Book Review

Theological Voices in Medical Ethics

N Engl J Med 1995; 332:1523-1525June 1, 1995

Article

Theological Voices in Medical Ethics
Edited by Allen Verhey and Stephen E. Lammers. 256 pp. Grand Rapids, Mich., William B. Eerdmans, 1993. $12.99. ISBN: 0-8028-0664-3

Theological Voices in Medical Ethics, a stimulating collection of essays compiled by the Park Ridge Center for the Study of Health, Faith, and Ethics, asks that explicit reference to religious faith play a greater part in the contemporary bioethical debate. Many physicians will feel uneasy with that suggestion. Accounts of murders at abortion clinics, book bannings, and attempts to require the teaching of “Creation science” reinforce the association of religious faith with dogmatic provincialism. We have good reason to recall with gratitude the wisdom of our founding fathers in separating church and state, a tradition that allows members of many different faiths to live and work together in peace. In the era of molecular biology, the religious outlook appears to many to be increasingly sentimental and irrelevant, if not dangerous.

Although these essays are unlikely to change that assessment among committed secularists, the book offers the possibility that genuine ecumenical dialogue will lead to enhanced mutual respect and understanding. The authors argue against the form of our contemporary American compromise in which we profess religious faith in private but avoid talking about the religious underpinnings of our beliefs in public. In walling off our own private faith from public discussion and debate, we maintain the purity and integrity of our own belief structure and spare ourselves the pain of causing offense or provoking conflict. We pay a heavy price for our reticence, however, in an impoverished public discourse.

These essays need to be seen as part of a nascent effort to offer a model for ethical debate as an alternative to what the authors see as the polar extremes of sectarian fundamentalism and listless universalism. They propose a process of critical engagement among competing faiths in which disagreement is grounded in respect. Out of the process, one would hope to see each individual faith strengthened by challenge and the public realm enriched as areas of common understanding emerge. The underlying premise is that devotion to a particular religious tradition is the best path to the discovery of universal truths.

Nine prominent thinkers representing Protestant, Catholic, and Jewish approaches to bioethical matters are represented in individual chapters. The outlook of each, along with each thinker's response to concrete ethical issues such as abortion, euthanasia, tube feeding, and organ procurement for transplantation, is summarized and critiqued by a younger, theologically oriented scholar. The format serves to foster intergenerational conversation. An introductory chapter by the editors and a concluding chapter by the noted historian Martin Marty round out the book. These essays can serve as a useful introduction to the principal religious approaches to bioethical problems for those unfamiliar with the field.

The Protestant thinkers represented in the book share an emphasis on the experiential dimension of religious faith and ethical decision making. In contrast to the approach favored by Catholic thinkers, which holds moral values to be timeless and universal, these thinkers stress the particularities of the individual's history and circumstances in evaluating the morality of an act. By acknowledging the authority of religious tradition in moral decision making, they distance themselves from the situational ethics of the Episcopal theologian and medical ethicist Joseph Fletcher.

Substantial differences divide these theologians, however. Paul Ramsey stresses the overriding ethical importance of the principle of Christian love and comes close to traditional Catholic positions on questions such as abortion rights. He and Stanley Hauerwas argue for a morality based in covenant, a sense of mutual obligation between God and humanity at a particular time in particular circumstances.

James Childress focuses on the individual. He derives his “respect for persons” from the Quaker tradition of “answering that of God in every person.” In so doing, he places emphasis on patients' autonomy and is critical of what he considers Ramsey's “paternalism.” Coauthor with Tom Beauchamp of Principles of Biomedical Ethics, one of the authoritative works in the field, Childress attempts to derive a universal set of ethical principles, which he identifies as respect for persons (autonomy), beneficence, justice, utility, and nonmaleficence, and shares ground with secular moral philosophy.

James Gustafson and Hauerwas criticize Childress for failing to specify the theological basis for his positions, and for behaving in practice as if theological convictions were unimportant; they, along with William F. May, are less interested in providing solutions to specific ethical dilemmas than in investigating how religious faith transforms character. For May, for example, what religion offers is “a kind of corrective vision”: “It corrects our vision by seeing the issue not simply as a puzzle to be solved but as a human mystery to be explored.”

For Gustafson, religion is not a substitute for morality but “qualifies morality.” There are “no divinely initiated or infallibly revealed prescriptions of proper actions,” he argues. “But experience of the power of God and God's purposes on the basis of scripture, tradition, nature and the interdependencies of life can provide `indications of points to be taken into account in making personal and social choices and set such choices within a larger context.' ” In other words, moral decision making for Gustafson and these other thinkers involves a process of dialogue between an individual's particular circumstances, family, and community and the authority of a religious tradition that consists of a revealed scriptural core and a body of historical practice.

Hauerwas, perhaps the most radical of the thinkers represented, calls on each faith to recover its own unique voice and to hold itself “distinct from the culture in which it finds itself.” “Christians have a particular morality because they have distinctive commitments,” he argues.

The Catholic thinkers represented here are united in their deference to the natural-law tradition, a tradition that understands moral values to be grounded in an objective moral order established by God and accessible to human reason. They differ, however, in the implications that they draw from that tradition, with Germain Grisez defending traditional Church teaching in areas such as abortion and contraception and Richard McCormick and Bernard Haring dissenting to some degree.

For Grisez, there are moral truths, prime among which is “the notion that an individual human life is absolutely unique, inviolable, irreplaceable, noninterchangeable” and that there are actions that are “intrinsically evil” regardless of the circumstances. Right intention is central to the morality of an act, so that the intentional taking of innocent human life is never justified by reference to some other end. McCormick, in contrast, would allow abortion to save the life of the mother and the use of contraception and artificial reproductive techniques by spouses, arguing that each decision involves balancing the good effects and the bad effects of the act.

Haring defends the traditional Catholic proscriptions against abortion and birth control but differs from Grisez in stressing the personal aspects of moral decision making and the ways these may affect timeless moral standards. Rather than focus on reasoning from abstract principles in deciding on the morality of an act, he suggests having reference to experience, tradition, scripture, and the opinions of others close to us. Like the Protestant thinkers represented in this book, he is more concerned with good character than with right action.

Marc Gellman, a Reform Jewish rabbi, offers an appreciation and critique of the work of Immanuel Jakobovits, a pioneer in the study of Jewish medical ethics. He faults Jakobovits, however, for failing to account for historical contingency, the fact that the law has changed with time, for ignoring the views of non-Orthodox Jews, and most fundamentally, for failing to develop a philosophical position that would express the moral values that underlie Jewish law. These values, according to Gellman, include an emphasis on duties rather than rights, a sense of the divine ownership of all creation, including our bodies, and a powerful, though not absolute, commitment to the sanctity of life. Having failed to promote these values, Gellman argues, Jakobovits is left with “a monotonous litany of `some authorities believe this but other authorities believe that' ” when confronting a difficult problem like abortion or euthanasia. For Gellman, the contemporary thinker Baruch Brody offers the most promising synthesis of traditional Jewish practice and secular ethics.

In the face of such serious disagreement among members of the same religious faith, not to mention the doctrinal beliefs that separate the different religions, it is reasonable to ask whether religious thinking simply contributes another layer of confusion to an already muddled field. A physician friend summarized the case against religion well. “You can't talk about religion as such,” he wrote, “because some, like Judaism, require you to do without believing, and others, like Catholicism, have an ethic of intent, whereas Protestants believe in faith alone. No one can make generality about such matters and we haven't even considered the Buddhists, animists. . . .” Religions in this view are imprisoned by their own dogmas, “conversation stoppers” that obstruct serious intellectual effort.

This is a strong argument, but the cumulative effect of the essays in this book amounts to an effective rejoinder. It is hard not to come away from reading this collection with the hope that religion can play a more constructive part in ethical analysis. Religious conviction, as conveyed by subtle thinkers like Gustafson and Haring, for example, is not necessarily identical to religious dogma, and Gellman's call for a deeper sense of dialogue between religious thinking and secular philosophy seems a promising approach. It may be most useful to view the religious outlook not as a series of certain answers but as a challenging alternative to the usual cost–benefit approach to ethical problems.

Despite their differences over particulars, the thinkers in this book share a core of universal issues of concern — chief among these, the conviction that the universe is not just the product of random chance and that there is a Creator to whom we are always in debt. This sense of debt can inform and transform our way of thinking about ethics even if it cannot tell us precisely what to do. It implies, for instance, that just because a part of our world does not have a use at a given moment, that does not mean we should feel free to discard or destroy it.

For medicine as a whole, the religious voice offers a reminder that physicians are more than scientists, technicians, or gatekeepers. At a time when communities are increasingly conceived as “health care markets” and people as “covered lives,” it may be particularly valuable to recall that the ultimate authority of medicine comes from the moral skill that we as physicians possess.

Alan B. Astrow, M.D.
St. Vincent's Hospital and Medical Center of New York, New York, NY 10011-8397