An introduction to bioethics decision making within the context of the theological principles, wisdom, and virtue underlying the broader Christian life. For thoughtful laypeople, pastors, elders, and seminarians.
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About the Author
David VanDrunen (PhD, Loyola University Chicago) is the Robert B. Strimple Professor of Systematic Theology and Christian Ethics at Westminster Seminary California in Escondido, California.
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CHRISTIANITY AND HEALTH CARE IN A FALLEN WORLD
This book focuses primarily on personal bioethical decisions that Christians must make for themselves or for loved ones. As such it does not focus on bioethics in the public square, that is, upon the economic, legal, and political dimensions of bioethics. The fact that the book has this particular focus, however, does not imply that the public dimensions of bioethics are unimportant or that Christians should be uninvolved with them. If I am to set forth a Christian view of bioethics, then I must provide at least a general perspective on the relationship between the believer's Christian commitment and his life in the broader — and largely unbelieving — world of health care. This is because thoughtful Christians who seek to be faithful in their private bioethical decisions will necessarily confront important issues that involve the public dimension of bioethics. Should Christians participate in the mainstream health-care system or should they establish their own Christian hospitals, medical schools, and insurance companies? Are Christians' biblically shaped convictions on matters such as abortion or euthanasia unique to Christianity, or are they also binding upon non-Christians? Are believers able to have morally meaningful discussions with unbelievers and, if so, how should these discussions take place?
In this chapter I argue that, though readers should strive to attain a perspective on bioethics and to make private health-care decisions in ways that are consistent with their distinctive Christian life (the focus of this book), they should do so while continuing to participate in the mainstream health-care system and making appropriate contributions to public policy debates about bioethics.
Christian Bioethics and Secular Bioethics: Contemporary Approaches
To describe important contemporary perspectives on the relationship of Christianity to the public dimensions of bioethics, I use the terms Christian bioethics and secular bioethics. By "secular" bioethics I do not mean "evil" or "godless" bioethics, but simply the discussions and debates about bioethics that take place in the broader world where there is no universally shared religious faith. Where do Christians stand in relation to the broader world of health care, and how should they participate in the bioethical debates that take place within this world? Bioethicists from a variety of theological and philosophical persuasions have attempted to answer such questions, with a remarkable divergence of opinion.
Five general approaches to the relationship of Christian bioethics and secular bioethics can be found among contemporary writers: (1) secular bioethics only, (2) Christian bioethics only, (3) secular and Christian bioethics identical, (4) secular and Christian bioethics radically different, and (5) secular and Christian bioethics distinct but legitimate.
Secular Bioethics Only
Writers who represent the first category, secular bioethics only, make morally serious arguments about bioethical issues for society as a whole and do so through philosophical or pragmatic argumentation. Though some of these bioethicists are religious people, their writings are non-theological, and they seek to address all people in a way that appeals to their moral sensibilities no matter what their religious convictions. The influential framework for bioethics espoused by Tom Beauchamp and James Childress, often called principlism, falls into this category. Beau-champ and Childress argue for the existence of a "common morality" that is shared by all morally serious people in all cultures. This common morality is not a theory of ethics but a set of principles and norms of conduct. Beauchamp and Childress acknowledge that there are also moralities specific to particular communities and that some people in all cultures refuse to live by aspects of the common morality, but they believe that the common morality provides a means for cross-cultural critique of immoral practices in particular communities. Beauchamp and Childress derive four fundamental principles from the common morality that ought to guide the professional ethics of health-care providers: respect for autonomy, nonmalificence, beneficence, and justice. Through application of these principles in concrete circumstances, Beauchamp and Childress aim to provide an ethical standard for medical practice in a health-care system that encompasses people from a range of communities and creeds.
Another example of a secular bioethics only approach is that of Robert Veatch. Veatch argues against a medical ethics derived solely from within the medical profession and advocates instead a medical ethics that emerges out of a social contract or covenant among all the members of society — medical professionals and nonprofessionals, those with social power and those without it. Though Veatch determines the content of bioethics in a way different from Beauchamp and Childress, the two approaches agree in seeking to develop a universally applicable bioethics governing a medical system comprised of people from all communities and faiths.
Christian Bioethics Only
A starkly different alternative to the secular bioethics only perspective is the Christian bioethics only approach. Adherents to this approach set forth a bioethics derived solely from their theological convictions and wish their distinctively Christian approach to bioethics to control all health-care practice. John Frame's Medical Ethics provides an example. Appealing to the doctrine of sola Scriptura, Frame sets out to answer various bioethical questions through application of biblical teaching. He notes the deficiencies of secular bioethics, but never discusses whether secular bioethics is a legitimate enterprise in any respect, nor does he acknowledge the legitimacy or usefulness of any nonbiblical source of moral knowledge (such as a concept of natural law known through God's general revelation). For Frame, society-wide bioethical questions are simply to be solved by applying biblical principles. Should the child of a Jehovah's Witness be given a blood transfusion against the wishes of her parents? Frame states that the Bible considers people "competent" who obey God's will, and therefore since Jehovah's Witnesses have a false view of God, they are not competent to make such decisions for their children. Civil courts should order the transfusion against their objections. What if a physician becomes concerned about the question of confidentiality? Frame says that he should require his patients to agree to "biblical principles of confidentiality."
Other examples of a Christian bioethics only approach may be found in various visions of the Christian transformation of modern health care. Marsha Fowler's contribution to a volume of essays on Christian engagement in society's bioethical debates is illustrative. Appealing to the convictions of her own denomination (Presbyterian Church [USA]) and to her interpretation of the broader Reformed tradition, Fowler argues that the church is to be actively involved in transforming the health-care practices of the world. The church should have a prophetic voice in society and engage in political action and critique. Through an "incarnational ministry" that "embraces the whole of life," the church must seek to usher in the biblical vision of shalom. As an example she points to her own congregation's "health ministry," which offers aerobics classes, walking groups, and free blood pressure screening for church members and the community.
Secular and Christian Bioethics Identical
A third general approach is what I call the secular and Christian bioethics identical perspective. This approach differs from the secular bioethics only approach because it seeks to bring religious and theological considerations to bear upon bioethical discussions. It also differs from the Christian bioethics only approach in that it refuses to see theological reasoning as the only way to resolve bioethical questions and does not attempt to impose a distinctively Christian vision upon the broader society. This secular and Christian bioethics identical approach is probably best exemplified by a number of prominent Roman Catholic bioethicists. These writers refer to a concept of natural law in order to identify sets of goods, values, and experiences that are common to all people, promote general human flourishing, and provide a foundation for a universal and cross-cultural morality. Bioethics, then, ought to develop in conformity with this universal morality.
For such writers, Christianity and theological truth contribute little or nothing substantive to bioethics, but serve to reinforce and enrich natural law bioethics in various ways. For the late Richard McCormick, "the Christian tradition only illumines human values, supports them, provides a context for their reading at given points in history. It aids us in staying human by underlining the truly human against all cultural attempts to distort the human." For Lisa Sowle Cahill, theology can contribute to bioethics by raising awareness of the importance of justice and social solidarity and "explicitly religious narratives and symbols can also have a public role in widening the moral imaginations of people from diverse traditions and faiths." James Walter and Thomas Shannon argue that religion, and specifically their Roman Catholic tradition, illumines or "adds value to" certain aspects of issues that are often overlooked, such as inclusive concern for all people through ideas of the common good, justice, and human dignity. For all of these Roman Catholic ethicists, theology serves primarily to clarify, reinforce, and inspire adherence to truth about bioethics that is generally known and applicable to all people apart from Christian conviction.
Secular and Christian Bioethics Radically Different
Almost diametrically opposite this last perspective is the secular and Christian bioethics radically different approach. The most well-known advocate of such an approach is H. Tristram Engelhardt, a physician and philosopher who converted in mid-career to Eastern Orthodox Christianity. Engelhardt takes a very pessimistic view of the possibility of genuine moral discourse in a pluralistic secular society. In the post-Enlightenment world, Engelhardt argues, there are no commonly held metaphysical or theological convictions that could serve as a basis for substantive moral conversation and agreement. Some common, secular bioethics is possible, but it is procedural only, not substantive. In other words, secular bioethics is simply a set of procedures and rules that people agree to live by. This is what Engelhardt calls the "principle of permission" that binds people who are moral strangers to one another.
Yet Engelhardt also describes a Christian bioethics that is as substantively rich as secular bioethics is substantively poor. Engelhardt believes that traditional Christianity (particularly in its Eastern Orthodox expression), through its theological teaching about life, grace, and union with God, provides the basis for a profound bioethics that binds communities who adhere to these teachings. Hence Christian bioethics must be radically distinct from the secular bioethics that rests only upon the bare will of individuals consenting to live with one another in a certain way. Not surprisingly, Engelhardt encourages Christians to develop their own medical-care system in order to put into practice their distinctive moral convictions.
Secular Bioethics and Christian Bioethics Distinct but Legitimate
I label the final approach to these issues secular bioethics and Christianbioethics distinct but legitimate. Unlike the first two approaches, this approach seeks to account for both a Christian, theological inquiry into bioethics and a common, secular inquiry in which people from various religious convictions can participate. Unlike the secular and Christian bioethics identical approach, this approach does not simply equate secular and Christian bioethics, but recognizes that Christian bioethics rests on theological truths unknown to the broader world and hence cannot be substantively identical to secular bioethics. Finally, this approach differs from the secular and Christian bioethics radically different approach in believing that secular bioethics is not simply procedural but can involve genuine and meaningful moral discussion.
We find examples of the distinct but legitimate approach in both Roman Catholic and Protestant sources. Among Roman Catholics, for instance, Edmund Pellegrino and David Thomasma have written two books whose very titles hint at their approach: The Virtues in Medical Practice (1993) and The Christian Virtues in Medical Practice (1996). In the first volume, they use a philosophical conception of virtue in order to set forth an "internal morality of medicine" (i.e., a medical ethics derived from the goals that the practice of medicine seeks to attain, not a medical ethics derived from the principles of a general theory of ethics). In the second volume Pellegrino and Thomasma argue that these philosophical virtues, when combined with (Roman Catholic) Christian commitment, are transformed to a level of grace. Christian commitment brings "charity" into the picture. Charity gives new insight into the virtues and "perfects" philosophical morality through transcending the possibilities of nature. A Christian ethic of medicine, therefore, imposes obligations that are purely optional or supererogatory from a naturalistic perspective.
Among evangelical Protestants, John Jefferson Davis, Scott Rae, and Paul Cox offer examples of this distinct but legitimate approach but in a different vein from the Roman Catholic perspective of Pellegrino and Thomasma. These three evangelical writers believe that Christians must operate within the broader health-care system and participate in its bioethics debates, and they encourage Christians to utilize arguments from general revelation (or natural law) rather than exclusively from Scripture in order to be as persuasive as possible when dealing with unbelievers. Nevertheless, they also recognize that Christians' knowledge and experience of redemption in Christ, as revealed in Scripture, provides crucial perspective on bioethics that shapes a Christian approach to bioethics in significant ways. From a different angle, but also representing a distinct but legitimate approach, is the recent work of Joel Shuman and Brian Volck. These authors argue that modern medicine is among the "powers" ordained by God, but that it is also prone to abuse its power in god-like fashion. Therefore Shuman and Volck believe that Christians should continue to access the mainstream health-care system — with appropriate caution and detachment from its false promises. But Christians should also learn to care for one another holistically in the church through giving counsel to one another in their medical decisions, helping the poor to gain access to health care, and practicing hospitality.
Christianity, Secular Bioethics, and Mainstream Medicine: A Proposal
These few simple categories illustrate the variety of approaches to the question of Christian involvement in the health-care system and of Christian theological contribution to the bioethics enterprise. I believe that the most theologically sound and balanced approach is a version of the last: secular bioethics and Christian bioethics are distinct but legitimate. Christians should participate in the mainstream healthcare system and contribute to its bioethical debates, while recognizing that their Christian faith has radically transformed their perspective on many important issues of life and death.
According to this approach, God has ordained a common cultural task for all human beings to pursue together, and the practice of medicine and the protection of life fall within this task. Christians may therefore participate freely in the secular health-care system with people of many different religious beliefs. The common cultural task, as God-ordained, is not morally neutral (even though it is not uniquely Christian), and thus Christians can pursue meaningful moral conversations with non-Christians in regard to bioethics in modern medicine. Within the context of this general, secular bioethics that concerns all people in their common life, Christians must also shape their individual and communal views of bioethics in accord with their distinctive theological convictions. The range of Christian truth about matters such as the image of God, suffering, death, and resurrection cannot help but mold their perspective on bioethics. Scripture's teaching should aid Christians in understanding the kind of bioethics that should govern all people in the public realm. But the knowledge and experience of God's grace in Christ should also instill a range of virtues and a perspective on life and death that will transform Christians' attitude toward bioethical issues and transform the way that they make decisions about a host of matters for which there are no universally binding moral rules.(Continues…)
Excerpted from "Bioethics and the Christian Life"
Copyright © 2009 David VanDrunen.
Excerpted by permission of Good News Publishers.
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Table of Contents
Introduction: The Christian Confronts Bioethics,
Part 1: Foundations of Bioethics,
1. Christianity and Health Care in a Fallen World,
2. Theological Doctrines,
3. Christian Virtues,
Part 2: The Beginning of Life,
4. Marriage, Procreation, and Contraception,
5. Assisted Reproduction,
6. The Human Embryo,
Part 3: The End of Life,
7. Approaching Death: Dying as a Way of Life,
8. Suicide, Euthanasia, and the Distinction between Killing and Letting Die,
9. Accepting and Forgoing Treatment,
Conclusion (with a Bibliographic Essay),