantive evidence suggests that care is as available, if not more available, to the poor. Therefore, if a patient goes without medical care, it is usually for factors other than availability. The community is better than government at providing compassion in a manner that demands patient responsibility, and community and church efforts are voluntary acts of love, rather than coercive acts of the state. Our ethic must emphasize the role of the church over the role of the government.
At the end of the book, Kilner refuses to endorse any selection criteria for the states' allocation of hypothetically "limited" resources, and he does the ultimate cop-out: He proposes the random distribution of resources, after certain limited criteria have been met (p. 228). Thus, for Kilner, justice and morality become a toss of the dice. The Bible never defines justice in this way; neither is "justice" equivalent to "equality" in the Bible, as Kilner implies elsewhere (p. 229). The lottery evolves into the means of allocating justice and moral principle. Kilner thus trivializes the entire book by implying that Biblical principles are inadequate to allow for rational moral decisions. The Christian community should be challenged to make principled decisions in difficult matters-not rely on the lot, the dice, or drawing straws.
Kilner discusses tough issues, and I commend him for his willingness to tackle problems which often do not have immediate answers. I argue against both his philosophical approach to medical ethics and his resultant practice of ethics. I agree with Kilner that the principles of the ethical practice of medicine must be derived first from Scripture, then from physicians with moral character.
I do hope, however, that ethical decisions would be made by physicians practicing in a community that is theocentric in its thinking and intent on exploring the application of God's law in the contemporary medical environment.
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