The Ethics of Pastoral Ministry in Medical Care

Complex and agonizing bioethical issues face Christians at the beginning of the twenty-first century. Should infertile couples resort to in vitro fertilization? Is it ever appropriate to rely on doctor assisted suicide? Ought we to call for a moratorium on the logging of tropical rain forests? These kinds of questions and many more, brought about by modern technology, stretch our ability as Christians to respond with reason and biblical insight.

As Christians it is important to respond to the pressing issues of our day with both sound philosophical reasoning and biblical authority.

Christianity is relevant for the social issues of our day. Its principles can apply to even the toughest of our dilemmas. For thousands of years the Bible has proven itself to be a trustworthy guide. But not only must we respond because we have a reliable text. We must enter the fray as salt and light. It is our responsibility to respond.

As Evangelical Christians we want to base our positions on specific passages of Scripture but many of the issues we are facing were unknown to the biblical authors and we cannot find explicit teaching to help us through the maze of current bioethical difficulties. We must therefore find our answers by considering implicit principles that will guide us through the thorny questions of our day.

The term "paradigm" is currently being used to describe ways of looking at the world. Its use springs from the writings of Thomas Kuhn who wrote The Structure of Scientific Revolutions in the early 1960's. It was Kuhn who held that normal science works within paradigms. His notion was that the scientific community adopts a paradigm through which it views the natural world.

We encounter a new paradigm whenever we read an advanced textbook in a subject area with which we are unfamiliar. Much of what we read at first seems so difficult to understand. We begin to grasp the meaning of the words as we become more aware of the author's way of viewing the subject. We grasp the subject as we begin to adopt or at least understand the paradigm.

While we should be cautious about accepting Kuhn's version of the historical process of science, it is generally accepted that even scientists hold certain conceptual and theoretical beliefs that to some extent affect their way of knowing the world. Science is a human endeavour. It involves some subjectivity. Paradigms are not just personal, they are communal. Communities of scientists, or theologians, or even philosophers for that matter are influenced by their paradigms.

Paradigms can be general and influence how we view, understand and interact with the whole world and not only one particular area of inquiry. In this case they are called worldviews or macroparadigms.

All this is to observe that there is a paradigm through which Evangelical Christians seek to view bioethics. Just as scientists work within a prevailing paradigm so Christians endeavour to understand bioethical issues in the light of a biblical paradigm. Our way of evaluating bioethical issues is based on the Word of God for to us this is the final authority on matters of morality. We are concerned that our paradigm is truly biblical and the result of sound theology. The present task of this paper is to delineate several of the facets of that paradigm.

Our discussion begins with two categories of inquiry. The first has to do with the theological underpinnings of our paradigm and the second deals with our philosophical foundations. While it might be obvious that Christians hold certain theological positions that influence their views on the tough questions, it may not be quite so apparent that we are also holding to certain philosophical principles.

It is very important to understand our philosophical position. For in order to articulate our views to those outside the church we need to speak their language. For many non-believers the language of the discussion is philosophical and not theological. If we confine our discussion to the theological aspects of the paradigm we may fail to speak to our secular culture. Part of the intent of this exercise in bioethics is evangelistic. We want to present our views in ways that are meaningful for those outside our camp. But let us first turn our attention to our biblical paradigm.

Biblical Principles

The concept that we have been made in the image of God is central to the whole of Scripture. In Genesis 1:26-27 God created man in His own image. In the poetic language of the text, male and female alike bear the image of God. Much debate surrounds the exact content of the imago Dei but for our purposes we should note that the image of God motif is central to understanding the biblical definition of mankind. On the one hand there is a fundamental distinction between man and the animals for we alone are created in His image. On the other hand we are not equal to God but dependent on Him for our very existence.

Some see a parallel between man created in God's image and the practice of ancient oriental kings to place statues of themselves throughout their territory to stake claim to their lands. Man as image bearer is an emblem of God's sovereign power (von Rad 1972, 60).

Since we were created to bear His image the study of anthropology must include an explanation for why we do not live up to our original intention. Obviously, that image is tainted or marred. We do not act according to the portrayal read in the creation story. The holy and righteous character of God is masked by the violence, greed and injustice that we see in modern society. The explanation is found in Genesis 3. We are sinners and have been broken by our fall from God's original intent.

Nevertheless, the creation story of Genesis' first chapters informs us that we have a special relationship with God in contrast to the rest of the created order. We were given a special place to live and unique responsibilities. He spoke to us and gave us certain instructions. We alone are image bearers. This special relationship reflected a special status. We are given a value and dignity unlike that of the rest of creation. Our ability to reason and our moral conscience also convey this special status. It is reflected in the Old Testament law. There are prohibitions against treating the image bearers with anything less than the respect due their position. Therefore we are warned not to kill one another, we are told that slaves should not be indentured for life and we are given many other indications that special status is to be given to those who bear the image.

This gives rise to what we refer to as the sanctity of human life. It is a natural outgrowth of the image paradigm. We believe there is something sacred about human life that is unique from the rest of creation. It is foundational to the entire Bible. We are warned in Numbers 35:33 that the shedding of innocent blood pollutes the land and cries out to God for judgment.

The New Testament emphasis on the resurrection of the human body further underscores this sanctity. In 1 Corinthians 15 the agricultural metaphor of the natural body sown and the spiritual body raised reveals there is some kind of continuity between the natural body and the imperishable, glorious and powerful spiritual body of the resurrection. We do not become sacred after the resurrection, rather there is something so inviolable about the human person that even our bodies, subject as they are to decay and dishonour, will be refit to live in eternity with the Lord.

This sanctity begins at fertilization. As Harold O. J. Brown argues in A Method in Which Killing Represents a Solution: The Soul of the Unborn and the Soul of America, any other position needs to be proven in order to be accepted since the known facts of embryology show human life begins at fertilization. All the genetic material is in place to produce a separate and distinct life (Brown 1993, 179-80). The Scriptures assume a continuity between prenatal and postnatal life. The Hebrew word yeled that is used of children generally is also used of the unborn in Exodus 21:22. In the New Testament the Greek word brephos used in Acts 7:19 that refers to children killed by Pharaoh, is also used in Luke 1:41, 44 to refer to John the Baptist while he was still in his mother's womb (Brown 1977, 119).

Human life is sacred because God has made it so. It does not rest on our circumstances. Even if we are weak, unhealthy, dependent and unconscious our lives are still sacred. Just as God is actively at work in the womb (Psalm 139:13-16; Job 10:8-13) he is also present in the dying and comatose.

The second facet of our paradigm is again connected to the imago Dei. But while we previously discussed in brief the content or meaning of the image we must now address the function. We refer to this as the stewardship paradigm. It is again based on the first two chapters of Genesis.

God is portrayed as the ruler of His creation. The Bible views Him as a monarch ruling over the vast realms of the created order. Since everything is created by God, He exercises His ownership over everything that is. One of the functions of those created in His image is to exercise that dominion as a reflection of God's ultimate lordship.

In Genesis 1:26-27 God blesses Adam and Eve and commands them to be fruitful and fill the earth, and to subdue and rule over it. In these two commands God assigns His stewards two administrative functions. A third function that helps to answer the question of how we are to rule is seen in Genesis 2:15 where Adam is called to work the earth and take care of it.

The second function assigned to humankind is to rule the land as the representatives of the Ultimate Ruler. The Hebrew words for "subdue" and "rule" are powerful, dominance terms. Subdue (kabash) comes from a Hebrew word that means to tread down or bring into bondage and brings the image to mind of an emperor placing his foot on the neck of the conquered. Rule (radah) is drawn from a word meaning to trample or to prevail against and draws the image of one treading grapes in a winepress. Therefore the stewards are given by the Creator absolute hegemony over the kingdom (Wilkinson 1991, 209).

Adam's act of naming the creatures also denotes his control over creation since in biblical times the act of naming was a sign of ownership or power over something. But one must remember this is delegated authority. The power is God's power given by permission to His image bearing creation.

The third injunction sets out the obligation the steward has in respect to God's dominion. He is to "work it and take care of" the property of the Owner. This is a tending function. It is seen in Genesis 2:15. The word "work" in Hebrew, abad, is sometimes translated "till" and has of course an agricultural motif. But the word translated "take care of" the Hebrew, shamar, means "to watch and preserve, to guard and protect" (Wilkinson 1991, 286-87). The same word is used by Cain when he asks if he is his brother's "keeper" in Genesis 4:9.

The three stewardly functions are to fill, subdue, and care for creation. Through most of human history it would seem as if humankind has been in greater danger from creation than vice versa considering the awesome power of the environment. But in recent history technology has given us the ability to do great damage to the environment. When we consider nuclear waste, habitat destruction, and all the other ways we have damaged our world it becomes very clear that our injunction to care for the land must be taken seriously for we have the ability to destroy that which God has given us to protect. And if we have this responsibility it only seems fitting that we will also be called to accountability for the way we are fulfilling our duties.

So this then gives us our second facet to the paradigm. It helps us consider our responsibilities. Our bioethical concerns can be seen in the light of these injunctions. As stewards we are to fill the world. We are also to rule over and subdue the earth. Our dominion means that we have power over the earth as between a ruler and his subjects. We are also to care for the earth. This means we must pay careful attention to how we use our power over the earth. We have obligations both to God and to the earth to make sure we do justice to the creation.

The third facet of our paradigm has to do with general revelation. By this we mean that the fundamental demands of God's moral law are not hidden but obvious to all humankind. Evidence for this belief can be found in the first three chapters of Romans as well as in the first three chapters of Amos. Here we discover that even those who do not know the word of God are judged on their innate understanding of right and wrong.

In Romans 1:18-20 the Apostle Paul states that the wrath of God is revealed against all those who are involved in wicked behaviour. The fact that they have not heard of the Bible or Jesus is no excuse for the whole created world reveals Him. His invisible qualities can be clearly seen from what He has made. They will be held accountable for their idolatry and sexual perversion because they knew it was wrong and chose to ignore their consciences.

But not only are the Gentiles without excuse, the same and more can be said about the Jews. Although they had God's moral law in detail they too failed to obey and will be held accountable for their actions. No one is righteous. Our only hope is the righteousness that comes through faith in Jesus Christ.

In Amos the prophet's message contains the same warning. The prophet begins by announcing God's judgment on Israel's neighbours. Damascus, Gaza, Tyre, Ammon, Moab and even Judah are soundly condemned for various atrocities ranging from their brutality aimed against captured people to greed over land. One is made to picture Israel rubbing her hands in glee as the pronouncements roll down against the enemies that surround her. But shockingly the prophet continues and even includes Israel in his condemnation. They too had trampled on the poor and taken advantage of the oppressed.

The point is clear. Those who do not have the written moral law will be held accountable for what they do know. There is a general revelation of God's morality that all humankind holds in common. This moral awareness includes the areas of sexual perversion and the killing of innocent life. The unbeliever may deny in very vocal terms the voice of conscience but the Christian paradigm will include the belief that we all have a fundamental and innate understanding of right and wrong.

This third facet of our biblical paradigm is argued in C. S. Lewis' broadcast talks published in Mere Christianity. Here he points out that there is a "law of human nature" common to all people. The moral teachings of different civilizations in different ages are very much like each other and like our own. The differences between their moralities do not amount to anything like a total difference but are only minor. He asks us to try to imagine a culture where running from battle is a virtue, selfishness is to be admired, or where double crossing a friend would be something of which to be proud. Certain moral principles are indeed innate and no more a matter of "mere taste and opinion any more than the multiplication table" (Lewis 1960, 5). Lewis has much to say on this issue but it has more to do with philosophy than theology and we will come back to his argument as we consider our philosophical paradigm.

Philosophical Principles

In order to understand our philosophical paradigm we must look at the branch of philosophy called "ethics." This moral philosophy or philosophical thinking about morality, moral problems and moral judgments is a large field of inquiry and for our purposes we will limit our discussion to a brief overview of the discipline pertinent to our discussion.

According to William Frankena in his introductory book simply called Ethics there are three kinds of thinking that relate to morality (Frankena 1973, 4-5). The first is descriptive empirical inquiry that is historical or scientific. It is the realm of anthropologists, historians, psychologists and sociologists. The goal is to describe the phenomena of morality or to work out a theory of human nature. The second is described as "normative" thinking. It is done by anyone who asks what is right, good or obligatory. It is not so much concerned about what "is" done as in the first category. It is more concerned about what "ought" to be done. The third type of thinking that relates to morality is called "meta-ethical" thinking. It does not concern itself about what is good, right, or obligatory but tries to answer logical, epistemological, or semantical questions. It discusses the nature of morality, the distinction between the moral and nonmoral, and the meaning of various words or expressions such as: right; good; free; and responsible.

Our discussion will centre on the second kind of thinking regarding morality. We are concerned about normative ethics, what ought to be done. In general, moral philosophers can be divided into two camps, those who hold deontological theories and those who are teleological in their views.

A teleological theory has the end result in mind. It is consequence-based. The ultimate criterion of what is morally right, wrong or obligatory is the nonmoral value that is brought into being. The final appeal is to the comparative balance of good over evil. An act is right if there is at least a greater amount of good over evil produced. It is wrong, if and only if, it does not do so. Perhaps the most well known example of a teleological theory is utilitarianism. Jeremy Bentham and John Stuart Mill, British philosophers in the eighteenth and nineteenth centuries, would maintain that the ultimate end is the greatest general good in the universe or the greatest possible balance of good over evil (Frankena 1973, 13-17).

Deontological theories contradict what teleological theories affirm. They are rule-based. They do not agree that the morally right, wrong, or obligatory is determined by what promotes the greatest good over evil. They are not as concerned about the consequences of an action but they believe that there are other considerations that make an action or rule right or obligatory. The act or rule may be obligatory because of certain features of the act or rule itself. It may be good in that it keeps a promise, or is just, or is commanded by God or the state. An act may be right and good even if it does not produce the greatest amount of good for self, society or the universe. It may indeed produce evil consequences.

Perhaps the best known deontologist would be Immanuel Kant, the German philosopher of the eighteenth century. His dictum or "categorical imperative" was that we should "Act only on that maxim which you can at the same time will to be a universal law" (Frankena 1973, 30).

Kant is also known for his defense of the principle that nature is uniform. He proposed that various categories and principles of thought were built into the very structure of our minds. Every experience was organized accordingly even without us knowing it. The principle that nature is uniform is one of those organizing structures and since it will be imposed on any experience we ever have it will never be violated. But this argument came at a great price. If true, then all we can know about the world around us has been shaped by our minds. We cannot know the external world as it really is, only as we perceive it.

But Kant's emphasis on rules is characteristic of the deontological view. They rest on a rational foundation and consideration is given to their universal nature. For example the question: "Should I lie?" would be considered in terms of its value as a universal law. The consequences of a particular lie would not be as important as the value of this rule as a universal dictum.

It should be clear by now that the Christian perspective is deontological. We believe that there are rules by which we endeavour to decide what we ought to do. Consequences certainly play an important role in moral decisions, especially for Christians. But basing our ethic on teleological considerations would be a dangerous road. Not only is it extremely difficult to imagine all the outcomes of our various actions, the process of weighing good over evil seems a rather subjective endeavour. The Bible clearly sets out rules to live by and warns that the consequences to which we should be attentive are not of the teleological variety mentioned earlier but the repercussions of ignoring the moral absolutes of a holy God.

Arthur Holmes in Ethics: Approaching Moral Decisions distinguishes four ingredients to a Christian ethical theory. They are: (1) cases; (2) area rules; (3) principles; and (4) bases. The cases are the particular moral problems we face almost daily. They would include decisions on how to treat an irritated client or what we might do if asked to lie to cover for the mistake of a friend. We usually rely on moral rules to make our decisions. There are rules about how we conduct business, the value of telling the truth and the sanctity of life. In turn these rules depend on underlying principles which can be applied to various areas of activity. These principles are logically justified by reference to theological or philosophical bases or presuppositions (Holmes 1984, 50-51). The pattern is discernible in almost any ethic, and we could readily trace it in the biblical materials on morality. Consider, for example, the well-known Ten Commandments in Exodus 20:1-17, which include moral rules for major areas of human responsibility: the sanctity of human life and of the marriage relationship, respect for others' property and for the truth. A fascinating array of case applications appears in subsequent chapters in Exodus, cases which can be classified under the various rules in the Decalog (the Ten Commandments). The bases for these rules is quite explicit: they are commands of God. And the principles on which they rest, while implicit in the Exodus account, became explicit elsewhere. (Holmes 1984, 51)

The principles of our ethic are critical. They have universal application, to every kind of involvement. They are without exception and must never give way to expediency. Holmes sees the principles of love and justice as the two principles upon which we must build our ethic. He finds ample evidence for this in passages such as Micah 6:8 "He has showed you, O man, what is good. And what does the Lord require of you? To act justly and to love mercy and to walk humbly with your God" (Holmes 1984, 52).

Both of these principles are concerned for persons. Justice is concerned with their equitable treatment: 'The Lord works . . . justice for all who are oppressed' (Ps 103:6), and so ought we. Just laws and just government, a just economy with fair prices and fair wages, an equitable relationship between faithful husband and faithful wife, a peaceful and equitable relationship also between the nations of the world: these should be our concern as they are God's (Is 9:2-7;11:1-15). (Holmes 1984, 52)

Love is concerned for their good. By this he means their highest good, not just their enjoyment or success. This is a self-giving, sacrificial attitude. It does not have to be reciprocated in order to survive: It is rather an overall moral principle, all-inclusive and exceptionless, that should govern all our actions, a selfless devotion to God that issues in sacrificial service to others. (Holmes 1984, 52)

Justice and love are not in conflict but contribute to each other. Justice obligates love to distribute its benefits equitably. Love motivates justice to keep its quest alive. These are the principles of God's kingdom. They are to guide our judgments and our conduct.

Conflicting obligations are bound to occur. In many specific cases there appear to be rules that are in conflict. Can we lie to save a Jewish person from the Gestapo? Should we obey God even if it means to disobey the government? Joseph Fletcher's "situation ethics" of the early sixties maintained there was only one absolute: "love." Our only obligation is to do the loving thing. Rules are treated as love's servants and subordinates. The difficulty with this view is that Fletcher failed to define criteria for what constitutes a loving action in any given situation. The moral agent is left to his own interpretation of what is the loving thing and this of course is influenced by the subjectivity of personal preference.

Holmes' view is that there are definite rules to live by, but when these rules conflict we should look at justice and love to help guide our course. The kind of justice and love is not left to our own interpretation but is based upon the justice and love of God as demonstrated in the Bible.

Christian and non-Christian ethics are more likely to differ on principles than on rules or cases. But our greatest area of disagreement will be on the most fundamental level, the presupposition or base that there is a God who is the author of morality.

In Mere Christianity, C. S. Lewis argues that there is a natural moral law, in that humankind invariably do recognize right from wrong. This "natural law" gives evidence of a Director or Guide. He appears in us as a law which urges us to do right and makes us feel responsible and uncomfortable when we do wrong. This Somebody or Something behind the moral law gives us two "bits" of evidence about what He is like. The first is from the universe He has made. From this we can conclude He is a very great artist for the world is a beautiful place. But we could also note that He is quite merciless and no friend to humankind because the universe can be a dangerous and terrifying place:

The other bit of evidence is that Moral Law which He has put into our minds. And this is a better bit of evidence than the other, because it is inside information. You can find out more about God from the Moral Law than from the universe in general just as you find out more about a man by listening to his conversation than by looking at a house he has built. Now, from this second bit of evidence we conclude that the Being behind the universe is intensely interested in right conduct-in fair play, unselfishness, courage, good faith, honesty and truthfulness. (Lewis 1960, 23)

In summary, the Christian philosophical paradigm in regard to bioethics begins with God. He is the author of morality. His moral character is seen in His justice and love. From these principles we have been given rules to obey. Specific cases arise in our everyday lives that challenge us to apply the rules. In the rare instances when we face conflicts in obligation we must look to the character of God-His justice and love-to help chart our path.

Our philosophical and biblical paradigms help us to evaluate the tough bioethical issues of our day. We can now turn our attention to some of these matters and endeavour to evaluate them in the light of our Christian outlook. This is not to say that Evangelicals will agree on conclusions about the morality of the various procedures. Unanimity is hard to find even among those who hold to a similar paradigm. Ongoing discussion and critical thinking is needed that will continue to sharpen our focus and more clearly delineate the issues. The thoughts contained in the following paper on the tough bioethical issues facing pastors are certainly not intended as a final word but merely some small contribution to the ongoing debate. Perhaps more accurately, it is only an attempt to view some of the issues in the light of the above mentioned paradigms.