Archive for February, 2013

Reflections on Medical Ethics

The following is an assignment from my Medicine and Ethics class at Loma Linda University.

My Medical Ethic

Ethical questions are often difficult to resolve, and the ethical issues involved in medicine present some of the toughest ethical situations to address. There are many different opinions about what is the correct ethical decision in any given medical situation, but these differences of opinion reflect deeper differences: differences of worldview. A person’s worldview consists of his presuppositions about the nature of reality (metaphysics), how we know reality (epistemology), and how we ought to relate to reality (ethics). When two people start with different presuppositions about reality, different worldviews, it is not surprising when they come to different ethical conclusions.

As a Christian, my worldview and presuppositions come from the Bible. There can only be one ultimate source and standard of truth in general, and ethical truth in particular, by which all claims and actions must be evaluated. If we start making ethical judgments based upon what “seems right” or “makes good sense” to us instead of based upon what God has revealed in his word, we have placed our own human reason as a higher authority than God’s word. Human reason is fallen and utterly insufficient to the task of ultimate ethical authority and reasoning.[1]

However, that is not to say that human reason and situational considerations are irrelevant in ethical decision making. The Lord who reveals himself in his word is equally the Lord of the world and our minds. As Christians are transformed more and more by the renewal of our minds to conform to the image of Christ, we are more able to discern the will of God in our ethical decisions.[2] In the end, what is revealed in the Bible will cohere perfectly with properly functioning human reason and with what we find in the world.

On the whole, then, I am advocating a divine command theory of ethics, with the clarification that what is commanded cannot arbitrarily change, since God’s law is an expression and outworking of his own perfect, eternal, and unchangeable character. Ethical behavior is perfect conformity to the law of God. The crux of God’s law is the love of God and neighbor,[3] but we must look to the Bible to determine what that love looks like; we cannot use our own abstract definition of love, or else we would be once again subjugating God’s word to our own reason. We look to God’s law to find out how to love God and our neighbors.[4]

There are several broad principles which can be derived from Scripture concerning medical ethics in particular. The most overarching ethical principle governing medical ethics is the sixth commandment, “You shall not murder.”[5] In addition to the proscription of the taking of innocent human life, this commandment encompasses several other more specific ideas. The rationale given earlier in Scripture for this commandment is that men are made in the image of God, and, therefore, every human life is sacred and has intrinsic value.[6] Here we have the concept of the sanctity of life, from which can be derived the well-known concept of non-maleficence. The robust application of the sixth commandment, though, goes beyond proscription of harm to the prescription of preserving life and minimizing suffering, an idea corresponding to the concept of beneficence. We can see this clearly illustrated in the parable of the Good Samaritan.[7]

One final principle which is worth addressing in the context of medical ethics is that of the patient’s autonomy. While we can protect some of the main concerns of the principle of autonomy by acknowledging that no physician save Jesus has the right to impose a treatment by force, it seems to me that we must reject the language of autonomy itself. Humans are God’s creatures, and, as such, we are subject to his authority and responsible to him.[8] Competent persons should have the right to make their own medical decisions, insofar as their decisions are in conformity with the law of God, an authority which is higher than the person’s own desires. In the case of incompetent persons, it seems to me that family and church authorities should have a significant say in a patient’s medical decisions.

For an example of how these ethical principles might be applied, let us examine the case of Matthew Donnelly. The most ethically salient facts of his case are as follows: (1) he was terminally ill with no hope of recovery, (2) he was in constant and intense pain, (3) under the current treatment plan, he was expected to remain in this condition for about a year before he would die, (4) he desired to die, and he expressed this desire to his brother Harold, (5) Harold retrieved a gun and consumed alcohol with the intention of becoming inebriated, and presumably with the intention of killing his brother, and (6) Harold shot Matthew, killing him violently. An additional fact, although it is more of an inference, is that (7) there was a lack of discussion and consideration of other options for Matthew’s care, both with family and with doctors.

In this case, the relevant ethical principles are (A) the intrinsic value of Matthew’s life (the sanctity of life), (B) the scriptural proscription of taking or harming life (non-maleficence), (C) the scriptural prescription of doing good for others (beneficence), and (D) the extent to which Matthew’s desires expressed a competent fulfillment of responsibility to God.

On the one hand, one could argue that Harold was justified in taking Matthew’s life, for the following reasons. First, that was Matthew’s autonomous desire. Second, ending Matthew’s life ended his physical suffering, which could be an expression of minimizing harm as well as doing good for Matthew. One could argue that a sophisticated view of beneficence includes more than simply prolonging life at all costs; the whole person must be taken into account. However, I reject these arguments. In the first place, one does not have the right to desire one’s own death in order to have relief from suffering, since this is contrary to God’s law.[9] A patient’s right to make his own medical decisions only applies to decisions which are in conformity with the law of God. In the second place, while I agree that beneficence includes more than simply prolonging life at all costs, I believe it also includes more than ending pain at all costs; it seems to me that there is even a positive role that unavoidable suffering can play in the life of a Christian.[10] It seems that a better solution to Matthew’s situation would be to increase his pain management to be more aggressive and to discontinue other treatments such as radical and invasive surgeries, thereby letting Matthew die as comfortably as possible without actively killing him.


[1] Romans 1:18ff., especially v. 21.

[2] Romans 12:2, 8:29.

[3] Matthew 22:34-40.

[4] In keeping with Reformed tradition, I hold that the moral law is summarily comprehended in the Ten Commandments, so that is a good place to begin looking for ethical principles. However, all of Scripture is normative, and we must carefully navigate the whole counsel of God in making our ethical decisions.

[5] Exodus 20:13 (ESV).

[6] Genesis 9:6.

[7] Luke 10:25-37.

[8] See 1 Corinthians 6:19ff., for example.

[9] “Scripture always presents mercy killing negatively. Consider the following. (a) People in the Bible who either killed themselves or who sought to have themselves killed to avoid suffering are always seen as disobedient (Judges 9:54-57; 1 Sam. 31:3-6; 2 Sam. 1:9-16; 17:23; 1 Kings 16:15-19; Matt. 27:5; Acts 1:18). (b) The command against murder includes murder of the self; suicide contradicts the legitimate self-love that Scripture assumes and commands (Matt. 22:39; Eph. 5:28). (c) Suffering does not render a life meaningless or valueless (Rom. 8:18; 2 Cor. 4:11-18 and chapters 11 and 12). (d) Our lives are not our own; they are not at our own disposal (1 Cor. 6:19f.; 7:4).” (John M. Frame, Medical Ethics: Principles, Persons, and Problems, Presbyterian and Reformed Publishing Company, Phillipsburg, NJ, 1988, p. 69.)

[10] See Romans 5:3, 2 Timothy 2:3, and 1 Peter 2-4, for a few examples off the top of my head. Christians are expected to suffer; while we should mitigate suffering if we can, suffering is not the ultimate evil and does not justify the taking of life.

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Double Chiasm in Galatians 2? Perhaps…

Rick and I were discussing the structure of Galatians 2 in light of a blog post by Peter Leithart here. I adopted the slightly re-worked translation of v.16 from that post along with some slight changes which I think are merited in each case. For example, the ESV’s triple redundancy of “believing in Christ” in parts E, F and E’ is too much for me to swallow. I also prefer to use “Torah” instead of “law”, because it focuses the reader into what I think Paul is talking about, namely, the Mosaic administration of the Covenant of Grace. Also, where Paul uses the Greek word for “flesh” I think it should always be translated “flesh” because of the rich contextual meaning which is stuffed into that word in Paul’s writings as a whole and in this letter in particular.

I have laid out what I believe to be a particularly neat chiastic structure in verses 14b-18, and possibly 18-21 below.

A: If you, though a Jew, live like a Gentile and not like a Jew,

B: how can you force Gentiles to live like Jews?

C: We ourselves are Jews by nature and not “Gentile sinners”

D: yet we know that the “man of the works of Torah” is not justified

E: except through the faithfulness of Jesus Christ,

F: so we also have believed in Christ Jesus,

E’: in order to be justified by the faithfulness of Christ

D’: and not by works of Torah, because by works of Torah no flesh will be justified.

C’: But if, in our endeavor to be justified in Christ, we too were found to be “sinners”, is Christ then a servant of sin? Certainly not!

B’: For if I rebuild what I tore down,

A’: I prove myself to be a transgressor.

Explanation:

A/A’: Peter proves himself to be a “transgressor” (A’) in his initial “[tearing] down” of the Torah regulations when he “though a Jew, lived like a Gentile” (A)

B/B’: Then Peter, out of fear, “rebuilt” (B’) Torah regulations relating to his table fellowship with Gentile Christians, when he forced them to “live like Jews” (B).

C/C’: The key word here is “sinners”. In a Christ-ministered justification, both “Jews by nature” and “Gentile sinners” (C) are shown to be “sinners” (C’) in need of the grace of God. In Galatians language, is Christ a “minister of sin”? By no means! (See Romans for a detailed analysis of this particular question, though with slightly different context and wording!)

D/D’: A “man of the works of the Torah” (D) would mean, especially in context, a circumcised-in-the-flesh man, i.e. a Jew,  will not be justified by virtue of that status. Because, no “flesh” will be justified by “works of the Torah”. Fleshly circumcision is of no value in the courtroom of God, being a “man of the works of the Torah” is not how God intends to justify His people.

E/E’: Justification through/by the faithfulness of Christ.

F: The real crux of the whole section is that justification is by believing in Jesus!

 

At the functional end of the first chiasm, a new one sprouts!

 

 

A: a) For if I rebuilt what I tore down, I prove myself to be a transgressor. b) For through the Torah I died to the Torah that I might live to God.

B:  I have been crucified with Christ.

C: a) It is no longer I who live, b) but Christ who lives in me.

C’: a) And the life I now live in the flesh b) I live by the faithfulness of the Son of God,

B’: who loved me and gave himself for me.

A’: a) I do not nullify the grace of God, b) for if justification were through the Torah, then Christ died for no purpose.

A/A’: If you rebuild what you tore down, you nullify the grace of God! (A/A’ a)). The key word in b) is “through”. Through the Torah there is no justification, but there is death. We die to the Torah, and the purpose is so that we can live to God (A b)) If justification was through the Torah, then Christ’s death was “for no purpose” (A’ b)), instead of having the purpose of “[living] to God”. If

B/B’: To be “crucified with Christ” is the “reason” that the atonement is effective for believers. Only by being “in Christ” can we “impute ourselves dead to sin” because we are united with Him in His death on the cross. In other words, the expression of His faithfulness, of his great love is His giving of Himself for me in crucifixion, was so that I can be crucified with Him, and reckon myself dead to the Torah of sin and death and alive in the Spirit of life and righteousness.

C/C’: The life that Paul lives “in the flesh”, i.e. as a Jew, (C’ a) is not his own life (no boasting in the flesh), because that fleshly identity was already crucified with Christ (C a)). His life is rather Christ’s life, i.e. resurrection/new creation life (C b)), which is only possible, or is summarily comprehended as, the “faithfulness of the Son of God” (C’ b)) even unto the death of the cross, that God would exalt Him in resurrection and ascension.

 

If you have any nitpicks or serious issues with this structural breakdown, let me know. I would love the input. I am a little shaky in how Paul structures the second section (or if it is legitimate to have the first section bounded how I have it here!).

Your comments and corrections are appreciated.