Biomedical Decision Making: The Blessings and Curses of Modern Technology

Introduction

The debates are everywhere. “60 Minutes” tells us euthanasia is common (although technically illegal) in Holland. Physicians argue whether placing a baboon’s heart in an infant girl is good medicine. Proabortionists fight to protect their current legal advantage, and the rest of us fight to overturn the 1973 Supreme Court decision that legalized abortion on demand.

In vitro fertilization, surrogate motherhood, artificial insemination, prenatal diagnosis and surgery, organ transplants, mechanical life-support systems, and many other advances have made the biblically ordained three score and ten years almost a certainty—even for many of the severely handicapped and ill. And yet, because of the ethical questions involved, it is sometimes difficult to identify these same technological advances as blessings or curses.

Today technology can maintain biological life for months and years even after brains have long since ceased to function. Do we keep the physical body going even after the person we once knew is no longer “there”? We find ourselves in a spiritual far country where signposts telling us what direction to take in the cases of severe suffering and disability are written in an unfamiliar language—if they exist at all.

The stakes are high. Christians hold individual life to be sacred, of inestimable worth before God. Yet Christian theology also teaches that death is not the ultimate enemy and that physical life is not the ultimate good. As science draws closer and closer to reducing life to a test-tube variable, the inevitable questions about who decides the questions of life and death, and the priorities placed upon those decisions, loom large.

Theologians, physicians, and pastors struggle to develop guidelines to deal with the problems. The struggle is well-intentioned, but fraught with difficulty. Hospital guidelines sometimes fail. Christopher Reilly, a New Jersey gynecologist, recalls a recent incident: “A man was doing poorly in one of our hospitals just a few weeks ago. He had a malignancy and his bowels were not working. The doctors had an evening meeting. Based on this man’s living will, which asked the physicians not to use any unusual measures to prolong his life, they decided that in the morning they would pull the tubes. The next morning the attending physician went in to do this and found the man doing quite well. Four days later he went home relatively healthy and made the doctor’s committee sit back and reevaluate what they were doing.”

Left with this uncertainty are the individual decision makers—those of us faced with seemingly impossible situations. And it is for these individual decision makers that the Christianity Today Institute convened a forum made up of a physician, a theologian, and an ethicist to discuss the elements that go into a difficult medical-ethical decision. The discussion was based on the premise that although theologians, doctors, and pastors advise Christians about what course to take, it is the individual who is finally faced with the awesome responsibility to say no, yes, or wait.

The panel members did not talk about easy decisions, situations for which a clear consensus has developed in the Christian community. Abortion on demand, infanticide, and euthanasia have been sufficiently analyzed so that a Christian response is clear. On the contrary, panel members discussed the impossible decisions, those with seemingly no right answer; where the decision maker is confronted with choosing between the “lesser of two evils.” In the end, the forum dealt with those decisions that can send us home wondering if we did the right thing, decisions that often leave neither peace nor contentment, only guilt and nagging doubt.

What are the biblical principles we must apply to those situations? How does Scripture serve us in these times of uncertainty and need? These are the questions our panel addressed, in general discussion and in three case studies.

Paul Brand served as a missionary and surgeon at the Christian Medical College in India for 20 years. Currently he heads rehabilitation at the U.S. Public Health Service leprosy hospital in Carville, Louisiana.

Millard Erickson is dean and professor of systematic theology at Bethel Theological Seminary in St. Paul, Minnesota.

Hans Tiefel is professor of ethics in the religion department at the College of William and Mary, Williamsburg, Virginia.

Kenneth Kantzer, chancellor and former president of Trinity College, Deerfield, Illinois, and dean of the Christianity Today Institute, moderated the forum.

I. Biomedical Decision Making

Why is it difficult? • How do we deal with polarization?

Kenneth Kantzer: What makes biomedical decisions so difficult?

Millard Erickson: There’s so much new ground. On many ethical questions, Christians have years of answers and commentary to work with. But on these questions, there is an immense amount of new data. Technology has created new problems.

Hans Tiefel: We have no direct guidance from our traditions. We can’t look in Genesis or Jeremiah or Matthew. There just wasn’t anything like in vitro fertilization then. The Bible and our traditions do supply guidance, but we have to work hard to apply that guidance.

Paul Brand: I was born before it was known that women ovulated only one day per month. And yet, all the natural laws scientists are discovering are part of God’s original design. We must, therefore, control these discoveries by using God’s principles as set forth in Holy Scripture.

Tiefel: Another factor complicating bioethical decision making is modern culture. Culture creates many obstacles to thinking about these issues in the light of faith. Too often we think about religion as citizens or as secular people.

Kantzer: Give us an example.

Tiefel: The common notion that religion is just for the inner life—a dreadful notion. The result is to relegate religion to how you feel. This kind of individualization puts religion on the fringes of life.

What religion means in biblical traditions is that we are to confess Christ at the very center of life—in politics, economics, money, vocation—and bioethical decisions.

Brand: I can think of a third complication relating to bioethics. There is a tremendous tendency these days to think one has to be extreme Right or extreme Left on every issue. It makes it very difficult for us to look at some of these decisions clearly and in a balanced way.

Kantzer: Is that any different today than it has ever been?

Brand: There’s something about the way our society works that encourages polarization. It’s easier today to focus our society on single issues than broad policies. I’m an environmentalist, but I get disturbed at the extent to which environmental organizations will sometimes press for policies that are obviously economically unfeasible. But to be effective, they think they’ve got to go to the extreme.

Kantzer: How do we face this polarization?

Tiefel: We cannot cut each other off on the human or caring level. The test of a genuine Christian community is the ability to disagree and still love one another.

Kantzer: Is it possible that some polarization is an attempt to control what is uncontrollable—an attempt to reduce complex situations to black and white terms?

Erickson: I think so. We get nervous because we don’t always see clearly the correlations between our biblical principles and the issues of the day.

Ii. Scriptural Principles

What is man? • Human relationships and the image of God

Kantzer: How do we determine what scriptural principles apply to difficult medical decisions?

Brand: The basic question for the Christian is, What is man?

The answer: Man is qualitatively different from the rest of creation. Therefore, man is sacred.

But is life itself sacred? Albert Schweitzer was a wonderful example of dedication to medicine. To him, all life was sacred. He wouldn’t knowingly kill a bedbug. Life was created and set in motion by God, and therefore inviolable.

I don’t reject Albert Schweitzer’s reverence for life—he was expressing a deep appreciation of God’s creation. And any form of cruelty to animals is antithetical to Christianity.

But that is not what we’re talking about in bioethical decisions. We are talking about human life. So the question is, How is human life different?

For years I have studied the muscles of the hand. But human muscle tissue is identical to muscle tissue in the elephant and the mouse. The elephant has more and a mouse has less, but the components are identical. So I am forced to ask, What is special about a human being? My muscles are not as strong as the muscles of a horse. My eyes are not as clear as the eyes of a hawk. My ear isn’t as good as the ear of my dog. I can’t run as fast as a deer. In almost every aspect of my human life I can find an animal that God created before me in which that particular thing was done as well or better.

The unique feature of the human is the mind—the one area in which we are separate from the rest of created life. When God said, “Let’s make man in our image,” he cannot have meant “in our shape” or “of similar flesh,” because God is spirit and not confined to any shape. God is spirit, so the image of God must have a spiritual basis. Therefore, he must have meant he was going to allow his human creation to be a vessel, the temple of his spirit. The spirit resides in the mind. When God said, “On the day you disobey me you will die,” he was not referring to the flesh, but to the spirit.

Now, this doesn’t matter very much as long as you can think of the human being as one—soul, spirit, body. But today in medicine it is possible to keep alive the body—the muscles, bones, blood vessels, heart, lungs—to the point where the brain is dead, where the spirit has been yielded up. Yet we somehow feel that because the body before us is in the shape of a human, that it is still a human being. Therefore, we feel compelled to keep it going.

Jesus Christ on the cross said, “Into thy hands I commend my spirit,” and he died. But his body remained there. Anyone looking on him superficially would say, “There’s Jesus.” But no longer is it the whole Jesus. It is the biological body, which is now without spirit.

Once the soul has left, once the immortal part is separated from the mortal, I don’t feel as a physician that I have a responsibility for treating that mortal body as something sacred in the same sense that human life is sacred.

Case History #1: Preserving the Braidamaged Life

Jimmy Barash was born prematurely with multiple severe complications, including respiratory distress syndrome (which once killed seven out of ten premature infants) and hydrochephalus, or a buildup of fluid in the brain usually leading to mental retardation. “When I heard that,” Paul (the father) recalls, “I told them [the doctors] I wanted Jimmy removed from all that equipment so that God could decide whether he should live.” But the doctor shook his head.

“Our job is to save lives,” he declared.

“I’m not telling you to destroy him,” Paul argued. “I’m saying, ‘Let nature take its course.’ ”

Jimmy did eventually go home. However, the high cost of his care—complicated by other medical crises in the Barash family, the resulting loss of insurance, and federal cutbacks in government assistance programs that would have helped the family—have left the Barashes nearly destitute.

“The doctors used to say to me, ‘Look, he’s fighting for his life.’ I said, ‘He’s not fighting for his life, you’re fighting. The machines are fighting!’

“I think Jimmy’s soul is trapped in that little body. But I don’t blame God for this. I don’t think God decides to give you a healthy baby and me a sick one. I blame man! I wanted them to take off the machines—then, if a baby lives, help the family to cope!”

Erickson: The case illustrates the success of the medical profession. But it also illustrates a failure of community, of our civic community. We have cut these people off and said, “I’m not responsible.”

Tiefel: It’s moral schizophrenia. We’re so keen on keeping handicapped newborns alive—and I’m glad we are. But then to cut back on Aid to Dependent Families or the various nutrition programs in schools and elsewhere is inconsistent.

Kantzer: Could Jimmy display the qualities of humanity or the image of God we talked about earlier?

Brand: A person with Down’s syndrome will often have a very positive human life. Even though the child isn’t able to go to school and learn math and so forth, he projects and receives affection. Many a family has found raising such a child a joy. The weak, the infirm, the handicapped, and the homely are a positive benefit to society. They teach us the meaning of living together and supporting one another.

Erickson: A comment in this case bothered me. The father says, “I wanted Jimmy removed from all that equipment so that God could decide whether he should live.” The assumption in that statement is that God doesn’t work through the various medical mechanisms.

Brand: But he is referring to Providence. God the Creator has arranged for the majority of the human race to be healthy. We can call it survival of the fittest, not in terms of evolution, but in the sense of keeping the stream of life—the DNA—intact. As generation follows generation, sperm or eggs with damaged DNA are unlikely to fertilize or be fertilized. If fertilized, spontaneous abortion is likely. Stillbirth is the next natural consequence. And finally, if the child isn’t stillborn, it is likely to die shortly after birth. That way, the broken DNA line is terminated.

Tiefel: But are you saying that nontreatment of some seriously handicapped newborns must be God’s will because it’s providentially already indicated? Nature doesn’t tell us life is good. It doesn’t tell us very much at all. We learn what is good from revelation.

Brand: Nature tells us life is wonderful.

Tiefel: No, it doesn’t tell us that at all. Nature can be destructive and flawed, and we use the best of our genius, creativity, and technology to improve on nature. We cannot rely on nature to tell us what to do. What is good about nature is what we know only from our faith. Nature doesn’t speak. We make it speak. And it’s our interpretation. It’s our meaning that we project into it.

Kantzer: Yet some things happen in the natural course of events that are good; and when modern science interferes, we can eliminate that good.

Brand: For example, earlier and earlier the children whom nature would have aborted are being brought to term with devastating handicaps. The more we interfere to prevent these spontaneous, natural abortions, the more they are born handicapped. One of the safeguards God has put into the whole system of procreation is that these defective DNA molecules are naturally discarded.

Tiefel: But that’s like saying many of the advances of medical science are interferences. Before we did blood transfusions prenatally certain childhood diseases were fatal. Now they are not—and perfectly normal children result. We would all say we are right to attempt to cure those fetal diseases.

Brand: Not all fetal diseases. Only those that are incompatible with human life. If by experience we know we get healthy children if they are treated properly, then by all means treat them. I would never say we shouldn’t interfere. If interfering results in good, we should do it. My question is whether we should interfere just because it’s possible to interfere. A stillbirth in the case of a grossly deformed fetus can be classified as providential. It’s part of a system that helps to insure that the race remains human.

Tiefel: But that seems such a subjective judgment. Tell me again what you mean by human.

Brand: The capacity to love, express love, and receive affection. But a person who doesn’t have a brain, a receptor, is not capable of that.

Tiefel: I agree that some spontaneous abortions are God’s will. Some may not be God’s will. Because the mother smokes or drinks or because she jumped off a cliff—I don’t want to let nature speak like that. I want to have critera consistent with what we know of God and Scripture.

Kantzer: Can we test for the presence of the soul?

Brand: There is no doubt in my mind. If a person has a totally nonfunctioning brain, is brain dead, then the soul is gone.

It becomes more difficult, unfortunately, when the brain dies a little at a time. As one gets older, for example, you may have a minor stroke. A little blood vessel gets blocked, a few cells become older, you forget things and start to become disoriented. Yet that doesn’t necessarily mean the soul has left. You get people with what we used to call senile dementia—no rational thought, memory, recognition, no consciousness of who they are. With these there is no well-defined point at which we can say the soul has departed.

But the fact that we cannot define it does not mean it doesn’t happen. And thinking this way has helped me make decisions when dealing with a terminal situation. That is, I ask myself: Am I still dealing with a person whose body contains his or her immortal soul?

Kantzer: So the distinction between human life and other kinds of life is not just physical?

Brand: No. I’ve worked with leprosy most of my life. In many countries, with many religions, people feel themselves cursed when their physical visage is destroyed by leprosy. Their faces are marred. Their noses have collapsed. They lose their fingers. These people feel they are an insult to God. That’s the danger of identifying God’s image with the physical.

We face the same problem in the way we view the handicapped. The handicapped child may have eyes that are too far apart, too big a tongue, and various other deformities. He may have no arms. Can that child possibly be in the image of God? Of course—so long as the child has a brain that can reach out and love.

Tiefel: I am worried that Paul Brand defines the soul and our relationship with God too spiritually. We should resist relating God’s image only to the soul or mind. For we are God’s image in our total being, in body, soul, and mind, as male and as female. A human face disfigured by leprosy not only grieves the leper but it grieves God. Such devastation will be healed in the resurrection, we trust. But even now, Dr. Brand dedicates himself to mitigating that disease. And in that care for human bodies he acknowledges the divine image and honors God.

A similar point holds for God’s relationship with us. God does not deal with us solely or merely as spirit or mind, but he loves us before we can think. The light of God’s love shines even into the darkness of the womb. As the care of parents precedes and surrounds any thinking or minding of their child, so our Lord would acknowledge love and care for us at the mindless edges of life.

Unhappily, evangelical Christians move too easily away from the body and our broken embodied existence here and now to an otherworldly realm of souls, where no one suffers from leprosy, genetic disease, or any bodily affliction. We should resist such escape and insist that this is our Father’s world, including the sick, misshapen, and very-much-in-need-of-redemption human bodies. We must not crowd God out of the bodily world into a soul-world, for God relates to us even when we are preoccupied, when we become senile and incapacitated, when we lose our minds or are still too young to have a mind of our own.

Such inclusive and bodily care should characterize the church. We instead assume that being prolife is sufficient. Yet God’s caring should be expressed in our physical ministry, too. Being prolife should include feeding the hungry, healing the sick, and voting for Aid to Families with Dependent Children.

Health, Medicine, and the Christian Tradition

The Early Church Fathers

Early Christian thinking about health and medicine took several different forms. Tatian strongly opposed medicine, arguing that those who used it (matter and worldly wisdom) would be subject to God’s punishment. This view was shared by Hippolytus and Arnobius, who regarded physicians as “earth born creatures not relying on true science.”

Tertullian viewed all illness as from Satan, but other Christian thinkers such as Irenaeus, Clement of Alexandria, Cyprian, and Ambrose believed illness could come from God as a means of testing and spiritual conditioning.

Thus, views on the appropriateness of the Christian seeking medical cures for physical illnesses varied widely—from Tatian’s outright rejection to Clement’s belief that medicine and the knowledge making it possible were the result of God’s providence and human effort. Clement’s disciple Origen, however, believed faith and medicine were, in fact, two alternative responses to illness. It was an ordinary human response (and quite legitimate) to resort to medicine, but better to turn to the higher, more spiritual curatives of prayer and devotion.

Iii. The Use Of Principles

The priorities in Scripture • God’s will and “misused” grace

Kantzer: How do these principles help us make difficult medical decisions?

Erickson: The biblical revelation gives guidance as to the priorities of these principles. For example, Scripture places a higher value on life than on property. When a child is trapped under a building, we don’t stop to count the cost of the building. We save the child.

Regarding the difference between infants and the elderly, several other principles come into play. There is a general concept in Scripture about fullness of life. Threescore and ten years is the number given, but I don’t think that is sacrosanct. However, there is a principle of a limit to longevity: the idea that one has had opportunities that others may not have had.

Brand: Although we need to think through the general principles, ranking their importance is very difficult. As a physician in India, we had one kidney dialysis machine for a population of hundreds of millions. And one hospital bed for a lifesaving operation, with seven or eight people who needed it. How do you choose?

Kantzer: Should expense be taken into account?

Brand: Yes. The case of kidney dialysis is a good one. It used to be very expensive. Its modern equivalent, perhaps, is the artificial heart operation. These operations are tremendously expensive, and we must ask the question of whether $100,000 for a single operation is the best use of that money.

Kantzer: You’re saying that in the case of a dying grandmother it’s not wrong to take medical expertise, economic considerations, moral judgments, and relational factors into consideration along with our specifically biblical ones. But it would be wrong to take all those factors and come up with a hard and fast formula that says the spiritual factor is worth three times as much as the economic factor, which is worth twice as much as the moral factor, and so on?

Tiefel: That’s part of the problem. When you say there are certain biblical principles that will help us decide specific issues—that makes it too easy. There are such principles. But every physician has two obligations: one is not to harm, the other is to heal. And they may be in terrible conflict with each other. Our biblical principles will not give us an answer—we still must choose. We still must apply the principles.

Respecting human life is a biblical principle. It always holds. But there may come a point at which that life is so hopelessly diseased and painful that the command to love, not to inflict harm in medical terms, takes precedence. The Christian, like anyone else, faces a dilemma: No matter what you do, you do something wrong. You have to give something up.

Erickson: We have to be as conscientious as we can be in ascertaining all the data, and the biblical considerations, and so on. But we will not do this infallibly. Even if we have absolute truth we don’t understand it absolutely.

Tiefel: I take that to be at the heart of these difficult situations. They’re difficult not just because we don’t know what to do, but because when we make a hard choice, we do something wrong. There is no beautiful system of principles we can construct. You make your decision as best you can in the light of what you know about God—and with a lot of prayer. But when you finally come up with the decision, you don’t say: Well, God tells me to do this one. No, you say, I’m the one who chose this one. It’s my decision. And I’m not off the hook. And so help me, God, this is what I’m going to do.

As to enthanasia, there does come a point where we ought to stop trying to keep a human being alive.

Another way to state the conditions: When we can no longer offer effective care, when care cannot be received, when care will not do any good, when the condition is incompatible with life. But we decide to stop treatment. And no one can absolve us from the risk, responsibility, and guilt such decisions involve. Here, too, we live by forgiveness and not by the correctness of our decisions.

Erickson: I agree. But the obvious danger is drawing the line. I had a doctor in my congregation who was in physical medicine and rehabilitation. One of the things I learned from him was the variety of ways people respond to their disability. He had one typist who had a little problem with her thumb. She could barely function. She felt disabled. He also had an engineer who had polio, couldn’t breathe for himself, but he could move his head and talk. The Honeywell corporation paid him to lie on his back, reading articles they projected on the ceiling.

Tiefel: Earlier, Millard, you mentioned a sense of the tragic, a sense of limits, a sense of having to live with the consequences of our decision making. We tend to say there’s always grace, there’s always forgiveness, there’s always a chance for a new start. That’s an optimistic, American version of the gospel. It’s true, but unless we balance it with an equally important gospel truth—that we are responsible for our past—we will never come to grips with difficult ethical decisions.

Brand: The only thing a Christian can do is consider the whole situation: the quality of the patient’s life, the people who depend upon him or her, the time they have left. We must think about all these things and then pray—seeking the guidance of the Holy Spirit.

I take issue with your statement, Hans, that you’re bound to do something wrong. I believe if you really submit it, seek the will of God, and say, Lord, this is all I’ve got, help me to decide, I think you can make a correct decision.

Tiefel: God is holy. We are not. We ought to be careful about identifying God’s will with our own. And we tend to do that all the time. “Thus speaks God” is an awesome preamble. When the prophets said that, they were speaking in selfjudgment. I want to keep that element of selfjudgment.

God is really like a parent here. You might say to your son, “I’ve taught you to be a responsible human being and a Christian. On these decisions, we can talk about them, to be sure; but you’re on your own. I’m not going to tell you what to do.”

In these very hard choices God does not tell us, “Do X.” He’ll do the sorts of things you’ve done for your son: he’ll support, he’ll forgive us if we make wrong choices. But we are on our own.

Brand: God has a way of allowing us to begin with principles as we understand them: principles of righteousness, principles of godliness as revealed to us in the Scripture. Our interpretation of them—thoughtfully, humbly, and pray-fully made—is reliable.

Health, Medicine, and the Christian Tradition

Saint Basil the Great

Saint Basil the Great (A.D. 330–79), bishop of Caesarea, was a great defender of orthodox, trinitarian faith. Born into a wealthy Christian family and very well educated in Athens, Basil entered the priesthood in 364 and became bishop in 370. His lasting contribution to the church’s attitude toward health and medicine was to place the two seemingly competitive cures—medicine and faith—into a relationship that would stand for centuries.

Basil suggested that there are six explanations of illness in God’s economy. Illness may be: (1) for our correction and discipline; (2) for our punishment; (3) from such naturalistic, physical origins as poor hygiene; (4) sent by Satan (as in the case of Job); (5) to allow the faithful to serve as models of fortitude for the weak; and (6) as for Paul, to keep us from transcending our creaturely boundaries. Basil thus recognized a natural basis for at least some illness, and allowed that for (1) and (3), it is appropriate to consult a physician.

Basil agreed that medical resources could be wrongly used, but that the Christian responsibility is to use them properly as “gifts of God.” Medicine should be used when necessary, “not making it wholly accountable for our state of health or illness, but as redounding to the glory of God and as a parallel to the cure of the soul.” In this light, Basil claimed that for the Christian physician, “the science is ambidextrous,” addressing both “bodily ills” and “spiritual ills.”

Case History #2: The Surrogate Mother

Valerie is a New Jersey mother of two boys, aged two and three. Her husband works as a truck driver, and money is tight. One day last March, Valerie, 23, who prefers to remain anonymous, saw the following advertisement in a local New Jersey paper:

Surrogate mother wanted. Couple unable to have child willing to pay $10,000 fee and expenses to woman to carry husband’s child. Conception by artificial insemination. All replies strictly confidential.

After an interview at the Infertility Center of New York, a profit-making agency that matches surrogate mothers with infertile parents, her application was selected, and she was asked to return to the agency to meet the couple.

Aaron and Mandy (not their real names) had undergone years of treatment for infertility. They considered adoption, but were discouraged by the long waiting lists at American agencies and the expense and complexity of foreign adoptions.

Aaron and Mandy have agreed to pay Valerie $10,000 to be kept in an escrow account until the child is in their legal custody. In addition, they have paid an agency fee of $7,500 and are responsible for up to $4,000 in doctors’ fees, lab tests, legal costs, maternity clothes, and other expenses. In April, Valerie became pregnant after just one insemination with Aaron’s sperm. Mandy says she was speechless with joy when she heard the news.

Tiefel: What concerns me is the woman knowingly carrying a baby she has no intention of mothering—and another woman raising a baby she and her husband have arranged to have birthed from his seed but not her egg. I believe this creates tensions within that relationship.

Erickson: In one sense, it doesn’t violate the prohibition against adultery. There is no sexual intercourse, physical attraction, personal commitment, or lust. For the surrogate mother, it does raise the question of whether your mate, by virtue of the marriage vow, has exclusive rights to your organs of reproduction, whether there is copulation or not.

Surrogate motherhood differs in one significant point from artificial insemination by donor. In artificial insemination, the biological father is probably never identified. In surrogate motherhood, the mother is. That makes me uneasy, at least from a psychological point of view. When the child finds out about the arrangements, the possible repercussions could be great.

I think all other possibilities should be adequately exhausted first. This should be an act of last resort.

Brand: I wonder if the Christian family shouldn’t think more in terms of divine Providence when it comes to these areas. God has different plans for our lives, which may or may not include children. Adopt a baby when there is one available. We need to take care of unwanted children. But there must be limits to how far we should go in creating birth situations.

I don’t like in vitro fertilization, artificial insemination, or surrogate motherhood. I would counsel against them all. But we have two problems in connection with having babies: (1) Too many unwanted pregnancies, and (2) Too many people who want to be pregnant but can’t. The one problem can solve the other through adoption.

We need to encourage adoption rather than abortion. The church can be at the forefront of this. It gives our counselees an alternative to both abortion and these scientific gymnastics that are being tried out these days.

Tiefel: As parents we are often confused as to why we want children. The Bible doesn’t teach us to procreate ourselves but to reproduce carriers of the image of God. Do our reasons for wanting to be parents have anything to do with our confession to Christ, or do we have secular notions about what it means to be a parent?

Is surrogate motherhood an action that builds up, that points to God? Or are we increasing the chances of disrupting God’s commandments? It’s not clear. But we need to ask these questions from a broader, confessional perspective.

Adoption seems a far better choice. The argument that there aren’t many around to adopt is weak. There are many handicapped children and minority children that need parents.

Individualism penetrates our culture. Having a child that is, as much as possible, “my own flesh and blood” is an expression of the me-and-mine values that surround us. In a Christian context, on the other hand, we have bonds to children primarily because they are God’s children and only secondarily because they are our children. The notion of community, of being the body of Christ, should create bonds between a couple and a child not biologically their own.

We must make sure assumptions like that are behind all our bioethical decisions.

Iv. Outside Help

The role of physician and pastor • Anticipating the tough decisions

Kantzer: How does the decision maker integrate the wisdom of the physician into the decision-making process?

Tiefel: Guardedly. Let me give you a personal example. Our son was born with rocker bottom feet, and an orthopedic surgeon did three corrective surgeries. Our son was in casts for much of his first five years of life. Then the doctor decided on a fourth surgery. Yet, in getting a second opinion, we discovered there was another way to treat the condition. We went to a hospital in Salt Lake City, and my son was helped permanently.

The process taught us something about responsible decision making. We cannot just leave a decision in the hands of the physician. My wife and I trusted our first physician’s judgment. And he is competent. But we trusted too much.

Brand: Doctors have far too much authority—or take too much authority. And it isn’t entirely their fault. The public puts them on pedestals and expects them to know everything—and expects them to pay if they make a mistake.

But I’ll go a step further: The healing of the patient is far more efficient if the patient knows he’s calling the shots. The physician supplies expertise and advice, but the decision is clearly the patient’s.

It is important for the physician to make clear to the patient: This is your problem. You’ve got a wonderful body, a tremendous immune system, terrific white cells—all equipment God has designed for healing. I am going to tell you about it and offer certain treatments. But it is up to you.

Tiefel: I agree with what’s been said. On the other side, the physician, Christian or non-Christian, has his own set of values. He has a right to a judgment. And as a patient, I want his judgment. I want more than pure facts. I want him to tell me what he thinks I should do. Not that I will accept it, but at least I want his wisdom.

Brand: As long as we know it’s one man’s view.

Tiefel: Our culture has two incorrect models of who a physician is. One is the patriarchal, father-figure model we’ve been talking about. The other model, however, is equally dangerous: the idea of a physician as solely a dispenser of medicine. In this “consumer” model, we reduce the physician to the status of a car mechanic. To the contrary, medicine is still a profession dedicated to service.

Kantzer: What is the role of a spiritual counselor—a pastor, chaplain, or trusted friend?

Tiefel: On one level, it’s parallel with that of the physician. The spiritual adviser helps inform the decision maker of the religious values coming to bear on a situation. At another level, this person helps those paralyzed by fear and unable to make necessary decisions. The parents of a child just born severely handicapped feel overwhelmed by what has happened. Someone skilled in interpersonal dynamics needs to help them with their feelings of helplessness and rage.

Erickson: The pastor can play a significant role here. People need to think ahead: One of these days it’s going to happen to me. And at the time you’re in the middle of it, you’re not going to think clearly.

Hypothetical situations—what you would do—with key family members sometimes help resolve such situations: sketch out all the possible scenarios and ask them to comment on each. That helps get their view of the situation and of life. If it can be done before the crisis point is reached, so much the better.

Tiefel: Yes, and that doesn’t prevent a person from reversing his decision once he’s in the crisis. But you are still ahead if you have thought through the issues beforehand.

V. Anti-Christian Biases

The bias of language • Putting a price tag on life

Kantzer: Are there any anti-Christian biases in hospitals that the Christian decision maker must take into account when making a difficult medical decision?

Tiefel: Yes, several. The language medical professionals use tends to dehumanize and undercut Christian values. For example, we use the word fetus. Fetus is a biological term we share with the animals. It’s perfectly all right to use that kind of language in certain disciplines—in science you use scientific language. But medicine is a combination of care and science. And the caring aspect does not always come through in scientific language.

I realize I am just arguing over words. But I want to argue over words. How we pose a problem in many ways shapes the answer. Words are not neutral; they are the keys to the world. If we use the wrong language, we will never enter the Christian world.

Brand: But don’t you think that the public knows more anatomy nowadays and uses scientific terms more? For example, “womb” used to be a common English word, but today “uterus” is more commonly used. People are exposed to more scientific terms.

Tiefel: That’s precisely the point! We think education means scientific language. That’s a mistake. I expect you to speak that way because you are a professional. But there are also many other languages we use that have very different connotations.

I am not saying that doctors and physicians ought to always change their language. I’m simply saying that the Christian decision maker in a crisis situation needs to watch out. When doctors speak a scientific language, that’s not the only way of speaking or thinking. And recognize that the very language you use will color your thinking.

Kantzer: What’s another example of anti-Christian biases?

Tiefel: Cost and efficiency can be very utilitarian. There are limits to what we can spend, to be sure. But we must avoid asking about cost in individual cases. We can’t put a price tag on the worth of an individual life.

Vi. The Effects Of Decision Making

Asking the right questions • Creating role models

Kantzer: Any final thoughts?

Tiefel: I think the decision maker needs to ask himself, “Am I asking the right questions?” The press is not asking the right questions. Our culture is not asking the right questions. And too often even our churches are not asking the right questions. The language of the prevailing debate is not amenable to Christian reflection. Our questions should acknowledge that we live in a Christian community operating on principles that are antithetical to those of the world.

Kantzer: We haven’t been saying much about it, but my sense of church history bothers me about this absolute objection to polarization. At times the Christian has got to be absolutely polarized against a society in which he lives. The early Christians were.

Tiefel: Yes, but polarization should not mean that we no longer try to communicate with or understand each other. It’s not that we shouldn’t be opposed at some point. It’s just that we must be true to our traditions and be able to talk with each other—so we can care for one another. We must love those in the church with whom we disagree. And that’s where we are missing the boat.

Brand: How these decisions are made can have a great modeling effect. Janet Goodall, a pediatrician in Britain, tells the story of a Methodist minister and his wife who had a severely deformed infant. The prognosis for this kind of deformity is always death, and the infants are almost always kept in the hospital, where they are cared for and fed until death comes.

But this minister and his wife wanted to take their baby home. And they did. She breast fed him, and they gave him several months of life in a home filled with love.

The impact? It enriched their lives. It gave that child a taste of love and life—the consequences of which we can’t measure. But it did far more. It changed the pattern of treatment for other infants born with those defects. Several years later, a Christian surgical resident in the Department of Pediatrics at that hospital did a study and found that after this couple’s experience, more than 90 percent of the babies suffering this deformity and living for more than a week had gone home on their parents’ request. Caring for someone so helpless, dealing with grief and inevitable death, coming to grips with the deep problems in the context of their marriage—a clear majority of these couples were strengthened by this experience.

The decisions we make affect far more than just our own lives. They can change the very fiber of the body of Christ and bring us ever closer to the true realization of Christian community.

Case History #3: Deciding When to Die

June Horton is a 29-year-old mother of two small children, and the wife of a surgeon. For three years she has had an arrested case of leukemia, but now a crisis has arisen. She is in intensive care receiving chemotherapy, is extremely weakened, and struggling for her life.

The prognosis at best is three weeks to six months. She has not lost any mental capacity, but the chemotherapy has temporarily skewed her ability to communicate. To the degree that she is conscious, she is experiencing considerable suffering. In periods of lucidity, she appears to be struggling hard for life.

Her own treatment preferences, however, have not been openly discussed. Her husband, the surgeon, and her mother are determined that all viable forms of active treatment should continue. The remainder of her family, her father and brothers, are all convinced that the medications are only prolonging her suffering, and that she should be allowed to die.

Brand: We have a tremendous fixation on the importance of the continuation of biological life. For Americans, death is seen as a defeat—for the physician, for the medical profession, for you, and for the family. Even Christians behave as if it’s the ultimate disaster.

That’s pagan. The Christian ethic is different. For the pagan, biological life is all there is. A Christian view is rather like the apostle Paul’s soliloquy: I’d really like to die, because then I should be with Christ, which is much better. But maybe it’s important for me to stay a little while longer, because you, the church, need me.

Tiefel: However, there is a risk of people at the end of life thinking they may not be a burden to anyone. Our culture teaches individualism and independence. We are taught to do our best to spare others excessive medical bills or emotional trauma. There may be some very dehumanizing implications about laws designed to offer dignity to the dying.

Brand: Diagnosis and prognosis are imperfect at best. But I did not write my living will because I didn’t want to be a burden on society or that my family would have to support me. I simply do not want to prolong a terminal illness. Second, if my mental state is such that I’m not able to interact, or if my behavior is demeaning and gross, I don’t want to go on. That is demeaning to the concept of a human being. You no longer have dignity or personhood. I hate to think that my dear ones should have their final remembrances of me as being somebody who needs to be tied down or gagged. It isn’t euthanasia. I simply ask that if I get to that stage, I don’t want anything to be done to prolong it.

Tiefel: It’s a question of line drawing. I’m worried that the line may be drawn too early precisely because people are conscientious, precisely because they are Christians. We ought to be willing to bear with each other in our pain and in our miseries.

Erickson: There is a morally significant difference between the person who jumps off a bridge and the soldier who throws himself on a hand grenade to protect others. Their motivation is different. It really is a different act.

Brand: The Holy Spirit enables one sometimes to rise above the fear of death—with marvelous consequences for the rest of the Christian community. I’ve written elsewhere about Mrs. Savaryian, who was dying of advanced breast cancer. She knew it was terminal. She refused any medication that would make her unable to communicate with other people. She was one of the most inspiring examples of faith I’ve ever met. Visitors would stream into her room, ostensibly to comfort her, but actually to have their own faith strengthened. Her death came on Good Friday. It was one the people of her church were really able to rejoice about. I think God honors a commitment to allow Providence to take its course.

Tiefel: There is a time to say, “No more.” But I don’t want to make it all that benevolent. Suffering is a cross we may have to bear. It is not to be avoided at all costs. I wonder if we don’t have an implicit notion about happiness here. The happy life is not the goal of Christian existence.

Kantzer: Or a painless life.

Tiefel: Jesus said take up your cross and follow me. It may well be that a disease like this could be a cross we are supposed to bear for some time.

Kantzer: Behind our decision should be solid Christian instruction as to the meaning of pain and the discipline of life.

Tiefel: Some suffering, I don’t know how much, is compatible with the Christian life—as long as it is shared by the body of Christ.

Brand: I agree. We can handle pain spiritually in several ways: by rising above it or by sharing it. The church, hospital, and hospice all exist to help us deal with pain.

Tiefel: A common thought is that decisions like this should be directed by a notion called the quality of life. Does the life I will live under the strictures of this disease have enough quality to be worth the suffering? But generally, the idea of quality of life comes out of a culture that we may not want to avow as Christians. It is usually interpreted as how I feel about the quality of my life.

We are not called to feel good about the quality of our life. We are called to be obedient, to serve others, to love God, to share burdens. What does Jesus’ statement, “Come, take up your cross and follow me,” mean for the world’s perception of “quality of life”? The two don’t connect very well.

Health, Medicine, and the Christian Tradition

Enlightenment Thinkers

René Descartes (1596–1650), the French philosopher, mathematician, and scientist considered “the father of modern philosophy,” was a devout Roman Catholic, schooled by the Jesuits, who sought to attain philosophical truth without recourse to revelation. Descartes is probably the most appropriate figure to credit with the sharp division between the mind and body that has dominated not only our theology but our conceptions of medicine up to this day.

Descartes taught that the mind, or consciousness, is the true self, and is “intimately conjoined” with the body although distinct from it. Descartes, an enthusiast for the new science, saw nature as mechanistic and deterministic. The human body is fully a part of this world and can be entirely understood by scientific laws as a sort of “biological machine.” The mind, however, transcends nature.

This dualism, conjoined with the rise of the empirical sciences, yielded a new emphasis on scientific medicine, and the separation of physical ailments from the psychological and emotional aspects of a person. This perspective received impetus from Descartes’s contemporary, Francis Bacon (1561–1626), who saw knowledge as “a rich storehouse for the glory of the Creator and the relief of man’s estate.”

Bacon believed that speculative philosophers were like “spiders” who spun webs out of their own bodies, and that those in empirical professions (such as alchemy) were like “ants” in collecting unsystematic bits of data. The scientist, on the other hand, should be a “bee,” working in concert with other scientists to collect and interpret data and conduct experiments. This perspective energized and directed scientific investigation into all fields, including human health and disease.

Biomedical Decision Making: We Dare Not Retreat

KENNETH S. KANTZER

John Calvin warns us that most people agree on broad principles of right and wrong. It is only when they apply those principles to their own thought and life that they disagree.

His warning was splendidly illustrated by the Christianity Today Institute panel in its discussions on biomedical decision making. Rarely did the panel members—all holding to a biblical faith—disagree seriously on broad principles. If one member demurred from the statement of another, it was usually only to point out an important counter principle.

Not surprisingly, there was agreement among our participants that a human being is unique among God’s creation. In one sense, of course, all creation is sacred. Land, sky, and seas, and all therein belong to God and are entrusted to us with the provision that they will be used only for his good purposes. Yet human beings have a special status, for they are created in his divine image and are specially protected by him.

For this reason we cannot buy the antibiblical attitude toward human beings evident in the thinking that an unborn child can be aborted for the convenience of the mother. Neither can we accept—as in accord with biblical teaching—the planned abortion of a deformed or handicapped child. Handicapped persons are human beings.

It is as his image bearers—building relationships with those both inside and outside the church, and basing those relationships in the selfless love of Jesus Christ—that we are enabled to live in hope against the forces of sin in a broken world. Upholding the sacredness of the human being in the context of our servant relationship to both God and man gives us, then, the right perspective from which we can at least begin to grapple with the assortment of complex medical decisions facing us today.

That said, there was nevertheless no precise agreement on how these principles should be applied in the three cases we discussed. On biomedical issues, it became clearly evident that the Bible does not provide specific and sharply defined ethical rules to fit every situation.

For example, my wife’s father died in a hospital bed set up in our living room over the last months of his life. He proved a great joy and blessing to all of us. Near the end of that life, the doctor told us Dad would die in a few days if we kept him at home, but that he could live for weeks in an unconscious or a semi-conscious state if we took him to the hospital. My father-in-law could not indicate his preference, but the immediate family chose to keep him in our home. He died in two days.

Did we make the right decision? We believe we did. But decisions like this one are very difficult to make. Yet the relevant scriptural principles are clear. Conscious human beings are a sacred treasure. Merely to preserve the physical human body alive would not have high priority among biblical values.

“Right” And “Wrong”

Why did God not give us a complete and exact list of “rights” and “wrongs” defined precisely enough so there could be no mistaking his intent? The reason, I think, is very simple—although it has infinitely complex results. The goal of Christian ethics is not rigid adherence to a set of rules, but the divine creation of a kind of person—in biblical terms, a Christlike person of perfect love. For each of us, God’s goal is to make us morally like Christ.

A legalistic ethic that would merely seek absolute conformity to a set of rules would not necessarily foster love. God, therefore, chooses to create good people through a process of moral struggle—sometimes long and difficult. The Holy Spirit works in us through the experiences of life, leading us to understand and apply the principles of love to God and to our neighbor. He fleshes out these fundamental principles with the subprinciples, the sub-subprinciples, and the multiplied applications set forth in Scripture. This is all part of the method by which God molds us into caring and loving persons.

Unfortunately, such a process also means we make mistakes—even with Holy Scripture and the subtle persuasions of the Holy Spirit to guide us.

Of course, God forgives us, even when our mistakes are due to pride or our unwillingness to listen carefully to the voice of our Lord. And we likewise need to forgive each other for mistakes, as together we learn to love and care for one another. This does not mean we should refrain from condemning wrong and opposing wrong applications of the love ethic of the Bible. It does, however, mean we should gently understand and, in a spirit of kindliness and love, seek to get the church back on track—all the while recognizing our own failures and how often God has had to forgive us.

Though we are fallible and woefully awkward in the childlike steps by which we grow, our seemingly inevitable mistakes should not paralyze us. God loves us and he will forgive us. From one stumbling, hesitant step after another, he leads us patiently toward maturity.

We cannot avoid making moral decisions. To live is to decide. Even to thrust all responsibility on others is to decide. Life is a continuous path of decisions, and by these decisions God creates our character—for good or ill.

And we dare not, indeed we cannot, retreat from the awesome responsibility of the new decisions modern medicine is forcing upon us. At many points these decisions are exceedingly difficult. The issues are complex and often the principles we draw from Scripture seem to support opposite conclusions. Yet fundamental biblical teaching is at stake, and we dare not refuse to make hard decisions by retreating from life or refusing to assume moral responsibility for our actions.

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