How Do Today's Medical Ethics Compare with Christian Ethics?
by Robert D. Orr, MD, CM
Today's Christian Doctor - Spring 2012
Robert Carpenter, then a senior medical student and president of the Philadelphia chapter of the Christian Medical Society, penned an article in 1951 for the CMS journal comparing medical ethics and Christian ethics. Have things changed in 60 years?
Medical ethics has changed a great deal in 60 years, especially regarding what issues come under the umbrella of medical ethics. Carpenter assumed that medical ethics primarily involved the relationships physicians had with patients and other physicians, not unlike Percival who wrote the first book on medical ethics in 1803, focusing on physician etiquette. Today we call this professional ethics, one division of medical ethics. But medical ethics has expanded into many other subdivisions as well.
The physician-patient relationship has been, even since the time of Hippocrates, a fiduciary relationship, i.e., a relationship of trust. The physician has more knowledge, authority and power than the patient. This places a moral responsibility on the physician to always seek the best interests of the patient rather than to serve him- or herself. This responsibility has also been characterized as a covenant, a mission or even a ministry. This remains unchanged.
What has changed is that the duty-based relationship has evolved into a rights-based relationship. Prior to the last generation, most physicians interpreted this unequal relationship to mean that they were in charge. Physicians were paternalistic and patients were expected to be subservient. In the social upheaval of the 1960s and ’70s, individual rights came to the foreground with a focus on minority rights, women’s rights, consumer rights and patient rights.
This leveling of the playing field has been a major improvement, preventing the unethical imposition of unwanted treatments on vulnerable patients. The down side, however, is that the professional relationship has taken on a contractual patina, even sometimes with an adversarial tone. Physicians have become “providers.” In addition, social and financial changes have made the long-term trusting relationship between a patient and physician much less common than in the past. Also, internet access to medical information (good and bad) has raised the level and intensity of discourse. Another consequence of the changed relationship is increasing claims of malpractice when patients are dissatisfied.
Carpenter alludes to what we would now recognize as a second division of medical ethics—health policy—when he asserts that euthanasia is wrong based on an understanding of the sovereignty of God. However, the arguments for and against physician-assisted suicide and euthanasia have been refined over the ensuing 60 years. Opposition on religious grounds alone is not always persuasive in our pluralistic society. We must also raise the specter of bad consequences if such a sea of change were to be adopted.1
The health policy perspective of medical ethics has exploded in the past 60 years to include such issues as mandatory immunizations, contraception, abortion, assisted reproductive technology, definition of death, transplantation, mind-altering drugs, cloning, use of embryonic stem cells, physicians’ participation in capital punishment, care of the poor and uninsured and so many more. “Medical ethics” is much broader and deeper than it used to be. In addition, discussions and decisions in health policy involve advocates, legislators and the courts.
It is of historical interest that major failures in the professional ethics of some physicians led to the development of an entirely new subdivision of medical ethics. Physician-researchers in the Nazi death camps undertook experiments using prisoners as subjects, often resulting in pain, disability or death. They forsook their primary goal (seeking the best interest of individual patients) and replaced it with a secondary goal (enhancing the German war effort). Post-war discovery of these atrocities led to the Nuremberg Code and subsequent documents to prescribe the boundaries of ethical research.
Tragically, North American researchers felt those ethical guidelines applied only to the “evil” German researchers. When the Tuskegee Study was exposed in 1972, we recognized that forsaking professional ethical standards could also lead to home-grown evils.2 This failure was repeated in studies of hepatitis in mentally disabled children, radiation experiments during the cold war, research on U.S. prisoners and many more. These revelations led to the establishment of Institutional Review Boards and federal oversight of research involving human subjects beginning in the 1970s and continuing with increased intensity and more stringent rules.
In the past 60 years, advances in medical technology have led to extensive discussion of how and when that technology should be applied. The old maxim, “the ability to act does not justify the action,” has never been truer than in modern medicine. Just because we can do dialysis for renal failure does not mean that everyone in renal failure should receive dialysis. Thus, we now face many decisions that were not even contemplated a generation or two ago. Many times these tough decisions lead to disagreement, even conflict. And these conflicts occasionally lead to court battles and public discussion via the media. Beginning with Karen Quinlan in 1976, many such “media cases” have been discussed in the classroom and the living room.3
Soon thereafter, hospitals began to establish ethics committees to encourage education on issues of bedside ethics, to review hospital policies that raised ethical issues and eventually to consult on individual cases.
Gradually in the 1980s and ’90s, the field of clinical ethics emerged. This discipline dealt less with policy and focused instead on bedside dilemmas. What are the ethically permissible options for a specific patient? Consultations in clinical ethics were originally done by a full ethics committee; more recently using a subcommittee model or individual ethics consultants.
Even more recently, healthcare institutions have developed committees in organizational ethics to help the institution examine its role and responsibilities in relation to its mission and its obligations to the local community and to society in general.
“Medicine is inherently a moral enterprise.” Ethics is about right versus wrong; good versus bad; or even disciplined reflection on ambiguity. Thus it is not surprising that people of faith would be involved in discussions of ethics as it applies to medicine. The Christian Medical & Dental Associations was one of the leaders in such endeavors. Our first iteration, the Christian Medical Society, established an Ethics Commission in 1973. Over the ensuing 39 years, this body has proposed position statements on 45 issues involving professional ethics, health policy, research ethics and clinical ethics. These statements have been reviewed and modified by the Board of Trustees and the House of Representatives.5 This process continues. Several other Protestant and Catholic professional health organizations and many individual denominations have similarly developed position statements.6 In addition, countless books have been written from a Christian perspective on various issues and on medical ethics in general.
Carpenter, in his original comparison of medical ethics and Christian ethics, said, “. . . the Christian physician has a different system of evaluation than that used by non-Christian physicians” and the Christian position “is based on the authoritative Word of God.” He did not, however, articulate how the Word could be applied in Christian medical ethics. In addition to the standard four principles of secular medical ethics (nonmaleficence, beneficence, autonomy and justice), believers have additional help from a number of scriptural principles:7
Sanctity of Human Life – Since we are made in the image of God, each person is of inestimable value, regardless of his or her level of function.
The Finitude of Life – Because Adam and Eve sought to be like God, everything changed. Because of the Fall, we are now subject to the human frailties of illness, suffering and death. Unless Jesus returns first, we will all die.
God is Sovereign – God very often allows us to make decisions that are not compatible with His will. However, He has final authority.
Miracles – God is all-powerful, and He can overrule the laws of nature that He established. The biblical accounts of miraculous intervention in illness are amazing. Believers often pray for His miraculous intervention in the illness of a loved one, but all such prayers should end with, “Thy will be done.”
Stewardship – God has entrusted to us the earth, its resources and even our lives. We are responsible to Him for how we care for ourselves and our environment.
The Quality of Life – Since the Fall, individuals have lives of varying quality. Some have limited functional or intellectual capacity; some have chronic pain or suffering. Sometimes the burdens of illness or disability exceed our ability to carry out our personal mission. In some circumstances, we may decide to use less than maximal efforts to preserve life.8
Justice – Based on the command for human justice, we should treat all people equally, without discrimination.
Hope – We often cling to a hope that a loved one will survive and thrive in spite of dire medical predictions. However, our true hope is not in this life, but in eternal life, forever praising God. Part of our hope is that we have a Comforter who can help us as we confront difficult decisions. Our prayer might take the form of, “Thank you God for this person’s life. As we struggle with difficult decisions, we seek your wisdom, your guidance and your peace that passes all understanding. Amen.”
Medical ethics has changed a great deal in 60 years. The Word of God has not.
1 Orr, Robert D. “What are the Arguments Against Legalization of Physician-Assisted Suicide?” Today’s Christian Doctor 2011; 42(2):30-2
2 The U.S. Public Health Service observed and investigated 400 poor black men with early syphilis for 40 years (1932-72) to learn more about the natural progression of the disease, but did not give them curative penicillin when it was discovered in the early 1940s.
3 Karen was in a persistent vegetative state and ventilator dependent. Her parents asked that her ventilator be stopped, expecting that she would die. Her physicians felt they couldn’t do that because they would then be the agents of death. The Supreme Court of New Jersey eventually said it is permissible to stop life-sustaining treatment in some circumstances. She was subsequently weaned from the ventilator and she lived for another 10 years.
4 Often stated by Leon Kass and Eric Cassell in the 1970s. I have been unable to determine who said it first.
5 The position statements and countless resources on ethical issues are available at http://www.cmda.org.
6 The Center for Bioethics and Human Dignity is currently working on a compilation of such statements.
7 See chapter two in Medical Ethics and the Faith Factor by the author for an expanded discussion of biblical principles that can be applied in medical ethics.
8 Two cautions regarding quality of life: (a) it is very subjective; it is very difficult to assess someone else’s perception of their own quality of life; (b) non-believers often misconstrue the concept of quality of life, deciding that some lives are worth less than others, leading to horrific results (e.g., slavery, the Holocaust, ethnic violence).