Note: This chapter is from my dissertation, "A Time To Die: Guidelines For Making End-Of-Life Decisions". The posting process left out part of the diagrams and the footnotes. I'll try to fix that.
CHAPTER FOUR
ETHICAL ISSUES
The English word "ethics" derives from the Greek word eqoj
which expresses the ideas of habit and custom of a people or country. Ethics is a study of the standards of right and wrong and of the moral principles by which people guide their lives. Ethics is an attempt to determine the morality of choices and is the branch of philosophy which describes the rules or standards which govern conduct and moral judgment and focuses on what a person's moral duty should be. "Ethical" is what conforms to accepted rules and standards of conduct in a society. Yet practical questions of right and wrong are not the only issues. Since conduct is "an outward expression of character," ethics must also consider a person's character, motives, and desires, areas of life which are difficult to analyze. Limiting ethics only to rules and guidelines may transform ethical investigation into a legalistic mechanism to "look good" to others.
Ethical dilemmas are common in the Bible. For example, Luke 12:3 requires parents to circumcise male infants on the eighth day after birth. But what should parents do if the eighth day occurs on the Sabbath, a day on which the Old Testament forbids work? Pharaoh forced the Hebrew midwives (Exod. 1:15-22) into an ethical dilemma by his order to kill male Hebrew infants. The prophet Samuel encountered an ethical dilemma when he needed to anoint David as king yet also needed to keep Saul uninformed of this action (1 Sam. 16). The early Christians had to choose between obeying government or obeying God (Acts 4).
People regularly encounter ethical dilemmas at work and home. For example, professional drivers are pressured to falsify driving records in order to appear to follow federal limitations on the maximum amount of hours driving without rest or to travel at speeds that exceed the speed limit in order to meet shipping deadlines. Christian students debate the ethics of working on Sunday in order to earn money for college education or of accepting scholarship money from gambling sources such as lotteries. Many people struggle with questions of whether lying, stealing, or killing another human being would be morally permissible in certain circumstances.
"Christian Ethics" approaches the study of right and wrong from an explicitly biblical perspective, using the Bible, the written expression of God's mind on all relevant issues, as the foundation for determining ethical behavior. Biblical ethics is "the study of the way of life that conforms to the will of God as revealed in Christ and in the holy Scriptures" and is "a means of determining which human persons, acts, and attitudes receive God's blessing and which do not." Figures 2 and 3 illustrate the difference between secular ethics, which may include the Bible as one of many sources for determining ethical behavior but which primarily relies on consensus among different groups of people, and biblical ethics.
Figure 2. Comparison Of Secular And Biblical Ethics
Secular Ethics Biblical Ethics
Man / Ideas & Opinions GOD / Bible
Figure 3. Comparison Of Man's Character And God's Character
What People Believe Is Right/Proper What God Says Is Right/Proper
Man's Character God's Character
Figure 3 illustrates that one of the fundamental flaws in secular ethics is that the conclusions are based upon the character of human beings.
Since man's character is thoroughly affected by sin, contaminating our relationships and judgments, then what people believe to be proper ethical behavior has been influenced by that condition, and that condition will determine the conclusions. Non-biblical ethical systems do not adequately, if at all, consider the condition of the human heart and are therefore susceptible to error and optimism regarding man's ability. Postmodern secular ethics is an ethics which is "constructed" from the experiences and beliefs of society.
One of the fundamental benefits of biblical ethics is that its conclusions are based on the character of God. Since God's character is perfect and unchanging, then what God says is perfect, always right, and, therefore, also proper ethical behavior for people living at any time. Biblical ethics is revealed from God and based on propositional truth in the Bible. Secular ethics is fundamentally an ethics of practical consensus: "What can we all
agree upon as right and proper?" Biblical ethics asks: "What has God told us about what is right and proper?"
Academic discussion of ethics generally classifies ethics into two main categories: Teleological Ethics, which emphasizes goals, and Deontological Ethics, which emphasizes duty. One form of goal-oriented ethics is utilitarianism, popularized by John Stuart Mill (1806-1873), which determines what is ethical by finding the greatest good for the greatest number of people. Utilitarianism places a strong emphasis on using consequences to determine morality. End-of-life decisions based on utilitarian ethics must be minimized as it is very easy to rationalize terminating treatment based on the overall good of the patient, his family, or finances. Although for many patients a point will arrive when a decision to end treatment must be made, those who follow utilitarian ethics may tend to decide earlier than is necessary in order to avoid "bad" consequences (i.e. pain, suffering, financial drain, emotional distress). One form of duty-oriented ethics is based on the writings of Immanuel Kant (1724-1804) who stressed that once a person determines what is "right" or "good," then that person has a duty to perform the "right" or "good," regardless of the consequences. Duty-oriented ethics emphasizes individual autonomy, using a
person's freedom and reasoning ablity to decide moral issues. But biblical ethics incorporates elements of both teleological and deontological ethics. The Christian's "goal" is the glory of God (1 Cor. 10:31), and the Christian's "duty" is to do the will of God, which is good (Rom. 12:1-2). Yet a Christian must consider consequences when making decisions. For example, Romans 14:21 teaches that a Christian must refrain from behavior which may cause another Christian to "stumble." In order to apply this teaching, a decision has to be made about the consequences of certain behavior. Consequences are not the only factor in making ethical (i.e., biblical) decisions, but they must be considered.
Biblical ethics, a "God-centered system of ethics . . . revealed in Scripture," applies God's revelation to specific moral and ethical problems. Sometimes what God has revealed may conflict with the consensus society has developed. For example, a general principle of work is that the number of hours a person works determines the wages he will receive. And generally
this is a proper and fair policy. However, Matt. 20:1-16 records the Parable of
the Vineyard in which all of the workers are paid the same regardless of the number of hours they worked. Although the parable focuses on salvation rather than economics, the parable teaches that God may at times have a different set of ethics based on motives and knowledge which people are not aware of. God has purposes which are often beyond man's immediate comprehension. Yet ethics involves moral decisions and behavior which are either working with God or are working against God, which is a motivation to be very careful when making decisions.
In order to correlate biblical authority with the practical difficulties of living in a world affected by sin, Christians have developed several systems of ethical classification. Unqualified Absolutism proposes that moral conflicts are only apparent, and sin is always avoidable. Conflicting Absolutism admits that real moral conflicts exist but proposes that a person must do the "lesser evil," confess the sin, and ask forgiveness. Graded Absolutism also
admits that real moral conflicts exist but proposes that the Christian follow a
hierarchy of moral duties outlined in Scripture. The Christian does not do the "lesser evil" but instead obeys the "greater good."
Of these three systems, Graded Absolutism seems to best correspond with what God has revealed in the Bible. Christians struggle with genuine moral dilemmas because the Bible reveals authoritative prescriptive absolutes. Ironically, the recognition of absolutes helps to create ethical problems. For example, recognizing that lying is wrong, truth-telling is right, and human life, which reflects the image of God, deserves protection may eventually lead to a conflict between lying to protect human life and telling the truth and consequently risking human life.
End-Of-Life Ethics
Technological advances in medical care reveal how unprepared society is for deciding end-of-life situations. A sudden or accidental death eliminates many typical end-of-life ethical problems. A slowly progressing terminal illness with its eventual complications will probably create ethical problems. Yet the ethical problems presented in end-of-life issues give believers an
opportunity to think through basic philosophical and biblical principles and
apply these principles to new situations. Since all descendants of Adam are
created in the image of God, since God is sovereign, and since suffering has purpose, the burden of proof to end life is not on those who are "pro-life" but instead on those who wish to end life. This burden of proof creates a healthy restraint which prevents people from acting too quickly to withhold or to withdraw medical treatment. This burden does not prevent the withholding or withdrawing of treatment, but it does encourage careful thinking and prayer before treatment is refused or terminated.
Ethical issues in end-of-life decision-making focus on three basic principles of healthcare: the principle of nonmaleficence, which requires those caring for patients to "do no harm"; the principle of beneficence, which requires promoting the welfare of the patient; and the principle of patient autonomy, which is the competent patient's right to make his own decisions concerning his medical care. Because medical personnel are not to harm patients and, at the same time, are to promote the welfare and health of patients, yet are also to respect patient autonomy, the potential exists for conflict between these three principles. For example, a comatose patient may be breathing with the assistance of mechanical/artificial respiration and may be receiving fluids and nutrition through invasive tubes, practices which follow the principle of beneficence. Yet the prognosis for improvement in his condition is minimal, and some of the treatment may cause bruising and infection, which relates to the principle of nonmaleficence. Since the patient is unable to express his autonomous choices for his medical care, his family or some other designated individual or group must decide for him. Or if a competent patient decides that he does not want certain treatments, his family and physicians must respect that decision, perhaps violating what they believe is the patient's best interests.
Ethical issues in end-of-life decision-making primarily focus on two groups of people: 1) the physican and other health-care workers and 2) the patient and his family. The purpose of end-of-life bioethics is to develop criteria for defining and deciding proper, ethical conduct for these two primary groups at the end of the patient's life while respecting the principles of nonmaleficence, beneficence, and autonomy. Additionally, the Christian must include all relevant biblical principles.
Basic Biblical Ethical Factors
Biblical ethics is based on the truths which God Himself said were
important. Figure 4 shows how these truths can be arranged.
Figure 4. Ethical Arrangement Of The Bible.
Jesus Christ distilled ethics into two major precepts: love the Lord God with all of the heart, soul, mind, and strength and love our neighbor as ourselves (Matt. 22:35-40; Mark 12:28-34; Luke 10:25-28). The Ten Commandments (Decalogue) are a brief, practical explication of these two precepts, and the Bible itself is an extended explanation and illustration of these two precepts.
Three controlling principles influence ethical decisions for the Christian. The controlling purpose of biblical ethics is the glory of God (1 Cor. 10:31), the controlling motive is the love of God and pleasing the Lord (2 Cor. 5:9), and the controlling good is the will of God (Rom. 12:1-2). Secular teleological and deontological ethics contradict these three principles. Rules and guidelines may become a legalistic mechanism to "look good" if a person does not have a heart desire to follow these controlling principles. Some secular ethicists such as Leon Kass also recognize the importance of thinking beyond rules and guidelines.
Several factors must be integrated into making ethical decisions, such as the reality and influence of the sin nature. The sin nature affects everything a person does, and therefore each person needs specific help from God to establish a clear and consistent biblical ethics. The sin nature is especially important because secular ethics tends to emphasize education as the solution to ethical problems, not realizing that "the mind is in the service of a morally rebellious will." Since the human heart is unpredictable and the source of evil (Jer. 17:9; Matt. 15:16-20; Mark 7:14-23), the potential is very real for sin to affect ethical decisions.
Although conscience is a valuable resource in making ethical decisions, the conscience alone is not sufficient for deciding right and wrong. Romans 2:14-15 teach that God uses the human conscience to restrain the sin nature since God's fundamental law is written in the human heart. Yet the conscience is most effective only if trained properly. Conscience tells a person that he should do right, and may give him some idea of what is right, but conscience by itself cannot determine what is right. Those who minimize the sin nature often place too much emphasis on and confidence in the conscience.
The conscience is not always correct. For example, Paul (Acts 7:58; 8:1; 26:9; 1 Cor. 15:9; 1 Tim. 1:13) believed he was acting properly when he persecuted Christians, apparently his conscience agreeing with his actions. Only after meeting the risen Christ and having his thinking changed did his conscience bother him about what he had done (1 Cor. 15:9; 1 Tim. 1:12-13).
However, the conscience is particularly important in end-of-life decisions. Family members sometimes have to consider medical alternatives with which they are uncomfortable. They may even have doubt about the appropriateness of those procedures. Their conscience may "bother" them about the decisions and the potential consequences of those decisions. If a person does that which he believes to be wrong, even if later events demonstrate that those actions were not wrong in themselves, doing so "sins against conscience" and such a person has some degree of blame for those actions (1 Cor. 8:7,12). Therefore, a biblical-ethical approach to end-of-life decisions must guard against this possibility by thorough education and growth in knowledge of God's Word, how that Word applies to difficult decisions, and remembering the subtle influences of sin and Satan.
Satan is often ignored in Christian ethical writings. Since ethics is an attempt to discover what is moral and right, then ethics is fertile ground for subtle Satanic deception. This Satanic factor becomes clearer when evaluating end-of-life questions since these issues directly affect people made in the image of God, an image that Satan hates and tries to destroy (John 8:44). Perhaps the most subtle Satanic deception is to terminate treatment too quickly, rationalizing the decision by an overemphasis on quality of life issues.
Another important factor in biblical ethics is truth. One aspect of lying is to deceive someone who has the right to the truth. If family and physicians wish to respect those who are dying, then such respect means telling the patient the truth about his medical condition. A person cannot make proper end-of-life decisions if he does not know the reality of what is happening to him. If a patient is competent enough to make his own medical decisions, then that patient has the right to know the truth in order to make those decisions.
One of the purposes of ethics is to work through complex situations and think through the steps of making decisions which please God. The interaction of people and the influence of the sin nature on a person's mind, will, and emotions add to the complexity of situations. In contrast to secular ethics, biblical ethics clarifies issues and offers objective principles for making decisions.
Patient And Family Ethical Issues
Patient autonomy is a legal right established over the last thirty years by various courts and has become a very influential principle in bioethics.
For example, autonomy is the philosophical foundation for physician-assisted suicide (PAS). If a person is dying and faces the possibility of living with pain and disability, then if he wishes to end his life by some type of suicide or assisted suicide, the philosophical principle of autonomy gives him the support for that action.
Patient autonomy is the basis for much of the paperwork which patients must read and sign before surgery. Federal law now requires hospitals to inform patients about living wills and other end-of-life legal mechanisms and to give full disclosure to the patient of medical conditions and treatment. Autonomy is the principle which gives patients the legal right to refuse any treatment.
Ethical issues develop when patient autonomy conflicts with the medical philosophies of nonmaleficence and beneficence. For example, if a patient and/or his family request a doctor to administer medication which may possibly end that patient's life, should the doctor respect autonomy or follow his own ethical obligations? Or if a patient insists on medical procedures which the doctor believes will probably produce very little benefit for the patient, should the doctor follow the patient's wishes?
Another important issue which relates to patient autonomy is that a patient should never be coerced or intimidated by other people into making a decision the patient is hesitant to make. Families eager to relieve themselves of the "burden" of a sick relative may exert subtle coercion upon that vulnerable patient, influencing him to end treatment prematurely. On the other hand, families may desire a sick relative to continue difficult treatment because they cannot "let go" of the dying relative. Taking advantage of vulnerable patients is unethical and unbiblical, even if the reasons seem appropriate.
No human being is completely autonomous, however. Every person depends on others to varying degrees. A person's autonomy or free will is always limited by and subject to several factors, such as current legal restrictions, his own physical limitations, and God's sovereignty. The Bible is the written expression of God's sovereign will, designed to help and limit human beings during their lives. For example, people do not have the autonomy to steal from other people, to lie to other people, or to kill innocent
people. The believer belongs to God (1 Cor. 6:19-20) and is not free to do as he pleases but is "free to do what is right." Therefore, although autonomy is an important factor in end-of-life decisions, autonomy by itself is not the deciding factor.
Figure 5 illustrates that many people and groups influence a patient's medical care and decisions, even though ultimately the patient is responsible for his decisions. Figure 6 shows that a patient filters all influences through his own belief system and experiences. Almost every person will have to make decisions about his personal medical care, usually with advice from several people and sometimes with subtle pressure from other people. Yet every person will analyze the information he is told through his own personal belief system and experiences. Some of those exerting influence on a patient may have good intentions, but the pressure still exists.
Unless a patient or his authorized surrogate understands what he believes (content) and why he believes (basis), these pressures can lead to unethical (unbiblical) decisions.
Figure 5. Influences On Patient Health Care
Figure 6. Patient Filter
One ethical issue which often occurs in medical care is the withholding or withdrawing of medical treatment. As part of their responsibilities, physicians give recommendations concerning proper treatment, including whether treatment should be discontinued (withdrawn) or not started at all (withheld). This advice is part of the information which patients and their families must think through. Therefore, the ethical issue focuses on whether withholding or withdrawing treatment is ever morally and ethically appropriate. This decision is one of the major decisions a patient and/or his family must make.
Paul's attitude toward his own life and service for Christ is a good example in this area. In Philippians 1:12-26, Paul describes how the Lord has used his difficult circumstances to reach more people with the gospel and to encourage believers to proclaim Christ (12-18). Then he honestly describes his inner struggle concerning two desires: to continue living in order to serve the Lord and help other believers (22, 25) or to accept the end of life and be with Christ, which he refers to as "better" (21, 23).
Paul was willing to continue living, even in difficult circumstances, if his life could exalt Christ (20) and if he could help other believers (24-25). In fact, he recognized that to continue living was necessary in order to accomplish some benefit for others (24), and he regarded this benefit to others as "fruitful labor" (22). Yet he also recognized that death was infinitely better since death would bring him to Jesus Christ (21,23).
One criteria developed from Paul's example is that medical treatment is appropriate if it will allow the person to minister to others, either during the treatment or after treatment. Although life itself is a gift from God (Gen. 1-2), life does have a functional aspect: to serve the Lord and others. As long as medical treatment can provide benefit toward the end of enabling to serve God, then treatment is appropriate.
This criteria is different from the often used "useful to others or society" argument. Usually by "usefulness" people mean that a person must provide some tangible benefit to society. Lack of usefulness has been a common reason for ending a person's life since the Greek philosophers. In secular thinking, and sometimes in Christian thinking, if a person is limited to bedrest and requires continual care, then that person is not "useful" to society and is, in fact, a burden to others. Therefore, the life of such a person is not "worth living." However, the biblical teaching on God's sovereignty and the purposes and potential benefits of suffering must be remembered. Although a believer in this condition may not appear to have any tangible purpose or benefit, his "usefulness" may extend to less tangible benefits such as personal example and prayer ministry for others.
"Quality of life" is a difficult concept to define yet does seem to have a limited role in end-of-life decisions. The benefit and/or burden of treatment relates to quality of life considerations. If quality of life can be restricted only to the benefit or burden of treatment, then quality of life considerations are appropriate. For example, if the physician believes that further medical treatment will not be beneficial and will create a burden to the patient that will outweigh any benefit the treatment might produce, then this would be an appropriate "quality of life" consideration. But to consider a person's "usefulness" to others as a quality of life factor in making end-of-life decisions relies too heavily on utilitarian considerations.
One ethical aspect of withholding or withdrawing treatment is the concern of "causing to die." By refusing treatment, is the patient or his family causing the patient's death, thus violating the Sixth Commandment (Exod. 20:13)? In addition to expressly prohibiting a specific sin, the Sixth Commandment also implies the duty to preserve human life. Is refusing treatment a failure to preserve human life?
Perhaps the concepts of commission and omission are relevant here. To omit is to "leave undone" or to fail to do what is within a person's ability and responsibility. To commit is to perform an action. In end-of-life issues, the distinction focuses on death which occurs by omitting life-preserving treatment or death which occurs by performing a specific action which directly causes death. The ethical problem focuses on whether a sin of commission or omission has occurred.
Several questions must be asked and answered about withholding or withdrawing treatment:
1. Is/Will the treatment be effective in restoring or improving health?
2. What are the benefits and burdens of the treatment?
3. Does/Will the treatment cause an excessive burden to the patient that outweighs the benefits of the treatment?
4. Is the patient near death?
Question four is particularly important. One responsibility of physicians is to confront death and disease and provide treatment for the illness and the suffering associated with the illness. At some point in every person's life, medical treatment will be ineffective in healing the underlying medical condition and will not be able to prevent death. Withholding or withdrawing treatment then becomes a recognition by the patient and family of God's sovereignty and that they must allow death to occur. Continuing treatment which does not provide any benefit to the patient may then become a vain attempt to prolong life at any cost and to avoid inevitable death.
An important point to remember is that the withholding or withdrawing of treatment does not cause the death, but, instead, the underlying medical condition causes the death. When refusing treatment, the patient and family recognize that the medical condition has become more powerful than the healing possibilities of medical treatment and that death will inevitably occur. Paul recognized God's sovereignty in his situation, and Christians today recognize the same by not prematurely ending their life nor by clinging to life at all costs. Neither the patient nor his family are committing a sin by withholding or withdrawing treatment.
These are ethical issues as well as medical issues because the practical result of refusing treatment may be the death of the patient. Since all persons are made in the image of God, thus requiring respect for human life, each person deserves treatment in order to preserve his life. Yet Christians do not view life itself as the highest good and an end in itself. The believer may reach a point in his medical care where he has to consider the burdens and benefits of his care. However, the question is not, "How worthwhile is the patient's life?" This type of question focuses too much on quality of life issues and can easily deteriorate into premature termination of treatment. Rather, the proper question is, "Is this treatment providing medical benefits to the patient?"
The Sixth Commandment also implies the obligation to be very careful concerning human life. Under Old Testament law, even accidental killing of a human being by another human being required restrictions upon the one who caused the accidental death (Exod. 21:12-14; Num. 35:9-28; Deut. 19:1-10). The Parable of the Good Samaritan (Luke 10:25-37) teaches the obligation to "love your neighbor" by helping the neighbor who has genuine needs.
Therefore, withholding or withdrawing treatment is a decision that must be made cautiously. "Loving our neighbor" means using available medical treatment to preserve and heal human life, yet also recognizing that death ultimately will overwhelm any treatment.
The issue of withholding or withdrawing treatment often arises in connection with euthanasia, which may be either active or passive. Active euthanasia is the "active causation of a patient's death by a physician, usually through the injection of a lethal dose of medication." Active euthanasia is the purposeful ending of human life by introducing a toxic substance into the patient's body. Passive euthanasia is allowing a patient to die by withholding or withdrawing treatment. Euthanasia is also classified as either voluntary, where the competent patient himself expresses his desire to die, or involuntary, where the patient has not expressed his desire to die yet the patient's life is discontinued anyway. PAS is similar to euthanasia except that the physician provides the lethal medication (or knowledge of how to use lethal medication) for the patient or someone else to use but does not administer the lethal medication himself.
Active euthanasia in any form violates biblical teaching against murder, regardless of whether or not the patient consented to the action. The Sixth Commandment is an emphatic negative prohibition in the Hebrew text. Other biblical data, as presented in chapter three, also prohibits active euthanasia.
Passive euthanasia, however, is an ethical issue that Christians must understand. The principles of beneficence, nonmaleficence, and patient autonomy may combine to create a situation where a patient and his family will consider withholding or withdrawing treatment. Whether the medical treatment itself is useful is a valid subject for analysis, even if the withholding or withdrawing of that medical treatment might hasten a patient's death.
Withholding or withdrawing treatment must also consider the issue of motive, which is "the sense of need, desire, fear, etc. that prompts an individual to act." Motive is relevant, but not decisive, in end-of-life decisions. For example, family members may wish medical treatment withdrawn or withheld because the treatment does not provide any benefit to the patient. Yet the physician believes that continued treatment will eventually be beneficial. Although the family's motives are sound, good motives are not the decisive factor nor enough to determine the appropriateness of a decision.
In another situation, family members may also wish medical treatment withdrawn or withheld because the treatment provides no benefit to the patient. On the surface, this seems ethically sound. Yet hidden motives may be a desire to obtain an inheritance sooner rather than later, relieve the family of the stress and burden of the patient, or even enact revenge over a past wrong done by the patient. Thus, the hidden motive is very relevant to the final decision.
Another ethical issue that increasingly factors into end-of-life situations is "privacy." In 1996, the U.S. Congress passed the HIPAA law. These regulations restrict the range of individuals who may obtain information about a patient. Normally, the patient must give specific permission for someone to obtain this information. Therefore, family members do not automatically have the right to health information about a relative. These restrictions may apply to end-of-life decisions by limiting the number of people who have accurate knowledge of the patient's condition and treatment and therefore limiting the decision-making process to a small number of people.
As society deteriorates and becomes more self-oriented (2 Tim. 3:1ff), more people will avoid their responsibilities to aging parents and also to newborn children who have birth defects or severe handicaps. These actions will place responsibility on others to care for these individuals, such as government programs and charity organizations. The desire for self-reliance and personal freedom and the pursuit of careers and hobbies will be a strong influence for people to accept some form of socialism as a means to solve personal obligations and end-of-life ethical issues. The biblical data overwhelmingly indicates that believers must understand the ethical ramifications of end-of-life issues in order to perform our responsibilities to the Lord and to our family and in order to maintain a testimony of integrity before the Lord and the world. The final ethical responsibility remains with the individual Christian.
