This assignment will incorporate a common practical tool in helping clinicians begin to ethically analyze a case. Organizing the data by means of the four bo

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3. Biomedical Ethics in the Christian Narrative Throughout the land, arising from the throngs of

converts to bioethics awareness, there can be heard a mantra, “…beneficence…autonomy…justice…” It is this ritual incantation in the face of biomedical dilemmas

that beckons our inquiry. (Clouser & Gert, 1990, p. 219)

Ethics as a theological discipline is the auxiliary science in which an answer is sought in the Word of God to the

questions of the goodness of human conduct. As a special elucidation of the doctrine of sanctification it is reflection on how far the Word of God proclaimed and

accepted in Christian preaching effects a definite claiming of man. (Barth, 1981, p. 3)

By Paul J. Hoehner, Manny Cota Jr., and Valerie De La Torre

Essential Questions

What are the four elements of a Christian worldview, and how do they influence a Christian approach to medicine, healing, and medical ethics?

What are the four principles of medical ethics, and how are they defined? How can a Christian appropriately use these four principles?

What is meant by specifying, balancing, and weighing the principles? How does a Christian worldview influence how one defines and uses each of these four principles?

What is the four-boxes approach to organizing an ethical case study? What is the difference and the relationship between the four-boxes approach and the four principles of medical ethics?

What are the four ethical topics that compose the four-boxes approach, and what questions does each topic entail? How does the four-boxes approach help solve ethical dilemmas in a case study?

Introduction Biomedical ethics, or bioethics, is a subfield of ethics concerned with the ethics of medicine and the ethical issues involving the life sciences, particularly those raised by

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modern technologies, such as stem cell research and cloning. The term medical ethics is closely related to biomedical ethics but is primarily focused on ethical issues raised in the practice of medicine and medical research, such as abortion, euthanasia, and medical treatment decisions (World Medical Association, 2015).

Because the terms biomedical ethics and medical ethics are closely related and involve a great deal of overlapping subject area, they will be used interchangeably to avoid confusion. The study of biomedical ethics and medical ethics presents some of the most complex and controversial challenges in applied ethics. The complexities of dealing with individual patients and the intricacies of modern health care, coupled with the rapid advances being made in medical science, present formidable challenges. For many health care workers, clinical ethical dilemmas will often challenge their own settled positions, especially if they have not taken the opportunity to reflect critically on their own moral presuppositions and how their own intuitive ethical positions may be justified.

When one encounters the many ways the world and even portions of the Christian church respond to ethical issues, it is easy to be tempted to think there are no right or wrong answers. The complexity of these issues and the myriad answers and justifications given by so many “experts” can drive many students toward some form of ethical relativism.

There are certainly many complexities in health care ethics: competing ethical ideologies, beliefs or virtues, different interpretations of the facts surrounding an issue, and differing approaches on how to address these issues; however, one should not confuse complexity with ethical relativism. These are two vastly different things. Relativism is the belief that “what is right and wrong, good and bad, true and false varies from time to time, place to place, and person to person. There are no absolute standards of truth or morality” (Cook, 1995, p. 726).

Coupled with the complexity of biomedical ethics is the loss of moral consensus in the medical profession and society as a whole, whereby moral positions once taken for granted cannot be taken for granted any longer. There are plenty of examples in the medical field: abortion, contraception, euthanasia, suicide, and anything that has to do with sexual morality. This lack of moral consensus is primarily a result of the cultural plurality that exists in many Western nations. Cultural plurality is a term that simply refers to the sheer diversity of race, value systems, heritage, language, culture, and religion. It is the simple observation that many cultures contain people with different worldviews, ideologies, and moral frameworks.

One of the consequences of many pluralistic societies is an increased tendency toward secularization. Secularized societies tend to relegate religious perspectives, and moral frameworks based on those perspectives, to the periphery of public discussion or limit them to the private spheres of life. According to most secularist thinkers, religious, spiritual, or faith-based perspectives may play an important role in one’s personal life, but they have no place in the public square of politics, public education, law, or medicine, particularly medical ethics. As Guinness (1983) notes, this results in a faith that is “privately engaging, but socially irrelevant” (p. 79).

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Limiting one’s faith, spirituality, or religion to merely private matters does not do justice to the role that religious or spiritual worldviews play in deciding how to live and interact within the world and society. Biblical Christianity stresses the role of the Christian in the world in matters of justice as well as civil engagement.

Plurality, the fact that different worldviews exist side-by-side in a culture, needs to be distinguished from pluralism, an instance of relativism. The distinction is important. Pluralism is a philosophical or ideological statement that maintains that no single ideological or religious claim is actually “right”; all truth claims have equal validity (Hoehner, 2006). The practical result of philosophical pluralism is to deny any objective truth claim or deny that any objective truth can ever be obtained. This leads many students to conclude that there can be no common approach to finding right amid the many perplexing and complicated moral issues of the day.

In this postmodern and relativistic world, divine or even natural, given norms of moral behavior are soon replaced by a form of morality based solely on one’s own personal subjective views, conforming the world to one’s own feelings and desires. Instead of orienting one’s behavior to an objective standard beyond oneself (e.g., divine and biblical revelation), many in today’s postmodern society seek to orient norms and standards of morality to their own self-referential existence (e.g., what one feels, intuits, or wills according to one’s own needs, wants, or desires). What is “right” and “true” has no reference outside of one’s own personal experience and feelings. What is right and true for one person may not be right and true for another. This can be profoundly challenging and perplexing for the Christian health care worker attempting to insert a Christian ethic into this social mix. Most people would never apply this way of thinking to empirical scientific matters. There is an inconsistency in much of modern culture that holds simultaneously to both relativism and scientism; however, this way of thinking is itself incoherent and is generally only applied to issues of morality and religion.

While there are many different approaches to medical ethics, this chapter will introduce the four-principles approach to biomedical ethics and how they are used to work through ethical dilemmas in health care. While there are many principle- oriented approaches to biomedical ethics, the approach originally popularized by the 1970 publication of the book Principles of Biomedical Ethics by Tom Beauchamp and James Childress is unarguably the most influential.

Centered on the four core principles of beneficence, nonmaleficence, respect for autonomy, and justice, Beauchamp and Childress’s (2013) four-principles approach is currently considered to be the dominant framework for discussing issues in biomedical ethics, at least in this country, and “one of the most important methodological inventions of modern practical ethics” (Lee, 2010, p. 525). DeGrazia (2003) acknowledges that, “one would be hard-pressed to find a text that has been more influential and more frequently cited” (p. 219). It is important and necessary for anyone involved in medical ethics to understand the use of the four-principles approach to biomedical ethics not because it is the only framework used for medical ethics, as there are several others, but because of its near universal influence and

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status in modern-day medical ethics discussions, in hospital ethics committees, and in managed care.

One of the most important aspects that must be understood in using the four principles is that these four core principles do not immediately and directly provide a solution to most ethical dilemmas. It is not always clear how each of the four principles are to be applied or what their implications might be. More importantly, for the purposes of this chapter, it also requires interpreting them—whether consciously or not—in terms of a particular worldview, philosophy, and/or ethical theory. For example, in a specific medical ethics case, beneficence may mean something quite different for a Christian than for a Muslim or philosophical utilitarian.

Many of these different meanings are assumed rather than subjected to critical reflection. For this reason, this chapter will begin with a discussion of how the Christian worldview, as informed by the biblical narrative, understands the concepts of health, wellness, and disease. The biblical narrative is the context by which the Christian justifies how one specifies, defines, and interprets the four principles in light of specific cases and provides the Christian health care professional with an accurate and consistent normative guide for the ethical and moral uses of medicine and medical technology within a Christian worldview.

Medicine and Medical Technology from a Biblical Perspective

As discussed in Chapter 1, in the Christian worldview, the ultimate foundation for determining the right, the good, and the just is the triune God. The triune God is the ultimate foundation of reality, including ethics. Moral goodness and justice are derived from the very character of God. God is holy and set apart (Leviticus 20:26, English Standard Version), so people are to live lives of holiness and goodness. God is love (1 John 4:10–11), and love is a virtue and an essential principle for life and relationships. Because God is just toward people (Deuteronomy 15:15), they are to act justly toward the poor, sick, and disenfranchised. People are to live in covenant faithfulness to their spouses and to honor covenantal relationships in their professions (e.g., the doctor–patient and nurse–patient relationship) because God is a covenant God, faithful to his people, even when they were unfaithful (Hosea 1–3; Malachi 2:10, 14).

As discussed previously, all ethics flow from one’s worldview and its basic assumptions about ultimate reality. One’s view of human nature, the fundamental problem of humanity, the solution to that problem, and the ultimate direction and goal of history will determine personal ethics. Every worldview embodies these elements in some sense, and the substance of these elemental conceptions influences everyone’s moral vision. These assumptions deeply influence what one believes to be the right, good, and just, and they will direct, whether consciously or subconsciously, one’s individual daily choices and actions.

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The Christian worldview, which is the focus of this text, is founded on the biblical narrative or story. This narrative is often summarized as the story of the creation, fall, redemption, and restoration of human beings, along with the entire created order (see Figure 3.1). This section will examine how key concepts within this narrative, such as sin, righteousness, and shalom, provide a framework by which the Christian worldview understands the concepts of health, disease, life, and death as well as provide guiding norms for how one should approach healing and caregiving, the ethical use of medicine and new medical technologies, and justice in health care.

Figure 3.1

Biblical Narrative and Christian Worldview

Creation

The Christian narrative of creation is essential for both Christian theology and for Christian ethics. At the foundation of the biblical narrative is the Christian God who is the Creator of everything that exists (Genesis 1–2). The most important aspects of the biblical view of creation are the following:

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1. Nothing exists that does not have God as its Creator (Colossians 1:16; Revelation 4:11).

2. There is a clear distinction between God and his creation (God transcends creation). At the same time, God continues to be involved in every aspect of creation, providentially directing and guiding all things that come to pass for his purpose and design (God is immanent within his creation).

3. God is neither dependent on creation nor is creation necessary to God.

4. God’s act of creation was intentional; everything exists for a purpose, not accidentally or randomly.

Implications of the Biblical Narrative of Creation for Health Care Ethics

Several aspects of the biblical view of creation give substance and direction to ethical issues. First, the biblical narrative of creation is the account of a good God who creates a good world (Genesis 1:21) with human beings at the apex of his creation. When God described both his act of creating and the creation itself as good, it meant that it was valuable, and everything in its original state was the way it was supposed to be. The goodness that remains in the world, even after the fall, reminds one that God has called humans to live in his world, not to abandon or reject it. There is a harmony and orderliness to creation and the physical world, the human body, and the institutions of culture and society, and these are good gifts of the Creator God.

Second, man and woman are created in the image of God, a concept that was discussed in Chapters 1 and 2. As stated in those chapters, various ideas for what the image of God in humans actually is have been proposed by theologians and philosophers throughout history. Nonetheless, there are clear relational and dynamic aspects entailed in the image of God that give rise to implications that are generally affirmed across Bible-believing churches and organizations. These implications are important for a Christian view of ethics.

Being created in the image of God implies that humans are set apart from the rest of the created order and provides a foundation for the intrinsic dignity and value of all human beings. All human beings, without exception, have an intrinsic dignity and value that is to be protected in every stage of life. Whether in health or sickness, with mental or physical disability, from its formation in the womb through the sometimes debilitating effects of old age, humans have intrinsic value. The Benedictine monk Illtyd Trethowan (1970) expresses this beautifully:

To love people because they are creatures of God, “reflections” of God, is the only way to love them as they really are. To say that they are God’s creatures is not just to mention an interesting fact about them. It is the essential truth about them. They have value indeed in themselves, but only because God gave

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it to them. Unless we see God in them as the source of value, we should not really see that they had it. (p. 84)

It is also the foundation for distinguishing human beings from other species or kinds. Only human beings are created in God’s image. That dignity is intrinsic means that moral dignity is not dependent on any capacity or specific characteristic or attribute that a human being possesses—there is no distinction, for instance, between being a human being and being a person. To be sure, human beings can be distinguished from other animals based on certain capacities, characteristics, or attributes, but this is not the foundation for their being in God’s image. This means that all human beings have equal moral worth. Dignity and moral worth are conferred on all human beings by God who has created them to be in relationship with him, to reflect him, and to represent himself in the care of his creation. This applies from a person’s physical beginning to their physical death and beyond.

To say that all human beings have intrinsic moral worth and dignity is to say that it is morally wrong to use one person for the mere benefit of another. One cannot say that one kind of human being, or a certain human being that lacks certain attributes or capacities, is of less moral worth than another. It is morally wrong to use another human being (or a class of human beings) as an end to someone else's purpose. That is why Christian ethics views certain biomedical and medical practices, such as embryonic stem cell research, as immoral because it is using another human being (even a human being that is still an embryo) as a means to another end, even if that end is providing medical advances that may help many others—emphasis on the word may.

To justify any act merely because it results in overall good on balance is a theory that is foreign to Christian ethics (i.e., utilitarianism). To accept this way of moral reasoning, one would have to say that things such as experimenting on people without their consent is morally acceptable because those experiments will bring greater good to more people. This thinking has been used to justify many of the atrocities committed in this and the past century in the name of producing “good” things for many people (e.g., the Tuskegee syphilis study).

Third, the biblical narrative of creation provides a foundation for the care of God’s creation. Just as God in his providence cares for all creation, humankind is given a cultural mandate to represent him in the care of his creation. As created image- bearers of their Creator, humankind is to reflect God’s character, do his will, and rule on earth on his behalf as stewards and vice-regents. The discovery of God’s creation through the use of God-given intellect and curiosity is part of that cultural mandate. Medical science is part of the discovery of that created order. Human rule over God’s creation, however, is never absolute but, instead, a moderated service. It is always subsumed under the higher rule of God and for his glory alone. Humankind’s relationship to creation is one of covenant-stewardship, not co-creator. It is a stewardship that must be used for God’s purpose, not humankind. Part of that cultural mandate is reflected in the proper use of medical science.

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Finally, the biblical narrative of creation affirms that there is an order to creation, that everything was how it was supposed to be and how everything ought to be. This state of order and peace can be described by the term shalom. Yale theologian Nicholas Wolterstorff (1994) describes shalom as “the human being dwelling at peace in all his or her relationships: With God, with self, with fellows, with nature” (p. 251). Cornelius Plantinga (1995) describes shalom as,

universal flourishing, wholeness, and delight—a rich state of affairs in which natural needs are satisfied and natural gifts fruitfully employed, a state of affairs that inspires joyful wonder as its Creator and Savior opens doors and welcomes the creatures in whom he delights. (p. 10)

Moreover, there is a creative normative design that provides a Christian vision of health and flourishing. The concept of shalom offers a glimpse into the multidimensional view of biblical understanding of health and how healthy persons should function. Health is not merely about physical or biological functioning but also encompasses the spiritual and communal dimensions of what it means to be a human being created in the image of God. Walter Brueggemann (2001) highlights this multidimensional view of health as shalom:

Health refers to stability enough to share in the costs and joys, the blessings and burdens of the community. To be healthy means to be functioning full in terms of the norms, values, and expectations of the community. Healing refers to the restoration and rehabilitation of persons to their full power and vitality in the life of the community. Sickness, then, does not refer primarily to physical pain as much as to the inability to be fully, honorably, and seriously engaged in the community in all its decisions and celebrations. (p. 199)

Communal and relational aspects of health are just as important as the physical and psychological.

The spiritual dimension of all human beings cannot be disassociated from the physical dimension as if it were a separate part of the person. Human beings are not only a physical body (i.e., atoms in motion, a concept referred to as monism or physical reductionism); instead, they are multidimensional beings that are a unity of a body and soul. The biblical account of creation describes Adam—and all subsequent human beings—with the Hebrew term nephesh, which means either “ensouled bodies” or “embodied souls.” This has important ramifications for health and healing according to the biblical narrative of creation. Health and disease involve all dimensions of the person at once—the body and the soul. Furthermore, the biblical narrative describes human beings as relational, embodied spiritual beings.

As will be discussed in the next section, sin and the fall affect all aspects of a human being: the body, soul, and its relationship to others and the world. This is the biblical foundation for the biopsychosocial–spiritual model of health and healing in which wellness is concerned with and defined by not only the physical but also the emotional, spiritual, and social wellness of human beings (Sulmasy, 2002).

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The Fall

According to the Bible, the fall has universal and cosmic implications. Just as illness in the body can be viewed as a break in the homeostasis of the body’s physiology, the fall and subsequent separatio

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