Healing & Autonomy Final
Biomedical Ethics in the Christian
NarrativeBy Paul J. Hoehner
Throughout the land, arising from the throngs of converts to
bioethics awareness, there can be heard a mantra,
…beneficenceautonomyjustice It is this ritual incantation
in the face of biomedical dilemmas that beckons our inquiry
(Clouser & Gert, 1990, p. 219).
Ethics as a theological discipline is the auxiliary science in which
an answer is sought in the Word of God to the questions of the
goodness of human conduct. As a special elucidation of the
doctrine of sanctification it is reflection on how far the Word of
God proclaimed and accepted in Christian preaching effects a
definite claiming of man. (Barth, 1981, p. 3)
Essential Questions
What are the four elements of a Christian worldview and how do they influence a
Christian approach to medicine, healing, and medical ethics?
What are the four principles of medical ethics and how are they defined? How can a
Christian appropriately use these four principles?
What is meant by specifying, balancing, and weighing the principles? How does a
Christian worldview influence how one defines and uses each of these four principles?
What is the four-boxes approach to organizing an ethical case study? What is the
difference and the relationship between the four-boxes approach, and the four principles
of medical ethics?
What are the four ethical topics that compose the four-boxes approach and what
questions does each topic entail? How does the four-boxes approach help solve ethical
dilemmas in a case study?
Introduction
Biomedical ethics, or bioethics, is a subfield of ethics concerned with the ethics of medicine and
the ethical issues involving the life sciences, particularly those raised by modern technologies,
such as stem cell research and cloning. The term medical ethics is closely related to biomedical
ethics but is primarily focused on ethical issues raised in the practice of medicine and medical
research, such as abortion, euthanasia, and medical treatment decisions (World Medical
Association, 2015).
Because the terms biomedical ethics and medical ethics are closely related and involve a great
deal of overlapping subject area, they will be used interchangeably to avoid confusion. The study
of biomedical ethics and medical ethics presents some of the most complex and controversial
challenges in applied ethics. The complexities of dealing with individual patients and the
intricacies of modern health care, coupled with the rapid advances being made in medical
science, present formidable challenges. For many health care workers, clinical ethical dilemmas
will often challenge their own settled positions, especially if they have not taken the opportunity
to reflect critically on their own moral presuppositions and how their own intuitive ethical
positions may be justified.
When one encounters the many ways the world and even portions of the Christian church
respond to ethical issues, it is easy to be tempted to think there are no right or wrong answers.
The complexity of these issues and the myriad of answers and justifications given by so many
experts can drive many students toward some form of ethical relativism.
There are certainly many complexities in health care ethics: competing ethical ideologies, beliefs
or virtues, different interpretations of the facts surrounding an issue, and differing approaches on
how to address these issues; however, one should not confuse complexity with ethical relativism.
These are two very different things. Relativism is the belief that what is right and wrong, good
and bad, true and false varies from time to time, place to place, and person to person. There are
no absolute standards of truth or morality (Cook, 1995, p. 726).
Coupled with the complexity of biomedical ethics is the loss of moral consensus in the medical
profession and society as a whole, whereby moral positions once taken for granted cannot be
taken for granted any longer. There are plenty of examples in the medical field: abortion,
contraception, euthanasia, suicide, and anything that has to do with sexual morality. This lack of
moral consensus is primarily a result of the cultural plurality that exists in many Western nations.
Cultural plurality is a term that simply refers to the sheer diversity of race, value systems,
heritage, language, culture, and religion. It is the simple observation that many cultures contain
people with different worldviews, ideologies, and moral frameworks.
One of the consequences of many pluralistic societies is an increased tendency toward
secularization. Secularized societies tend to relegate religious perspectives, and moral
frameworks based on those perspectives, to the periphery of public discussion or limit them to
the private spheres of life. According to most secularist thinkers, religious, spiritual, or faith-
based perspectives may play an important role in ones personal life, but they have no place in
the public square of politics, public education, law, or medicine, particularly medical ethics. As
Guinness (1983) notes, this results in a faith that is privately engaging, but socially irrelevant
(p. 79). Limiting ones faith, spirituality, or religion to merely private matters does not do justice
to the role that religious or spiritual worldviews play in deciding how to live and interact within
the world and society. Biblical Christianity stresses the role of the Christian in the world in
matters of justice as well as civil engagement.
Plurality, the fact that different worldviews exist side-by-side in a culture, needs to be
distinguished from pluralism, an instance of relativism. The distinction is important. Pluralism is
a philosophical or ideological statement that maintains that no single ideological or religious
claim is actually right; all truth claims have equal validity (Hoehner, 2006). The practical
result of philosophical pluralism is to deny any objective truth claim or deny that any objective
truth can ever be obtained. This leads many students to conclude that there can be no common
approach to finding right amid the many perplexing and complicated moral issues of the day.
In this postmodern and relativistic world, divine or even natural, given norms of moral behavior
are soon replaced by a form of morality based solely on ones own personal subjective views,
conforming the world to ones own feelings and desires. Instead of orienting ones behavior to an
objective standard beyond oneself (e.g., divine and biblical revelation), many in todays
postmodern society seek to orient norms and standards of morality to their own self-referential
existence (e.g., what one feels, intuits, or wills according to ones own needs, wants, or desires).
What is right and true has no reference outside of ones own personal experience and
feelings. What is right and true for one person may not be right and true for another. This can be
profoundly challenging and perplexing for the Christian health care worker attempting to insert a
Christian ethic into this social mix. Most people would never apply this way of thinking to
empirical scientific matters. There is an inconsistency in much of modern culture that holds
simultaneously to both relativism and scientism; however, this way of thinking is itself
incoherent and is generally only applied to issues of morality and religion.
While there are many different approaches to medical ethics, this chapter will introduce the four
principles approach to biomedical ethics and how they are used to work through ethical
dilemmas in health care. While there are many principle-oriented approaches to medical ethics,
the approach originally popularized by the 1970 publication of the book Principles of Biomedical
Ethics by Tom Beauchamp and James Childress is unarguably the most influential.
Centered on the four core principles of beneficence, nonmaleficence, respect for autonomy,
and justice, Beauchamp and Childresss (2013) principle approach is currently considered to be
the dominant framework for discussing issues in biomedical ethics, at least in this country, and
one of the most important methodological inventions of modern practical ethics (Lee, 2010, p.
525). DeGrazia (2003) acknowledges that, one would be hard-pressed to find a text that has
been more influential and more frequently cited (p. 219). It is important and necessary for
anyone involved in medical ethics to understand the use of the four principles approach to
biomedical ethics, not because it is the only framework used for medical ethics, as there are
several others, but because of its near universal influence and status in modern-day medical
ethics discussions, in hospital ethics committees, and in managed care.
One of the most important aspects that must be understood in using the four principles is that
these four main principles do not immediately and directly provide a solution to most ethical
dilemmas. It is not always clear how each of the four principles are to be applied or what their
implications might be. More importantly for the purposes of this chapter, it also requires
interpreting themwhether consciously or notin terms of a particular worldview, philosophy,
and/or ethical theory. For example, in a specific medical ethics case, beneficence may mean
something very different for a Christian than for a Muslim or philosophical utilitarian.
Many of these different meanings are assumed rather than subjected to critical reflection. For this
reason, this chapter will begin with a discussion of how the Christian worldview, as informed by
the biblical narrative, understands the concepts of health, wellness, and disease. The biblical
narrative is the context by which the Christian justifies how one specifies, defines, and interprets
the four principles in light of specific cases, and provides the Christian health care professional
with an accurate and consistent normative guide for the ethical and moral uses of medicine and
medical technology within a Christian worldview.
Medicine and Medical Technology in Biblical
Perspective
As discussed in Chapter 1, in the Christian worldview, the ultimate foundation for determining
the right, the good, and the just is the triune God. The triune God is the ultimate foundation of
reality, including ethics. Moral goodness and justice are derived from the very character of God.
God is holy and set apart (Leviticus 20:26, English Standard Version), so people are to live lives
of holiness and goodness. God is love (1 John 4:1011), and so love is a virtue and an essential
principle for life and relationships. Because God is just toward people (Deuteronomy 15:15),
they are to act justly towards the poor, the sick, and the disenfranchised. People are to live in
covenant faithfulness to their spouses and to honor covenantal relationships in their professions
(e.g., the doctor-patient and nurse-patient relationship) because God is a covenant God, faithful
to his people, even when they were unfaithful (Hosea 13; Malachi 2:10,14).
As discussed previously, all ethics flow from ones worldview and its basic assumptions about
ultimate reality. Ones view of human nature, the fundamental problem of humanity, the solution
to that problem, and the ultimate direction and goal of history will determine personal ethics.
Every worldview embodies these elements in some sense, and the substance of these elemental
conceptions influences everyones moral vision. These assumptions deeply influence what one
believes to be the right, the good, and the just, and they will direct, whether consciously or
subconsciously, ones individual daily choices and actions.
The Christian worldview, which is the focus of this text, is founded on the biblical narrative or
story. This narrative is often summarized as the story of the creation, fall, redemption, and
restoration of human beings, along with the entire created order (see Figure 3.1). This section
will examine how key concepts within this narrative, such as sin, righteousness, and Shalom,
provide a framework by which the Christian worldview understands the concepts of health and
disease and life and death, as well as provides guiding norms for how one should approach
healing and care-giving, the ethical use of medicine and new medical technologies, and justice in
health care.
Figure 3.1
Biblical Narrative and Christian Worldview
Creation
The Christian narrative of creation is essential for both Christian theology and for Christian
ethics. At the foundation of the biblical narrative is the Christian God who is the creator of
everything that exists (Genesis 12). The most important aspects of the biblical view of creation
are the following:
1. Nothing exists that does not have God as its creator (Colossians 1:16; Revelation 4:11).
2. There is a clear distinction between God and his creation (God transcends creation). At
the same time God continues to be involved in every aspect of creation, providentially
directing and guiding all things that come to pass for his purpose and design (God is
immanent within his creation).
3. God is neither dependent on creation nor is creation necessary to God.
4. Gods act of creation was intentional; everything exists for a purpose, not accidentally or
randomly.
Implications of the Biblical Narrative of Creation for Health Care Ethics
Several aspects of the biblical view of creation give substance and direction to ethical issues.
First, the biblical narrative of creation is the account of a good God who creates a good world
(Genesis 1:21) with human beings at the apex of his creation. When God described both his act
of creating and the creation itself as good, it meant that it was valuable, and everything in its
original state was the way it was supposed to be. The goodness that remains in the world even
after the fall reminds one that God has called humans to live in his world, not to abandon or
reject it. There is a harmony and orderliness to creation and the physical world, the human body,
and the institutions of culture and society, and these are good gifts of the creator God.
Second, man and woman are created in the image of God, a concept that was discussed in
Chapter 2. As stated in that chapter, various ideas for what the image of God in humans actually
is have been proposed by theologians and philosophers throughout history. Nonetheless, there
are clear relational and dynamic aspects entailed in the image of God that give rise to
implications that are generally affirmed across Bible-believing churches and organizations.
These implications are important for a Christian view of ethics.
Being created in the image of God implies that humans are set apart from the rest of the created
order and provides a foundation for the intrinsic dignity and value of all human beings. All
human beings, without exception, have an intrinsic dignity and value that is to be protected in
every stage of life. Whether in health or sickness, with mental or physical disability, from its
formation in the womb through the sometimes-debilitating effects of old age, humans have
intrinsic value. The Benedictine monk Illtyd Trethowan (1970) expresses this beautifully:
To love people because they are creatures of God, reflections of God, is the only way
to love them as they really are. To say that they are Gods creatures is not just to mention
an interesting fact about them. It is the essential truth about them. They have value indeed
in themselves, but only because God gave it to them. Unless we see God in them as the
source of value, we should not really see that they had it. (p. 84)
It is also the foundation for distinguishing human beings from other species or kinds. Only
human beings are created in Gods image That the dignity is intrinsic means that moral dignity is
not dependent on any capacity or specific characteristic or attribute that a human being
possessesthere is no distinction, for instance, between being a human being and being a
person. To be sure, human beings can be distinguished from other animals based on certain
capacities, characteristics, or attributes, but this is not the foundation for their being in Gods
image. This means that all human beings have equal moral worth. Dignity and moral worth are
conferred on all human beings by God who has created them to be in relationship with him, to
reflect him, and to represent himself in the care of his creation. This applies from a persons
physical beginning, to their physical death, and beyond.
To say that all human beings have intrinsic moral worth and dignity is to say that it is morally
wrong to use one person for the mere benefit of another. One cannot say that one kind of human
being, or a certain human being that lacks certain attributes or capacities, is of less moral worth
than another. It is morally wrong to use another human being (or a class of human beings) as an
end to someone else’s purpose. That is why Christian ethics views certain biomedical and
medical practices, such as embryonic stem cell research, as immoral because it is using another
human being (even a human being that is still an embryo) as a means to another end, even if that
end is providing medical advances that may help many othersemphasis on may.
To justify any act merely because it results in overall good on balance is a theory that is foreign
to Christian ethics (i.e., utilitarianism). To accept this way of moral reasoning, one would have to
say that things like experimenting on people without their consent is morally acceptable because
those experiments will bring greater good to more people. This thinking has been used to justify
many of the atrocities committed in this and the past century in the name of producing good
things for many people (e.g., the Tuskegee syphilis study).
Third, the biblical narrative of creation provides a foundation for the care of Gods creation. Just
as God in his providence cares for all creation, so humankind is given a cultural mandate to
represent him in the care of his creation. As created image bearers of their Creator, humankind is
to reflect Gods character, do his will, and rule on earth on his behalf as stewards and vice-
regents. The discovery of Gods creation through the use of God-given intellect and curiosity is
part of that cultural mandate. Medical science is part of the discovery of that created order.
Human rule over Gods creation, however, is never absolute, but moderated service. It is always
subsumed under the higher rule of God and for his glory alone. Humankinds relationship to
creation is one of covenant-stewardship, not co-creator. It is a stewardship that must be used for
Gods purpose, not humankind. Part of that cultural mandate is reflected in the proper use of
medical science.
Finally, the biblical narrative of creation affirms that there is an order to creation, that everything
was how it was supposed to be and how everything ought to be. This state of order and peace can
be described by the term Shalom. Yale theologian Nicholas Wolterstorff (1994) describes
Shalom as the human being dwelling at peace in all his or her relationships: With God, with
self, with fellows, with nature (p. 251). Cornelius Plantinga (1995) describes Shalom as,
universal flourishing, wholeness, and delighta rich state of affairs in which natural
needs are satisfied and natural gifts fruitfully employed, a state of affairs that inspires
joyful wonder as its Creator and Savior opens doors and welcomes the creatures in whom
he delights. (p. 10)
Moreover, there is a creative normative design that provides a Christian vision of health and
flourishing. The concept of Shalom offers a glimpse into the multidimensional view of biblical
understanding of health and how healthy persons should function. Health is not merely about
physical or biological functioning, but also encompasses the spiritual and communal dimensions
of what it means to be a human being created in the image of God. Walter Brueggemann (2001)
highlights this multidimensional view of health as Shalom:
Health refers to stability enough to share in the costs and joys, the blessings and burdens
of the community. To be healthy means to be functioning full in terms of the norms,
values, and expectations of the community. Healing refers to the restoration and
rehabilitation of persons to their full power and vitality in the life of the community.
Sickness, then, does not refer primarily to physical pain as much as to the inability to be
fully, honorably, and seriously engaged in the community in all its decisions and
celebrations. (p. 199)
Communal and relational aspects of health are just as important as the physical and
psychological.
The spiritual dimension of all human beings cannot be disassociated from the physical
dimension, as if it were a separate part of the person. Human beings are not only a physical body
(i.e., atoms in motion, a concept referred to as monism or physical reductionism), instead they are
multidimensional beings that are a unity of a body and soul. The biblical account of creation
describes Adamand all subsequent human beingswith the Hebrew term nephesh, which
means either ensouled bodies or embodied souls. This has important ramifications for health
and healing according to the biblical narrative of creation. Health and disease involve all
dimensions of the person at once, the body and the soul. Furthermore, the biblical narrative
describes human beings as relational, embodied spiritual beings.
As will be discussed in the next section, sin and the fall affect all aspects of a human being: the
body, soul, and its relationship to others and the world. This is the biblical foundation for
the biopsychosocial-spiritual model of health and healing, whereby wellness is concerned with
and defined by not only the physical, but also the emotional, spiritual, and social wellness of
human beings (Sulmasy, 2002).
The Fall
According to the Bible, the fall has universal and cosmic implications. Just as illness in the body
can be viewed as a break in the homeostasis of the bodys physiology, the fall and subsequent
separation from God broke the homeostasis of creation itself, bringing disease, sickness,
suffering, and death. These are all effects of the fall and not part of Gods original design. This
deviation from the normative design of the original creation affects the mind, body and spirit of
each human being. The death that sin brings to the world is not merely physical death, but
spiritual death, which is eternal separation from God.
Humanitys predicament, a predicament of humankinds own making, is not merely physical, but
spiritual as well, and both are intertwined and enmeshed because of humankinds deliberate,
spiritual rebellion and estrangement from God. Restoration and healing cannot be perceived as
merely the return to physical health or psychological well-being, but requires spiritual and
communal restoration. Ultimately, it requires a renewed relationship with Goda renewal that
can only come by Gods own initiative.
Implications of the Biblical Narrative of the Fall for Health Care Ethics
The biblical narrative of the fall has several implications for a Christian view of medical ethics.
First, though Gods good creation still exists, humans can distort these good gifts and use them in
ways the Creator never intended. Science and technology are not unmitigated blessings. The uses
of science and technology are always impacted by the fall and, like all of life, need redemption.
This does not mean that Christians are anti-science or anti-technology, but that they should be
discerning about the application of certain technologies that may seek to usurp Gods wisdom for
his creation. Understanding the current technological culture from a biblical perspective helps to
determine how one should react to many of the recent developments in bioscience.
To be as God, as the serpent put it to tempt Eve in the Genesis narrative, is to embrace the
false expectation that something else is required other than Gods image for human fulfillment,
and that something else is fully achievable by man apart from God. For many, modern
biotechnology has become a false hope that will one day lead to that fulfillment and the ideal
human condition. Christians are not called away from modern biotechnology, especially that
which holds out promises to relieve the suffering and pain of fellow human beings in this fallen
world. But its use must always be constrained by Gods wisdom and direction, a gift of his good
creation, and the realization that physical illness and disease is only one dimension of
humankinds total predicament, which is fundamentally a spiritual rebellion and separation from
God (Hoehner, 2008).
The fall is also a warning about utopian perceptions of the world and humankinds efforts to
change the way things are. Self-deception and sin occur side-by-side in the story of the fall
(Genesis 3:1213). In the same way, utopian attempts to achieve justice, goodness, and perfect
healtheven beyond perfect in terms of enhancement of the perfecthave resulted in tragic
injustices and evil precisely because of self-deception and sin resulting from the fall. A Christian
ethic grounded in the biblical narrative will always hold together these two dimensions of human
nature:
1. Wonderfully made in Gods image with the potential for great works of mercy and
kindness toward one another, and
2. Terribly fallen in rebellion against the wisdom and design of their Creator with the
capacity for the greatest of evils.
Redemption
Because the fall not only has personal consequences, but universal and cosmic consequences,
redemption has universal and cosmic consequences as well. The brokenness and estrangement
that resulted from the fall is being restored. The restoration of Shalom, or peace, is a central
theme in the New Testament explanation of the ramifications of redemption. It is precisely
through justification, being made right again with God and his holiness through Christ, that
Shalom is reestablished between believers and God. The Shalom between believers and God is
the foundation for restoring Shalom in creation. The New Testament affirms that all things,
whether on earth or in heaven are brought back into Shalom through Christs atoning death on
the cross (Colossians 1:20), and that the creation itself will be set free from its bondage to
corruption and obtain the freedom of the glory of the children of God (Romans 8:21).
Just as the concept of Shalom in the Old Testament has implications for salvation (Isaiah 43:7;
Jeremiah 29:11), for bodily health (Isaiah 57:18; Psalm 38:3), and for communal well-being and
blessing (Numbers 6:24ff), and the New Testament gospel of peace (Ephesians 6:25) also
brings renewal to the whole of human and creational relationships. It is the beginning of the
restoration of all that was lost in the fall. According to J. I. Durham (as cited in Beck and Brown,
1976), the peace spoken of in the New Testament is a comprehensive fulfillment or completion,
a perfection of life and spirit which transcends any success which man alone, even under the best
of circumstances, is able to attain (p. 778).
Implications of the Biblical Narrative of Redemption for Health Care
Ethics
The restoration of Shalom that is the consequence of Jesuss life, death, and resurrection has
several implications for Christian ethics and the Christian view of disease, healing, and death.
First, it provides the motive for Christian ethics. Christian ethics is primarily an ethics of love. It
is one of gratitude and response to what God has already done. And while Jesus work of
salvation does not depend on mans efforts or goodness, it does not leave a Christians life
unaffected. God also works to renew an individuals heart, mind, and actions; therefore,
Christians should be more just, loving, merciful, and faithful because of the work of God within
them. Christian ethics is not merely individualistic, instead it spills over into social realities as
well. Christians should be empowered to work for justice and peace in all aspects of the world
and society, including issues of poverty, social injustices, racial reconciliation, and
environmental concerns.
In addition to its spiritual aspects, redemption also has physical dimensions. Jesus came to
redeem the whole person as a complete biopsychosocial-spiritual being; therefore, there is a
strong relationship between health and salvation in the New Testament. Jesus, as the ultimate
healer, is called soter, a Greek term that can mean both savior and healer. When Jesus heals
a paralyzed man, those watching were surprised to hear Jesus first say, your sins are forgiven
(Mark 2:5). There is both a spiritual healing and a physical healing. Most of Jesus miracles
during his life had to do with physical healing. In his healing miracles, Jesus life witnessed to a
beginning of the reversal of the effects of the fall.
Two caveats are in order when evaluating the healing miracles in the New Testament. First, one
must understand the purpose of Jesuss miracles. The miracles of Jesus and the Apostles in the
New Testament serve two primary purposes. On the one hand, they are powerful testimonies to
the truth of Jesus message of the gospel. They were signs of not only his divine nature, but also
of his divine authority. On the other hand, they were foretastes of the ultimate physical salvation
that would come to all believers, but only at the final resurrection. One could say it was a
breaking in and demonstration of the final restoration that will come after death. At that time the
bodies of Christian believers will be resurrected and renewed in eternal and perfect health and in
eternal fellowship with God.
Christians affirm that God has power over illness and death and can, as he chooses, provide
miraculous healing and recovery. But these miracles, which God uses for his own purposes, are
not something that can be expected as a test of faith or as a direct result of prayer, as if God can
be manipulated. Prayer can never be used like a secret incantation or spiritual therapeutic
regimen. Faith and the gifts of God in creation, including medicine, biotechnologies, and the skill
and judgment of physicians and nurses, are not opposed or set against one another. Faith is not
opposed to reason. Nothing in the traditional, historic Christian worldview gives such priority to
faith healing to the extent that it ignores good medical care. This form of faith healing is not part
of the traditional Christian worldview, although it appears in many sects of Christianity.
A second caveat is to recognize the relationship between sin, illness, and healing. According to
the biblical narrative, there is a connection between sin and the physical brokenness in this
world, a brokenness that includes disease and suffering. All illness and suffering are a
consequence of the fall in a general sense. This does not mean one can reason from specific sins
to specific illnesses or diseases; however, there are the exceptions of physical sins that lead to
their consequences, such as substance and physical abuse. When a man born blind was brought
to Jesus, religious leaders asked Jesus whose sin was responsible for the mans blindness. Was it
his own or his parents? Jesus, before going on to heal the mans blindness, gave a surprising
answer. It was not that this man sinned, or his parents, but that the works of God might be
displayed in him (John 9:3). There are two lessons in this story. First, one cannot directly link
specific spiritual sins to specific physical illnesses. While in general, all spiritual brokenness
results in physical brokenness, one should not equate the guilt of any sin with illness as a specific
punishment. Second, Jesus shows that God does use even the brokenness of a fallen world for his
own good purposes. Through Jesuss own suffering, suffering is given a higher meaning and
purpose that witnesses to the spiritual redemption that Jesus brings. God can transform suffering,
illness, and even death for much grander purposes in this world. Christian believers have an
assured hope of a full and complete healing in all their biopsychosocial-spiritual dimensions
when Christ returns.
As followers of their
