DIFFICULT QUESTIONS moral beliefs in medicine

Medicine is a moral enterprise. What I mean by that is, fundamentally, medicine has a moral dimension to it. The essence of the profession is to provide healing, treatment and comfort to the patient. When practised correctly, we believe that the medical action performed was the morally right thing to do. All doctors and healthcare professionals seek to do the right thing. The million-pound question though is: ‘What is the right thing to do?’ This is important for Christians who are called to honour the Lord in every area of life and do what is right. [1]

How do we determine what is the right thing to do? In many things the medical community will agree and there is no tension between Christians and others. However, there are certain issues where Christians will disagree with what the rest of the medical community say. Not only is it our duty to uphold what is right, but it’s also incumbent upon us to answer those who disagree with us with respect and conviction. [2] To do so, it’s helpful to have a grasp of basic moral epistemology (how we know whether something is right or wrong) and moral ontology (the nature and existence of the moral dimension), to help us understand countering perspectives and refute them.

modern medical ethics

Beauchamp and Childress’ ‘Four Principles’ are often seen today as the fundamental principles by which medical ethics are determined. They can be described as:

1. Autonomy — the patient has the right to make authoritative and independent decisions about their medical treatment free from coercion from others
2. Beneficence — doing good to the patient
3. Non-maleficence — avoid causing harm to the patient
4. Justice — ensuring what is done is fair to the patient and to the wider society

These principles are used to navigate clinical scenarios and often discussed in an academic sense. The difficulties arise when these situations happen in real life, in a high-pressured environment requiring a fast response with little or no time to think, when multiple principles clash with each other or when deep human emotions come into play. Many scenarios have been thought about and clear conclusions reached.

For example, a Jehovah’s Witness admitted after a road traffic accident needing a blood transfusion for survival: her religious beliefs mean that she will not accept one and yet it is essential to save her life. In the context of an adult, the adult is deemed autonomous and has the right to refuse the blood transfusion even to their own demise. In the case of a child, the court intervenes and overrules the parents’ and even the child’s own wishes and gives authority to the medical staff to administer the treatment. Another example is breaking confidentiality if a patient has recently been diagnosed with epilepsy and insists on continuing to drive. [3] Here, the patient’s autonomous right to drive a car and the right to confidentiality with respect to their medical condition is superseded by justice which looks out for the safety and wellbeing of the public on the road.

moral reasoning

How do we reach such conclusions? Here we discover that we operate in a philosophical framework, a worldview, schools of thought that guide us to right action. When weighing up the principles, we use these frameworks to come to a definitive conclusion. Here are three common schools of thought you’ll often see in the clinical setting, with some examples, and brief consideration of the shortcomings:

consequentialism

• The rightness or wrongness of an action is determined by the consequences that ensue. Also known as ‘the ends justify the means’ where the action itself doesn’t necessarily matter but what results.
• Example: informing the authorities that a patient has epilepsy is right because it means they will not be able to drive which could have resulted in deaths or injuries on the road.
• Shortcomings: This doesn’t usually fit with biblical thinking, as many commands in the Bible do not deem an action good because of the consequence. This philosophy can encourage justifying wrong actions with an overall good outcome. For example, one may justify conducting unapproved research without patient consent if it results in the discovery of a ‘miracle’ treatment. Such an approach may bypass bureaucracy and the risk of patient refusal improving the strength of research. However, this would be a wrong thing to do even if the result is brilliant and no-one was harmed in the process because deception and dishonesty were employed to conduct the research. Furthermore, this philosophy presumes future results when contemplating an act, something we can never predict with 100 per cent certainty, so we are basing our actions on assumption.

utilitarianism

• The right action is the one which causes the maximum amount of benefit or the least amount of harm for the community at large.
• Examples: the health service invests £100 million in a diabetic treatment rather than a cystic fibrosis treatment as there are millions of diabetic patients in the country but only about ten thousand cystic fibrosis patients. The last ventilator in the hospital is given to a 20-year-old man rather to an 80-year-old man, both of whom have COVID-19, as the younger man is statistically more likely to survive the infection and live many more years and therefore stands to benefit more from the ventilator.
• Shortcomings: It tends to reduce human beings to comparable commodities and not unique individuals when deciding what to do. Ten versus one is what matters most. Is it right to kill a healthy individual for organ harvesting so that you can save multiple patients who desperately need an organ transplant? This also contradicts biblical thinking where the shepherd is willing to leave the 99 to retrieve the lost one. [4] Furthermore, this philosophy doesn’t accurately define what good, pleasure, evil and harm is, nor does it provide a way of weighing up and comparing the different goods and evils. Most ideas of benefit and harm do not line up with a biblical understanding of right and wrong. Pleasure and avoidance of suffering may be the highest goals in a hedonistic worldview, but they are certainly not in the Christian faith where the highest ideal is loving the Lord, from which things such as pleasure and joy come and sometimes may involve the path of suffering.

deontology

• The rightness or wrongness of an action is dependent on whether you obeyed a moral principle. It is also known as ‘rules-based ethics’ and is in direct contrast with consequentialism.
• Examples: telling a terminally ill patient they are dying immediately after the results come in since it is a morally good thing to tell the truth without delay.
• Shortcomings: many duties in today’s society are translated in a way that contradicts biblical virtues. For example, giving a person freedom and choice is generally a good thing to do, but this is often used to argue that the termination of pregnancy or the legalisation of euthanasia is a morally good thing to do and should be allowed. Furthermore, sometimes the right thing to do confounds duty-based ethics. It may be unwise at times to apply black-and-white ethics to grey areas in life, and many duties may clash with each other. Duty-based ethics will not tell you which duty takes priority. Should you disclose to the mother that her underage daughter is given contraceptives and engaging in sexual activity out of respect to the fifth and ninth commandments?

The aforementioned schools of philosophy have their place in modern thinking and they can be very helpful at times. However, one cannot help but notice the assumptions of secular humanism. It’s often assumed there is no morality that comes from without, so we must seek to discern morality from within. Therefore, morality and ethical decisions come exclusively from human rationality and experience. [5] There’s little or no reference to God’s law, wisdom or commandments. This is unsurprising in a post-Christian world, but not only is it fundamentally different from the Christian worldview which states that objective morality and duties do exist, it is also disastrous to the morality and welfare of society. [6] When morality is solely derived from humanity itself, each person is a law unto themselves and can do whatever they please. There is no objective barrier preventing them flouting the herd morality and acting on their own desires which can lead to horrific results.

the Christian call to honour God

Jesus said the greatest commandment is to ‘Love the Lord your God with all your heart and with all your soul and with all your mind and with all your strength.’ [7] If we love the Lord with our hearts, we will desire that God and his ways are upheld in the world and we will obey his commandments above all else. [8] If we love the Lord with our soul, we will seek to present our whole lives as living sacrifices to him. [9] If we are to love the Lord with all our mind, we must worship the God of all wisdom and reason and use that wisdom and reason to contend for the truth in the public square, exposing false ideologies and convincing those who disagree why Christ’s way is the truth. [10] And if we love the Lord with all our strength, we will honour the Lord [11] and speak his truth, [12] even if that puts us at odds with the world. [13]Recent debates have raged about physician-assisted suicide, and some polls suggest that a sizeable proportion of people would have it legalised in the UK. [14,15] As Christians, we are saddened by this low valuation of human life and must ask ourselves: will we allow this to go unchallenged, or will we step up and honour our duty to speak up for God’s truth, that human life is precious and made in the image of God? [16] Will we defend those who will bear the brunt of this legislation, [17] knowing this could come with a heavy personal price? We can debate this topic in public forums giving people a counter-perspective to the one that’s all too prevalent, encourage those who speak publicly on this issue, research the topic carefully to equip us to speak with more confidence to friends, ask fellow Christians to get involved, and pray sincerely to the Lord for help on this matter.

The presumption of secular humanism has dominated medicine for far too long without being challenged, much to the detriment of patients and doctors, and it’s high time for Christians to stand up and contend for the faith in the medical sector. Let us never forget we worship the God of all creation whose sovereign rule and reign extends throughout the whole universe. He is on our side going before us and his ways are good to all people. [18]

Daniel Nie is a final year medical student in London and Nucleus Student Co-editor