A Christian framework for medical ethical decision-making

How should Christians make ethical decisions? Should we use secular decision-making systems that are deontological (rule-based) or consequentialist (outcome based)? Or can we derive an ethical framework from the Bible?

Christians are called to imitate God (Ephesians 5:2), imitate Christ (1 Corinthians 11:1) and to walk as Christ walked (1 John 2:6). We are to be holy because God himself is holy (Leviticus 19:2; I Peter 1:16).

We might say that this is impossible but we forget three things – that through Jesus death and resurrection God has granted us repentance (Acts 5:31), given us a new nature (2 Corinthians 5:17) and placed the Holy Spirit within in us to empower us to live lives which are pleasing to him (Romans 8:9-11). This is why it is possible for us both to ‘put off’ ungodly thoughts and actions and to ‘put on’ godly attitudes and behaviours (Ephesians 4:22-24).

So how are we then to make Christ-like ethical decisions? I would suggest that doing so involves four elements: sharing the mind of Christ, holding the commands of Christ, showing the character of Christ and carrying the cross of Christ.

Let’s consider each of those in turn.

Sharing the mind of Christ

To share the mind of Christ, we first need to have a Christian worldview. We need to think about the world in the way that Jesus does and in the way the Bible teaches; in terms of creation, fall, redemption and future hope.

We are created by God in his image for an eternal relationship with him. But we have also, individually and collectively, fallen from grace. We are sinful and this sin has every aspect of our beings; our bodies, our emotions, our relationships, and our moral decision making. We are masterpieces created by the grand master, but we are flawed masterpieces in need of redemption.

God has initiated his great plan of redemption through his dealings with Israel and ultimately through the sending of his Son Jesus Christ, through whose death and resurrection we can be reconciled to God through repentance and faith.

We now have a hope that is certain, guaranteed by God himself, that we can have confidence for the day of judgment because of what Jesus has done for us, and will live together with God and fellow believers forever in God’s presence in a new heaven and new earth.

Sharing the mind of Christ involves having that linear view of history and that confidence about the future. 

Holding the commands of Christ

Holding the commands of Christ means being guided by his word in the way we make ethical decisions. Jesus said that if we love him we will obey his comands (John 14:15, 15:14). But what are his commands?

What starts in the Old Testament as the Old Covenant, the Ten Commandments and the 613 laws of the Pentateuch is, of course, a shadow prophetically pointing to the person of Christ, who will be the only one who is able to fulfil them (Colossian 2:17; Hebrews 10:1).

In the New Testament, specifically in the Sermon on the Mount (Matthew 5-7), we see Christ going beyond the mere external legalities of Old Testament law to the very spirit of love that underlies it. 

He says (Matthew 22:37-40) that the most important commands in the law are to love God with all one’s heart, soul, mind and strength (Deuteronomy 6:5) and to love one’s neighbour as oneself (Leviticus 19:18).

Jesus also gave his disciples a new commandment, to love one another as he had loved them (John 13:34,35).

But we are told that all Scripture is inspired (literally breathed) by God and profitable for teaching, correction, reproof and training in righteousness (2 Timothy 3:16,17). So, we need to work hard at deducing biblical ethical principles to apply to today’s ethical dilemmas.

Here are some key biblical principles:

Stewardship: we are given skills and abilities, not in order to exploit the earth, but to be its vanguards and its stewards, caring for the earth and for each other in the same way that God would care (Genesis 1:26). We are God’s delegated vice-rulers. This obviously applies to the scientific knowledge and technology that he has given to us. In fact, we see the beginnings of science, in Adam naming the animals (taxonomy) (Genesis 2:19,20) and technology with Jubal and Tubal-Cain developing musical instruments and metal tools (Genesis 4:21,22).

The sanctity of life: every human being is precious in God’s sight because every human being is made in the image of God (Genesis 1:27). It is because of this that human beings cannot be unjustly killed (Exodus 20:13; Deuteronomy 5:17). God will hold us accountable for the shedding of innocent blood (Genesis 9:5,6).

Chastity: sexual faithfulness. As we learn, ultimately, in the New Testament, the pattern of ‘one man, one woman, for life’ (Genesis 2:24) is a beautiful picture or metaphor of Christ’s marriage with the Church (Ephesians 5:31,32) and points, eschatologically, to the New Jerusalem, and the new Heaven and the new Earth (Revelation 22:17).

Veracity: the telling of truth (Exodus 20:16; Leviticus 19:11; Deuteronomy 5:20), because God is truthful and tells no lies (Numbers 23:19; Titus 1:2).

Justice: both at an individual and corporate level, so that vulnerable people are protected from exploitation. So much of the Old Testament law, of course, is about guarding the weak (Proverbs 31:8,9).

Grace: giving people what they don’t deserve (Matthew 5:43-48).

Mercy: not giving people what they do deserve, so that we are called to share the mind of Christ, both from a worldview and ethics (Micah 6:8).

Having the mind of Christ and keeping the commands of Christ are crucial, but we are also called to show the character of Christ because Christian ethics is not just about what we do, but also about how we do it. 

Showing the character of Christ

This brings us back to Plato’s idea that in order to act virtuously, one has to be a virtuous person. One can only act virtuously, in a Christian sense, by being born again, and then transformed by the Holy Spirit so that one develops the fruit of the Holy Spirit: love, joy, peace, patience, kindness, goodness, faithfulness, gentleness, self-control (Galatians 5:22,23).

It is one thing to know the right thing to do. It is something else altogether to have the character to do it.

Standing firm in making correct ethical decisions requires great wisdom, patience, perseverance and courage.

Carrying the cross of Christ

Carrying Christ’s cross means two things in a world hostile to Christian faith and values. It means, first of all, that we are prepared to fulfil the ‘Law of Christ’.

The Law of Christ is an interesting concept. It is mentioned twice in the New Testament. The first mention comes in 1 Corinthians, where Paul says, ‘I am not under the law, but I am under Christ’s law’ (1 Corinthians 9:21). Then, in Galatians, we have the command: ‘Bear one another’s burdens and so fulfil the law of Christ’ (Galatians 6:2).

This lines up with Christ’s words to his disciples at the Last Supper: ‘A new commandment I give to you: love one another as I have loved you’ (John 13:34,35).

If you like, it is the very opposite of the Darwinist ethic of the weak being sacrificed for the strong. It is instead the strong making sacrifices for, or laying down their lives for, the weak.

This is the guiding ethic for everything we see in the New Testament. For example, with the ethics of giving: ‘Christ, who was rich, became poor so that you might be rich’ (2 Corinthians 8:9). Why? In order that we ourselves might then become poor so that we can make others rich. We are called to emulate Christ in making sacrifices, or laying down our lives, for the weak (Romans 5:8).

Additionally, part of carrying the cross in a society hostile to Christian faith and values is that we are prepared to speak and act in godly ways, even when it is tremendously costly to do so; in other words, even when it leads to great opposition. This is part of the cross.

Christ bore the burdens of others and carried out great acts of compassion of healing and love. But he wasn’t crucified for these acts of compassion. It was actually his words that led to his death (John 7:7). It was when he spoke unpalatable truth about his own identity (John 5:18) and when he spoke prophetically about the nation in which he was placed (Matthew 26:63-68). That was when persecution really came to bear.

As Christ’s people living in this age we are called to carry the cross of Christ (Matthew 16:24; Luke 9:23, 14:27). That involves both sacrificial service and also faithfully speaking the truth, regardless of the cost, whether it is preaching the Gospel or speaking moral truth in the public sphere.

So there we have it – we can be imitators of Christ by having his mind, holding his commands, showing his character and carrying his cross.

The violations of medical ethics at Guantanamo Bay are not dissimilar to those that led ultimately to Nuremberg

Bioedge has this week drawn attention to an independent report which has highlighted ongoing violations of medical ethics at Guantánamo Bay and called on the Department of Defense (DoD) and the medical community to conform to ethical principles.

The Task Force on Preserving Medical Professionalism in National Security Detention Centers claims that medical staff have been forced to act unethically.

The 269-page report, Ethics Abandoned: Medical Professionalism and Detainee Abuse in the ‘War on Terror’, follows two years of review of public records by 19 medical, military, ethics, public health, and legal experts.

It discusses how medical personnel established and participated in torture and also outlines how the DoD committed a number of ethical breaches, including improperly using health professionals during interrogations; implementing rules that permitted medical and psychological information obtained by health professionals to be used during interrogations; requiring medical staff to forgo independent medical judgment and force-feed competent detainees; and failing to adopt international standards for medical reporting of abuse against detainees.

The report also says that the CIA’s Office of Medical Services played a critical role in torture, including waterboarding.

A second Bioedge article highlights a thoughtful post on the blog of the American Journal of Bioethics  by Dr Craig Klugman, a bioethicist and medical anthropologist at DePaul University in Chicago. He believes that medical students need much more training in ethics and character training and calls for reform of medical education to allow for courses on moral courage in the face of bullying by authorities and peer pressure.

He could also have pointed them to historical precedent about the dangers of doctors abandoning traditional ethics and conscience.

In June 1947, in the wake of the Nuremberg trials, the BMA published a statement on ‘War Crimes and Medicine’ which it later submitted to the General Assembly of the World Medical Association in September1947.

The statement included the following (emphases mine):

‘The evidence given in the trials of medical war criminals has shocked the medical profession of the world. These trials have shown that the doctors who were guilty of these crimes against humanity lacked both the moral and professional conscience that is to be expected of members of this honourable profession. They departed from the traditional medical ethic which maintains the value and sanctity of every individual human being.’

‘The doctors who took part in these deeds did not become criminals in a moment. Their amoral methods were the result of training and conditioning to regard science as an instrument in the hands of the State to be applied in any way desired by its rulers. It is to be assumed that initially they did not realize that the ideas of those who held political power would lead to the denial of the fundamental values on which Medicine is based. Whatever the causes such crimes must never be allowed to recur. Research in medicine as well as its practice must never be separated from eternal moral values. Doctors must be quick to point out to their fellow members of society the likely consequences of policies that degrade or deny fundamental human rights.’ 

Once fundamental principles of medical ethics are rejected, things can escalate rapidly by a series of small steps.

Perhaps the American Department of Defense (DoD) and the medical community need to be reminded that it was precisely small steps of this kind that led ultimately to Nuremberg.

Divorcing love from morality - the New Liberalism infecting British Evangelicalism

The Old liberalism had its roots in the radical biblical criticism of the 19^th century. Old liberals doubted core Christian doctrines like the incarnation, Christ’s death and resurrection, his ascension and second coming, the authority of Scripture, justification by faith, the day of judgement, the sovereignty of God, and so on.

The New liberalism is actually orthodox on these things. New liberals will gladly tick the boxes of the church creeds and the doctrinal basis of the Evangelical Alliance and many of them know their Bibles well.

They are liberal not on what we might call the core beliefs of Christianity, but on ethics (for examples of the wide range of views on ethical issues amongst British evangelicals see here). They would argue that ethical issues are in the category of what Paul, in passages like 1 Corinthian 8 & 10 and Romans 14, called ‘disputable matters’.

‘Disputable matters’ are things on which Bible believing Christians can legitimately disagree whilst remaining in fellowship with one another. If you like they are in the same category as debates about the timing and amount of water to be used in baptism, the modus operandi of the Lord’s supper, the sequence of events around the return of Christ, forms of church government and the place of Israel.

I see this view as a revival of what in a previous generation was called ‘situation ethics’.

Situation ethics is a Christian ethical theory that was principally developed in the 1960s by the then Episcopal priest Joseph Fletcher (pictured).

Fletcher taught Christian Ethics at Episcopal Divinity School, Cambridge, Massachusetts, and at Harvard Divinity School from 1944 to 1970 and wrote ten books and hundreds of articles, book reviews, and translations.

Situation ethics basically states that other moral principles can be cast aside in certain situations if love is best served; as theologian Paul Tillich once put it: ‘Love is the ultimate law’.

The moral principles Fletcher was specifically referring to were the moral codes of Christianity and the type of love he is specifically referring to is ‘agape’ love.

Fletcher believed that in forming an ethical system based on love, he was best expressing the notion of ‘love thy neighbour’, which Jesus Christ taught in the Gospels.

He believed that there are no absolute laws other than the law of ‘agape’ love, meaning that all the other laws are only guidelines on how to achieve this love, and could be broken if an alternative course of action would result in more love.

In order to establish his thesis he employed a number of examples of ‘situations’ in which it might be justified to administer euthanasia, commit adultery, steal, tell a lie etc.

But in effectively divorcing ‘agape’ love from moral law Fletcher was steering a subtly different path from Jesus himself.

Jesus indeed said (Matthew 22:34-40) that the most important commands in the Old Testament Law were love of God and neighbour (Deuteronomy 6:5 and Leviticus 19:18). In fact he said these two commandments summed up the whole of Old Testament Law (Matthew 22:40 and Luke 10:25-28). Furthermore he criticised the Pharisees for obeying the less important parts of the law (tithing mint and cumin) whilst neglecting the ‘more important matters of… justice, mercy and faithfulness’.

But he also said that ‘anyone who breaks one of the least of these commandments and teaches others to do the same will be called least in the Kingdom of heaven’ (Matthew 5:19) and reproved the Pharisees by saying that they should have ‘practised the latter’ (important commandments) ‘without neglecting the former’ (lesser commandments).

Certainly there is no place in the Gospels where Jesus implies that those commandments which deal with the shedding of innocent blood and sexual immorality (numbers six and seven of the Ten Commandments) should be disobeyed.

By contrast he exhorts his disciples in the Sermon on the Mount to go beyond the mere legalities of ‘you shall not murder’ (6) and ‘you shall not commit adultery’ (7) to embody the very spirit of love which undergirds them. Not only no murder or adultery but no hate or lust either! (Matthew 5:21-30).

It is this more exacting moral standard that also underlies the ethical teaching in the epistles. Christians are exhorted to be imitators of Christ (1 Corinthians 11:1) and God (Ephesians 5:1&2), to walk as Christ walked (1 John 2:6) and to ‘abstain from sinful desires’ (1 Peter 1:11).

In short we are to live by the law of Christ (1 Corinthians 9:21 and Galatians 6:2) and to love one another as he has loved us (John 13:34-35). And love of Jesus means obedience to Jesus (John 14:15,21 and 15:12). In fact Jesus famously answered one of the Devil’s temptations in the wilderness by quoting from Deuteronomy, ‘Man shall not live on bread alone, but on every word that comes from the mouth of God’. Note every word.

So whilst we may say that there are situations where choosing not to shed innocent blood or to carry out a sexually immoral act requires great grace, courage, restraint and self-sacrifice, there are no situations where one may choose to murder or to do something sexually immoral and claim to be acting in love.

If Christ had been directly tempted in such a way, and indeed he must have been if he was ‘tempted in every way, just as we are’ (Hebrews 4:15) as we are told he was, we can imagine him answering as he did in the wilderness, ‘It is written, “you shall not murder”, “you shall not commit adultery”’.

By my reading Situation Ethics is a distortion of biblical ethical teaching. It is, in short, heresy. But it is a heresy that appears to be very much alive and well amongst British evangelicals in the 21st century. No more clearly is it evidence than in the shifting views and lack of clarity amongst evangelicals about sexual morality and the shedding of innocent blood.

Interestingly, Fletcher later identified himself as an atheist and was active in the Euthanasia Society of America and the American Eugenics Society and was one of the signatories to the Humanist Manifesto. When he started out, his position was barely distinguishable from orthodoxy. But he finished up in a very different place altogether.

This is exactly what happens when we define ‘love’ in a different way from the way it is defined in the Bible. 

How historic codes of medical ethics have ‘evolved’ to endorse abortion

I’ve just come back from a trip to Derry and Donegal where I was doing a radio phone in and an evening meeting on abortion.

Abortion remains illegal in both Ireland and Northern Ireland under the Offences against the Person Act 1861. 

This Act also remains in force in England, Wales and Scotland although doctors can avoid being prosecuted under it by abiding by the provisions of the Abortion Act 1967.

The Offences against the Person Act, like many of our country’s laws, was originally based on the Judeo-Christian ethic which forbids the taking of innocent human life on the basis that all human lives are made in the image of God.  It treats abortion in the same way as murder - that is, as a crime punishable by life imprisonment.

Not many people know that abortion is also against historic codes of ethics like the Hippocratic Oath, the Declaration of Geneva (1948) and the International Code of Medical Ethics (1949) or that in1947 the British Medical Association called abortion 'the greatest crime'.

The Hippocratic Oath is an oath historically taken by physicians swearing to practise medicine ethically and honestly. It is widely believed to have been written either by Hippocrates (pictured), often regarded as the father of western medicine, or by one of his students.

The Oath, which dates from the 5^th century BC, is one of the most widely known of Greek medical texts.

The Declaration of Geneva and the International Code of Medical Ethics are modern restatements of the Hippocratic Oath which were developed in response to the unethical actions of Nazi doctors during the Second World War.

I was surprised to learn that not even Clare Gerada, the Chairman of the Royal College of General Practitioners (RCGP), seemed to be aware of the contents of the Hippocratic Oath.  

In a twitter exchange last week (see below) she agreed with another doctor (of the same name but not I think related) that ‘good GPs must be neutral/secular on the abortion issue’.

When I said to her that doctors doing abortions were actually breaking the Hippocratic Oath she told me it was ‘rubbish’ to say that the Hippocratic Oath forbade abortion (see below).

When I linked her to a modern translation of the Oath on Wikipedia demonstrating that it did another doctor said that if I relied on Wikipedia for a source it was no wonder I had to ‘bow out of medicine’

.

Someone else then implied, that the Oath was no longer valid because it forbade the crushing of bladder stones (see below) although in fact it simply suggests that bladder stones should be referred to those with the necessary skills.

‘I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.’

Judging by her reaction Dr Gerada didn't seem to be aware of this either. In fact this clause upholds proper referral and the necessity of experience and training for those undertaking surgical procedures. 

These views are not at all unusual amongst doctors today.

Most medics are not aware that the dramatic increase in abortion worldwide last century ran completely counter to all historically accepted codes of medical ethics.

The Hippocratic Oath includes the resolution ‘I will not give to a woman a pessary to  produce abortion’.

The Declaration of Geneva (1948)  states  ‘I  will maintain  the utmost  respect for human life from the time of conception even against threat...’ and the International Code of Medical  Ethics (1949) affirms that ‘a doctor must always bear  in mind  the importance of preserving human life from the time of conception until death’.

In the same spirit the UN Declaration of Human Life (1948) asserts that ‘everyone has the right to life’ and the UN Declaration of the Rights of the Child (1959) that the child deserves legal protection before as well as after birth.

When the legal abortion rate soared world-wide in the second half of last century – with almost all abortions performed by doctors - the World Medical Association was left with a choice of changing either its behaviour or rewriting its ethics. It opted for the latter.

In 1970 it adopted the Declarationof Oslo. This allowed ‘therapeutic’ abortion in circumstances ‘where the vital interests of the mother conflict with those of the unborn child’. Although the ‘utmost respect for human life from the time of conception’ as laid out in the Declaration of Geneva was affirmed, it was recognised that there was a ‘diversity of attitudes towards the life of the unborn child’.

The Declaration of Oslo went on to say that ‘where the law allows therapeutic abortion to be performed... and this is not against the policy of the national medical association’ then ‘abortion should be performed’ under certain provisos.

The Oslo declaration thus laid the framework for doctors to perform abortions if their ‘individual conviction and conscience’ allowed it and the law and the national medical association were not in disagreement.

The change appeared minor at the time but it represented a fundamental shift in the whole framework of medical ethics.

The Judeo-Christian ethic with its concept of absolute right and wrong was discarded and ‘individual conscience’ enthroned as absolute in its place. ‘Individual conviction and conscience’ which ‘must be respected’ has replaced God as the arbiter of truth.

The doctor was no longer obliged not to kill. Instead by a strange twist he or she was now obliged not to stop other doctors killing if their ‘consciences’ dictated that they should. 

As the abortion rate rocketed world-wide in this new ethical environment (there now over 42 million abortions per year) consistency of belief and practice were achieved by further amending other ethical codes.  At the 35^th World Medical Assembly held in Venice in October 1983 the WMA amended the words ‘from the time of conception’ in the Declaration of Geneva to ‘from its beginning’.

At the same time the words ‘from the time of conception until death’ were excised from the International Code of Medical Ethics.

The change in the medical profession’s attitudes and practice on abortion are the main reason these oaths and declarations are no longer used today in their original form.

In fact, we are now reaching the stage, it seems, where those who still wish to abide by the spirit of these historic oaths are thought by some to better out of medicine altogether. As RCGP Council Chair Dr Gerada says above, good GPs should be neutral/secular on abortion and if they are not then they should leave the profession.

The evolution of medical ethics codes is a fact unknown by most doctors. All the more important therefore for us to keep drawing it to their attention.