Ethics

Issues in medical ethics are not just relevant for Christian health professionals who have to make difficult decisions in a world which is increasingly antagonistic to Christ and his Gospel; they are relevant to pastors and church leaders who have to counsel church members in difficult situations and also for any ordinary Christian who is seeking to live in obedience to God's Word.

Medical ethics are 'obligations of a moral nature which govern the practice of medicine'[1] - principles of conduct prescribing what we ought to do. In the not-too-distant past, at least in Western society there was a broad consensus about what these principles should be. They were formulated in such ethical codes as the Hippocratic Oath and its modern restatement the Declaration of Geneva[2] and despite the fact that such codes were framed and adopted by secular bodies they were nonetheless broadly consistent with the Bible. As recently as the beginning of the century there was a lot of agreement among health professionals about what constituted ethical behaviour. This is no longer the case.

Why is ethical decision making more difficult?

Both medicine and society have changed dramatically over the last century in ways that have made ethical decision-making much more complicated than before.

First, medical knowledge and technology have advanced astronomically. The general practitioner managing a case of lobar pneumonia at the turn of the century did not have to make a decision about whether or not to give antibiotics. There weren't any. We now have surgical operations for the patient with an aortic aneurysm, ventilators for the premature infant with respiratory distress and phenothiazines for the schizophrenic, and we have to decide whether to use them.

Second, because of the influence of the mass media, medical knowledge is less and less secret and more and more public property. An increasingly educated public knows what technology is available and is demanding it. This increased scrutiny is making our decisions more visible and our practice more accountable.

Third, the specialisation that has resulted from the increase in knowledge and technology available has meant a move to team decision-making. The solitary doctor at the bedside has been replaced by a team of subspecialists, a hierarchy of medical staff, a host of paramedical specialties and a vast array of technical and management personnel - each expert in his or her own small field.

Fourth, financial and resource constraints in the face of rapidly advancing knowledge and technology have meant that we have more acute decisions of resource allocation to make. What should our priorities be - heart transplants or hypertension, ventilators or venereal disease, geriatrics or gene therapy?

Finally, and most importantly, all this is taking place in a moral vacuum. We live in a post-Christian society where there is no agreement on the underlying basis for decision-making. The plurality of religious traditions, cultural backgrounds, world-views and ideologies makes any real consensus impossible. Tolerance is paraded as the supreme virtue in such an ethical environment but tolerance of mutually contradictory views is both ludicrous and unworkable when decisions have to be made. It's simply impossible to please all of the people all of the time - so whose view should prevail?

These factors combine to create a minefield of ethical conflicts for Christian health professionals. Every new advance in knowledge and technology creates new dilemmas and our patients have higher expectations. We have to make our decisions in an atmosphere of increasing financial constraint, increasing public scrutiny and in consultation with those who increasingly do not share our faith.

How does the world make ethical decisions?

Before looking at the Bible itself, it's useful to review the ways that non-Christians make ethical decisions, not just so that we can understand others better, but because many Christians fall into exactly the same traps in the ways they come to hold their own opinions about ethical issues.

What criteria do people use?

Gutfeeling - It feels right

The first is gut-feeling. 'This is right because it feels right'. In a society as obsessed with the pursuit of pleasure as our own it is inevitable that some people will believe that their emotions should rule their behaviour. Of course, having feelings is part of being created in the image of God (Gn 1:27), but problems arise when they are made the sole basis for decision-making. They can be perverted as in the case of the sadist who derives pleasure from inflicting pain on others. They may disagree - witness the passion felt by those on both sides of the abortion debate, and they may change. The girl who wakes up with a hangover and pregnant after a one night stand knows with certainty that what 'felt so right' wasn't right at all. 'The heart is deceitful above all things' says Jeremiah (Je 17:9). It is no guide to ethical conduct.

Reason - It's logical

The second is reason. 'This is right because it's logical'. If not the heart, why not then the mind? Can human reason be our basis for ethical decision-making?

Part of the problem with reason as a tool for decision making is that reason never acts in isolation. For example, in making a decision to treat a patient with pneumonia with antibiotics we are making a number of prior assumptions, not least that it is morally right to kill millions of bacteria in order to save the life of one sick person.

Reason alone won't help us in finding the answers to questions like this. If the underlying assumptions we start from are wrong then we will reach the wrong conclusions even if our powers of reason are faultless our conclusions will be flawed - and whose powers of reason are faultless? Even the best of minds are not always reasonable. God gave us minds to think but reason also has its limitations.

Conscience - But I don't feel guilty

The third is conscience. 'This is right because doing it doesn't make me feel guilty'. Our capacity to feel guilt is a reminder that we are fallen creatures, and there is no doubt that God can use conscience for our good. 'Train a child in the way he should go' says the writer of Proverbs (Pr 22:6). However conscience also has weaknesses as the only criterion for making moral choices. It may become blunted. Many of the Nazi doctors who presided over the killing of millions during the Second World War felt they had done nothing wrong. They were nonetheless judged to be guilty. On the other hand there is the danger that conscience may become oversensitive as in the case of the neurotic patient who is paralysed with feelings of guilt despite having committed no sin. Consciences also need educating. 'There is a way that seems right to a man but in the end it leads to death' (Pr 14:12). Men are capable of 'suppressing the truth' (Rom 1:18) and 'exchanging the truth of God for a lie' (Rom 1:25).

Consensus - Everybody's doing it

The fourth is consensus. 'What is right is what most people believe is right'. The desire not to appear different is a strong one, but majority opinion may not be correct. It was once believed that the earth was flat, that the sun revolved around the earth, that there was no connection between smoking and lung cancer. Every major scientific discovery initially has to challenge the status quo of incorrect consensus opinion. Furthermore popular opinion varies across cultures. Female circumcision is regarded as barbaric in England and civilised in parts of Africa - but opinions about abortion vary in the opposite direction. Consensus opinion may change over time within any one culture. Euthanasia for handicapped children, and the demented elderly is perfectly acceptable in Holland today, but during the Second World War many Dutch physicians willingly chose imprisonment in preference to being involved with it. Democracy may in fact just be a euphemism for mob rule. The Bible sternly warns us 'Do not follow the crowd in doing wrong... do not pervert justice by siding with the crowd' (Ex 23:2). Consensus opinion, after all, crucified Christ.

Consequences - The best outcome

The fifth is to judge actions as being right or wrong on the basis of their consequences. 'What is right is what leads to the best outcome'. But this raises several questions, not least that the end does not justify the means. In the 1970s Pol Pot successfully eradicated leprosy from Kampuchea (a noble aim) but he achieved it by diabolical means (killing the leprosy sufferers). In our own society we are attempting to reduce the level of handicap by prenatal diagnosis and selective abortion. Is this justified? Considering outcome alone also ignores the fact that motives are important too? What of the person who does the 'right' thing for the 'wrong' reason? Also the consequences of actions can be very difficult to judge, in fact they may not become apparent until years afterwards. The heavy drinker does not have cirrhosis foremost in mind - nor does the promiscuous student consider that his actions may be leading to gonorrhoea or emotional hurt. The Bible is full of stories of entire nations who remained blind to the consequences of their actions until it was too late. So using outcome as our criterion also has limitations.

Relativism - What's true for you

The sixth is to throw up our hands and say that right and wrong is simply a matter of personal choice 'What's right is what is right for you'. With the loss of a common consensus and the infusion into our culture of an extraordinary range of religions and philosophies - many have responding by choosing to believe that right and wrong are entirely private matters. Over 75% of preclinical medical students in a recent survey answered that in their opinion there were no absolute moral standards, that it was rather up to each person to develop his own - relative to the individual , period of history, culture and situation. This sounds a nice idea but let us think about it a moment. If there are indeed no absolutes then the statement 'there are no absolutes' can only be relatively true. Similarly to claim that 'all things are relative' is to make an absolute statement. This position is first and foremost logically absurd. But it is also unworkable in practice. Nobody in reality is a true relativist. Everyone makes moral judgments about others. No-one really sincerely believes that a belief that is diametrically opposed to his own can be equally true. If we were complete relativists we would be unable to make any objective decisions at all and we could certainly not be health professionals with this perspective. Right and wrong is not simply private prejudice.

Authority - What so-and-so says

The seventh approach is to rely on some human authority. 'What's right is what so-and-so says'. In practice in the health-care team, the ultimate responsibility for ethical decisions often lies with the consultant. However there are problems with this. The presence of technical expertise and knowledge does not imply the possession of moral integrity. Just as there are politicians who cheat on their wives, embezzle funds and betray their countries so there are consultants who make decisions in their own rather than the patient's best interests. Even well-meaning people may be deceived or misinformed. I remember once being pressured by a nurse to prescribe mega doses of vitamin C for a patient with leg ulcers on the grounds that 'Linus Pauling believed in its efficacy and he was an eminent chemist'. If medicine has taught me anything it is to have a healthy distrust of all authority figures. We are all susceptible to being misled, deceived and having our judgment impaired by impure motives of which we ourselves may not be aware-'All a man's ways seem innocent to him, but motives are weighed by the Lord' (Pr 16:2). So whilst believing that all authorities have been instituted by God we mustn't fall into the trap of thinking that their decisions, even in their own areas of expertise, are therefore infallible. Doctors may possess God-like power and knowledge but it does not follow that they also have god-like character and judgment.

So where does this leave us? We are not discounting completely the above means as guides in human conduct - but merely recognising their limitations. Emotions buzz and fade. Reason may fail or start from flawed premises. Conscience can be blunted, oversensitive or uneducated. Consensus is subject to prejudice and perversion. Consequences are often difficult to judge before the event and human authorities are not infallible.

Christian ethical decision making

It's worthwhile reflecting at this point on the bases by we ourselves make ethical decisions, because if we are honest we come to hold the beliefs we do as a result of a combination of these different reasons. In fact, all of them have to be tested against the wisdom and authority of God.

As Christians believing in the wisdom and authority of God we should be seeking his will on these matters and obeying his commands. 'If you love me you will obey my commandments'. (Jn 14:15) But there are several reasons why, especially in the area of medical ethics, this can be easier said than done.

We are concerned with two principle questions: What would God have me do? How would he have me do it? The first is a question about what God has specifically commanded and the second is a question about character - the first about doing and the second about being. How should we act and be? The short answer is that we should act and be like Christ. God, Paul tells us, has predestined him (the Christian) 'to be conformed to the likeness of his Son' (Rom 8:29), to be an 'imitator of Christ' (1 Cor 11:1) (or alternatively an 'imitator of God' (Eph 5:1) as Christ is 'the exact representation of his being' (Heb 1:3), the one who 'has made him known' (Jn 1:18)).

So fundamentally the most important question to ask in medical ethical decision-making as in any other area of life, must be 'What would Jesus have done in this situation?' Now obviously we are limited here for a start. In order to act as Christ would in any given situation we need both his understanding of the will of God and his character - and for each of us that is a lifelong journey as he gradually prunes us through his word and produces in us more of the fruit of his spirit. The harder the ethical decision, the more it will make us aware of how far we have to go, both in our understanding of will and our emulation of his character.

Nonetheless Jesus not only calls us to follow in his footsteps but also, by his Spirit within us, gives us the power to do so. How are we to grow? Christ's own teaching on this matter is clear: we grow in our knowledge of him and love for him by holding to his teaching - by hearing his words and obeying them (Jn 14:21).

This will involve four things: having the character of Christ, carrying the cross of Christ, sharing the mind of Christ and holding the commands of Christ, Let's consider each of these in turn.

First, following Christ will involve sharing the character of Christ. It is one thing to recognise the right thing to do in a medical ethical dilemma. It is quite another to have the faith, patience, perseverance and courage to do it. Often we will find that the situation tests us to our absolute limit and simply exposes the fact that we have a long way to go. We are revealed in the context of the dilemma for what we are; lacking in the Spirit's fruit of love, joy, peace, patience, kindness, goodness, faithfulness, gentleness and self-control (Gal 5:22-23). Our lives simply do not measure up to that description of love (which Christ fulfils perfectly) which is given to us in 1 Corinthians 13.

Second, following Christ will mean carrying the cross of Christ. It will mean inevitably that we will suffer in this world. On some occasions that will mean that we face the exclusion, ridicule and loss of reputation that refusing to compromise in an ethical situation inevitably attracts.

Alternatively it may mean that we are prepared to carry the burden of the patient ourselves. If we are not going to kill the patient requesting euthanasia, are we prepared to expend ourselves to find more compassionate solutions for the symptoms prompting the request? On the other hand, if we say no to abortion are we willing to provide the financial, emotional and social support that an unmarried girl requires if she is to take responsibility for carrying her pregnancy to term?

Third, following Christ will involve sharing the mind of Christ. Thomas Sydenham, who was a devout Christian and known by many as 'the Father of English medicine' outlines for us something of what this means in a lecture to medical students in 1668.

'Whoever applies himself to medicine should seriously weigh the following considerations: First that he will one day have to render an account to the Supreme Judge of the lives of sick people entrusted to his care. Next, by whatever skill or knowledge he may, by the divine favour become possessed of, should be devoted above all things to the glory of God and the welfare of the human race. Thirdly he must remember that it is no mean or ignoble creature that he deals with. We may ascertain the worth of the human race since for its sake God's only begotten Son became man and thereby ennobled the nature that he took upon him. Finally, the physician should bear in mind that he himself is not exempt from the common lot but is subject to the same laws of mortality and disease as his fellows and he will care for the sick with more diligence and tenderness if he remembers that he himself is their fellow sufferer.'

We need to develop a Christian worldview, having always at the front of our minds the four great threads of the Christian meta-narrative; creation, fall, redemption and consummation. Human beings have been made in God's image for relationship with him but we are 'flawed masterpieces' damaged by the effects of sin. God has intervened in human history to restore us to himself and we are moving ever closer to the Day of Judgement when he will put everything right. We should live in the light of these truths.

Fourth, following Christ will involve holding the commands of Christ. The law of Christ referred to in such Scriptures as John 13:34-35, 1 Corinthians 9:21 and Galatians 6:2 involves bearing one another's burdens, loving each other as he has loved us.

Here we must be careful not to fall into one of three traps. 'Loving as Christ loves' is not legalism, a slave-like obedience where the letter of the law supplants the spirit. This was the mistake of the Pharisees (Mt 23:23-24). Nor is 'loving as Christ loves' antinomianism where the commands of God are simply dispensed with (Rom 6:15). The Christian life is one of obedience. Nor is 'loving as Christ loves' situationism, where the situation determines the action. Christ's life was a fulfilment of the law. He didn't by calling us to love make null and void all the other commandments which describe to us what love is in practice (Mt 5:17-20).

The authority of the Bible

Jesus endorsed the authority of the whole Bible.

First he put his stamp of authority on the Old Testament. He treated its historical narratives as straightforward records of fact. Interestingly the stories that are the least acceptable to the 'modern mind' are the very ones he seemed most fond of choosing for his illustrations (eg. Abel (Mt 23:35), Noah (Lk 17:26-27), Jonah (Mt 12:39-41)). He repeatedly quoted it as the final court of appeal in debates, not only with his earthly opponents but with the Devil himself (Mt 4:1-11) He believed its prophecies were fulfilled in him (Lk 24:44) and used them as proof of his claims to be the Messiah (Jn 4:25-26; Mt 16:20) and he obeyed its ethical teaching (Mt 5:17-21; Mt 23:23; Jn 8:46). We should have the same respect for the Old Testament that he did.

Second he commissioned the writing of the New Testament. We can be confident that what the Apostles recorded was what Christ said (Lk 1:3; Jn 20:30-31; 2 Pet 1:16), not only because they were eyewitnesses of all that he said and did but more importantly because he personally commissioned them and gave them the authority to teach in his name (Mt 28:19-20; Gal 1:11-12; Mt 16:18-19; 18:18). The fact that what is recorded in the New Testament is the testimony of eye-witnesses means that we can be confident that there were not errors of a 'Chinese-whisper' type that have crept into the text.

We have not only the Apostles' testimony themselves that what they wrote were the words of Christ but also Christ's own testimony that he would enable them by means of his Holy Spirit (Jn 14:25-26) to 'teach them all things', 'remind them of everything he said', 'take what was his and make it known to them' and 'guide them into all truth' (Jn 16:12-15).

The Bible is God's Word to us, coming to us with the very authority of Christ and given in order that we may 'be thoroughly equipped for every good work'(2 Tim 3:17). It is sufficient. There are accordingly very stern warnings in the Bible about adding to or subtracting from what God has already revealed (Dt 4:2; 12:32; Pr 30:6; Rev 22:18-19). A logical corollary of this is that we should share Jesus' own high regard for the Scriptures. We will want regularly to hear, read, study and meditate on what God has revealed in the Old and New Testaments so that our thoughts and actions will be increasingly in line with those of Jesus himself.

Authorities outside the Bible?

Some Christians would hold that Christ may speak to us by his Spirit in ways other than by the written word which has faithfully been passed down to us. There is good support for this thinking in Scripture itself but also much which should lead us to exercise caution. Everything must be carefully tested against the Bible and anything inconsistent rejected. The three main extra-biblical categories of God's speaking are church teaching, conscience and contemporary prophecy.

Let us consider each of these briefly in turn:

Church Teaching

First Church teaching. Helpful as the writings and words of great Christian teachers are, our study of them must never take precedence over our study of the Bible itself. All human beings are fallible and can be misled and deceived - a fact which the apostle Paul recognised too well. 'Even if we... should preach' a different gospel let us be 'eternally condemned' (Gal 1:8-9). It follows that we should maintain a healthy suspicion of all we hear, even from those we most respect within the church, having the attitude of the Bereans who, when they heard the teaching of the apostle Paul, 'examined the Scriptures every day' to see if it was true (Acts 17:11). All church teaching should drive us back to the Bible knowing that if any Christian teacher and the Bible ever disagree, then the teacher is wrong and the Bible right. Our views of medical ethics should not simply be absorbed from the pages of the books of Christian teachers without us asking the question, is this in line with Scripture? Christian teachers may be simply perpetuating the errors of the past, and each is fallible in some respect. No-one but Christ has a perfect understanding of God's Word.

Conscience

Second conscience. Conscience is a God-given faculty through which God can guide us but we need to ensure that our consciences are being continually shaped and moulded by exposure to God's word. Christians who claim to 'have a peace' about a certain course of action may simply have consciences which are uneducated through lack of exposure to God's word or blunted through habitual disobedience. Similarly those who 'feel convicted' may actually have oversensitive consciences which are more informed by human authority than God's law. So while we should take notice of conscience it has its limitations and must always be tested against God's Word. If given the wrong place it can lead us astray. So it is not enough for a Christian to say that because their conscience is clear over some medical ethical decision that therefore their decision must be correct. A clear conscience does not mean that we are therefore innocent as Paul clearly reminds us in 1 Corinthians 4:4.

Contemporary prophecy

Third, it is worth making some comments about contemporary revelation or prophetic words. I have known sincere Christians who have justified their use of abortifacient contraceptives or their doing of abortions on the basis that they have had words and pictures from God which have reassured them that they are acting in accordance with God's will.

There is of course a broad diversity of opinion among Christians about the contemporary function of the gifts of the Holy Spirit mentioned in Romans 12 and 1 Corinthians 12. At one extreme are the cessationists who hold that the use of certain gifts such as prophecy ceased in New Testament times. At the other extreme are those who have jettisoned the Bible and rely entirely on 'prophetic words' for guidance. The first group despise all prophecy, the second group capitulate uncritically to everything claiming to be 'from the Lord'.

The Bible reveals that there were 'prophets' in New Testament times (Acts 13:1; 21:8-10; Eph 2:20; 3:5) and gives us no reason to believe that this ministry should not operate today. There are detailed instructions about both the functioning of prophetic gifts within the church (1 Cor 14; 1 Thes 5:19-21) and also about the discernment of true and false prophecy (Mt 7:15-20; 2 Pet 2; Jude 3-16). God clearly did speak to his people directly; to warn them (Acts 11:27; 21:10,11), to encourage them (Acts 15:32; 1 Cor 14:3) and specifically to direct them (Acts 16:6-10). However Jesus and the apostles also warned repeatedly about the dangers of false prophecy and throughout the whole of Scripture we are given principles for assessing it: Prophets who make false predictions are not speaking God's word (Dt 18:21-22), but neither are those whose true predictions are accompanied by false teaching (Dt 13:1-5). True prophecy exalts Christ (1 Jn 4:1-3), edifies the church (1 Cor 14:4), is consistent with existing Scripture (1 Cor 14:37-38) and is accompanied by a godly life (Mt 7:15-20) and a teachable spirit (1 Cor 14:29-33) - for even those who have been used by God as his mouth-piece may be misled (Gal 2:11-13). What the speaker sincerely believes is a prophetic word may in fact have its origin in his imagination (Ezk 13:1) or worse still, in some ungodly source (1 Ki 22:19-23). This is why it is so important that all 'words from the Lord' be carefully weighed and tested (1 Thes 5:19-21; 1 Cor 14:29).

We should exercise caution and seek the confirmation of other Christians, and most importantly the words of Jesus and the apostles in the Bible. Any 'word' which is inconsistent with the teaching of the Bible cannot be from God and must be firmly rejected. Similarly any Christian who claims 'the Lord told me' contrary to the plain teaching of the Bible is simply wrong, regardless of the depth of their conviction.

So holding the commands of Christ mean that we will have the respect he has for the Bible, and while not rejecting the fact that God can speak to us through church teaching, conscience and contemporary prophecy, we will be careful to test everything against Scripture. But even among mature Christians who have studied hard and know their Bibles well there may still be disagreement and here great wisdom is needed. If even Peter and Barnabas could be led astray, as they clearly were over the circumcision issue (Gal 2:11-13) then how much more may we.

This inevitably brings us onto a discussion of how we can know we are interpreting the Bible correctly. Let's look at some principles of Bible interpretation. If the principles themselves are not helpful then at least the examples that illustrate them should be.

Interpreting God's Word

First, Scripture is authoritative as originally given. Translations which distort the original meaning of the text do not carry God's authority. Now clearly it is not practicable, possible or necessary for all of us to learn Hebrew or Greek, but at least if in doubt we should be referring to commentaries which are based on the original language rather than an English translation. An example of an incorrect translation which has misled people over medical ethics is Exodus 21:22-25 dealing with the situation where two men are fighting and in the process injure a pregnant woman. The text has been used for decades to support the view that life before birth is of less value than life after birth. If you read the passage in both the AV and the NIV the meaning seems quite different and in order to resolve the difficulty we need to go back to the original Hebrew and ask what it originally said. I plan to deal with this particular passage in tomorrow's talk as it has a strong bearing on the issue of abortion - so more of that later.

Second, Scripture is authoritative in all that it affirms. In narrative passages of Scripture there are things that the Bible records people doing and yet doesn't affirm. We don't emulate every thought, word and action of biblical characters (even 'righteous' characters) just because they are reported as happening once. For example people have used biblical narrative to justify laying fleeces and drawing lots whenever they cannot make up their minds. While Jesus himself did appeal to narrative to justify his disciples behaviour (as in the case of David's eating bread on the Sabbath), he didn't similarly appeal to David's census-taking or adultery as a precedent. These actions were not affirmed. If something seems right but is neither affirmed nor denounced in the passage in question, then we need to look at narrative and didactic passages elsewhere in Scripture.

Third, Scriptural truth is sufficient but not exhaustive. It is sufficient to make us 'thoroughly equipped for every good work'(2 Tim 3:17) but that doesn't mean that it will satisfy every idle curiosity we may have. It doesn't, for example, tell us whether there is life on other planets, probably because this is not relevant to our own salvation history. God tells us things on a 'need to know' basis. There are secret and revealed things (Dt 29:29). The challenge is having the wisdom to know the difference. God's word is there to train us to distinguish good from evil (Heb 5:14) but we should know our limits and, while not pretending to know everything, we should nonetheless live up to the truth that we have attained (Phil 3:15,16) and err on the side of caution about that of which we are not sure (Rom 14:22,23).

Fourth, Scriptural truth is objective not subjective. Scripture doesn't mean different things for different Christians. We can't say that this text means one thing for me and quite another thing for you. For example, 'it is not okay for you to perform euthanasia but it is admissible for me'. That's relativism! The Bible's author and not its reader determines the meaning. In saying this we are not saying that the Bible cannot have any meaning that was not in the minds of the human authors. It is quite clear that in many passages of Scripture God had intentions in the text which were not known to the human authors but nonetheless present. For example Paul justifiably applies a text about not muzzling oxen in the Old Testament (Dt 25:4) to the support of Christian workers in the New Testament (1 Tim 5:18). Similarly in saying that it was expedient for one man to die for the nation, Caiaphas was not intending to be prophesying in John 11:49-53 that Jesus' death would pay the price for our sins, but he most certainly was!

Fifth, Scripture does need to be understood in its historical and textual context. Some commands in Scripture apply only to certain individuals and groups. A text without a context can be simply a pretext! This is particularly relevant to the use of the Old Testament, in particular the Law and the Prophets. We are not for example expected to eat kosher food as Christians nor to participate in animal sacrifice, although these were part of the Old Testament Law. We rather see the Old Testament Law as having the function of leading us to Christ. Animal sacrifices under the Old Covenant point to Christ's sacrifice of himself for our sins under the New Covenant. Similarly the food laws were a reminder of God's holiness but are not binding on us as Christians. As Jesus said, it is not what goes into us, but rather what comes out of us that reveals where we stand with God (Mk 7:17-23).

On the other hand we cannot disregard the Old Testament Law either. We can disregard it as a means of gaining God's approval because we are under a new covenant where right standing before God comes by faith. But as instruction in right living the law is still of great benefit. When Paul said in 2 Timothy 3:16,17 that all Scripture is inspired by God and useful for teaching, rebuking, correcting and training in righteousness, he was referring primarily to the Old Testament.

Some Christians here get obsessional about the question of which parts of the Old Testament Law are then still binding on us, but this is the wrong question to be asking. The Bible does not divide the law into moral and ceremonial parts and say that the former (but not the latter) are still binding on us. Nor does it say that all law not specifically abrogated in the New Testament still holds, nor that all that isn't reaffirmed there is obsolete.

It says rather that we are not under law, but rather under Christ's law (1 Cor 9:20-21). We are to love one another as he has loved us (Jn 13:34-35), to bear one another's burdens (Gal 6:2). We must walk as he walked in the path of the cross ((1 Jn 2:6; Mt 10:38). Faith expressing itself through love is the only thing that counts (Gal 5:6).

Some have used this as a starting point to justify situation ethics. This approach popularised by Joseph Fletcher argues that the breaking of biblical law can be at times justified in the name of love. However, Jesus would never have attempted to justify murder, adultery, theft or lying in extenuating circumstances, and neither should we. Love and obedience are inextricably linked in the mind of God. I'll come back to this in a short while when looking at situations in which God's laws appear to conflict.

Applying the Bible to Contemporary Situations

The unchanging principles in Scripture can and should be applied to contemporary situations. Some wonder how a Bible written 2,000 years ago can speak to the ethical situations we face in the late 20th century, but because the Bible is God's Word, and God doesn't change (Mal 3:6) he has prepared for situations not envisaged by the original authors. The Bible was written to a preindustrial middle-eastern culture and primarily addresses preindustrial middle-eastern issues: cows rather than cars, vineyards but not ventilators, stone tablets rather than silicon chips.

However the principles apply across the generations. So we need to take on the hermeneutical task - sorting out how God's unchanging principles apply to contemporary situations which were anticipated in the mind of God. This can be hard work, but if we are to live in obedience to God in today's society (and we have no choice because this is exactly what knowing and loving him involve), then we have a responsibility to use our minds to work out contemporary codes of conduct based on the revealed principles we find in Scripture.

It would of course be easy if we could simply look up contemporary issues in a concordance, but God hasn't arranged it that way. He expects us to think.

Genetic engineering is not mentioned in the Bible but there are principles about stewardship (Gn 1:26-28; Mt 25:14-30) and cross-mating of different species (Lv 19:19). Abortion is not specifically dealt with but there is much about intentional killing (Ex 21:12-14), prenatal life (Ps 139:13-16) and child sacrifice (Dt 18:10; 12:31). AIDS was not known but there is a lot about sexual morality (1 Cor 6:18) and compassion for sinners (Jn 8:11). We'll be looking at some of these issues in more depth in the coming sessions, but to give you a foretaste let's consider some we won't be covering.

Take negligence for example. Negligence is a big issue in medicine. Under Old Testament Law you were obliged to build a parapet around the roof of your house so that people wouldn't fall off and get injured (Dt 22:8). If you dug a pit and someone fell into it, you were criminally responsible (Ex 21:33,34). Now clearly we don't use our roofs as verandas in the way that middle-easterners did (or even dig pits); but might this not be saying something about, for instance, the fencing of swimming pools?

Or consider the example of payment for healthcare: On the one hand we are told that the labourer is worth his hire, and that the worker deserves his wages (Lk 10:7). On the other hand, the fact that others are unable to pay for our help doesn't mean that we are not obliged to give it (Lk 10:25-27). If your neighbour needs money you lend it to him (Dt 15:7,8) at no interest (Dt 23:19). If he comes upon hard times you are to tide him over (Dt 15:11). If you have the world's goods and don't respond to his need, then how can you say you love God (1 Jn 3:17). A good case can be built for those who can afford it paying, while free treatment is given to those who can't, for instance.

Or take the issue of the allocation of limited resources? For a start we must do what we can with what we've got (Mt 25:21). Not being able to meet the need fully ourselves is no excuse for not doing what we can and demonstrating how the need could be met (Mk 12:41-44). God works miracles when we do what little we can do (Mt 15:29-39). On the other hand getting a big task done involves time and prayer. It also requires vision, planning, delegation and the involvement of others (Ne 2&3).

In closing, I want to briefly consider three other issues which are important in applying the Bible in medical ethics. The first is the question of whether the end ever justifies the means, the second is what we should do in situations where God's commands appear to conflict, and the third is whether we have a right to 'impose our morality'.

Ends and Means

Does the end ever justify the means? Secular ethicists classically divide ways of making ethical decision-making into two categories: deontological and consequentialist.

The deontologist judges an action right or wrong on the basis of whether it conforms to a set of rules or principles. Immanuel Kant was one of the first advocates of deontological decision-making and in the 1980s Beauchamp and Childress first enunciated four prima facie principles of ethics in health care which have become the basis of most contemporary secular ethical discussion. They are beneficence (the obligation to do good); non-maleficence (the obligation not to do harm); autonomy (the obligation to respect the decision-making capacities of autonomous people) and justice (the obligation of fairness in the distribution of benefits and risks).

The consequentialist on the other hand judges an action by its consequences. The names of John Stuart Mill and Jeremy Bentham are usually associated with this category of decision-making and it would be fair to say that most popular contemporary ethical discussion gives far more weight to consequences of decisions than the principles underlying them.

The Christian obviously will respect the authority of Christ and the Bible above Kant and Bentham, but it can legitimately be asked whether Christian ethics are deontological or consequentialist? In fact the Bible has elements of both. Take for example the question 'Is adultery, right?' On the one hand the seventh commandment states 'you shall not commit adultery' (Ex 20:14). Why not? Because God commanded it and we have a duty to obey God. This is a rule-based or deontological argument.

However the writer of Proverbs takes a different approach. 'Think about the consequences of adultery' he says in effect. 'All the shame and disgrace not to mention the fury and rage of a jealous husband to contend with. Is it really worth it for a few moments of pleasure? You'll probably end up destroying your marriage and then what about the children? How can that be right?' (Pr 5:1-14; 6:20-35). This is a consequentialist argument.

So the Bible sees rules and consequences as being intimately connected. God is loving, trustworthy and profoundly concerned with the welfare of man. It therefore makes sense to obey his commands since to ignore them is to choose unpleasant consequences.

However, recognising this is not enough. We must also recognise that because God is a far better developer of deontological principles and judger of consequences than we are (Pr 3:5,6) it follows that we should trust his judgment rather than our own. This will mean that even in situations where the consequences of a course of action seem to dictate that we should ignore the rules and trust our own judgment rather than God's, we should nonetheless abide by the rule. This is to recognise the limitations imposed on us simply by virtue of being human and sinful. This is the way of faith and this is what makes Christian ethics so diametrically different from secular ethics. They are based on God's revelation rather than human wisdom. God is a far better judge than us of principles of conduct and consequences of action. It follows that we must trust his word and not our own judgment.

Scripture is full of examples of this. The great men and women of faith are commended for their faith in obeying God's word despite the perceived consequences (eg. Abraham's sacrifice of Isaac (Gn 22:1-19), Moses' return to Egypt (Ex 3:7-4:31), Daniel's persistence in public prayer (Dan 6:6-10)). Conversely those who exhibited lack of faith were those who chose not to obey and rather trusted their own judgment of consequences (Saul's attack without Samuel (1 Sa 13:1-14), Aaron's golden calf (Ex 32)). Perhaps the best example of all is Christ's third temptation. Satan offered him all the kingdoms of the world if he would worship him (Mt 4:8-10). We know that to rule over the kingdoms of the world was Christ's destiny - but the means to it was not through worshipping Satan but through submitting to God on the cross. With God the end never justifies the means. We must do his work his way.

Conflicting Commands?

Do God's commands ever conflict in such a way that it is impossible to obey one while not at the same moment disobeying another? If so then how should we act in such situations?

Much has been made of moral conflicts by situation ethics writers such as Joseph Fletcher: Is it ever right to tell a lie to preserve innocent life? Is it ever ethical to kill in order to relieve suffering? Is it right temporarily to compromise one's values in order to stay in a position of influence?

There are examples of each of these in medicine - take abortion: Should a doctor who believes abortion is wrong give false information to prevent it happening? Should he do it anyway in some situations to relieve other people's suffering? Should he perform some abortions in order to get to a position where he can prevent a greater number of others?

Now it is clear biblical teaching that it is wrong to tell lies (Lv 19:11) and wrong to disobey the governing authorities (Rom 13:1-5) - yet the Bible mentions examples of godly men and women apparently acting counter to these divine directives when faced with conflicting priorities. Is deceiving an evil person justified to protect innocent lives? (Ex 1:15-20; Joshua 2:2-7; 2 Sa 17:17-22) Is disobeying the governing authorities justified if it is to honour a direct command of God? (Dan 3:13-18; 6:6-10; Acts 4:18-20; 5:29)

Jesus and moral conflict

Jesus must have faced moral conflicts of this kind. If we deny that he did then we are in effect denying that he was tempted in all ways as we are (Heb 4:15). But if we say that he sinned by neglecting one duty to perform another then we are in effect saying that he was not the perfect sacrifice (Heb 10:12-13). It seems then that we must accept that Jesus both faced moral conflicts and that he didn't sin in the choices he made.

On occasions he used his miraculous powers to resolve the conflict and somehow perform both duties. When faced with a choice between attending to a chronic illness near at hand or a rapidly fatal one at a distance, he healed the first patient and raised the second from the dead (Lk 8:40-56). When faced with a crowd hungry both for food and teaching he fed 5,000 people with a handful of fish and bread rather than turn them away (Jn 6:1-15).

But there were clearly other occasions when he made a choice between two apparently conflicting moral duties: He gave priority to God rather than his family (Mt 12:46-50) or the governing authorities, prayed rather than went on responding to desperate need while exhausted (Lk 5:15-16), healed (Lk 6:6-11), and relieved hunger rather than resting on the Sabbath (Mk 2:23-28), and offered mercy rather than insisting upon justice (Jn 8:1-11). He went to the cross because he refused to submit by lying about his identity (Lk 22:70-71) or by speaking out in defence of his innocence (Mk 15:1-5).

Jesus came in for much criticism by the authorities who believed that he had in fact broken God's law. But he himself criticised the teachers of the law and the Pharisees because they introduced an unbiblical hierarchy of moral duty (Mt 23:23), failed to obey God's real law (Mt 7:21-23; 1 Cor 12:31-13:3) and replaced it with their own oral tradition (Mt 23:3). Although they repeatedly tried to trap Jesus in situations of moral conflict (Lk 11:53-54; Mt 12:9-14; 22:15-22), they themselves made deliberate choices to obey one commandment over another in similar situations (Mt 23:1-39; Mk 7:5-13; Lk 11:37-54). Jesus exposed their hypocrisy.

A hierarchy of duties?

What can we learn from this? First that there do seem to be higher and lower moral laws. There was a range of punishments for sin in the Old Testament depending upon the severity of the offence (Ex 22:23-25). Jesus himself spoke of the 'greatest commandment' (Mt 22:38) the 'more important matters of the law' (Mt 23:23) and the 'greater sin' (Jn 19:11). This pattern is also evident in the apostles' teaching. Whereas it is never denied but rather affirmed that all wrongdoing is sin, there were nonetheless some sins that called for excommunication (Mt 18:17), some which led to or didn't lead to death (1 Jn 5:16-17) and some which were unforgivable (Mt 6:15; 12:31-32; Heb 10:26-31).

But second we must affirm that all God's laws are important. Jesus said that he had not come to abolish Old Testament Law but to fulfil it, that anyone who relaxed 'the least of the commandments' and taught others to do the same would be called least in the kingdom of heaven (Mt 5:17-20). Obedience to the more important of the commandments was not an excuse for neglecting those of lesser importance (Mt 23:23).

In the mind of Christ the choice of 'the lesser of two evils' did not arise. Rather he seemed to understand the exact meaning, application and scope of every commandment.

The mind and character of Christ

It is one thing to say that the resolution of difficult moral conflicts can be extremely difficult, requiring the mind, the courage and the character of Jesus himself. But it is quite another to say that to disobey any of God's laws is ever morally right.

We need like the psalmist to pray for wisdom and grace; 'I am your servant; give me discernment that I may understand your statutes'.

Imposing our morality

Finally, do we have a right to 'impose our morality'? We live in a pluralist culture where religious belief is seen as a private matter and the supreme virtue is tolerance. It's not surprising that when we submit to God's rule in the way we behave, we will be accused of attempting to 'impose our morality' on our colleagues and patients. Of course we mustn't impose our beliefs in the sense that we force them to do what we say. After all the Gospel is an invitation not an imposition. But neither must we let the world 'squeeze us into its mould' (Rom 12:1-2). We must resist having the morality of others imposed on us to the extent where we refrain from speaking the truth or become a party to things which we know are wrong for fear of causing offence. The gospel is offensive and our allegiance to Christ will cause us at times to do things which others find offensive (Mt 5:11-12).We must be careful to ensure that the only offence we cause is that of the Gospel, that is, that our manner is not ungracious (Col 4:5-6) but we must realise that at times people will dislike or even hate us purely because of how what we believe leads us to behave (Jn 15:18-21; 16:1-4).

There are two main areas where we can be tempted to compromise in our allegiance to Christ. The first is in giving medical advice which challenges our patients' or colleagues' lifestyles, and the second is in participating in unethical practices which society has given tacit approval to.

Firstly, giving medical advice. As well as having skills in the diagnosis and treatment of disease doctors also possess knowledge about the aetiology, progression and spread of disease. Because before God all knowledge confers accountability, doctors have a responsibility to educate and warn patients about lifestyle factors and prognosis. If we fail to do so we are not giving them the opportunity to change their behaviour or prepare properly for the future. A patient's illness may well be linked to some lifestyle factor such as alcohol, smoking, fat consumption, stress or sexual promiscuity and if so they themselves may not be aware of the link. Some patients will take such advice well but others may be offended at our suggestion that they may have contributed to their illness in some way. Either way it's our duty to inform them sensitively and firmly in the hope that they will take our advice and change their behaviour.

Secondly, participating in unethical practices. There are situations when our patients or colleagues want us to help them do something we regard as unethical. It may also be illegal, such as making false statements on an official document or certificate or it may be something quite 'legal' such as being party to an abortion. If we refuse to co-operate in such situations we may be putting our relationships, reputations or careers at risk. In these conflict situations we have to remember that we are ultimately God's servants - and not primarily the servants of our patients, colleagues or superiors. Although we must never be rude or disrespectful there are times when we are obliged politely to refuse to act improperly remembering that 'we are not trying to please men but God, who tests our hearts' (1 Thes 2:4).

Summary

In summary we started by looking at why ethical decision making is now more difficult than at any time in history before moving on to a consideration of the different ways people make ethical decisions. That led us to consider what following Christ in this whole area involves: having the character of Christ, carrying the cross of Christ, sharing the mind of Christ and holding the commands of Christ. This led on to a discussion of principles of biblical application and then finally to a discussion of three problem areas particular to medical ethics: ends and means, conflicting commands and imposing our morality.