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HARD DECISIONS IN HEALTHCARE: BIOETHICS FOR PASTORS

Last December, my mother died. She was a severe diabetic and, as is typical with the disease in its later stages, she suffered from neuropathy. Neuropathy is the loss of sensation; with diabetes this deprivation of pain moves from the fingers and toes into the appendages (from the out in, so to speak). The process, as noted by famous Christian surgeon and missionary P. Brand, is not unlike that of Hansen’s Disease (what used to be called leprosy) and the final results can be the same. The loss of sensation means no “warning system,” and no warning means that stepping on a pin or being bitten by an insect can result in a dangerous infection or, with associated diminished blood flow, gangrene. For my mother, it was gangrene. She went into the hospital just before Christmas for arterial bypass surgery. The hope was that improved blood flow might allow her body to fight off the seemingly continuous infections in her leg. As the saying goes, the surgery was a success, but the patient died. My mother never really came out from under the anesthesia. Rather, she drifted in twilight for a few days and, then, died. She had been born on a Christmas day and died decades later as a Christmas day came to a close.

My mother had a choice. She had already lost some toes in therapeutic amputations and did not want to lose a leg. She made a “calculation” (consciously or not) that the risk of surgery was “worth” the risk of death. She talked it over with my father. He agreed with her. Most Americans are, at some point, asked to make similar calculations. It may be about surgery or long-term care for a sibling or genetic tests prior to pregnancy, but most will make “life-changing” healthcare decisions.

Indeed, the healthcare arena is increasingly the site for major moral decisions, literally having to do with life and death. It is also the arena in which the society is making cultural decisions about human existence. Healthcare is an increasingly important corner of the public square. It is a place where the definition of human, the meaning of “personhood” and the rights associated with those concepts in a liberal (in the philosophical sense) democratic state are being decided. It is the place where the economic, political, scientific, and religious spheres overlap and, sometimes, where the very manner of understanding truth (which varies from sphere to sphere) comes into conflict. While it is not best to think of ethics as the study of moral conundrums or crisis decisions, the rapid change in healthcare and the rise of moral pluralism has made much of bioethics precisely that.

Clergy must be prepared to interact in this arena. They must be prepared to guide believers and they must be prepared to participate in public moral discourse. To be prepared, clergy need to have a knowledge base. Being caring and concerned is not enough. Although good pastors are generalists (that is, basically skilled in many fields), they must never forget that moral analysis is one area in which they are supposed to have some higher level of expertise. The minister must be prepared to guide. Indeed, non-directive counseling approaches are woefully inadequate when parishioners turn to their pastor in the face of ethical complexity. Yet, to offer guidance without knowledge is not only arrogant, but can be quite destructive. Clergy should be informed about the issues of healthcare and about the various moral debates that have arisen over the past thirty years.

With these needs in mind, the minister who wants to begin developing an expertise in bioethics is best served by reading one of the better anthologies published over the past decade. The best of these works should (1) explain how moral problems can be understood (i.e., provide an introduction to ethics); (2) cover a broad range of bioethics topics (a difficult task, given the fluidity of the field); (3) present a breadth of perspectives; (4) present historically significant events and legal cases; and (5) include a reasonable Christian voice. 

Of course, no bioethics volume will be perfect. Even if a book is relatively comprehensive in topics, no single work can convey all the subtle distinctions that arise so rapidly when technology, politics, and economics change the issues almost daily. Still, there can be a reasonable presentation of different perspectives on dominant themes. Likewise, commentators may differ on which events and cases are the most significant; nonetheless, a good bioethics anthology should contain some reference to most of the following: the Nazi human research; the Tuskegee and Willowbrook disease studies; the abortion cases of Roe v. Wade and Planned Parenthood v. Casey; major artificial reproduction events such as Baby M and Dolly the Sheep; the end-of-life cases of Quinlan, Conroy, and Cruzan, as well as end-of-life laws like the Patient Self-Determination Act and the Oregon Right to Die law; and mental health cases like Tarasoff. Also, of course, a genuinely good anthology intended for use in the U.S. should contain significant readings from religious (in particular, Christian) authors. Although a pastor may need this in order to be better prepared to address issues within and for the congregation, the editors should want this since Christianity is claimed by a very significant portion of the American population.

Although there may be others just as good, five books meet at least four of these criteria. Each has specific strengths and weaknesses, but all can serve as introductions to the field. 

Two strong works approach the material in roughly the same manner. Contemporary Issues in Bioethics (4th ed.; ed. T.L. Beauchamp and L. Walters [Wadsworth, 1994]) and Ethical Issues in Modern Medicine (5th ed.; ed. J.D. Arras and B. Steinbock [Mayfield, 1999]) have each gone through numerous revisions. Both begin with an introduction to ethical analysis and both explain moral reasoning using standard categories (e.g., deontology/Kantianism, utilitarianism) while allowing for entirely different approaches (e.g., “ethics of care”).

The Arras and Steinbock work includes in this introduction a section specifically devoted to religious ethics which accurately notes that “religious ethics is one of the parent disciplines of bioethics” (19). Appropriately, this section includes an introduction to natural law and double-effect arguments; both have been very important in the development of the field and are influential beyond religious communities. Also included in this section is a brief description of “ordinary versus extraordinary treatment”; this concept has been dismissed by some, but remains useful for Christians who, for example, want to protect human life from the calculated harshness of bureaucratic utilitarianism, but do not want to compel the use of every experimental technology possible when death is imminent as if biological death were the end of existence. 

The Beauchamp and Walters volume seems more philosophically oriented than the Arras and Steinbock assemblage. Contemporary Issues does not include any specific section noting the contribution of religious thought. Further, it seems to emphasize a specific model for approaching bioethical problems—namely, principlism. Essentially, the argument of principlism is that, in such a complex arena as healthcare in a pluralistic society such as our own, there can be no agreement on core values, so it is best to look for certain values which are shared by all (or almost all). These are, according to those favoring principlism, autonomy, beneficence, non-maleficence, and justice, with the strongest emphasis almost inevitably being placed on autonomy. (Slightly varying from some who use principlism, the editors compress beneficence and non-maleficence into one principle, as did the President’s Commission in the ‘70s and many others who use principlism). Regardless of principlism’s flaws and disregard for the embeddedness of faith, every minister working in bioethics should be familiar with this language, as it was the dominant approach to bioethics for almost two decades. One strength of the Beauchamp and Walters work is the section on how to approach a morally difficult situation practically; it is a useful model for pastors dealing with moral disagreement.

Both books are strong in their inclusion of precedent-setting cases, laws, and significant incidents. The most recent edition of Arras and Steinbock has the advantage being published in 1999 (currency is essential in bioethics anthologies). On the other hand, Beauchamp and Walters include more of the actual court decisions. Both books attempt to present differing opinions on significant issues. The religious voice, specifically the evangelical Christian voice, is not strong in either. This is partially due to the fact that evangelical ethicists are less engaged with the professional ethics community than secular philosophers and, to a lesser degree, Catholic thinkers. 

Carol Levine has edited a volume called Taking Sides: Clashing Views on Controversial Bioethical Issues (8th ed.; Dushkin/McGraw-Hill, 1999). The most recent edition was published in 1999 and a real effort has been made to address the most immediate issues (e.g., the late-term abortion debate). Levine, too, includes an introduction to moral theory and places an emphasis on principlism. The book clearly assumes that bioethical problems are best understood in adversarial terms. This is both a strength and a weakness. The strength is that, very intentionally, differing opinions are presented; there is no assumption that one view is intrinsically preferable (though the exclusion of some issues, for instance, the morality of “early-term” abortions, may demonstrate such an assumption or it may reflect the shape of the professional bioethicists debates which often dismiss a strong prolife/antiabortion position as a specifically religious view not compelling in a pluralistic setting). The adversarial approach is also a weakness in that it tends to present responses as falling into one or the other camp, when subtle variations may well be essential for Christian ethical analysis. The introductions to topics include consideration of legal precedents and historically significant cases, though usually they are not presented in depth. There is virtually no religious voice to be heard. Perhaps the greatest strength of the volume is that it really does place the novice into the debates at an introductory level without all the complexity that bioethics professionals sometimes bring into discussions.

Another approach to studying bioethics is to focus not on the debate, but the cases that elicit the debates. Such is the tack taken in a set of books, that should be used together, edited by A. Ridley and B.-J. Crigger, entitled Beginning Bioethics: A Text with Integrated Readings (St. Martin’s Press, 1998) and Cases in Bioethics (3d ed.; St. Martin’s, 1998), respectively. The Ridley volume includes a more rigorous analysis of ethical approaches; indeed, much of the early portion of the book is an introduction to moral analysis in a pluralistic setting. Ridley does include an explanation as to why he will not focus on religious arguments and, though this will not be satisfactory to those who think that specifically religious voices should be heard in the public square, it does include the kernel of truth when noting the necessity for some common terms and values for bioethical discussions among those who do not share a worldview. Ridley’s inclusion of a section on mental health that includes a challenge to traditional mental health models (the article by mental health iconoclast Szasz) is noteworthy. Perhaps the greatest strength of the Ridley work is its very intentional link to the cases and commentary drawn from the Hastings Center Report (probably the best-known bioethics journal) in Crigger’s volume. Ethics, after all, is about real life not abstract speculation, and bioethics is only understood when one understands the application to cases. This, of course, should be obvious to pastors.

The best volume for dealing with the religious, specifically the Christian, perspective (or, for some issues, more properly, perspectives) is On Moral Medicine, edited by S.E. Lammers and A. Verhey [2d ed.; Wm.B. Eerdmans, 1998]. Happily, this work has recently appeared in a second edition. The text includes discussion of how religious persons have and can interact in a public arena. Importantly, in various ways, the volume includes consideration of the problems of theodicy. As any pastor knows, this is one of the primary concerns of persons involved in bioethical decisions, from abortion and euthanasia to healthcare distribution and genetic chimeras; and, it could only be hoped that secular bioethicists would more intentionally include the topic in their discussions. 

The book includes arguments on the concepts of personhood and human mastery (or the lack thereof) of nature, as well as those categories one would normally expect in a bioethics anthology. Lammers and Verhey attempt to cover the span of Christian positions; for instance, Harrison’s proabortion and Pope Paul VI’s prolife arguments are both presented. The book includes works by Hauerwas, Pellegrino, W. May, S. Callahan, Meilaender, and others known for their specifically Christian perspective. The editors’ broad coverage is offered without denying that some, for instance the vast majority of evangelicals, would find certain works very much Christian in name only. Unlike many bioethics anthologies, the text includes several works on disability issues. The book lacks any significant presentation of laws or judicial precedents except as cited by authors making broader arguments. Likewise, there is little use of cases as a pedagogical tool. Still, this book stands out for its balance and its appropriate consideration of Christian religion (for more on history, see also Religion and Medical Ethics: Looking Back, Looking Forward [ed. A. Verhey (Wm.B. Eerdmans, 1996)]; the first in a promised series from the Institute of Religion).

My mother’s last days were filled with questions about the limits of healthcare expenditures for the very sick and the elderly, questions of when death is the proper next step for life, questions about the meaning of suffering, and questions about who decides for whom. In the same hospital, people were debating the survival of newborns, considering what is or is not acceptable in birth technology, and which diseases and disabilities will be treated. Christians must be informed if they are going to be participants in the debates and the educational process must include an understanding of the broad variety of issues and perspectives in bioethics.

By James R. Thobaben, Ph.D., M.P.H.