Much of our culture has been shaped by, or at least greatly influenced by, centuries of religious belief. Our Western culture has largely been shaped by Christian belief. However, the present-day multicultural matrix has resulted in the secularization of contemporary culture and the marginalization of religious influence. Indeed, efforts at encouraging political correctness have resulted in the silencing, ignoring, and even ridiculing of theological voices. This is clearly demonstrated in medical ethics. I propose that clinical ethics, one segment of medical ethics, is an avenue where this trend can be reversed.
Medical ethics is the systematic application of moral principles and values to medicine and the health sciences, addressing issues and public policy, including such matters as abortion, euthanasia, cloning, and a host of others. Clinical ethics, on the other hand, involves the identification, analysis and resolution of moral problems that arise in the care of individual patients. As such, it involves many individuals: the patient, the patient’s family, and many healthcare professionals. Each of these individuals brings to the table his or her own world view, most often encompassing religious beliefs. Such beliefs and values are significant, and often paramount, in the resolution of the dilemmas and conflicts that arise in clinical ethics.
History of Medical Ethics
The history of classical medical ethics is rife with theological voices, including Hippocrates (Greek polytheism, ~450 BC), Ishaq bin Ali Rahawi (Muslim, 9th C), Maimonides (Jewish, 12th C), Thomas Aquinas (Roman Catholic, 13th C), Thomas Percival (Anglican, 19th C) to name a few individuals from different religious perspectives. Western medicine in particular has a great religious heritage. Albert Jonsen, medical historian, concludes that the current Western medical ethos is a rope weaved from two strands — the competence taught by Hippocrates and the compassion taught by Jesus[i].
Contemporary medical ethics is considered to have started in the 1960’s and was initiated by theologians asking questions of practicing clinicians[ii]. Sadly, over the past 50 years, the discipline of medical ethics has been taken over by philosophers, judges, attorneys, legislators and health policy experts[iii]. Healthcare is, for the most part, a secular endeavor, and its practitioners often point out that faith is a private matter, outside the boundaries of health policy.
However, at the bedside, when individual patient dilemmas are encountered, issues of spirituality are increasingly recognized as pertinent[iv]. This is not new. It was recognized in antiquity and even in the 1960’s. At about the same time that contemporary medical ethics emerged 50 years ago, the maxim “Medicine is inherently a moral enterprise” was articulated, i.e., the practice of medicine involves making decisions between right and wrong, good and bad. As multicultural diversity has been increasingly recognized in recent decades, the importance of individual religious beliefs has been emphasized among healthcare educators and practitioners.
The Scope of Medical Ethics
There are two parallel, but different, questions in medicine — the “Can we…?” questions and the “Should we…” questions. Can we dialyze this elderly man with advanced dementia who has developed kidney failure? Yes, we can. This is a medical question. But should we dialyze him? That is a different question. That is an ethics question.
For many reasons, contemporary medical ethics is more complicated than it was for Hippocrates or even Percival, the author of the first book entitled Medical Ethics (1803). Technology has introduced so many new options that the “Should we…?” questions are today much more common than they were a generation or two ago. In addition, the doctor-patient relationship is much different than it has been in the past. Now instead of one doctor caring for one patient, we often have multiple specialists involved, along with nurses, therapists and others. The very high cost of many medical treatments also leads to such questions. And finally, the diversity of beliefs in our society frequently causes people to look at these questions from differing perspectives.
The Principles of Secular Medical Ethics
There are four well-recognized principles in secular medical ethics[v]:
Non-maleficence – “First of all, do no harm” has survived from Hippocratic writings[vi].
Beneficence – This similarly ancient precept of seeking the patient’s best interests has endured over the centuries and is now a vital part of the physician’s fiduciary responsibility.
Autonomy – The understanding and acceptance that a patient has the right to make his or her own treatment decisions is a rather recent development in medical ethics. In earlier times, the physician was accorded primacy in making treatment decisions, based on the principle of beneficence. However, in the social upheaval of the 1960’s and ‘70’s, individual rights came to the fore — minority rights, women’s rights, consumer rights and even patient rights. Currently in Western medicine, the physician makes recommendations, and may even try to persuade a reluctant patient, but ultimately it is the patient (or patient surrogate) who makes the final decision about treatment or non-treatment in most cases. This precept is not as widely accepted in non-western or developing societies where family and community wishes may be allowed to trump patient wishes.
Justice – Along with the development of patient autonomy has emerged the concept of non-discrimination — like patients should be treated alike without favoring one over another because of race, nationality, economic status, religion, etc. However, in our current generation, this concept of justice in healthcare has taken on a new shade. Whereas in the past, healthcare professionals were expected to focus solely on their individual patients, now we are expected to also consider the good of society as well as the individual patient. This not infrequently creates seemingly irresolvable dilemmas. For example, if my patient develops kidney failure and wants to live as long as possible, as his physician I should try to arrange for him to have dialysis. However, if he also is demented and has a relatively short life expectancy, the modern concept of justice would encourage me to discourage him or his family from pursuing this expensive treatment, making it available for someone else with kidney failure who has a better overall prognosis. Should I seek the best interests of my patient or of society?
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.
Issues can become contentious, however, if the physician’s reluctance to provide a requested treatment is based on moral rather than medical reasons. The paradigm here is a patient’s request for an abortion, a procedure formerly considered both immoral and illegal that is now deemed by our society to be legally permissible in some circumstances. The physician’s right of conscience has traditionally allowed him or her to decline participation. However, in recent years, this right of conscience has been challenged by those who claim that the physician is obligated to provide any treatment that is legally available or at least to refer the patient to someone who is willing to provide the service[xi],[xii].
Religious beliefs should inform our discussion of issues of public policy in health care, recognizing that it may not always be possible for people of faith to convince others in the public square if they do not share those beliefs. However, when we are confronting moral dilemmas at the bedside, dilemmas that involve individuals rather than public policy, we not only may, but we must recognize the importance of religious beliefs of the patient, family and healthcare professional. This articulation of and focus on matters of faith may open the door in our multi-faith culture, an opening that could transform our culture.
Four brief case vignettes illustrate dilemmas in clinical ethics stimulated by differing religious beliefs:
CASE 1 A previously healthy woman develops a condition that will inexorably lead to her death within a few days. Dialysis might postpone her death by a few hours or days, but she decides against it. Her devout nurse has been witnessing to her about salvation from eternal damnation. She insists that dialysis be used because she believes the patient is not prepared for eternity and is almost ready to make a decision to accept Jesus. Should dialysis be used in spite of the patient’s refusal?
CASE 2 A 4 month old infant is clearly dying from an uncorrectable birth anomaly, but his mother insists on continued life support. His nurses and physicians believe he is needlessly suffering from this treatment and urge her to consent to withdrawal of life support. She says she is waiting for God to miraculously intervene, and further that she believes God will not intervene if she does not demonstrate faith by continuing the treatment. Should life support be continued?
CASE 3 A 13 year old girl with severe anemia urgently needs surgery that will cause substantial blood loss. Her surgeon is unwilling to operate without first giving her blood transfusions. She has recently been accepted into her parents’ Jehovah’s Witness congregation. She and her parents decline blood products, even if that means she will die. Should a court order be sought to give blood?
CASE 4 A 63 year old previously healthy woman suffers a devastating stroke with a dismal prognosis for any significant recovery. She could live in a severely disabled condition if major interventions are continued. Two of her children are convinced she would not want to survive in this condition and would prefer to go to heaven. They ask that the treatment be stopped. However, a third daughter insists that it be continued because she believes human life is sacred. Should the treatment be continued?
 I have been unable to identify whether this was first said by Leon Kass or Eric Cassell.
 From the mission statement of Loma Linda University
 It is estimated that when an individual dies in a hospital setting, 70% of the time, the timing of death is a matter of choice.
 The societal mandate is different if the patient is a child and the decision to decline treatment is based on parental religious beliefs. In such a case, the physician is obligated to request judicial intervention to protect the child if refusal of treatment endangers the child’s life or is likely to lead to permanent disability.
 These cases are taken from Medical Ethics and the Faith Factor (Orr, 2009) where each is reported and analyzed in detail.
[i] Jonsen, Albert R. The New Medicine and the Old Ethics. Harvard University Press, 1992
[ii] Verhey, Allen and Lamers, Steven. Theological Voices in Medical Ethics, Wm. B. Eerdmans,1993:1-2
[iii] Orr, RD. Bioethics and the fundamentalist agenda (guest editorial). Ethics & Medicine Spring 2004;20(1):3-5
[iv] Puchalski CM. The role of spirituality in health care. Proceedings (Baylor University Medical Center) 2001;14(4):352-7
[v] Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 6th ed., Oxford University Press, 2008:99-280
[vi] Jouanna J. Hippocrates. The Johns Hopkins University Press, 1999
[vii] Orr RD. Medical Ethics and the Faith Factor: A Handbook for Clergy and Healthcare Professionals. Wm. B. Eerdmans Pub. Co., 2009
[viii] Orr RD. Pain management rather than assisted suicide: The ethical high ground. Pain Medicine 2001;2(2):131-7
[ix] Havel V. The Politics of Hope. New York: Vintage Books, 1991:180-1
[x] Micah 6:8 (Holy Bible, New International Version)
[xi] Orr RD. Medical ethics and the faith factor: The endangered right of conscience. Ethics & Medicine 2010;26(1):49-54; on-line In Pursuit of Truth (www.cslewis.org/journal) and at: findarticles.com/p/articles/mi_qa4004/is_201004/ai_n53077376/?tag=content;col1
[xii] Orr RD. The right to refuse to treat: Conscience clauses and the duty of medical professionals. Christian Bioethics (in press)