Thus competition between two patients may lead to a difficult ethical dilemma. In addition, even when dealing with only one patient, some dilemmas cannot be resolved just by looking at these four principles. Sometimes two or more principles are in conflict regarding an individual patient. For example, it is beneficent to immunize a child against serious illness, but we recognize that it is also potentially maleficent because immunization involves a risk of causing harm, i.e., a significant risk of minor problems (pain at the injection site) and a very small risk of major problems. Thus we often need to look beyond these fundamental principles to resolve conflicting obligations. Other guidance is needed here.
Theological Principles Pertinent to Medical Ethics
Several years ago, I was invited to speak at a conference on spirituality in healthcare hosted by the Center for Health Ethics and Law at the University of West Virginia in Morgantown. The panel of speakers came from Protestant, Roman Catholic, Jewish and Muslim backgrounds. It was exciting to realize that we all shared two foundational theological principles: the sanctity of human life and the sovereignty of God. Though we did not always agree on the application of these two tenets of the faith, nor on some other tenets of faith, we at least had a common starting point for discussion. Since that time, I have become more interested in identifying theological principles that may apply in specific ethical dilemmas confronted in clinical ethics[vii].
Let’s look from a faith perspective, specifically from a Christian perspective, at these two and several other principles gleaned from scripture that may be applied in helping us resolve dilemmas in clinical ethics.
- The imago Dei – From Genesis 1:26-27 we learn that each individual, regardless of ability or disability, bears the image of God. This is inherent, not imputed. This may be difficult to understand as we contemplate individuals born with anencephaly or afflicted with severe dementia. Though such disabilities are part of the fallen nature of humankind, they do not detract from the underlying principle.
- The sanctity of life – Because we bear the image of God, each human life is sacred. Human life is special; it is different from animal life. Our God-given dominion allows us sometimes to humanely end an animal’s life, but it does not allow us to intentionally end a human life. However, this belief in the sanctity of life does not mean that we must always attempt to postpone human death, another inevitable consequence of the Fall.
- The Fall, suffering, disease and death – Because of Adam’s sin, we live in a fallen world with all its manifestations. We should try to relieve suffering. We should try to cure or control disease. We should try to avoid death when possible. But, in the end, unless Jesus returns first, we are all finite.
- Quality of life – Some believers bristle when the issue of quality of life is mentioned, arguing that we should only focus on the sanctity of life. But we all have a quality to our lives — good, bad or neutral. And when the burdens of continued life make it impossible for us to carry out God’s purpose, I do not believe we are obligated to use disproportionate measures to forestall death.
A couple of cautions are in order in regard to quality of life. First, it is very personal and subjective. Two individuals may have what appears to be the same stage of the same disease, and one may express misery while the other seems to flourish. It is very difficult, sometimes impossible, for me to assess your quality of life. Healthcare professionals are particularly inept at assessing someone else’s quality of life because we generally focus on a person’s physical abilities or disabilities, while the person may give higher marks to their cognitive, psychological, social, and spiritual dimensions. Second, those who do not accept or understand the sanctity of life based on the Imago Dei may conflate quality of life and worthiness of life. They may consider that a person with a very low quality of life is thus unworthy of continued life, and they may support unjust discrimination by recommending limitation of treatment or even intentional ending of that life.
As believers, it is our obligation to try to enhance the quality of life of those with disabilities and those with chronic and life-threatening illnesses, using excellent medical treatment, including palliative and hospice care when appropriate. But if our best efforts fail, we may support that person’s choice to forego measures that might postpone death[viii].
- Miracles – Our God is a supernatural God. Believers from all three of the monotheistic faith traditions also believe, based on their own sacred texts, that God is capable of intervening in our lives in ways that we cannot explain or understand, in ways that seem to contradict the laws of nature. Unfortunately, we tend to use the word “miracle” too loosely, as in “miracle drugs,” “miraculous survival,” etc. True supernatural interventions are not common in my experience. But God can do such things when He chooses. In addition, He does not need our machines or procedures to accomplish His miracles.
- Compassion – God’s incomprehensible love for us is clearly reflected in the compassion taught and demonstrated by Jesus. It is incumbent on us to remember that compassion means “to suffer with,” as Jesus did for us. Some misinterpret the word to mean merciful ending of a patient’s life. Instead, we are called to do our utmost for their suffering, and to not abandon them but to suffer along with them.
- The ministry of health care – Most Christian healthcare professionals believe that the work we do is a ministry to those in need, a way to show forth God’s love and to “further the healing and teaching ministry of Jesus Christ ‘to make man whole…’”.
- The hope of eternity – Christians believe that this life, with its suffering and death, is not all there is. We have the true hope of eternal life with a loving triune God. Many people, including unfortunately many Christians, believe that we should always hope for a good outcome to illness. Vaclav Havel, former president of the Czech Republic, insightfully wrote that “Hope is not the conviction that things will turn out well, but the certainty that something makes sense, regardless of how it turns out.”[ix]
- The sovereignty of God – As the multiple monotheistic speakers mentioned above stated, we are human beings, living in a fallen world, beneath the sovereignty of an all-powerful God.
- Dominion and stewardship – God has granted us liberty, expecting us to make decisions about the use of our abilities and resources. In contemporary medicine, the timing of death is often a matter of choice. The time of death for a patient may vary considerably based on whether we choose to use cardiopulmonary resuscitation, ventilator support, dialysis, one more round of chemotherapy, antibiotics, or a feeding tube.
- Free will – Many believers equate the biblical concept of free will and the secular concept of autonomy. In one sense, perhaps they are similar in that God allows us to make decisions that may not accord with His divine will. However, in a clearer sense, scripture places a limit on our free will. “He has showed you, O Man, what is good. And what does the Lord require of you? To act justly and to love mercy and to walk humbly with your God.”[x] We are not to walk arrogantly as an autonomous free moral agent, making our own decisions based only on our personal values. Rather, we are to humbly acknowledge our position under God’s authority.
- Justice – Our imperfect efforts at justice must constantly strive to reflect God’s perfect justice. However, justice involves getting what we deserve. In a Christian context, we should also strive to reflect His mercy (not getting what we deserve), and His grace (getting what we do not deserve).
- The priesthood of believers – My favorite image from the Easter story is the tearing in two of the veil that separated all but the High Priest from the Holy of Holies, giving us direct access to God. And this access is not only for ourselves. Believers are to act as priests for others. When a patient or family is struggling with a difficult decision about treatment, they do not have to struggle alone. We can offer counsel, comfort and support, praying with and for them, seeking God’s wisdom, guidance and peace.
When Religious Beliefs Clash
As implied earlier, not all people of faith claim the same religious beliefs. There are differences between the three monotheistic faith traditions; there are not infrequently differences within these traditions. What should be done when the religious beliefs of the patient (or family) are different from those of the healthcare professional? Fortunately, secular medical ethics has addressed this and comes to a clear conclusion. Based on a strong Western belief in individual autonomy, it is assumed that the patient’s values trump those of the professional. Thus if a patient of mine is one of Jehovah’s Witnesses, and he chooses to forego transfusion of potentially life-saving blood products, as his physician I am professionally bound to honor this belief, even when I disagree about the tenet of his faith. I should, however, continue to provide all modalities of treatment that might otherwise be beneficial.
Another word of caution. The societal emphasis on individual autonomy is sometimes misapplied. There are actually two aspects to individual autonomy: negative autonomy and positive autonomy. Negative autonomy in medicine is the right to refuse treatment, i.e., the right to be left alone. That is nearly inviolable. However, some incorrectly assume that support for negative autonomy automatically translates into positive autonomy, an entitlement to whatever the patient wants. Not true. A physician also has autonomy. He or she may, in fact should, decline to provide a requested treatment that is non-beneficial or potentially harmful. For example, if a patient wants antibiotics for an infection that is clearly of viral origin, the physician should decline to provide it. There is general acceptance of this concept in the medical profession and in society.