Ethical and Spiritual Decision Making in Health Care
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https://journalofethics.ama-assn.org/article/incorporating-spirituality-patient-care/2015-05
Biomedical Ethics in the Christian Narrative
Introduction
Bioethics is a subfield of ethics that concerns the ethics of medicine and ethical issues in the life sciences raised by the advance of technology. The issues dealt with tend to be complex and controversial (i.e., abortion, stem cell research, euthanasia). There have been several approaches to the theory and methodology of ethical decision-making in bioethics, but this discussion will focus on what is likely the most influential approach called principlism, which stresses the application of four moral principles to all ethical decisions in health care. A practical tool, commonly used by ethicists and hospital ethic committees, known as the “four-boxes approach” will be introduced as a way to organize hard cases and appropriately apply the four principles. Principlism and the four-boxes approach will be used and interpreted in light of the Christian worldview and the overarching narrative presented in the Bible.
Principlism
Principlism is often referred to as the “four-principle approach” because of its view that there are four ethical principles that are the framework of bioethics. These four principles are the following, as spelled out by Tom L. Beauchamp and David DeGrazia (2004):
1. Respect for autonomy − A principle that requires respect for the decision-making capacities of autonomous persons.
2. Nonmaleficence − A principle requiring that people not cause harm to others.
3. Beneficence − A group of principles requiring that people prevent harm, provide benefits, and balance benefits against risks and costs.
4. Justice − A group of principles requiring fair distribution of benefits, risks, and costs. (p. 57)
While these principles will guide ethical decision-making, they only provide a general and abstract framework for thinking about particular ethical cases. Other information is required before one can make a concrete ethical decision. First, one must specify the particular context and details of a case or dilemma in order to concretely apply these principles and arrive at concrete action-guiding results (i.e., individuals need to know how to apply these principles to specific cases and circumstances).
Second, one must figure out how each of the four principles ought to be weighed in a particular case. One needs to determine which of the four principles deserves the most priority in any given case, especially in cases in which there are conflicts between the principles. The details of a specific case as well as the way in which principles are weighed and prioritized necessarily involves discussion of worldview. This is because a patient’s preferences will involve his or her worldview, and because different worldviews would rank the importance and priority of principles differently. Thus, one might approach the four principles from a Buddhist perspective, or an Islamic perspective, or an atheistic perspective and achieve vastly different results. When one utilizes the principlist approach to bioethical dilemmas, it will always also incorporate broader worldview considerations and never be purely neutral or unbiased. In order to understand how the Christian worldview would apply the principles, it is important to understand the grand story told in the Bible that Christians believe describes reality.
The Christian Biblical Narrative
While it is not possible to survey every possible religion, the description below will at least attempt to do justice to the biblical narrative and Judeo-Christian tradition.
The Bible is a collection of 66 books written over thousands of years in several different languages and in different genres (e.g., historical narrative, poetry, letters, prophecy), yet there is an overarching story, or big picture, which is referred to as the Christian biblical narrative. The Christian biblical narrative is often summarized as the story of the creation, fall, redemption, and restoration of human beings (and more accurately this includes the entire created order). Concepts such as sin, righteousness, and shalom provide a framework by which the Christian worldview understands the concepts of health and disease.
Briefly, consider the following summary of each of the four parts of the grand Christian story:
Creation
According to Christianity, the Christian God is the creator of everything that exists (Gen. 1-2 NIV). There is nothing that exists that does not have God as its creator. In Christianity, there is a clear distinction between God and the creation. Creation includes anything that is not God–the universe and everything in it, including human beings. Thus, the universe itself and all human beings were created. The act of creating by God was intentional. In this original act of creation, everything exists on purpose, not accidentally or purely randomly, and it is good. When God describes his act of creating, and the creation itself as good–among other things–it not only means that it is valuable and that God cares for it, but that everything is the way it is supposed to be. There is an order to creation, so to speak, and everything is how it ought to be. This state of order and peace is described by the term Shalom. Yale theologian Nicholas Wolterstorff (1994) describes Shalom as, “the human being dwelling at peace in all his or her relationships: With God, with self, with fellows, with nature” (p. 251).
The Fall
Sometime after the creation, there occurred an event in human history in which this created order was broken. In Genesis 3, the Bible describes this event as a fundamental act of disobedience to God. The disobedience of Adam and Eve is referred to as the fall, because, among other things, it was their rejection of God’s rule over them and it resulted in a break in Shalom. According to the Bible, the fall had universal implications. Sin entered into the world through the fall, and with it, spiritual and physical death. This break in Shalom has affected the creation ever since; death, disease, suffering, and, most fundamentally, estrangement from God, has been characteristic of human existence.
Redemption
The rest of the story in the Bible after Genesis 3 is a record of humanity’s continual struggle and corruption after the fall, and God’s plan for its redemption. This plan of redemption spans the Old and New Testaments in the Bible and culminates in the life, death, and resurrection of Jesus Christ. The climax of the Christian biblical narrative is the atoning sacrificial death of Jesus Christ, by which God makes available forgiveness and salvation by grace alone, through faith alone. The death of Christ is the means by which this estrangement caused by sin and corruption is made right. Thus, two parties, which were previously estranged, are brought into unity (i.e., “at-one-ment”). For the Christian, salvation fundamentally means the restoration of a right and proper relationship with God, which not only has consequences in the afterlife, but here and now.
Restoration
The final chapter of this narrative is yet to fully be realized. While God has made available a way to salvation, ultimately the end goal is the restoration of all creation to a state of Shalom. The return of Jesus, the final judgment of all people, and the restoration of all creation will inaugurate final restoration.
Summary: The Christian Ethical Approach
While the principlist approach may be used by the Christian as a general methodological tool for bioethical reflection, the general contours of a Christian approach to ethics (not only bioethics) include the principles and rules found in the Bible, as well as the example of Jesus Christ (Rae, 2009, p. 24). The way in which Christianity answers the worldview questions will be in the context of the above narrative. Similarly, a Christian view of health and health care will stem from the above narrative and God’s purposes. Of course, the pinnacle of this framework is the person of Jesus Christ. Thus, for Christianity, medicine is called to serve God’s call and purposes, and everything is done in remembrance of, and in light of, Jesus’s ultimate authority and kingship.
The Four-Boxes Approach
The four-boxes approach is a practical tool developed by Jonsen, Siegler and Winslade that helps clinicians identify ethical issues in medical cases and reach reasonable a conclusions that lead to ethical actions (Jonsen, Siegler, & Winslade, 2010). This approach introduced four topics that describe the way in which the four principles of principlism actually apply to a certain. These topics include (1) medical indications, (2) patient preferences, (3) quality of life, and (4) contextual features.
Medical indications refer to “those facts about the patient’s physiological or psychological condition that indicate which forms of diagnostic, therapeutic, or educational interventions are appropriate” (Jonsen et al., 2010, p. 10). This topic concerns the professional judgment of the physician and involves the concrete application of the principles of beneficence and nonmaleficence.
Patient preferences refer to “the choices that persons make when they are faced with decisions about health and medical treatment…[which] reflect the patient’s own experience, beliefs and values as informed by the physician’s recommendations” (Jonsen et al., 2010, p. 47). This topic primarily involves the concrete application of the principle of respect for autonomy.
Quality of life refers to “that degree of satisfaction that people experience and value about their lives as a whole, and in its particular aspects, such as physical health” (Jonsen et al., 2010, p. 109). This topic is difficult to define, and it involves the concrete application of beneficence, nonmaleficence and respect for autonomy. However, it seems that the most important principle here is an aspect of the principle of beneficence. Beneficence is not only acting in ways that help other persons in need by way of treating or curing illness, but it also involves “acting in ways that bring satisfaction to other persons” (Jonsen et al., 2010, p. 109). Thus, it is also part of beneficence to attempt to improve a patient’s life such that they are satisfied with their quality of life.
Contextual features refer to the context in which a particular case occurs, which includes “professional, familial, religious, financial, legal and institutional factors” which influence clinical decisions (Jonsen et al., 2010, p. 161). Thus, for example, an influential contextual feature in a case in which the medical indications for a person include a blood transfusion, would be if a patient were of the Jehovah’s Witnesses religion. This is because blood transfusions are considered to be immoral according Jehovah’s Witnesses teaching.
When considering a difficult ethical case in medicine or health care, the relevant information of that case is arranged into four boxes which correspond to the four topics above and aligns them with the key ethical principles (Jonsen et al., 2010):
Medical Indications (Beneficence and Nonmaleficence)
Patient Preferences (Autonomy)
Quality of Life (Beneficence, Nonmaleficence, Autonomy)
Contextual Features (Justice and Fairness)
The four-boxes approach is a useful tool to make sure that you have gathered all the relevant data (or as much data as possible) so as to come to an ethical decision and plan of action. Keep in mind that many times in clinical ethics, there may not be a single right course of action, but there are certainly better or worse options. This does not mean that there is no such thing as right and wrong (i.e., relativism), but simply that real life is messy and imperfect.
Applying the Principlism and the Four-Boxes Approach
Consider the following analysis from a Christian perspective of the case study, “End of Life and Sanctity of Life,” in the American Medical Associations Journal of Ethics, included in the topic readings(Reichman, 2005). That case is analyzed from a Jewish and Buddhist perspective by different commentators. This case will be analyzed by addressing the four principles in the principlist approach, and then that data will be considered in light of the Christian worldview in order to recommend a course of action in accordance to Christian values and biblical principles. As practice, begin filling the four boxes based on the information provided by the case itself, as well as the analysis below.
Depending on the case, different principles will come to have greater prominence in deciding an ethical course of action. At times there may be conflicts among the principles themselves, in which it will have to be determined which principle will have the greater priority. For example, a common conflict is that between a patient’s autonomy and what a physician considers to be beneficent, or in the best interests of the patient. A physician might see that a particular course of treatment will be beneficial for a patient (beneficence), and yet the patient refuses the treatment (autonomy). Should the physician simply allow patients to choose for themselves a course of action that will knowingly bring them harm? Is it right for the physician to coerce or force a patient to undergo a treatment against his or her will and violate autonomy, even if it will bring about some medical benefit?
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