Medical Ethics: A Reformed Perspective
I need to make a few disclaimers at the beginning. First of all, although I am a member of the Ethics and Public Affairs Committee of the Free Reformed Churches, the original speech is not a position paper of the Committee. The views that I will be sharing are not ‘denominational positions.’ They are my views, which I hope, are founded on Scripture. I anticipate that we may have differences of opinion on certain issues. Drs. Kenyon and Bilkes are present and I hope they will provide some assistance in fielding questions during the afternoon session.
The second disclaimer is that I am not an ethicist. I am a medical doctor, an anesthesiologist. As such, my background is in medical science, not in philosophy or theology.
Before any lecture, it is valuable to set out some goals. So I have come up with five that I hope that I can achieve by the end of our time together.
- Discuss why medical ethics matter;
- Gain an understanding of the prevailing ethical mindset/ background of most secular physicians in North America;
- Discuss what is a Reformed Medical Ethic;
- Look at some principles from the Bible that we can use when making decisions;
- Look at some Christian values that are important in making ethical decisions;
- Apply this framework to a few situations.
Why Medical Ethics Matter
Before I talk to you about medical ethics, let’s define ethics. Ethics is concerned with the manner of life and with behaviour.
It is concerned with what is the ‘right’ or correct thing to do. It involves decision-making, but not just decision making. For we all know that it can be very easy to make a decision, but moving on to the next step and acting on that decision can be much harder. So ethics also involves intent or motivation as well as action. Medical ethics is concerned with making the right decision in matters regarding healthcare/medical technologies. Although we will come back to this theme, let me start by saying that for the Christian, making the right decision involves relying on the revealed will of God.
All of you as individuals, and likely also in your calling as office bearers, have had to deal with ethical questions. Ethical questions often start like this, “What should I do in this situation...” or “What is the right thing to do here...”
If you have not had to deal with ethical questions related to medicine or healthcare either personally or as office bearer, I think that it is safe to say that you will, at some time. So in the first place, medical ethics matter because it is something we will have to deal with. These matters will arise. They are common.
The second reason why I think medical ethics matter is because the ethical questions and issues that arise often arise suddenly. There is often very little time to think about them. A question may come up in your family, on a home visit or a hospital visit. You may not have been anticipating the question, and then, all of a sudden there it is. You are asked to give counsel, and help with a decision.
In addition to being sudden and unexpected, questions regarding medical ethics are often highly charged with emotion. Rarely are office bearers asked whether it is okay to take an antibiotic to treat a skin infection. But you may be asked what to do about fertility treatment. These are difficult situations to deal with, even when you’ve had much time for prayer and study. They are even more difficult when you haven’t. Therefore, I think that it is good to have thought about things in the light of God’s Word before we are faced with such decisions.
The third reason it is useful to think about medical ethics is because it involves a discipline with which most of us are unfamiliar. Although you probably feel at times that you are struggling for the right answer when you are asked about deep spiritual things, at least you feel that you can go to the Word, or recommend a book you have read. With medical ethics, you may wonder, “how can I even start?” Preparing yourself by knowing some of the language related to medical issues, especially as they relate to the beginning and end of life, can help to make these situations a little easier.
The fourth reason that medical ethics matters is that the advice that you are most likely to receive from a doctor or other healthcare provider, is from a secular man-centred perspective, rather than a God-centred perspective. Therefore, if you are armed with the knowledge of some biblically-based concepts about how to make decisions, you will be more prepared to critically assess the advice that comes from a secular perspective.
Understanding Secular Medical Ethics
If what I have said is true, that the prevailing advice that you will receive is from a secular perspective, I think that it is helpful to try and understand that perspective to a certain degree. What are doctors taught about ethics? Frankly, not much. At least, this was the case ten years ago when I attended medical school. Ethics is really a neglected part of the medical curriculum.
Though it is implicit in many discussions that take place throughout medicine, ethical issues are not often discussed openly. For instance, the medical school that I attended had one formal lecture on ethics. There was an opportunity for motivated students to pursue elective studies in medical ethics but I don’t think that many did this. Therefore, much of ethics and ethical behaviour that physicians learn, they learn from what others around them do. This being said, the various regulatory bodies that regulate health care professionals set out various guidelines regarding ethical behaviour. You could do a ‘Google’ search about the CMA code of ethics for the standard for behaviour for Canadian physicians. The Canadian Medical Association has a code of ethics that lists 54 ethical responsibilities that should guide the behaviour of Canadian physicians.
So most physicians learn very little about ethics, but if they do, they are often taught three basic ethical principles. These principles are: Patient Autonomy, Beneficence/Non-Maleficence, and Justice.
- Autonomy means essentially “self law.” Perhaps it is best described in the following way: “Every human being of adult years and sound mind has a right to determine what shall be done to his own body.” In other words, it is not up to the doctors to decide what should be done to you. For instance, a doctor might recommend that you have surgery, but it is ultimately you who must make the decision. This is, I think, a good thing. History is littered with horrible examples of what happens when autonomy is neglected. Also, doctors may not always know what is best for a patient. Involving the patient in the decision-making protects against abuse of physician power. Autonomy is also in some ways, protective to the Christian. Ideally, if cared for by a physician who respects his autonomy, the Christian can make decisions that are God-honouring. But, Christians must be aware that physicians will in a sense, ‘give them what they want.’ What we want may not always be right. This should give us pause for thought.
- The principle of Beneficence or Non-Maleficence (these are essentially the same thing) is a more ‘traditional’ ethical principle. This principle states that the physician should act in the best interest of the patient and avoid doing harm. It is the part of the Hippocratic oath that is most often quoted: ‘above all do no harm.’
It is this principle that is responsible for the paternalistic, “doctor knows best” type of medical practice that was common in the past. In modern medicine, although this is still a fundamental principle, it has taken a definite backseat to autonomy. This is somewhat sad, because I think that in de-emphasizing this principle, especially for the sake of autonomy, we as a medical profession are at risk of losing some of the sense of compassion that used to characterize our profession. Christians involved in healthcare should rise to this challenge and seek to express compassion and care, following in the footsteps of the Saviour.
- The final ethical principle is justice. Justice is primarily concerned with the appropriate allocation of scare resources. Many of the debates taking place in government and the media in this time of limited healthcare resources have to do with issues regarding justice. For example, in a publicly funded healthcare system, choosing to pay for a particular treatment/ procedure means having less to fund another treatment. How should one decide? Should money be spent on cataract surgery for the elderly or on vaccination programs for children? Should money be spent on increasing the number of lung cancer surgeries (often a result of years of smoking) or should those funds instead be directed to funding ovarian cancer (not related to life-style choices) treatments?
Often, frontline physicians play a small role in these allocation decisions. Yet, the issues of justice are rarely far from our minds. Christians should seek to ensure that the policies that our governments enact are just, and Christian healthcare providers should seek to act justly. Acting in a way that is just or fair, should characterize our life. Micah 6:8 states, “What doth the LORD require of thee, but to do justly, and to love mercy, and to walk humbly with thy God.”
What I have just outlined is an extremely brief sketch of some of the major ethical principles that most doctors have learned and will apply in their daily practice.
For the Christian, these principles on their own are not enough to guide our decisions or govern our behaviour. For the Christian, any discussion of the ‘right manner of life and behaviour’ must involve Scripture. As Christians we confess that the revealed will of God is the final rule of life. We confess that He has shown us how we should live through His Word and the work of His Spirit in applying this Word.
Yet, when a Christian goes to a physician, looking for advice, unless that physician is a Christian, that thought will not cross that doctor’s mind. For example, suppose that you have a loved one who is in the intensive care unit on life support, the advice that you will receive will come through a secular viewpoint. Also, when you go to your doctor seeking help with regard to reproductive issues, the advice and care that you receive will centre on your autonomy. The physician will outline various options and expect you to choose. Patient autonomy defines what is right. What is ‘right’ is determined by what you want. As Christians, this should make us pause. We are taught in Scripture that the carnal mind is enmity against God.
How then are we to make right decisions? In medical issues, just like in all of life, in order to make the right decisions, God-honouring decisions, we must know the fear of the Lord. As Proverbs points out, the fear of the Lord is the beginning of wisdom. All of our inquiries, indeed our lives must begin with Him.
Although today we are talking specifically about medical ethics, medical ethics cannot really be separated from the rest of our Christian life. Our lives cannot be compartmentalized into our church life, our work life, our school life, our health decisions life, and our financial life. No, if we are Christians, then the life of faith must be demonstrated in all of these spheres. Our whole life should be a walk with Christ. This is the starting point for any counselling regarding medical ethics.
A Reformed Christian Medical Ethic
So let’s move on to my third goal: Outlining a Reformed Medical Ethic. In choosing this title, I wish to emphasize that the principles or watchwords of the Reformation, Sola Scriptura, Sola Fide, Sola Gratia, Solus Christus and Soli Deo Gloria are important in the realm of ethical decision-making. Sola Fide and Sola Gratia; unless we know saving grace, which can only be obtained through faith in Christ alone, we cannot truly make right decisions. Also, just as the Reformation re-affirmed the importance of the Scriptures, Sola Scriptura, we too must look to the Scriptures as our guide for all of life; a life that must be lived in a way that gives glory to God.
The second purpose in choosing this title is to remind you that when looking for books dealing with the topic of ethics it is often helpful to look for those written by authors who hold a Reformed perspective.1Although it is easy to say that we will follow the teachings of Scripture, it seems hard considering the dilemmas that modern medicine raises such as, “should we consider discontinuing life support” or “is contraception right?” to find a clear biblical answer.
Where can we begin? You wish to open Scripture, but where to start? I would like to caution you against looking for a quick fix. In many areas of our lives we can make things more difficult than we need to. I would submit to you however, that in ethics, this is often the opposite. Ethical matters are often more complex than we may appreciate at the outset. They take effort. Effort in prayer. Effort in reading. Effort in listening. Effort in deciding and effort in acting. Rarely is it possible to find a ‘one verse’ answer to our ethical struggle.
Biblical Doctrines In Medical Ethics
I left off with the plan to present a framework that may be helpful when working through ethical dilemmas. This framework is not my own. It is drawn from a book that I recommend, “Bioethics and the Christian Life,” by David VanDrunen.2
VanDrunen suggests that there are four key doctrines found in Scripture that can help to inform our decisions. There are many other doctrines that are found in Scripture that can apply in different situations. In fact, for each dilemma or decision that we face, we must do our utmost to prayerfully consider the whole counsel of God before proceeding; however, these four doctrines are a starting point.
1. The Sovereignty of God
The first is the doctrine of the sovereignty of God and divine providence. The Bible makes it very clear that God is in control of all things. Not one sparrow falls to the ground without the will of our heavenly Father (Matt. 10:29). He ordains every detail of our lives. The hairs of our head are numbered (Matt. 10:30). What we perceive as ‘good’ or even what we perceive as evil, is under His control. We often find it easy to see the providential hand of God and acknowledge His sovereignty in the good things that happen to us. In times of adversity this is much more difficult. As the Heidelberg Catechism states in Question and Answer 27, the providence of God is “the almighty and everywhere present power of God;
- whereby, as it were by his hand, he upholds and governs
- heaven, earth, and all creatures; so that herbs and grass, rain and drought,
- fruitful and barren years, meat and drink, health and sickness,
- riches and poverty,
- yea, and all things come, not by chance, but by his fatherly hand.”
Scripture also tells us that God’s providence and sovereignty are directed toward the up-building of His people. “All things work together for good to them that love God” (Rom. 8:28). Even the evil that befalls His children, works to their good.
One of the most vivid examples that we find in Scripture of someone submitting to the sovereignty of God is the story of Job. He received much evil at the hand of Satan, allowed by God. After all the awful things had happened to him, he could still say, “Though he slay me, yet will I trust in him” (Job 13:15). So, first and foremost when a challenge arises, consider this — God is in control. However, if one is not united to Christ, then all things will not necessarily work together for good. This provides us with a place to begin in our counselling.
2. The Image of God
Another key biblical doctrine to keep in mind when dealing with medical ethics is that man is created in the image of God. It is worthwhile to pause for a minute to consider that truth as well. God made this entire wonderful, awesome creation with all its vastness, beauty, and incredible diversity. But out of all of it, only man was created in the image of God. Psalm 8 comes to mind as an exposition of how man truly is the pinnacle of God’s creation. Today, most physicians, and in fact most people in our society at large fail to see much of a distinction between human beings and the rest of creation. Human beings are held in much the same regard as other animal life. The reality that a human being is special because he/she is created in the image of God has largely been lost.
To most physicians the concept of an eternal soul is foreign. But in reality, human life is radically different from any other life that we find on this earth. From the moment that new life is formed at conception, God creates a unique human being with both a body and a soul, which remain together until separated by death. No other creature has a living soul.
We live in a very visual culture; we thrive on images. If we can’t see something, we tend to disbelieve it or minimize its importance. This can have a subtle, yet profound influence on how we think about the beginning and end of life issues. Human embryos, only a few cells in number, invisible to the naked eye, look nothing like a human being. In our visually driven culture, these are not given the respect that they deserve. These tiny microscopic collections of cells are a living soul, incredibly precious, deserving of honour and protection as God’s image bearers. The elderly person, curled up in a fetal position in bed, too weak to rise up, his mind clouded by Alzheimer’s, his voice too weak to speak, is also an image-bearer.
Perhaps what I have said sounds a little too man-centred or almost as man-worship. That is not my intention. Mankind as image bearers has tarnished this image by the fall. I believe that the Bible teaches that in our natural state we are totally depraved. As Psalm 9 teaches us, we also need to know ourselves to be ‘but men.’ Our true, full glory as image bearers will not be seen until we are risen again when the Bridegroom returns and we are found among that company gathered around the throne of the Lamb. We must view mankind from this balanced perspective. Every image bearer, bears the image of God and because of this deserves our respect.
3. The Reality and Nature of Death
This is the third doctrine that is often helpful to consider when thinking about medical ethics. This is somewhat of a difficult thing to explain. In our current society, perhaps even more so in Europe than in North America, we normalize death. Death is seen as a natural thing. Much has been written to define the stages of dying and coming to terms with a terminal diagnosis. The goal of this is to help lessen the sting of death, to take away the fear associated with death. We are told that those suffering from chronic diseases should welcome death as a means to escape this suffering. Yet is this understanding and attitude toward death scriptural?
Death first entered into the world through sin. Death is a punishment for sin, man’s sin. Death was never supposed to be. Man was created to live. God breathed into his nostrils the breath of life. Life (both physical and more importantly eternal life) is what humans were created for. It is in life that we bear the image of God. Therefore we as Christians should always act to affirm life; to choose life over death. We need to accept that death will come to all, but death in and of itself should not be embraced. Death is a fearsome thing. It is an awful thing. It separates soul and body. This is, in the deepest sense, wholly unnatural.
I agree that in once sense of the word death is natural. It is natural in that it happens to all creatures; none will escape it. Perhaps it is better to say that death is inevitable (as a result of sin) but not natural. In fact, Jesus has come and conquered death so that His people do not have to suffer eternal death. For His people even the sting of physical death has been taken away. Now death, instead of being a portal to eternal woe, is a portal to eternal life in anticipation of the resurrection and the world to come.
This biblical concept of death is utterly foreign to our society. By focusing on the manner of how we die, free of pain, dignity intact, in full control of our faculties, society has distracted us from the fearsome reality of what lies beyond the grave. According to this view, death is good if it is noble and preserves our autonomy or pride.
We too can be drawn into this way of thinking; this misguided focus on the manner of death. Now, please don’t misunderstand me. Physicians, healthcare workers, and family members, when caring for those who are experiencing a great deal of pain and suffering, have an obligation to provide comfort, support and care for those at the end of their lives. We must hold firm, however, to the belief that life, even when it may involve suffering or pain or incapacity is still an inherent good, a God-breathed gift, worth protecting.
4. The Reality of Suffering
The fourth key doctrine to consider is the reality of suffering. Suffering is inevitable. To quote VanDrunen: “For Christians the question is not really whether we will suffer but how we will suffer. Will we suffer in a godly way or not?”3Scripture says: “In the world ye shall have tribulation” (John 16:33). Many issues that give rise to difficult ethical dilemmas involve suffering. Issues regarding infertility, chronic pain, chronic illness, these all can cause those struggling with these matters to experience great suffering.
Our natural response to suffering is often to question God. Reflexively we ask, “Why me?” or “How could a loving God allow, even ordain that such a thing should happen?” Yet we must accept, through prayerful submission, that God is loving and wise. “For (as) the heavens are higher than the earth, so are my ways higher than your ways, and my thoughts than your thoughts” (Isa. 55:9). Think again on the example of Job. When Job questions why all these things have happened to him, God reminds him in chapters 38-41 how great He is and how small Job is.
Although we are not called to go looking for suffering, we should pray for grace to bear a burden of suffering if God chooses to place it upon us. Suffering is not the ultimate evil. We may not necessarily do all that we can to avoid suffering; at times we must accept it as God’s will. Think for instance of the suffering that a person with a spinal cord injury experiences. Such a person may be unable to walk, possibly unable to perform even basic self-care. Now suppose medical science had found a way to use embryonic stem cells, derived from ‘spare’ human embryos to cause regeneration of the nervous system and treatment of the injury. This would provide immense relief and heal the suffering of many, yet it would be wrong, because it has involved the taking of innocent life.
Suffering must be endured if the means that we would use to end it are contrary to the revealed will of God. In fact, it is in times of suffering that God’s people are often drawn closer to Him, made more dependent on Him and become more gloriously aware of their adoption as His children. “Yea, though I walk through the valley of the shadow of death, I will fear no evil for thou art with me” (Ps. 23:4).
So, to briefly recap, four important biblical doctrines that we should keep in mind are the providence of God — He controls and directs all things. Second, man is an image bearer of God and as such deserves respect. Third, the reality and nature of death — that it is wholly unnatural and that the only way for the sting of the grave to be lost is through redemption by Christ. Fourth, the nature of suffering — at times we are called to suffer and we must do so in a God-honouring way.
Christian Character Traits
These are some doctrines of the Bible that we should consider when making ethical decisions. But in order to make right, God‑honouring decisions, we must be a certain kind of person. We must, above all, be born again. What then are the virtues or character traits that a Christian must possess and bring to bear when making ethical decisions? David VanDrunen,4an ethicist whose book has formed much of the basis of these articles, has highlighted six virtues or characteristics that Christians should seek to put into practice when making ethical decisions: Faith, Hope, Love, Courage, Contentment and Wisdom.5
How does faith help us to make right decisions and go on to do the right thing? The most basic answer to this question is found in Hebrews 11:16, “without faith it is impossible to please God.” The positive side of this statement is that only with faith is it possible to please God. The Heidelberg Catechism acknowledges this in Lord’s Day 3, Q&A 91, “What are good works? Only those which are done out of true faith in accordance with the law of God, and to his glory, and not those based on our own opinion or on precepts of men.”
Faith is the foundation. We cannot be justified in the sight of God and we cannot do good works outside of faith in Christ. We see that medical ethics and, in fact, any decision-making is at its very core a spiritual matter. What is our relationship with God? If this is not right, then can anything else go right? These questions provide a place to start, especially from a pastoral, counselling perspective. Romans 14:23 teaches us that whatever is not of faith is sin. Faith is the starting point. All of the other virtues that we will consider spring from faith.
The second virtue or character trait that we must seek to put into practice when making decisions, is hope. Hope is an essential virtue when facing trials. If faith is trusting in God and in His goodness in the present, then hope is looking forward in trust. Hope is the expectation that God will do what He says. It is what the psalmist is urging when he says, “wait on the Lord” (Ps. 27:14).
How does hope help us to make the right decisions — also as it relates to our health? Often ethical challenges and the suffering that can come with them, tempt people to despair. The future can seem very bleak. Take for instance the couple grappling with infertility. The hope they have placed in medical remedies has been disappointing. This couple needs to be exhorted to hope in the Lord. Romans chapter 4 relates how Abraham placed his hope in the Lord, even when things seemed impossible. In chapter 5 we read, “But we glory in tribulations also; knowing that tribulation worketh patience; and patience experience; and experience, hope: And hope maketh not ashamed.” We ought to live as citizens of heaven and set our minds on things above. Whatever we suffer here pales in comparison to the glory that shall be revealed.
The third of the six virtues that should characterize our approach to decision-making is love. In our culture, love refers to a feeling or a state of action. The biblical concept of love, unlike how we tend to use the term in our culture, does not refer to a feeling, but rather something or things that we do. Think of first Corinthians 13, which gives us a grand description of love, or the words of the first epistle of John, chapter 4:10-11: “Herein is love, not that we loved God, but that he loved us, and sent his Son to be the propitiation for our sins. Beloved, if God so loved us, we ought also to love one another.” The essence of love involves self-sacrifice.
How can we demonstrate this virtue or characteristic when making decisions? Suppose we have been diagnosed with a serious illness and we are trying to decide whether to continue treatment. In difficult situations, we can be so focused on our own troubles that we may not even consider how our decisions may impact others. Yet, if we are to show the kind of self-giving love of Scripture, we must think about what impact our decisions will make on others. It is often helpful to ask ourselves or ask those whom we are counselling, how we can show love through the choices that we make.
So far we have looked at three virtues that are important to demonstrate when making decisions: faith, hope and love. There are three other virtues, perhaps more particularly relevant to medical decision-making that we need to discuss. They are courage, contentment and wisdom.
The fourth virtue is courage. Courage is pursuing what is good in the face of danger or hardship. The Bible gives examples of courage and the good that can result and also the evil that can result from a lack of courage. Think of David fighting Goliath. David’s faith in the God who had kept him from the paws of the bear and of the lion gave him hope that he could defeat the giant and therefore he proceeded with courage.
For a biblical example of the consequence of lacking courage, think also of Numbers 13:31-33. Ten of the twelve spies who had been sent out to scout the land of Canaan gave an evil report. They said that Israel would never be able to conquer the inhabitants of Canaan. It was because the ten spies lacked faith in God that they had no hope of possessing the land and because of the hardships that they perceived, they lacked courage. As a result, God’s judgment fell upon Israel and the spies with the evil report.
These examples show how courage proceeds from faith and hope. But how then, is courage necessary in ethical decision-making? There are times when it is very clear what is the right thing to do (or not do) but the course of action is very difficult, fraught with personal sacrifice. To proceed requires courage, courage that only God can give. “Be of good courage, and he shall strengthen your heart, all ye that hope in the Lord” (Ps. 31:24).
The fifth virtue is that of contentment. Contentment is submitting to and finding peace in God’s will for our condition in every circumstance of life. Although none of the virtues mentioned thus far are found in us by nature, contentment seems to be even more alien to our fallen state than some of the others. Contentment is especially rare in our current age.
The mantra of the world in which we live is “strive, succeed, overcome, work for the top, try to earn more, get ahead in life.” This implies a dissatisfaction with our current state and a desire to have something more or better. This prevailing attitude or characteristic of discontentment is completely at odds with what Scripture teaches. One of the clearest expressions in the Bible of the value of contentment is found in the book of Philippians. Paul begins in chapter 1 stating the all-sufficiency of Christ for him. In chapter 2 he urges those in the church to look after each other. In chapter 3, he speaks about his previous zeal in persecuting the church and contrasts this with his current zeal in serving Christ. Then, in chapter 4, he sums up this discussion of his faith and life with the words of verse 11: “Not that I speak in respect of want: for I have learned, in whatsoever state I am, (therewith) to be content” or as he exhorts in 1 Timothy 6:6: “Godliness with contentment is great gain.”
How then does this virtue function in ethical decision-making? Take for instance an experimental therapy for a chronic illness. We can place all our hope in this therapy, become so caught up in the prospect of relief from our illness, that we lose sight of the need to be content with the state that we are in. In praying for deliverance, we should also pray for the grace to accept and bear our burden, if it is God’s will that we not be delivered from it.
The final virtue or characteristic of a Christian that must be demonstrated when making a decision is wisdom. What is wisdom? Wisdom is that virtue that enables a person to put his/her virtues into concrete practice and apply his/her moral rules in real life.6It is not enough simply to know moral rules, we need understanding about how to apply them, how to live them out in the real world.
How do we obtain such wisdom? Two key texts come to mind: “The fear of the Lord is the beginning of knowledge” (Prov. 1:7) and “If any of you lack wisdom, let him ask of God, that giveth to all men liberally and upbraideth not” (Jas. 1:5). The book of Proverbs demonstrates very clearly the wisdom we can gain by listening to the wise advice of fathers and elders.
This is something that, I fear, we as individuals and office bearers do not do enough. I am sure that you as office bearers have seen instances in your congregation when members have made certain ethical decisions that may have come as quite a surprise to you. You may not have been aware that someone was struggling with a particular issue, because they never shared it with anyone.
I fear that often, we as members of a church do not share our burdens and trials with others. In so doing, we miss out on the opportunity to be led and instructed by those who may have gone through the same struggles that we are facing. Also, we miss out on the opportunity to be exhorted to continue in the faith. I think that this presents a challenge to office bearers. To rise to this challenge, I suggest that they strive to be men who know the church. They need to be men who know what is on the minds of the members in the congregation, but not in a way that pries unnecessarily into the affairs of others. Office-bearers must be seen to be friendly and approachable to members and visitors alike. Only then will members feel comfortable sharing their burdens. Seek to develop a reputation as one who is warm, open, understanding and wise; ready to speak a word in season and to share the riches of Christ.
Perhaps another virtue that we must have, and I am not sure that it is distinct from love, is kindness and humility. When advising those who are grappling with difficult decisions or are experiencing much suffering, our advice and counsel should be rooted in God’s Word mixed with love. We need to speak to one another in love. “Speak the truth in love” (Eph 4:15). Much good counsel can be made to be harmful, when it is not given in humility and love.
We need to realize that having considered all these virtues that they are not virtues that are found in the natural man. True faith, true hope, true love; these are not found in any of us by nature. Just as the Beatitudes describe the characteristics of the true Christian, so too, these virtues that we have discussed are only found in those who are in Christ. The outworking of this is clear; none of our actions, none of the ethical decisions that we make, can be truly made rightly unless we are in Christ.
Let us now try to work through a few medical-ethical decisions, applying what we have considered thus far. I would like to consider issues both at the very beginning and at the end of life.
First, let’s consider reproductive issues. Imagine a young Christian couple. They desire that God would bless their marriage with children. However, years pass and the wife still has not become pregnant. They have made it a matter of prayer, and they decide to consult their family doctor. After taking a brief history, the family doctor says, ‘Well, I’m going to send you to a fertility specialist.’ They anxiously wait for the day of the appointment. After the appointment has been completed and the testing done, the physician recommends in vitro fertilization. In the couples’ mind it has been such a long process, from one doctor to the next, the puzzle has been slowly put together and now they are faced with a choice. What kind of advice might they get from the doctor? What ethical principles will inform the doctor’s advice?
As we touched on earlier, patient autonomy will be the major ethical principle. Whatever the patient wants will be the right decision.
So how then should the couple proceed? How should they go forward in a God-honouring way? It is important for the couple to first educate themselves on what is involved in the procedure. It is not enough to say, ‘Well, I don’t really understand all the terminology, doctor; just tell me what you recommend.’ How can we bring to bear the four principles that we considered: the sovereignty and providence of God, humans as image bearers of God, the nature of death and nature and the place of suffering? Surely, the sovereignty of God, the place of suffering and humans as image bearers are principles that will be important in coming to a decision.
The Sovereignty of God
When we first consider the sovereignty of God, we must acknowledge that this period of infertility, which we pray will be temporary, is part of His divine plan. If it is His will that it be permanent, we must also pray for grace and strength to bear this great burden. Indeed, this burden is likely to bring a great deal of suffering to a couple. This couple should actively seek support to bear this burden, first in the way of prayer, but also in communion with others in the church (Gal 6:2). Also, in bearing this suffering, the couple should seek to take comfort in the fact that God is able and willing to sustain them in this hardship. A helpful verse is 1 Peter 5:7 — ‘casting all your care upon Him: for He careth for you.’
Image-Bearers of God
Then, when considering what options are open to them, this couple must also keep in mind that they as husband and wife bear God’s image as well as any children that God will give them, and that they were created for communion with God and eternal life. IVF or in vitro fertilization involves the combination of egg and sperm in vitro, or outside of the body. Often a number of eggs are fertilized. Typically, not all of the fertilized eggs — which are in fact tiny human beings — will survive to the embryo stage. Those that do are placed in storage. This essentially means freezing them to arrest their development. This can happen for weeks, years or even indefinitely. When the time is right, these embryos are transferred into a woman’s uterus. Commonly, not all the embryos that have begun to grow are transferred; some are stored for future treatments. Typically, two to three embryos are placed into a woman’s uterus. It is expected that not all would grow to maturity. More than half of the time both embryos will die. If we accept that embryos as they are conceived by in vitro fertilization are human beings — which I think that we must — then I can’t help but say that IVF exposes our children to an extremely hazardous environment.
The technology used in IVF is continuing to advance. It has been reported that doctors now have the ability to fertilize only one egg, and then implant only that embryo. This means that there are no ‘excess embryos.’ This is certainly preferable to the technique of creating multiple embryos knowing that few will survive, in the hope that at least one will. Other Christian writers have questioned whether IVF is right from a variety of perspectives (not just with respect to potential for loss of life).7
In counselling couples dealing with the ethical issues of fertility treatment, we must always proceed in love. This means being empathetic toward those who are suffering from the burden of infertility. So much of our church life revolves around families and children, and I think that this is good, but there is a tendency for those who are unmarried or for childless couples to feel excluded as if they somehow do not fit in to our church life. We must be cautious to guard against this. I say this as someone who has been tremendously blessed with five children. I am acutely aware that anything that I say to someone struggling with the problem of infertility must be said in love. If I do not show empathy, what I say will be rejected as coming from someone who ‘could not possibly understand.’ Brothers, we must be ready to pray with and for each other.
End of Life Issues
I now change our focus from the beginning of life to the end of life. Much is being written recently in the popular press around end of life issues. Arecent Royal Society of Canada report suggests that assisted suicide should be made legal under very carefully controlled circumstances. The Quebec Medical Association has endorsed physician-assisted suicide. The states of Washington, Oregon and Montana have legalized physician-assisted suicide. We as Christians must stand against such changes. These issues should not cause us much of a moral dilemma. The choice seems clear. However, there may be other circumstances where the choice is not so easy.
Many of us will have to face, at some point, a decision regarding end of life care either for ourselves or for another. Many of the illnesses that would have ended in near-immediate death fifty years ago are now no longer immediately lethal. Take for instance an elderly parent who has suffered a severe stroke. The stroke has left him unable to speak, unable to communicate non-verbally, unable to feed himself. While in the hospital, the doctors state that it is unlikely that he will ever be able to recover these functions. In addition, they state that the only way to continue to provide nutrition and water is to surgically place a feeding tube into his stomach. What should be done?
As we have discussed at the beginning, it is important always to consider that God is sovereign and in control. He will cause all things to work toward His glory and for the good of those who love him. Death, though it is an enemy, will come to all mankind. This is especially true for those who are old. The psalmist says that we may live to be eighty years if our strength is great. We must also consider that even though our disabled father is unable to care for himself, unable to move and unable to communicate, he is still an image-bearer of God. This will help to protect us from some of the prevailing sentiments that exist in our society in favour of choosing death. Also, though we certainly do not want to increase or worsen his suffering, we need to accept that suffering is a reality in this sinful world.
We must first of all consider the relationship of our disabled father to the Lord. Did he profess faith in Christ and live out of that profession? If he is a child of God, then Christ has already conquered death for him, and death as it draws closer is not the great enemy, but rather a means through which he can enter eternal life.
Some may say, “if death is our enemy, shouldn’t we always do all we can to prolong life?” This is a difficult question, but I think that we can find scriptural basis for saying that we do not always have to try to prolong life. Prolonging life is not the ultimate good. We can think of examples in Scripture of Samson, who in warfare took actions to hasten his death in order to deliver his people. There is even the example of the apostle Paul, who though he was informed by prophecy that he would be captured in Jerusalem, yet he persisted in going for the greater good of preaching the gospel.
The question may also come up, “If we don’t place a feeding tube, how is this any different from starving him to death?” This too is a difficult question. My answer is that it is the stroke that has begun the process of dying. A feeding tube may slow the rate at which he is dying, but the stroke that has left him incapacitated will then still cause death. On the other hand, it is not necessarily wrong to place a feeding tube. It is not always clear at the outset of the illness how things will proceed. Because of this uncertainty, some may elect to place a feeding tube in order to provide support, while other treatments run their course. In situations like these, I don’t think that we have scriptural warrant to mandate a particular course of action.
Consider finally the situation of a young man who is involved in a severe car accident. He suffers extensive head injuries and is in the intensive care unit. His brain is severely damaged and the doctors state that there is “little hope for a meaningful recovery.” They recommend that he be disconnected from the ventilator that is keeping him alive. What should the family do? Is disconnecting a ventilator the same as killing this young man? Let me try and make some distinctions that I hope will bring some clarity to this situation.
Killing implies action taken to bring about a death that would otherwise not have happened. Letting die implies refraining from taking action or ceasing from performing an action that would prolong life. In other words, ‘letting nature take its course.’ By removing this young man from a ventilator, we are withdrawing a means of support that is keeping him alive. Without this, he may not be able to breathe on his own and so may die. But it is not the lack of the ventilator that caused his death; rather it was the accident which led to the brain damage that caused his death.
One caveat that I would place here is that there are reversible situations where patients are placed temporarily on life support where there is a very reasonable expectation that there will be a time when they will no longer require this support. Most surgical operations performed under general anesthesia fall into this category. If we were to withdraw life support for people in these situations we would be killing them.
If there are circumstances when it would be okay to withdraw life support, and let the course of an illness follow to its expected outcome, how do we know when this is the right thing to do? The language that people use often tells us much about their pre-formed worldviews. Think back to the term that the doctors used: ‘little hope of meaningful recovery.’ What do they mean? Often it may mean that it is unlikely that this young man will be able to speak or walk again. Many physicians and patients would say, “Well, if that’s how my life is going to be, I don’t want it to go on.”
But given the consideration that man was created in the image of God, and that we are to expect suffering in this world, should we still be so quick to say that a life, though but a shadow of the former life of health, is not worth living? I don’t think so. In this situation, it is very important for the family of this young man to ask the doctors what they mean by ‘little hope of recovery.’ Will he be able to breathe on his own, will he be able to eat, and will he be able to communicate? Also, it is important to ask the doctors how certain they are of the prognosis? Are there any further tests that can be done to help determine the prognosis?
Wisdom Love and Hope
We should bring the virtues of wisdom, love and hope to mind when considering this decision. First, we must consider the spiritual state of this young man, realizing that only God can know the heart. We must also remember that a sovereign God can still renew the heart of a person who cannot communicate with him. Consider the unborn children in the womb. We testify that even there, God can renew a heart. Think of the child of David and Bathsheba, conceived during their adulterous affair. God comforts David by letting Him know that this child has died, washed in the blood of the Lamb, and that one day David will go to him.
When considering the virtue of hope, we must prayerfully wait on the Lord to give healing. Should we wait on a miracle? Though we confess that with the Lord all things are possible, history shows that miracles are not His regular course of working out His plan. Although we can pray for a miracle, we must also learn to be content if God does not provide one. I do not think that it is right to continue life-sustaining treatment when there is no likelihood of recovery, because we are hoping for a miracle. This is hope without contentment or faith.
So far, I have not provided you with answers, and we still must make decisions. Often, in such events, over the course of several weeks, the path that the illness will likely take becomes clear. If after several weeks there is no change in his condition, I think that it would be reasonable to consider withdrawing life support. Sometimes, such patients are able to breathe on their own and they will live some time without life support. The end will often come weeks or months later from a lung infection, as they are unable to maintain proper lung defenses. Other times, the patient will not breathe at all when life support ends, and death will come quickly.
With these few examples I come to a close. I realize that there are many more ethical dilemmas that we could discuss. There were probably some that you hoped that I would touch on that I haven’t.
For a closing review, I want to briefly recap what we have discussed. At the beginning we briefly outlined some secular medical ethical principles and what physicians and healthcare providers are being taught today in secular institutions. We have seen how the most prominent ethical consideration in this system is patient autonomy. We then considered that if we are to approach medical ethics rightly, we must ask what God requires of us. What is His revealed will? We then considered four doctrines found in the Bible that often have relevance to ethical issues. Next, we considered six Christian virtues that we should seek to live out in everyday practice. Finally, we considered a few examples of common ethical dilemmas and attempted to show how to apply what we had learned.
I close with a few words of advice and caution. First of all, matters of medical ethics are difficult. They present us with hard questions. They require prayerful struggling and studying. Don’t shy away from this. Seek to educate yourself from the Word and from good Christian writers.
Dealing with ethical issues also requires self-examination. The person grappling with the issue as well as the one who is providing counsel must examine himself. So often dilemmas and difficulties arise when we do not appreciate the depth of our own depravity. We would do well to ponder our motives and desires when dealing with an ethical dilemma. It may be that the Spirit will uncover to us that the strong desire that we had to make a certain decision was motivated by sins such as greed or pride. We may find that it is not the ethical dilemma that is the real problem but our own sinful heart.
Another caution is that matters of medical ethics may not have a clear right or wrong answer. I have learned in reading through materials for this speech as well as grappling with some of the issues that as an Ethical and Public Affairs Committee we may not be able to come up with a clear yes or no answer in every situation. Therefore, we must be careful not to go beyond what Scripture teaches. We must, especially as office bearers, be careful not to bind the consciences of others in matters of Christian liberty. Even eminent, godly Christian thinkers have had differences of opinion on certain ethical issues. One day, all will be revealed, but until then we must humbly walk in the light that we have been given. We need to encourage others and take care that we ourselves seek to take the path that is as close to what we can find guidance for in Scripture. We must consider the whole of Scripture and live a life that is based on the Word of God.