Clinical Bioethics: Ethical Considerations in Pastoral Care of the Sick
When determining the best practices in the ethics of medical care, how can we as Christian healthcare professionals approach helping patients make difficult decisions?
We usually hear about bioethics when a new and potentially problematic research project comes to light or when a breakthrough in medical treatment makes the news. When scientific endeavors break new ground, like in the case of gene editing, there is often new moral ground that needs to be cultivated as well.
The topic of bioethics also has a more mundane life that isn’t usually newsworthy. It involves the difficult and important conversations and decisions that take place at a patient’s bedside—in a hospital or elder care facility—between patients, family and friends, and members of the healthcare team, including those providing pastoral care. Ministers, deacons, and church members might also be a part of these conversations. While these situations aren’t always newsworthy, it’s likely that you will one day find yourself in such a place.
“Both God and science are involved in health and healing.”
When medical care poses these hard questions, you might look to medicine alone for answers. But medical ethics is a discernment process that takes place at the juncture of the practice of medicine, and biblically and theologically-informed Christian beliefs. And when doing medical ethics in a clinical context, careful thought about moral principles, obligations, and goals is actually a form of patient care, alongside the more familiar physical, social, emotional, and spiritual care.
There are several potential tensions when we try to be sensitive and responsive to Christian commitments in the context of medical care. In Medicine as Ministry, Margaret Mohrmann suggests a question that helps to keep things in proper focus: What difference does it make to be a Christian in the context of healthcare? Consider the following three areas of tension and a few orienting convictions that can help negotiate the tensions.
Areas of Tension
The Goal of Medical Care
There is a comfortable and natural connection between Christianity and the practice of medicine. God created our bodies in ways that can heal—both physically and emotionally. The more we come to understand these healing capacities, the more we are amazed at the wonder of creation. God also created us with inquisitive and creative minds that can discover means to positively aid in human healing. Medical science, in the hands of skilled practitioners, can accomplish things earlier generations could not even imagine. In this sense, both God and science are involved in health and healing.
To what end do we employ this awesome God-given capacity to heal? A common sense reply would be that we use the resources that healthcare offers to fix things that go wrong. This, of course, assumes that we have a standard to know when something is wrong (unhealthy) or right (healthy). There is a general consensus about what counts as disease and debilitating conditions . The standard is sometimes misused to denigrate people who don’t “measure up.” But we use the standards well when we strive to live in ways that promote health, when we conduct research to discover cures, and by what we teach health professionals to treat.
But in the real world of medical care, gray areas quickly arise. There is considerable variety in the way we learn to think about what it means to be healthy and when we think something needs to be fixed. For example, we can use healthcare resources to pursue ideal body images, undoing and re-making what nature gives us, in order to meet cultural norms. Or we can use medical means to extend a person’s life well beyond their capacity to be aware of and interact with their environment and those they love. We can use medical resources to maximize our physical health as an antidote to unmet needs in the social, emotional, and spiritual components of our lives. It can be very difficult to draw the line between what’s appropriate and what isn’t. There’s considerable subjectivity in our images of what it means to be in good health.
An orienting conviction does not do the hard work of drawing moral lines for us. Instead, it points us in a direction. It provides insights and a moral framework, and in this way serves as a foundation for the hard choices that often accompany the details of a particular person’s story. Drawing again on the language of Margaret Mohrmann, from a Christian perspective, the goal of medicine is health, and health is the means to living a joyful life of service. This conviction can provide a helpful starting point for many of the other substantive moral questions that arise in the context of healthcare.
Autonomy is among the foremost moral values in American society as well as in medicine. As commonly used, autonomy is understood as our human right to self-determination: “I make my own rules.” In earlier generations, beneficence (to do good) was a primary moral principle. It was reflected in a physician’s duty to do good, and not harm, and was sometimes expressed in the familiar words “doctor knows best.” Today, it’s still a physician’s duty to do good, but it’s the patient who gets to decide what is good.
The pluralistic nature of American culture can account in part for the shift to autonomy as the dominant value. When there is no longer a social consensus about what is good, and we can no longer count on members of a professional community to share our personal or Christian vision of the good, we ask the medical community not to impose any notion of the good on us (the patients). Instead, we should be allowed to define the good we seek.
Autonomy is sometimes criticized as an alternative to Christian ways of understanding ourselves. Critics charge that in claiming autonomy we pretend to be the final authority in moral matters, when in fact God is the final source of moral authority. Claiming autonomy too strongly can become a way of idolizing our own moral wisdom. When it is expressed as the idea that “I alone matter,” autonomy also forgets that life is a gift from God and that all of God’s creatures matter.
My suggestion is not that Christians give up a claim to autonomy in the context of modern medicine, but that we claim a Christian understanding of autonomy. Sondra Wheeler (Stewards of Life) provides a helpful explanation of how autonomy also reflects Christian theological affirmations. Why would Christians respect the right and responsibility of people to make and act upon decisions regarding their own life? Wheeler says that for Christians, “the obligation to respect all persons is based on the obligation to recognize and honor the image of God” in each person. Since we reflect God’s image in our “capacity for reflective and responsible choice” it is important that patients are free to make choices that reflect this God-given capacity.
Respect for personal autonomy is a way to respect God’s image in everyone who faces the difficulty of making hard medical choices. This second orienting conviction does not tell us what specific treatments to pursue. But it does undergird the decision making process, cradling it in human dignity that physician-ethicist David Schiedermayer says “is reflected in respectful treatment; patients are worthy of esteem and honor.”
The question “How is God at work in the world?” poses a third important challenge to medical decision-making. If our answer expresses a high view of God’s care and control over the events of our lives (divine agency is primary) we are sometimes left wondering whether some of things we might do in the name of health care (exercising human agency) are actually instances of “playing God.”
It will be helpful to clarify what “playing God” might mean. Three meanings seem most common when someone wonders whether a particular medical decision is a case of playing God.
The first response might be that medical treatment is usurping an action that rightfully only belongs to God. For example, gene editing using CRISPR technology is currently being used as a treatment for several diseases like cancer and sickle cell anemia. But if God’s way of acting in the world includes determining our genetic make-up, should humans modify this, even if the goal is healing?
We feel the conflict more sharply when someone levels the accusation that we are “playing God.” When voiced as an accusation the words sometimes function like a warning sign: DANGER! You better think very carefully about doing this before moving forward. Consider the difficult decision family members must sometimes make about whether to continue mechanical ventilation when it is only prolonging the process of dying. Can people make decisions that will allow a loved one to die, or is the moment of death something God alone decides?
Or in the third case, the words “playing God” can take on a very different meaning when we ponder the promising options presented when our lives are threatened by death. Some of the things we can accomplish with the tools of modern medicine make it seem like we are playing God when we are employing such powerful and wondrous medical technology, for example, a heart transplant. Or consider gene editing again and some of the recent advances in treating diseases like sickle cell anemia. In this context, to say that we are “playing God” is to acknowledge that we are employing awesome powers. In this sense, “playing God” is actually an invitation and a calling.
A pair of orienting convictions can help us navigate this tension:
- God created our bodies in ways that can heal both physically and emotionally. The more we understand about these healing capacities, the more we are amazed at this wonder of creation.
- God created us with creative, inquisitive minds that can discover means to positively aid in human healing. Medical science, in the hands of skilled practitioners, can accomplish things we once never thought possible.
Combining these convictions pairs God’s actions with human actions, but in a way that allows them to provide a unifying perspective. The affirmations remind us that God is God, and not us, and that our lives are a creative gift of God. They also remind us that when we employ the gifts God has given us, we honor and nurture Gods’ gifts—and when we do this as healers, we imitate God by following the way of one who healed the sick.1
We might wish that orienting convictions would tell us precisely what to do when we face onerous medical decisions. Instead of providing easy answers they form us into people who see the world through a lens of faith. When we affirm faith in God in the context of medicine, these orienting convictions help us make moral decisions in the context of medicine, and they help us do that in a way that answers Margaret Mohrmann’s question: What difference does it make to be a Christian in the context of healthcare?
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Emily Smith | Science & Neighborliness