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ss nucleus - spring 2000,  Medical Ethics at the Millenium

Medical Ethics at the Millenium

Putting principles into practice

Autonomy: rights balanced with responsibilities

I believe Christians can give considerable support to autonomy in so far as it endorses the unique value of each human being - someone created in the image of God (Gn 1:26-7) and for whom alone Christ died (Jn 3:16). However, Christians would always want to see the rights inherent in autonomy balanced by responsibilities, and many of the medical ethical problems that confront us today are the consequences of unbridled, uncontrolled, unfettered autonomy. Some demand rights but deny responsibilities. (Fergusson A. Living wills: should we support them? Nucleus 1993; 16-21, April)

What is a moral framework?

Constructing a moral framework within which to operate is never an easy task. Where should we begin: from our own reasoning, from peer group standards, from public opinion or ethical codes for medical practice? As humans we often fail to abide by even our own shaky moral frameworks. Without a firm foundation, our ethics will never be secure. Only the unchanging standards of the Word of God give us a rock on which to build our lives (Mt 7:24-27). Even when we have forged firm principles on a biblical basis, the battle is not over. Do we make them the standard by which we live out our daily lives, or simply a quiet comfort for moments of contemplation? We need the wisdom of God in order to search out answers to the questions which we face as we strive to practise medicine to his glory. We also need the indwelling Holy Spirit to empower us to live consistently by these. Above all, we must realise that we can do nothing in our own strength. (Jn 15:5). (Pickering M. Editorial. Nucleus 1997; 1, October)

Informed consent: truth-telling and trust

It is crucial that patients are given information about the risks and consequences of investigations or procedures which they are about to undergo before consenting to treatment. However in any situation where one person in a transaction possesses much more knowledge than the other there has to be an element of trust. If I take my car to be repaired I want a simple description in words I understand of what the basic problem is, and an estimate of how long it will take, what it will involve and how much it will cost. If there is a range of options then I expect to be informed and if necessary consulted along the way. I don’t need or expect an exhaustive description of the mechanics of the procedure or to have every combination and permutation of outcomes discussed in detail. Most importantly I want to know if I can trust the person. If they are competent, knowledgeable and someone of good reputation and integrity, then I will relax far more than I will after an exhaustive resume from someone I feel I can’t trust. If I know he will treat my car in the same way he would like his to be treated (Mt 7:12), I can rest content. When doctors feel constrained to give, or when patients demand, an exhaustive catalogue of the percentages of obscure complications and side-effects of a particular drug or procedure, it is a sign that trust has broken down and if trust has broken down, even long discussions are unlikely to repair it. God does not give us answers to every question about our futures either, but he does give us enough revelation about his character and power for us to be able to trust him. (Dionysius Dialogues. Nucleus 1994;24-30, October)

Confidentiality

There is increasing interest in helping medical students and doctors to elicit personal information from their patients but unless the doctors can be trusted to keep it confidential patients will not reveal it and the quality of their care will suffer. Confidentiality therefore is not a medical game left over from the school playground. It is a vital part of effective medical practice. In the very first chapter of the Bible we are taught that man is made in the image and likeness of God (Gn 1:26-27). If I am made in his image than I must have personal worth and value as an individual. Similarly everyone must have individual worth and value. Surely we are called upon to protect that individuality and to avoid anything which might weaken it. Disclosing information about individuals weakens them. Those given the privilege of confidential information must know that they have a personal duty to protect it. (Horner S. Confidentiality: Christian virtue or Christian necessity? Nucleus 1994; 2-8, April)

Resource allocation

Due to a lack of resources in the developing world we have to decide on what is the ‘minimum essential treatment’ which will effect a cure in most cases. We cut back on diagnostic tests. We keep patients in the hospital for less time than in Western countries. We use the cheapest drugs for the shortest possible time and the great majority of our patients do well and are satisfied. Unfortunately, some of our wealthier Nepalese patients are not happy with this. They demand X-rays and cosmetic surgery. If they can pay for it, we provide the extra treatment. Our mission hospital then makes a little money from of these wealthier patients, which goes to help cover the costs of treating the poorer patients. (Hale T. Time and Money - developing world ethics. Nucleus 1999; 10-14, April)

Euthanasia

Unnecessary, dangerous and wrong

CMF is opposed to active euthanasia on the grounds that it is unnecessary (because alternatives exist), dangerous (because of abuses that inevitably follow legislation) and most importantly because it is morally wrong (violating the biblical prohibition on all intentional killing of innocent human beings). (Saunders P. Nucleus 1993; 18-22, July)

Is euthanasia murder?

You won’t find the word euthanasia in the Bible, but there are two cases described (Jdg 9:54; 2 Sa 1:9,10) and several others of suicide (2 Sa 17:23; Mt 27:5). We know that human beings are created in the image of God (Gn 1:27) which is why it’s wrong to kill (Gn 9:6; Dt 5:17). While there were exceptions in the case of guilty human beings under the Old Covenant(Ex 21:12, 22:2,3; Dt 20:10-13), the intentional taking of innocent human life was universally prohibited (Ex 21:14). (Dionysius Dialogues Nucleus 1997; 32-35, July)

Jesus and palliative care

Throughout Scripture, God shows his deep concern for the poor and weak, the fatherless and the widow. Nowhere in Scripture is there a hint that the weak and frail should be helped to die, but rather supported and cared for. The Lord Jesus gave himself, not only on the Cross, to secure man’s eternal forgiveness and heavenly life, but in daily life in healing the sick, feeding the hungry and even raising the dead to physical life again. Jesus’ will must surely continue to be that we should provide and care for sick, frail, distressed and disabled people, relieving symptoms, sitting with them where physical or mental relief cannot be provided and giving them support to the end. (Smith AM. A right to die? Nucleus 1994; 2-7, January)

Abortion

The arrogance of paternalism

On a superficial level, we may feel that the elimination of disease, even by selective abortion, is always worthwhile. But surely on deeper consideration we must realise that destroying human beings is too high a price to pay. We are in danger of judging a person’s inherent worth by their outward appearance and physical or intellectual ability, and forgetting that in God’s sight our greatest handicap is the sin which prevents us from relating to him. (Todd B. Pre-natal testing: an ethical problem? Nucleus 1994; 20-23, January)

Conscientious objection

Taking innocent human life is contrary to the whole strategy of medicine. It runs not only counter to Christian ethics but to the Hippocratic Oath and the Declaration of Geneva, which the BMA not so long ago embraced. It is not we who are advocating change, but rather the legal and the medical establishment who have betrayed their own ethics. Why should we allow them to squeeze us into the same mould? (Saunders P. Abortion and Conscientious Objection. Nucleus 1996; 9-14, January)

A moral graveyard

Huge technological advances are occurring in a moral graveyard where the ethical codes of yesteryear are simply rewritten in the face of changing public opinion. The Declaration of Geneva is a poignant example. Where doctors once promised to have the ‘utmost respect for human life from the time of conception’, they now pledge to respect it ‘from its beginning’. Not surprisingly the definition of life’s beginning is sufficiently hazy to allow the abortion lobby unprecedented freedoms. Having cut itself loose from the anchor of God’s word, the modern medical profession finds itself adrift in the ocean. Here, each new gust of technology is free to drive it still further from land. (Pickering M. Editorial. Nucleus 1998; 1, January)

Potential humans or humans with potential?

Human development is a continuous process beginning with fertilisation. Essentially the only difference between a fertilised ovum and a full term baby is nutrition and time. The genetic code is present in full from the very beginning. A fertilised ovum is human certainly. It is not a cat or a snake or a cabbage - and certainly it is alive! It possesses at least in rudimentary form those attributes of a living thing - movement, respiration, sensitivity, growth, reproduction, excretion and nutrition. By virtue of being alive is it not then a ‘being’? And by virtue of being a human is it not then a ‘human being’? Not a ‘potential’ human being but rather a human being with potential, a potential fetus, infant or adult? Should it not then be accorded the rights that any human being has by virtue of being made in the image of God? (Gn 9:5,6; Jas 3:9; Col 3:10). (Saunders P. Abortion - an emotive issue: a response. Nucleus 1992; 24-29, April)

When does life begin?

On my Obstetrics and Gynaecology firm, out of curiosity I witnessed a termination of pregnancy. I went with a non-Christian friend and witnessed the removal of these ‘products of conception’ (the termination of a first trimester pregnancy), using suction. I was shocked and numbed. The surgeon whistled through his teeth during the procedure and sent the tissue off for histology. In a few minutes it was over. I couldn’t believe that that was all there was to it. I asked my friend whether she thought we’d seen a baby die. She thought not. ‘Well, when does life begin then... conception?’ ‘No’ ‘Well, when?’ ‘I don’t know.’ She hadn’t thought of a sensible answer to this question and yet was prepared to defend a practice that, as far as she knew, may have been killing babies. It was then clear to me why the procedure is legal, and why it is carried out so easily and calmly - even to the accompaniment of whistling (or was that to cover his unease?) People don’t think, or won’t let themselves think, what is actually happening. (Cleaver B. Be prepared! Nucleus 1995; 20-22, July)

God gives the embryo status

The status of the embryo is derived not from the fact that it knows God in any sense. Clearly it is incapable of this. Its status is derived from the fact that God knows it. Its dignity does not depend on its own personal attributes but is rather given to it by God. (Saunders P. Abortion - an emotive issue: a response. Nucleus 1992; 24-29, April)

Work for better alternatives

If we make a stand on abortion we need to be working for better alternatives. This will be different for each person depending on their gifts and position of influence but it may mean being engaged in counselling, helping to set up support networks for women who decide to keep their babies, lobbying to introduce legislation which will give more protection to the unborn, helping to provide for unwanted children, giving financially to those involved in all these sorts of work - as well as being firm in our resolve not to be a party to the shedding of innocent blood ourselves - be it intentional or by default (Mt 7:1,2; 1 Cor5:9-13) This is part of carrying the cross: using our time, talents and money in searching for compassionate Christian alternatives where the world offers diabolical quick-fix solutions - and if necessary, putting our careers, reputations and lives on the line (Ex 23:2,7). (Dionysius Dialogues. Nucleus 1994; 28-34, April)

The strong lay down their lives for the weak

Abortion decisions can be extremely difficult, especially in situations of severe fetal handicap, rape and danger to the mother’s life. Those who have the courage to choose life for their unborn children in such circumstances deserve our deepest respect and support. But the fact that caring for children, especially handicapped children, carries a cost, is never a justification for killing them before birth. The Christian ethic is that the strong lay down their lives for the weak, not vice versa. (Saunders P. Thirty years of Abortion in Britain. Nucleus 1997; 30-31, October)

Contraception

Post-coital contraception?

Many of us who believe that human life should be respected from the time of fertilisation will not in all conscience be able to prescribe ‘post-coital contraception’. Until 1983, the World Medical Association itself declared that doctors should ‘maintain the utmost respect for human life from the time of conception’. It is not we who have changed our ethics! (Saunders P. Post-coital contraception. Nucleus 1999; 3-4, January)

Which contraceptives act to prevent fertilisation?

On the basis of the evidence, the following methods of contraception are ‘safe’ as far as the embryo is concerned:

  1. Sterilisation, male and female.
  2. The combined oral contraceptive, provided the pill-free interval (PFI) is never lengthened.
  3. The injectable Depo-Provera given every twelve weeks. 
  4. Full breast-feeding combined with the progestogen-only pill or with Depo-Provera. 
  5. Male and female barrier methods, and all spermicides. 
  6.  All methods based on fertility awareness (ie ‘natural family planning’ in which intercourse is avoided around the time of ovulation) .

The following, however, may indeed act by preventing the implantation of an embryo:

  1. All IUCDs
  2. Emergency contraception pill 
  3. Progestogen only pill (mini-pill)
  4. Norplant (contraceptive implant)

(Guillebaud J. Contraceptives: which act after fertilisation? Nucleus 1999; 19-22, January)

Contraception for the unmarried?

Contraception prevents unwanted pregnancies; but it also has the effect of enabling and encouraging people to fornicate - because it frees them from the fear of pregnancy. By providing contraception to unmarried people, we are actually making ourselves part of a system which facilitates, perpetuates and increases promiscuity - with the associated breakdown of family life leading to a rise in crime, poverty and homelessness etc. Perhaps some Christian doctors feel that if we refuse to give contraception to these patients, we are simply ‘passing the buck’ to another doctor. However, fornicating is not something patients have to do - it is something they choose to do. If they choose to reject our advice and go to another doctor to get what they want, they will later be doing something which is morally wrong, harmful and unnecessary - and be doing it of their own free will. We are under no obligation to help them do evil. Quite apart from what God’s will is in this matter, not even the government says we have to do it. It is recognised and accepted that some doctors have a conscientious objection to certain procedures and treatments, and this is respected. If the government were to make it compulsory for us to supply unmarried people with contraceptives, I believe that our response would have to be ‘We must obey God rather than men’ (Acts 4:18-21, 5:27-29). (Gurney R. Contraception for the unmarried? Nucleus 1996; 2-8, January)

The New Genetics

To clone or not to clone?

Christians have serious misgivings about human cloning on at least three counts. Firstly, all human beings are created in the image of God and, regardless of age or disability, are of infinite worth in his sight. Human diversity is part of his sovereign design. While the field of genetics opens many new and exciting therapeutic possibilities, we need to ensure that we do not usurp God’s role as Creator in pursuing them. God has made us stewards of his creation, thus validating scientific enquiry and application, but this must always be exercised for the ultimate good of individual human beings. Second, the end never justifies the means, especially when that means involves destroying existing human life, even embryonic life, and much research in this area is at the expense of embryonic life. Third, every human being has the right to the protection, nurture and discipline of a family upbringing, and a personal identity within that family.(Saunders P. Cloning. Nucleus 1998; 2-3, April)

Responding to surrogacy

Surrogacy is a complex and emotive issue. From Scripture several things seem clear:

  1. Infertility is a result of the fall and brings sadness to God as well as humankind. 
  2. We can use the God-given gift of science to try to restore fertility providing it does not contravene other ethical laws such as respect for the embryo as human life or violation of the marriage bond.
  3. Surrogacy may open the door to even greater pain for potential children, families and society. The events of Genesis 16 and 30 bear this out.
  4. For some Christian couples infertility and childlessness will be a painful reality, one that cannot be changed without breaking God’s moral code for life and for human relations.
  5. However, as Christians we have one further hope: that all things will work out for good, even childlessness (Rom 8:28; Je 29:11)
  6. Whatever our situation, no matter how painful, whether we are married or single, have children or are childless, were conceived naturally or by IVF, we are all equal before God. Each of us is equally in need of his grace and equally able to enjoy his rest and a relationship with him for eternity (Mt 11:2).

(Paul J. Surrogacy. Nucleus 1998; 25-31, April)

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