Topic 3: Biomedical Ethics In The Christian Narrative

Objective

1. Describe the four principles and four boxes approach to biomedical ethics.

2. Describe how the four principles and four boxes approach would be applied according to the Christian worldview.

Assignment 1

The four principles, especially in the context of bioethics in the United States, has often been critiqued for raising the principle of autonomy to the highest place, such that it trumps all other principles or values. How would you rank the importance of each of the four principles? How do you believe they would be ordered in the context of the Christian biblical narrative? Refer to the topic Resources in your response.

Assignment 2

What do the four parts of the Christian biblical narrative (i.e., creation, fall, redemption, and restoration) say about the nature of God and of reality in relation to the reality of sickness and disease? From where would one find comfort and hope in the light of illness according to this narrative? Explain in detail each part of the narrative above and analyze the implications.

Assignment 3

Case Study on Biomedical Ethics in the Christian Narrative

Assessment Description

This assignment will incorporate a common practical tool in helping clinicians begin to ethically analyze a case. Organizing the data in this way will help you apply the four principles and four boxes approach.

Based on the “Case Study: Healing and Autonomy” and other required topic Resources, you will complete the “Applying the Four Principles: Case Study” document that includes the following:

Part 1: Chart This chart will formalize the four principles and four boxes approach and the four-boxes approach by organizing the data from the case study according to the relevant principles of biomedical ethics: autonomy, beneficence, nonmaleficence, and justice.

Part 2: Evaluation

This part includes questions, to be answered in a total of 500 words, that describe how principalism would be applied according to the Christian worldview.

Remember to support your responses with the topic Resources.

APA style is not required, but solid academic writing is expected.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

Attachments


PHI-413V-RS-T3T5CaseStudyHealingAndAutonomy.docx
PHI-413V-RS-T3ApplyingFourPrinciplesCaseStudy.do


Case Study: Healing and Autonomy

Mike and Joanne are the parents of James and Samuel, identical twins born 8 years ago. James is currently suffering from acute glomerulonephritis, kidney failure. James was originally brought into the hospital for complications associated with a strep throat infection. The spread of the A streptococcus infection led to the subsequent kidney failure. James’s condition was acute enough to warrant immediate treatment. Usually cases of acute glomerulonephritis caused by strep infection tend to improve on their own or with an antibiotic. However, James also had elevated blood pressure and enough fluid buildup that required temporary dialysis to relieve.

The attending physician suggested immediate dialysis. After some time of discussion with Joanne, Mike informs the physician that they are going to forego the dialysis and place their faith in God. Mike and Joanne had been moved by a sermon their pastor had given a week ago, and also had witnessed a close friend regain mobility when she was prayed over at a healing service after a serious stroke. They thought it more prudent to take James immediately to a faith healing service instead of putting James through multiple rounds of dialysis. Yet, Mike and Joanne agreed to return to the hospital after the faith healing services later in the week, and in hopes that James would be healed by then.

Two days later the family returned and was forced to place James on dialysis, as his condition had deteriorated. Mike felt perplexed and tormented by his decision to not treat James earlier. Had he not enough faith? Was God punishing him or James? To make matters worse, James’s kidneys had deteriorated such that his dialysis was now not a temporary matter and was in need of a kidney transplant. Crushed and desperate, Mike and Joanne immediately offered to donate one of their own kidneys to James, but they were not compatible donors. Over the next few weeks, amidst daily rounds of dialysis, some of their close friends and church members also offered to donate a kidney to James. However, none of them were tissue matches.

James’s nephrologist called to schedule a private appointment with Mike and Joanne. James was stable, given the regular dialysis, but would require a kidney transplant within the year. Given the desperate situation, the nephrologist informed Mike and Joanne of a donor that was an ideal tissue match, but as of yet had not been considered—James’s brother Samuel.

Mike vacillates and struggles to decide whether he should have his other son Samuel lose a kidney or perhaps wait for God to do a miracle this time around. Perhaps this is where the real testing of his faith will come in? Mike reasons, “This time around it is a matter of life and death. What could require greater faith than that?”

© 2020. Grand Canyon University. All Rights Reserved.

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Applying the Four Principles: Case Study

Part 1: Chart (60 points)

Based on the “Healing and Autonomy” case study, fill out all the relevant boxes below. Provide the information by means of bullet points or a well-structured paragraph in the box. Gather as much data as possible.

Medical Indications

Beneficence and Nonmaleficence

Patient Preferences

Autonomy

Quality of Life

Beneficence, Nonmaleficence, Autonomy

Contextual Features

Justice and Fairness

©2020. Grand Canyon University. All Rights Reserved.

Part 2: Evaluation

Answer each of the following questions about how the four principles and four boxes approach would be applied:

1. In 200-250 words answer the following: According to the Christian worldview, how would each of the principles be
specified and
weighted in this case? Explain why. (45 points)

2. In 200-250 words answer the following: According to the Christian worldview, how might a Christian
balance each of the four principles in this case? Explain why. (45 points)

References:

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Biomedical Ethics in the Christian NarrativeBy Paul J. Hoehner

Throughout the land, arising from the throngs of converts to bioethics awareness, there can be heard a mantra, “…beneficence…autonomy…justice…” It is this ritual incantation in the face of biomedical dilemmas that beckons our inquiry (Clouser & Gert, 1990, p. 219).

Ethics as a theological discipline is the auxiliary science in which an answer is sought in the Word of God to the questions of the goodness of human conduct. As a special elucidation of the doctrine of sanctification it is reflection on how far the Word of God proclaimed and accepted in Christian preaching effects a definite claiming of man. (Barth, 1981, p. 3)

Essential Questions

· What are the four elements of a Christian worldview and how do they influence a Christian approach to medicine, healing, and medical ethics?

· What are the four principles of medical ethics and how are they defined? How can a Christian appropriately use these four principles?

· What is meant by specifying, balancing, and weighing the principles? How does a Christian worldview influence how one defines and uses each of these four principles?

· What is the four-boxes approach to organizing an ethical case study? What is the difference and the relationship between the four-boxes approach, and the four principles of medical ethics?

· What are the four ethical topics that compose the four-boxes approach and what questions does each topic entail? How does the four-boxes approach help solve ethical dilemmas in a case study?

Introduction

Biomedical ethics, or bioethics, is a subfield of ethics concerned with the ethics of medicine and the ethical issues involving the life sciences, particularly those raised by modern technologies, such as stem cell research and cloning. The term 
medical ethics is closely related to biomedical ethics but is primarily focused on ethical issues raised in the practice of medicine and medical research, such as abortion, euthanasia, and medical treatment decisions (World Medical Association, 2015).

Because the terms biomedical ethics and medical ethics are closely related and involve a great deal of overlapping subject area, they will be used interchangeably to avoid confusion. The study of biomedical ethics and medical ethics presents some of the most complex and controversial challenges in applied ethics. The complexities of dealing with individual patients and the intricacies of modern health care, coupled with the rapid advances being made in medical science, present formidable challenges. For many health care workers, clinical ethical dilemmas will often challenge their own settled positions, especially if they have not taken the opportunity to reflect critically on their own moral presuppositions and how their own intuitive ethical positions may be justified.

When one encounters the many ways the world and even portions of the Christian church respond to ethical issues, it is easy to be tempted to think there are no right or wrong answers. The complexity of these issues and the myriad of answers and justifications given by so many “experts” can drive many students toward some form of ethical relativism.

There are certainly many complexities in health care ethics: competing ethical ideologies, beliefs or virtues, different interpretations of the facts surrounding an issue, and differing approaches on how to address these issues; however, one should not confuse complexity with ethical relativism. These are two very different things. Relativism is the belief that “what is right and wrong, good and bad, true and false varies from time to time, place to place, and person to person. There are no absolute standards of truth or morality” (Cook, 1995, p. 726).

Coupled with the complexity of biomedical ethics is the loss of moral consensus in the medical profession and society as a whole, whereby moral positions once taken for granted cannot be taken for granted any longer. There are plenty of examples in the medical field: abortion, contraception, euthanasia, suicide, and anything that has to do with sexual morality. This lack of moral consensus is primarily a result of the cultural plurality that exists in many Western nations. Cultural plurality is a term that simply refers to the sheer diversity of race, value systems, heritage, language, culture, and religion. It is the simple observation that many cultures contain people with different worldviews, ideologies, and moral frameworks.

One of the consequences of many pluralistic societies is an increased tendency toward secularization. Secularized societies tend to relegate religious perspectives, and moral frameworks based on those perspectives, to the periphery of public discussion or limit them to the private spheres of life. According to most secularist thinkers, religious, spiritual, or faith-based perspectives may play an important role in one’s personal life, but they have no place in the public square of politics, public education, law, or medicine, particularly medical ethics. As Guinness (1983) notes, this results in a faith that is “privately engaging, but socially irrelevant” (p. 79). Limiting one’s faith, spirituality, or religion to merely private matters does not do justice to the role that religious or spiritual worldviews play in deciding how to live and interact within the world and society. Biblical Christianity stresses the role of the Christian in the world in matters of justice as well as civil engagement.

Plurality, the fact that different worldviews exist side-by-side in a culture, needs to be distinguished from 
pluralism, an instance of relativism. The distinction is important. Pluralism is a philosophical or ideological statement that maintains that no single ideological or religious claim is actually “right;” all truth claims have equal validity (Hoehner, 2006). The practical result of philosophical pluralism is to deny any objective truth claim or deny that any objective truth can ever be obtained. This leads many students to conclude that there can be no common approach to finding right amid the many perplexing and complicated moral issues of the day.

In this postmodern and relativistic world, divine or even natural, given norms of moral behavior are soon replaced by a form of morality based solely on one’s own personal subjective views, conforming the world to one’s own feelings and desires. Instead of orienting one’s behavior to an objective standard beyond oneself (e.g., divine and biblical revelation), many in today’s postmodern society seek to orient norms and standards of morality to their own self-referential existence (e.g., what one feels, intuits, or wills according to one’s own needs, wants, or desires). What is “right” and “true” has no reference outside of one’s own personal experience and feelings. What is right and true for one person may not be right and true for another. This can be profoundly challenging and perplexing for the Christian health care worker attempting to insert a Christian ethic into this social mix. Most people would never apply this way of thinking to empirical scientific matters. There is an inconsistency in much of modern culture that holds simultaneously to both relativism and scientism; however, this way of thinking is itself incoherent and is generally only applied to issues of morality and religion.

While there are many different approaches to medical ethics, this chapter will introduce the four principles approach to biomedical ethics and how they are used to work through ethical dilemmas in health care. While there are many principle-oriented approaches to medical ethics, the approach originally popularized by the 1970 publication of the book 
Principles of Biomedical Ethics by Tom Beauchamp and James Childress is unarguably the most influential.

Centered on the four core principles of 


beneficence



nonmaleficence



respect for autonomy

, and 


justice

, Beauchamp and Childress’s (2013) principle approach is currently considered to be the dominant framework for discussing issues in biomedical ethics, at least in this country, and “one of the most important methodological inventions of modern practical ethics” (Lee, 2010, p. 525). DeGrazia (2003) acknowledges that, “one would be hard-pressed to find a text that has been more influential and more frequently cited” (p. 219). It is important and necessary for anyone involved in medical ethics to understand the use of the four principles approach to biomedical ethics, not because it is the only framework used for medical ethics, as there are several others, but because of its near universal influence and status in modern-day medical ethics discussions, in hospital ethics committees, and in managed care.

One of the most important aspects that must be understood in using the four principles is that these four main principles do not immediately and directly provide a solution to most ethical dilemmas. It is not always clear how each of the four principles are to be applied or what their implications might be. More importantly for the purposes of this chapter, it also requires interpreting them—whether consciously or not—in terms of a particular worldview, philosophy, and/or ethical theory. For example, in a specific medical ethics case, beneficence may mean something very different for a Christian than for a Muslim or philosophical utilitarian.

Many of these different meanings are assumed rather than subjected to critical reflection. For this reason, this chapter will begin with a discussion of how the Christian worldview, as informed by the biblical narrative, understands the concepts of health, wellness, and disease. The biblical narrative is the context by which the Christian justifies how one specifies, defines, and interprets the four principles in light of specific cases, and provides the Christian health care professional with an accurate and consistent normative guide for the ethical and moral uses of medicine and medical technology within a Christian worldview.

Medicine and Medical Technology in Biblical Perspective

·

As discussed in Chapter 1, in the Christian worldview, the ultimate foundation for determining the right, the good, and the just is the triune God. The triune God is the ultimate foundation of reality, including ethics. Moral goodness and justice are derived from the very character of God. God is holy and set apart (Leviticus 20:26, English Standard Version), so people are to live lives of holiness and goodness. God is love (1 John 4:10–11), and so love is a virtue and an essential principle for life and relationships. Because God is just toward people (Deuteronomy 15:15), they are to act justly towards the poor, the sick, and the disenfranchised. People are to live in covenant faithfulness to their spouses and to honor covenantal relationships in their professions (e.g., the doctor-patient and nurse-patient relationship) because God is a covenant God, faithful to his people, even when they were unfaithful (Hosea 1–3; Malachi 2:10,14).

As discussed previously, all ethics flow from one’s worldview and its basic assumptions about ultimate reality. One’s view of human nature, the fundamental problem of humanity, the solution to that problem, and the ultimate direction and goal of history will determine personal ethics. Every worldview embodies these elements in some sense, and the substance of these elemental conceptions influences everyone’s moral vision. These assumptions deeply influence what one believes to be the right, the good, and the just, and they will direct, whether consciously or subconsciously, one’s individual daily choices and actions.

The Christian worldview, which is the focus of this text, is founded on the biblical narrative or story. This narrative is often summarized as the story of the creation, fall, redemption, and restoration of human beings, along with the entire created order (see Figure 3.1). This section will examine how key concepts within this narrative, such as sin, righteousness, and 
Shalom, provide a framework by which the Christian worldview understands the concepts of health and disease and life and death, as well as provides guiding norms for how one should approach healing and care-giving, the ethical use of medicine and new medical technologies, and justice in health care.

Figure 3.1


Biblical Narrative and Christian Worldview

Creation

The Christian narrative of creation is essential for both Christian theology and for Christian ethics. At the foundation of the biblical narrative is the Christian God who is the creator of everything that exists (Genesis 1–2). The most important aspects of the biblical view of creation are the following:

1. Nothing exists that does not have God as its creator (Colossians 1:16; Revelation 4:11).

2. There is a clear distinction between God and his creation (God transcends creation). At the same time God continues to be involved in every aspect of creation, providentially directing and guiding all things that come to pass for his purpose and design (God is immanent within his creation).

3. God is neither dependent on creation nor is creation necessary to God.

4. God’s act of creation was intentional; everything exists for a purpose, not accidentally or randomly.

Implications of the Biblical Narrative of Creation for Health Care Ethics

·

Several aspects of the biblical view of creation give substance and direction to ethical issues. First, the biblical narrative of creation is the account of a good God who creates a good world (Genesis 1:21) with human beings at the apex of his creation. When God described both his act of creating and the creation itself as good, it meant that it was valuable, and everything in its original state was the way it was supposed to be. The goodness that remains in the world even after the fall reminds one that God has called humans to live in his world, not to abandon or reject it. There is a harmony and orderliness to creation and the physical world, the human body, and the institutions of culture and society, and these are good gifts of the creator God.

Second, man and woman are created in the image of God, a concept that was discussed in Chapter 2. As stated in that chapter, various ideas for what the image of God in humans actually is have been proposed by theologians and philosophers throughout history. Nonetheless, there are clear relational and dynamic aspects entailed in the image of God that give rise to implications that are generally affirmed across Bible-believing churches and organizations. These implications are important for a Christian view of ethics.

Being created in the image of God implies that humans are set apart from the rest of the created order and provides a foundation for the intrinsic dignity and value of all human beings. All human beings, without exception, have an intrinsic dignity and value that is to be protected in every stage of life. Whether in health or sickness, with mental or physical disability, from its formation in the womb through the sometimes-debilitating effects of old age, humans have intrinsic value. The Benedictine monk Illtyd Trethowan (1970) expresses this beautifully:

To love people because they are creatures of God, “reflections” of God, is the only way to love them as they really are. To say that they are God’s creatures is not just to mention an interesting fact about them. It is the essential truth about them. They have value indeed in themselves, but only because God gave it to them. Unless we see God in them as the source of value, we should not really see that they had it. (p. 84)

It is also the foundation for distinguishing human beings from other species or kinds. Only human beings are created in God’s image That the dignity is intrinsic means that moral dignity is not dependent on any capacity or specific characteristic or attribute that a human being possesses—there is no distinction, for instance, between being a human being and being a person. To be sure, human beings can be distinguished from other animals based on certain capacities, characteristics, or attributes, but this is not the foundation for their being in God’s image. This means that all human beings have equal moral worth. Dignity and moral worth are conferred on all human beings by God who has created them to be in relationship with him, to reflect him, and to represent himself in the care of his creation. This applies from a person’s physical beginning, to their physical death, and beyond.

To say that all human beings have intrinsic moral worth and dignity is to say that it is morally wrong to use one person for the mere benefit of another. One cannot say that one kind of human being, or a certain human being that lacks certain attributes or capacities, is of less moral worth than another. It is morally wrong to use another human being (or a class of human beings) as an end to someone else’s purpose. That is why Christian ethics views certain biomedical and medical practices, such as embryonic stem cell research, as immoral because it is using another human being (even a human being that is still an embryo) as a means to another end, even if that end is providing medical advances that may help many others—emphasis on may.

To justify any act merely because it results in overall good on balance is a theory that is foreign to Christian ethics (i.e., utilitarianism). To accept this way of moral reasoning, one would have to say that things like experimenting on people without their consent is morally acceptable because those experiments will bring greater good to more people. This thinking has been used to justify many of the atrocities committed in this and the past century in the name of producing “good” things for many people (e.g., the Tuskegee syphilis study).

Third, the biblical narrative of creation provides a foundation for the care of God’s creation. Just as God in his providence cares for all creation, so humankind is given a cultural mandate to represent him in the care of his creation. As created image bearers of their Creator, humankind is to reflect God’s character, do his will, and rule on earth on his behalf as stewards and vice-regents. The discovery of God’s creation through the use of God-given intellect and curiosity is part of that cultural mandate. Medical science is part of the discovery of that created order. Human rule over God’s creation, however, is never absolute, but moderated service. It is always subsumed under the higher rule of God and for his glory alone. Humankind’s relationship to creation is one of covenant-stewardship, not co-creator. It is a stewardship that must be used for God’s purpose, not humankind. Part of that cultural mandate is reflected in the proper use of medical science.

Finally, the biblical narrative of creation affirms that there is an order to creation, that everything was how it was supposed to be and how everything ought to be. This state of order and peace can be 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). Cornelius Plantinga (1995) describes Shalom as,

universal flourishing, wholeness, and delight—a rich state of affairs in which natural needs are satisfied and natural gifts fruitfully employed, a state of affairs that inspires joyful wonder as its Creator and Savior opens doors and welcomes the creatures in whom he delights. (p. 10)

Moreover, there is a creative normative design that provides a Christian vision of health and flourishing. The concept of Shalom offers a glimpse into the multidimensional view of biblical understanding of health and how healthy persons should function. Health is not merely about physical or biological functioning, but also encompasses the spiritual and communal dimensions of what it means to be a human being created in the image of God. Walter Brueggemann (2001) highlights this multidimensional view of health as Shalom:

Health refers to stability enough to share in the costs and joys, the blessings and burdens of the community. To be healthy means to be functioning full in terms of the norms, values, and expectations of the community. Healing refers to the restoration and rehabilitation of persons to their full power and vitality in the life of the community. Sickness, then, does not refer primarily to physical pain as much as to the inability to be fully, honorably, and seriously engaged in the community in all its decisions and celebrations. (p. 199)

Communal and relational aspects of health are just as important as the physical and psychological.

The spiritual dimension of all human beings cannot be disassociated from the physical dimension, as if it were a separate part of the person. Human beings are not only a physical body (i.e., atoms in motion, a concept referred to as 
monism or 
physical reductionism), instead they are multidimensional beings that are a unity of a body and soul. The biblical account of creation describes Adam—and all subsequent human beings—with the Hebrew term 
nephesh, which means either “ensouled bodies” or “embodied souls.” This has important ramifications for health and healing according to the biblical narrative of creation. Health and disease involve all dimensions of the person at once, the body and the soul. Furthermore, the biblical narrative describes human beings as relational, embodied spiritual beings.

As will be discussed in the next section, sin and the fall affect all aspects of a human being: the body, soul, and its relationship to others and the world. This is the biblical foundation for the 


biopsychosocial-spiritual model

 of health and healing, whereby wellness is concerned with and defined by not only the physical, but also the emotional, spiritual, and social wellness of human beings (Sulmasy, 2002).

The Fall

·

According to the Bible, the fall has universal and cosmic implications. Just as illness in the body can be viewed as a break in the homeostasis of the body’s physiology, the fall and subsequent separation from God broke the homeostasis of creation itself, bringing disease, sickness, suffering, and death. These are all effects of the fall and not part of God’s original design. This deviation from the normative design of the original creation affects the mind, body and spirit of each human being. The death that sin brings to the world is not merely physical death, but spiritual death, which is eternal separation from God.

Humanity’s predicament, a predicament of humankind’s own making, is not merely physical, but spiritual as well, and both are intertwined and enmeshed because of humankind’s deliberate, spiritual rebellion and estrangement from God. Restoration and healing cannot be perceived as merely the return to physical health or psychological well-being, but requires spiritual and communal restoration. Ultimately, it requires a renewed relationship with God—a renewal that can only come by God’s own initiative.

Implications of the Biblical Narrative of the Fall for Health Care Ethics

The biblical narrative of the fall has several implications for a Christian view of medical ethics. First, though God’s good creation still exists, humans can distort these good gifts and use them in ways the Creator never intended. Science and technology are not unmitigated blessings. The uses of science and technology are always impacted by the fall and, like all of life, need redemption. This does not mean that Christians are anti-science or anti-technology, but that they should be discerning about the application of certain technologies that may seek to usurp God’s wisdom for his creation. Understanding the current technological culture from a biblical perspective helps to determine how one should react to many of the recent developments in bioscience.

To be “as God,” as the serpent put it to tempt Eve in the Genesis narrative, is to embrace the false expectation that something else is required other than God’s image for human fulfillment, and that something else is fully achievable by man apart from God. For many, modern biotechnology has become a false hope that will one day lead to that fulfillment and the ideal human condition. Christians are not called away from modern biotechnology, especially that which holds out promises to relieve the suffering and pain of fellow human beings in this fallen world. But its use must always be constrained by God’s wisdom and direction, a gift of his good creation, and the realization that physical illness and disease is only one dimension of humankind’s total predicament, which is fundamentally a spiritual rebellion and separation from God (Hoehner, 2008).

The fall is also a warning about utopian perceptions of the world and humankind’s efforts to change the way things are. Self-deception and sin occur side-by-side in the story of the fall (Genesis 3:12–13). In the same way, utopian attempts to achieve justice, goodness, and perfect health—even beyond perfect in terms of enhancement of the perfect—have resulted in tragic injustices and evil precisely because of self-deception and sin resulting from the fall. A Christian ethic grounded in the biblical narrative will always hold together these two dimensions of human nature:

1. Wonderfully made in God’s image with the potential for great works of mercy and kindness toward one another, and

2. Terribly fallen in rebellion against the wisdom and design of their Creator with the capacity for the greatest of evils.

Redemption

Because the fall not only has personal consequences, but universal and cosmic consequences, redemption has universal and cosmic consequences as well. The brokenness and estrangement that resulted from the fall is being restored. The restoration of Shalom, or peace, is a central theme in the New Testament explanation of the ramifications of redemption. It is precisely through justification, being made right again with God and his holiness through Christ, that Shalom is reestablished between believers and God. The Shalom between believers and God is the foundation for restoring Shalom in creation. The New Testament affirms that “all things, whether on earth or in heaven” are brought back into Shalom through Christ’s atoning death on the cross (Colossians 1:20), and “that the creation itself will be set free from its bondage to corruption and obtain the freedom of the glory of the children of God” (Romans 8:21).

Just as the concept of Shalom in the Old Testament has implications for salvation (Isaiah 43:7; Jeremiah 29:11), for bodily health (Isaiah 57:18; Psalm 38:3), and for communal well-being and blessing (Numbers 6:24ff), and the New Testament “gospel of peace” (Ephesians 6:25) also brings renewal to the whole of human and creational relationships. It is the beginning of the restoration of all that was lost in the fall. According to J. I. Durham (as cited in Beck and Brown, 1976), the peace spoken of in the New Testament is “a comprehensive fulfillment or completion, a perfection of life and spirit which transcends any success which man alone, even under the best of circumstances, is able to attain” (p. 778).

Implications of the Biblical Narrative of Redemption for Health Care Ethics

The restoration of Shalom that is the consequence of Jesus’s life, death, and resurrection has several implications for Christian ethics and the Christian view of disease, healing, and death. First, it provides the motive for Christian ethics. Christian ethics is primarily an ethics of love. It is one of gratitude and response to what God has already done. And while Jesus’ work of salvation does not depend on man’s efforts or goodness, it does not leave a Christian’s life unaffected. God also works to renew an individual’s heart, mind, and actions; therefore, Christians should be more just, loving, merciful, and faithful because of the work of God within them. Christian ethics is not merely individualistic, instead it spills over into social realities as well. Christians should be empowered to work for justice and peace in all aspects of the world and society, including issues of poverty, social injustices, racial reconciliation, and environmental concerns.

In addition to its spiritual aspects, redemption also has physical dimensions. Jesus came to redeem the whole person as a complete biopsychosocial-spiritual being; therefore, there is a strong relationship between health and salvation in the New Testament. Jesus, as the ultimate healer, is called 
soter, a Greek term that can mean both “savior” and “healer.” When Jesus heals a paralyzed man, those watching were surprised to hear Jesus first say, “your sins are forgiven” (Mark 2:5). There is both a spiritual healing and a physical healing. Most of Jesus’ miracles during his life had to do with physical healing. In his healing miracles, Jesus’ life witnessed to a beginning of the reversal of the effects of the fall.

Two caveats are in order when evaluating the healing miracles in the New Testament. First, one must understand the purpose of Jesus’s miracles. The miracles of Jesus and the Apostles in the New Testament serve two primary purposes. On the one hand, they are powerful testimonies to the truth of Jesus’ message of the gospel. They were signs of not only his divine nature, but also of his divine authority. On the other hand, they were foretastes of the ultimate physical salvation that would come to all believers, but only at the final resurrection. One could say it was a breaking in and demonstration of the final restoration that will come after death. At that time the bodies of Christian believers will be resurrected and renewed in eternal and perfect health and in eternal fellowship with God.

Christians affirm that God has power over illness and death and can, as he chooses, provide miraculous healing and recovery. But these miracles, which God uses for his own purposes, are not something that can be expected as a test of faith or as a direct result of prayer, as if God can be manipulated. Prayer can never be used like a secret incantation or spiritual therapeutic regimen. Faith and the gifts of God in creation, including medicine, biotechnologies, and the skill and judgment of physicians and nurses, are not opposed or set against one another. Faith is not opposed to reason. Nothing in the traditional, historic Christian worldview gives such priority to faith healing to the extent that it ignores good medical care. This form of faith healing is not part of the traditional Christian worldview, although it appears in many sects of Christianity.

A second caveat is to recognize the relationship between sin, illness, and healing. According to the biblical narrative, there is a connection between sin and the physical brokenness in this world, a brokenness that includes disease and suffering. All illness and suffering are a consequence of the fall in a general sense. This does not mean one can reason from specific sins to specific illnesses or diseases; however, there are the exceptions of physical sins that lead to their consequences, such as substance and physical abuse. When a man born blind was brought to Jesus, religious leaders asked Jesus whose sin was responsible for the man’s blindness. Was it his own or his parents? Jesus, before going on to heal the man’s blindness, gave a surprising answer. “It was not that this man sinned, or his parents, but that the works of God might be displayed in him” (John 9:3). There are two lessons in this story. First, one cannot directly link specific spiritual sins to specific physical illnesses. While in general, all spiritual brokenness results in physical brokenness, one should not equate the guilt of any sin with illness as a specific punishment. Second, Jesus shows that God does use even the brokenness of a fallen world for his own good purposes. Through Jesus’s own suffering, suffering is given a higher meaning and purpose that witnesses to the spiritual redemption that Jesus brings. God can transform suffering, illness, and even death for much grander purposes in this world. Christian believers have an assured hope of a full and complete healing in all their biopsychosocial-spiritual dimensions when Christ returns.

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As followers of their savior, Christian health care professionals are to be imitators of Jesus in his compassion and healing ministry. In gratitude and loving response to what the great physician and healer has done for the world, they are to reflect his love toward others as well. Christian health care workers recognize and use the gifts God has given in this world to mitigate the effects of the fall with loving compassion and mercy as they seek to relieve the pain and suffering of their fellow human beings. As God showed his love and mercy to the whole world through Jesus, so too should Christian health care workers bring that same love and mercy to all persons.

As discussed previously, all human beings are made in the image of God and have intrinsic worth and value deserving of care and compassion. Loving and caring for others shows God’s love, an unearned love that God has already shown the world. One’s love for God is also demonstrated in the love one has for one’s neighbor. Just as God’s love is free and gracious, so should a Christian’s love reflect this in selfless service to their neighbor. It is especially to the poor, the vulnerable, the sick, and the “least of these” (Matthew 25:40) that the Christian’s love should be directed.

Health care professionals are frequently called on to take care of very sick, broken, and sometimes undesirable patients. Some patients will not be kind and will be very difficult to care for. But Jesus calls his redeemed to care for and love all “the least of these” (Matthew 25:40) as if they were caring for and loving him because they are. Often this will not be the least bit rewarding from a personal perspective, but Jesus tells his followers that a greater reward awaits them in heaven.

Restoration

While sin, death, and suffering have all been completely and forever conquered by the life, death, and resurrection of Jesus, the full effect of that redemption awaits a fuller completion in the 
eschaton, Jesus’s second coming at the end of the age. The goal of the biblical narrative is a new creation—a renewed world that far exceeds the limitations and finitude of the original creation. Revelation, the final book of the Bible, speaks of the “new Jerusalem” and the “new earth” (Revelation 3:12; 21:1) that is being prepared for all of God’s redeemed people who will be resurrected to a new and more glorious life of eternal and perfect Shalom.

Implications of the Biblical Narrative of Restoration for Health Care Ethics

It is all too evident that this present age continues to suffer the effects of the fall. Suffering, pain, death, and injustices are ever present realities in the world. There is an already and not yet aspect to redemption. In one sense, it is complete (i.e., already) in that believers are fully forgiven, redeemed, and possess eternal life. In another sense, believers await a final perfection (i.e., not yet). All believers suffer the continuing effects of the fall, such as further temptation and sin, disease, and even physical death. It is like a sick patient who has been fully treated for a disease, assured of a complete cure, but must still convalesce from the lingering effects of the illness, awaiting a fuller return to health and wholeness. There is both joy and assurance, but there are continued struggles as well. The world itself is redeemed, but it still struggles with the lingering results of the fall, awaiting the new creation. Understanding this Christian 
telos, or where history is ultimately headed, has a powerful impact on ethics and a Christian view of health, illness, healing, and death.

For the health care worker, this already and not yet aspect of redemption gives an eternal as well as present perspective to the relief of suffering and illness to which they have been called. For instance, death is no longer the ultimate enemy, having been conquered through Jesus’s own death and resurrection. Believers await the resurrection of their bodies and a glorious eternity of embodied life and fellowship with God. But in the meantime, physical death and suffering remain a reality. A biblical narrative of restoration informs the Christian health care professional that while medical science is a great good, it is limited and imperfect. The way medical science pushes back against the reality of aging and death must at some point accept its reality and the finitude of all human beings.

The biblical narrative is very realistic about the sufferings and tragedies in the world. Death is something to grieve. It is not the way it is supposed to be. It is no small test of faith to hold a dying infant or to watch loved ones suffer at the end of their lives. The shortest verse of the Bible, “Jesus wept” (John 11:35), says that even though he knew he would bring him back to life, Jesus grieved over Lazarus’s death because of his great love for him. One can almost hear Jesus crying out of his love and sorrow, “This is not how it was supposed to be!” The biblical narrative affirms that there is something greater that awaits the believer that provides hope and comfort amidst the very real and tragic suffering and pain of this world. The Apostle Paul, who suffered more during his lifetime than many ever will, was still compelled to say, “For I consider that the sufferings of this present time are not worth comparing with the glory that is to be revealed to us” (Romans 8:18).

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Christian health care providers are called in this present time to do all they can to mitigate and push back against the effects of the fall, bringing relief from pain and suffering, loving all persons as image bearers of God and beings of intrinsic eternal worth and value. Sin, suffering, and illness are part of the brokenness of the world that was caused by humankind’s sin. The consequences of sin are not only personal, but also universal and cosmic. Even Christians suffer in this lifetime because of the effects of the fall and sin. While their eternal salvation is already secure and brings a spiritual peace with God, they still must await the final resurrection to bring full physical peace as well. Christian health care professionals, informed by and living in this biblical narrative and worldview, can show the mercy and peace of God to their patients as a foretaste of that future restoration here and now, even while awaiting and anticipating its ultimate fulfillment at Jesus’s return.

Summary: Biblical Perspective on Health Care

Health care professionals face a myriad of complex ethical and moral challenges in contemporary medicine. Christians need a firm foundation and framework to guide and sustain them. The ultimate foundation of Christian ethics is the character and work of the Christian triune God as revealed in the biblical narrative that informs the Christian worldview. The biblical narrative, outlined by the categories of creation, fall, redemption, and restoration, are not mere abstract theological beliefs, but provide a rich and deep perspective for the many ethical issues encountered in the world. It provides wisdom and guidance for deciding how best to approach many of the complex moral dilemmas faced in modern day health care.

A Christian perspective is now a minority position in many parts of the world’s pluralistic culture. The lack of moral consensus is, in part, due to the plurality and diversity of worldviews, religions, and philosophical/ideological positions that exist in contemporary society. Dealing with complex moral dilemmas without a solid foundation or consistent worldview presents a host of challenges.

Introduction to the Four Principles of Medical Ethics

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The most commonly used framework for current biomedical ethics centers on four core principles. These four principles are:

1. Respect for autonomy – requires respect for the decisions made by autonomous persons.

2. Beneficence – requires that one prevents harm to others, provides benefits, and balances those benefits against risks and costs.

3. Nonmaleficence – requires one not to cause harm to another.

4. Justice – requires the fair distribution of benefits, risks, and costs to a general population.

It is important to recognize that these principles do not function as moral absolutes or laws. This is a frequent misconception. Individual principles should never be conceived “as trumps that allow them alone to determine a right outcome” (Beauchamp & Childress, 2013, p. viii). Rather, principles are 


prima facie


 binding. By prima facie,
 one means that principles or duties must be fulfilled unless they conflict on a particular occasion with an equal or stronger principle, duty, or obligation (Ross, 2009). For instance, one might justifiably break patient confidentiality to prevent someone from harming or killing another person or disclose confidential information about a person to protect the rights of another person. Patient confidentiality must be protected unless a higher principle, such as preventing serious harm to another person, takes justifiable moral precedence. According to Childress (1994), the most defensible principle-based frameworks envision bioethics as principle-guided, not principle-driven.

Because these principles can be derived from different worldviews, traditions, and philosophies, they are necessarily general and broad in their definition and application and provide little direct help with actual moral decision-making and moral rules. Different worldviews interpret these principles in different ways. Disagreements in bioethics usually result from different views about what each principle entails, what they actually mean, and how they ought to be applied.

The way principles are specified and balanced in any given case scenario is also determined by prior moral commitments. Thus, the way in which a Muslim would apply the four principles to a case would differ from the way a secularist would apply them. While the four principles can provide a framework and common language within a pluralistic culture, they still require definition and content, specifying what they mean in given concrete situations and often require balancing two or more of the principles when they come into conflict.

As discussed in this and earlier chapters, a worldview has a significant effect on how one approaches moral dilemmas. Figure 3.2 shows a very simplified hierarchy of moral thinking that begins with one’s worldview that informs one’s ethical theory, which subsequently provides definition and meaning to the principles. From here, one’s understanding of the principles can then be applied to specific ethical cases. It is much more complicated than a simple diagram can convey, but the purpose is merely to illustrate a general concept.

Figure 3.2


Relationship Between Worldview, Theories, Principles, and Ethical Decisions

How one begins developing an approach to ethics is dependent, consciously or subconsciously, on a comprehensive and consistent worldview. Such a worldview includes, among other things, what is supremely valued and contributes to true human fulfillment that people are to desire. It is also dependent on one’s view of the nature of reality and the existence, or lack of, transcendent universal moral norms that are binding standards of right and wrong that exist for everyone at all times and in all places, independent of human reason and will. In other words, is what one terms “right” and “wrong” objective and discovered (i.e., in the natural order or through divine revelation, as in the Christian worldview) or subjective and invented (i.e., through philosophical reasoning alone as in most secular theories)?

Ethical or moral theories are those abstract reflections and arguments about ethics along with their systematic justification. These theories are each informed by a given worldview, such as atheism, pantheism, or theism. Three of the most common classes of philosophical ethical theory—deontology, utilitarianism, and virtue ethics—are listed in Figure 3.2. A purely secular worldview develops each of these moral theories beginning with human reason alone, while a Christian view begins with God’s revelation in the Bible.

Deontology is an ethics based on duties, obligations, or rules. It describes what one ought to do regardless of outcome or motive. In a secular approach, those duties or rules are derived solely from human reason. For the Christian, a form of deontology would be based on God’s commands, such as the Ten Commandments, which are reflections of God’s own character and goodness.

Utilitarianism is a form of ethical theory that looks at the consequences of one’s actions and is usually formulated as seeking the “greatest good for the greatest number.” The good that is being sought in secular forms of utilitarianism usually involve maximizing pleasure and minimizing pain or are centered on forms of perceived human fulfillment. A biblical view of the goals of one’s actions is centered on seeking God’s kingdom first (Matthew 6:33) and relying on God’s providential control of the outcomes of actions that are faithful to his commands.

An ethical theory of virtue focuses on the inner character of a person along with his or her motives. Which character traits are considered virtues and vices, depend on a given ideal of human nature, or what the purpose is of being human. Secular approaches to virtue ethics give many different answers to the purpose of human nature or deny there is any purpose or even human nature at all. According to the Westminster Shorter Catechism, one of several summaries of Christian teachings used by several Protestant denominations since the 17th century, a Christian approach to virtue ethics is based on being made in God’s image with the purpose of “glorifying God and enjoying him forever.” Furthermore, a Christian’s motive and character are always informed by the love of God. A biblical summary of those character traits, or virtues, that Christians should reflect is found in Galatians 5:22–23 and are called “the fruit of the Spirit.”

The Christian worldview provides a comprehensive basis for holding together three aspects of ethical reflection: direction for Christian living (the character of God as reflected in his will and commands), motive and character of Christian living (as reflected in the love of God and the fruit of the Spirit), and the goal of Christian living (to seek God’s kingdom while glorifying him and enjoying him forever). Secular approaches to these three aspects of ethical reflection remain in tension, as human reason alone is unable to provide a unifying and comprehensive ethical theory (Reuschling, 2008). A Christian approach to applied ethics, as based on the Christian worldview, is illustrated in Figure 3.2.

Figure 3.3


Relationship Between Christian Worldview and Principles

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Ethical theories informed by a worldview will, in turn, determine what specific principles will be appropriate or useful in approaching moral problems. Once given context by actual cases, these principles provide norms or rules that guide the actions that one ought to do in individual cases. This type of approach, going from worldview to ethical theory to principles to individual case decisions, rules, and policies is sometimes called a 
top-down approach to moral reasoning (see Figure 3.3). It is a deductive form of reasoning that applies general precepts to particular cases and is usually referred to as applied ethics. Because principles occupy a position between ethical theories and actual ethical rules, policies, or case judgments (see Figure 3.3), the four-principle approach is often referred to as 
midlevel principles.

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The approach to medical ethics that focuses on the midlevel moral principles of respect for autonomy, beneficence, nonmaleficence, and justice remains a highly influential and practical approach for ethical decision making, It is the most common and most used framework for discussion in American bioethics. If used appropriately and with a thorough understanding of how an appropriate worldview is necessary to interpret and apply these principles correctly, it can be a useful tool for addressing moral decision-making, especially in health care ethics. Christian health care professionals can and should use a principle-based approach, or at least become familiar with it, because it both affords a working vocabulary and framework for modern biomedical ethics in nearly all echelons of health care and because it can be readily adopted, with appropriate understanding, to the Christian worldview.

The following section will discuss each of the four principles in greater detail and define more precisely what is meant by 


specifying




weighing

, and 


balancing

 the principles as they are applied to specific cases. The role of 


reflective equilibrium

 will be discussed as a means toward consistency and coherence in one’s moral beliefs. Finally, how a Christian worldview informs how these principles are to be defined and applied will be addressed.

Respect for Autonomy

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The principle of respect for autonomy is a principle that requires respect for the decision-making capacities of autonomous persons. It means that patients have a right to hold views, to make choices, and to take actions based on their values and beliefs. The word 
autonomy comes from the Greek words 
autos, meaning “self” and 
nomos, meaning “rule, governance, or law” (Hoehner, 2000). Although it originally referred to the self-rule or self-governance of independent Greek city-states, autonomy has come to refer to individual self-rule that is free from both controlling interference by others and free from limitations that would prevent them from making meaningful choices, such as inadequate understanding.

To say that someone is autonomous is not a complicated idea. It simply means that they have the ability to make their own choices. As fundamental and simple as this concept is, in a health care setting in which patients are often vulnerable and surrounded by experts, it is easy to disrespect a patient’s autonomy. Beauchamp and Childress were writing the first edition of 
Principles of Biomedical Ethics during a time when physicians often took an overly paternalistic approach to their patients, doing what they decided was in the best interests of their patients rather than inquiring about the patient’s own interests. Recognizing the basic freedom of making one’s own choices was a starting point for Beauchamp and Childress in their formulation of the four principles.

Beauchamp and Childress (2013) discuss three general conditions required for someone to make an autonomous choice: intention, understanding, and freedom. An intentional action means that the chooser has a concept in his/her mind about the series of events that will occur if they decide on a given action. Simply put, someone who is autonomous must intend to do something by making a choice. The opposite of intentional is accidental or random. Flipping a coin to make a choice is not making an intentional choice, it is random or accidental. If the chooser does not understand the action they are choosing, they cannot make an autonomous choice. Sometimes illness, irrationality, and immaturity can limit understanding. If a patient receives incomplete or incorrect information about a procedure, they may not understand it and cannot make an autonomous decision. Finally, a person must also be free from external controlling influences to choose what they want. They cannot be controlled or coerced into making a decision. It should be a person’s own decision and free from unwarranted outside control.

A duty or obligation to respect a patient’s choice does not apply to persons who cannot act in a sufficiently autonomous manner. The immature, incapacitated, coerced, or exploited may not be sufficiently autonomous and they may not be making truly autonomous (i.e., free) choices. Also included would be infants, irrationally suicidal individuals, or drug-dependent patients (i.e., do not possess sufficient understanding or intention). This does not mean, however, that these individuals are not owed moral respect. According to the Christian worldview, each of these individuals is made in the image of God and is thereby afforded equal moral status. Each of them has significant moral status that obligates one to protect them (nonmaleficence) and care for them (beneficence), even if they cannot make decisions for themselves.

Freedom from external controlling influences does not mean that a person’s choice cannot be influenced by the authority of governments, religious organizations, families, and other communities and traditions that prescribe and proscribe certain behaviors. All choices are influenced in some way by these and other factors to varying degrees and this is part of respect for patient autonomy. The distinction is whether the patient is freely choosing to accept an institution, tradition, religion, or community that they view is important to them as a source of direction, or if these forms of authority are coercing the patient or controlling the patient to do something they really do not want to do.

For instance, say a physician is interviewing a Jehovah’s Witness patient about the possibility of receiving a blood transfusion during an upcoming procedure. In the exam room, one of their church elders is present when the patient refuses to sign the consent form for a transfusion. At this point, the physician may ask the church elder to step out of the room so that he/she can talk to the patient privately. By asking the patient again in private about the possibility of a blood transfusion, they can then try to understand if the patient is being coerced or not by the presence of the church elder. It is perfectly all right for the patient to say, “I still don’t want a transfusion because of my beliefs.” At this point the physician may have no cause to believe that the patient is being unduly influenced by the elder’s presence. It is also perfectly right for them to say, “I want to let my elder decide.” In this case they are autonomously choosing to accept another authority to guide their decisions (this does not go against the theory of autonomous choice).

If, on the other hand, the patient now whispers to the physician in a hushed voice, “I don’t want to die. If I need blood, please give it to me,” then the physician might conclude that the presence of the church elder was unduly coercing or influencing the patient to make a decision that was not truly his or hers. The patient was not acting autonomously when the elder was present.

Health care professionals need to ask their patients if they wish to receive information and make decisions or if they prefer that their families handle such matters. A right to choose is not a mandatory duty to choose. Patients largely wish to be informed about their medical circumstances, but a substantial number of them, especially the elderly and very sick, “do not want to make their own medical decisions, or perhaps even to participate in those decisions in any very significant way” (Schneider, 1998, p. xi). This is not abandoning the principle of respect for patient autonomy; rather, it affirms that the decision to let their family make a choice for them is rightly the patient’s own choice. A patient is free to delegate that right to someone else.

The choice to delegate can itself be autonomous. In some cultures, the family is considered to have a greater degree of decision-making authority than the patient. Health care professionals should, however, ask each patient about their wishes to receive information and to make decisions. One should not assume that just because a patient belongs to a particular culture, tradition, or religious community that he/she agrees with or believes that community’s or religion’s worldview and values.

The principle of respect for autonomy says that a health care professional must be respectful in treating a patient and in disclosing information and actions that promote their ability to make autonomous decisions. Proper information must be provided in a way that the patient can understand. Explanations that are too detailed or complex may confuse certain patients and impose on their ability to make decisions. The amount and types of information that need to be presented to a patient to make an informed choice is a subject that raises a lot of questions and is important to read about in other texts. The standard should be based on each individual patient’s needs, their capability to understand, and what information is needed for them to make an autonomous decision. Respecting autonomy implies the positive obligation to disclose information that fosters autonomous decision-making.

In many popular accounts of the four-principle approach, it is assumed that autonomy is the overriding principle that trumps all others. This is an easy assumption in a society that has become excessively individualistic, if not overly narcissistic. This misconceives the nature and role of the four principles. Respect for patient autonomy is usually given prima facie priority, meaning that, all things considered, one should normally respect a patient’s autonomous choices with regard to their health care decisions (Childress, 1990). Patients need to be respected as co-decision makers with their health care providers, a concept more popularly referred to as shared decision-making; however, respect for a patient’s autonomy does not automatically override all other moral considerations.

All individuals exist within a social structure and a web of relationships and interactions. There are few decisions that are truly personal and have no impact on others. Public welfare and the safety of others (e.g., forced quarantine with dangerous infectious communicable outbreaks) are examples in which there may be overriding moral considerations that would require balancing and weighing respect for autonomy with the other principles, such as justice and beneficence. A Christian worldview embraces the importance of respecting a patient’s autonomy, as long as it complies with the fundamental principles of the moral law, such as the sanctity of all human life and the mandate to not unjustifiably take an innocent human life.

Nonmaleficence

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Nonmaleficence is the principle that requires persons to refrain from harming others. It is based on the presumed Hippocratic maxim 
primum non nocere, which means “above all, do no harm.” Although this principle does not actually appear in the writings of the ancient Greek physician Hippocrates, the Hippocratic Oath does include both an obligation of nonmaleficence and of beneficence: “I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice” (Temkin & Temkin, 1967, p. 6). While the principle of nonmaleficence seems almost obvious on one level, it may be impossible to do in actual practice.

Almost all medicine routinely involves doing things most people would consider harmful. Patients are probed, poked, and stuck with needles. Anesthesiologists give drugs with no therapeutic benefit that may cause potential complications when patients are put into an induced coma so that surgeons can cut them open and rearrange or remove their organs. Internists write prescriptions for medicines with a range of bad side effects. Researchers give subjects experimental drugs with unknown side effects. In general, much of medicine is uncomfortable, painful, and involves risks. The surface meaning of nonmaleficence—do no harm—is obviously too broad to apply in any meaningful way to medical care. The term must be nuanced in order to be of any practical use and, hence, has come to mean avoiding anything that is unnecessarily or unjustifiably harmful or imposes unwarranted risks of harm. The level of harm (e.g., pain or discomfort) must be proportionate to the good it might achieve and must also take into account whether there are other alternative procedures available that might obtain the same result without causing as much harm, pain, or risk.

Beneficence

Medical ethics requires that health care professionals not only respect the autonomous decisions of their patients regarding their health care and refrain from harming them, but also requires that they should contribute to their patients’ welfare. Beneficence underlies all medical and health care professions and embodies medicine’s goal, rationale, and justification (Beauchamp & Childress, 2013). The term 
beneficence implies acts of mercy, kindness, friendship, charity, and altruism. As a principle, it is used in a broad sense to include all forms of action intended to benefit other persons. Beneficence involves two aspects: positive beneficence and utility. Positive beneficence requires one to provide benefits to others. Utility, on the other hand, requires persons to balance benefits, risks, and costs to produce the best overall results. One can also distinguish between specific beneficence, which is directed toward specific parties (e.g., a patient and their physician), and general beneficence, which is directed toward a larger community (e.g., how a national health system provides care to those who cannot afford it).

Beneficence and nonmaleficence are, according to Beauchamp and Childress (2013), two distinct principles. The distinction can be seen in that, according to nonmaleficence, one is morally prohibited from causing unjustified or unnecessary harm to anyone, whereas, according to beneficence, one is morally permitted to help or benefit those with whom they have a special relationship (such as a formal physician-patient relationship) and are often not required to help or benefit those with whom they have no such special relationship.

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Conflict between the principles of beneficence and respect for patient autonomy is one of the most frequent causes of moral dilemmas in a health care setting. Patients may not consent to medical advice or a procedure that would be, from a medical point of view, in their best interests. Patients or their families may request continuing or initiating treatments that will have little or no medical benefit and may even cause more harm or entail greater risk of harm. How is one to proceed in these instances?

According to Beauchamp and Childress (2013), the prima facie priority of respect for autonomy can only be violated in the most extreme circumstances, such as the risk of serious and preventable harm. The benefits of a procedure must outweigh the risks, and the path of action must empower autonomy as much as possible while still administering appropriate treatment. Beauchamp and Childress’s (2013) philosophical position, however, is not consistent with most legal precedents that prohibit, in almost all circumstances, the administration of any medical procedure without fully informed consent, as this constitutes the criminal charge of battery. How to best balance these two principles in this case is a point of current debate among bioethicists.

Respect for autonomy does not mean, however, that health care professionals must provide patients or their surrogates with any form of medical care they request. Physicians are obligated, as integral to the principle of beneficence, to balance the burdens, risks, and benefits of their patient’s treatment decisions and may be obligated to refuse to provide such treatments that will not be beneficial, are contraindicated, or where the balance of risks versus benefits is too great. Respect for patient autonomy is not a trump card that allows patients or their surrogates alone to determine whether a treatment is required or necessary (Truog, 1995). Life-sustaining medical treatment, even when a patient is not terminally ill, may not be obligatory if its burdens outweigh its benefits to the patient.

With respect to beneficence and treatment decisions, 


medical futility

 is a commonly used term that many feel should be avoided for more precise language. The term medical futility is morally ambiguous and usually expresses a combined value and medical/scientific judgment without distinction. Futility can have several meanings. Medical futility can be defined in a strict sense as a situation wherein a medical procedure or course of treatment will not provide beneficial or necessary physiological effects. Examples might include administering CPR despite knowing that well-designed studies under similar circumstances have not yielded any survivors, or in cases of progressive septic or cardiogenic shock despite maximal treatment. There is no obligation for physicians to provide medically futile treatments, even when families want everything done.

Whereas a physician may have the expertise to assess whether a particular intervention is likely to achieve a certain outcome, determining whether an outcome is an appropriate or valuable objective for a patient is dependent on the patient’s own value judgments. In this sense, medical futility can also mean a given therapy will have no reasonable chance of achieving the patient’s goals and objectives. CPR may be futile in this sense if, for example, it will not achieve a patient’s stated goal of leaving the hospital and living an independent life. This definition of futility respects the autonomous value judgments of individual patients (Hoehner, 2018). Because medical interventions are futile in relation to the patient’s values and goals, this sense of futility provides a very limited basis for unilateral decisions to withhold interventions that a patient may want.

Medical futility can also be defined in a less strict sense as a situation wherein there may be a low survival rate, but the rate is not zero. Although a physician may have the expertise to determine what is reasonable, according to a particular standard of reasonableness, setting a particular standard involves a value judgment that goes beyond that expertise. For example, an elderly cancer patient desires CPR and that everything be done in the event of cardiopulmonary arrest because they believe that any
 chance of survival is worthwhile and that any
 prolongation of their life is also valuable (e.g., allowing a family member to return who is currently away). The physician may assess that the chance of CPR restoring cardiopulmonary function is 
x%, where 
x is greater than zero, but whether that chance of restoring function is reasonable, valuable, or worthwhile depends primarily on the patient’s own value judgments.

Objective medical and scientific judgments and subjective value judgments of what constitutes futility in a given situation do not always coincide and requires careful and open communication. Futility should never be used to communicate a false sense of scientific objectivity and finality that discourages or ends discussion. Nor should it be used to obscure the inherent evaluative nature of these types of judgments (Hoehner, 2018).

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In the New Testament, beneficence is often referred to as charity. Christians are implored to works of beneficence, or charity, by the example of Jesus and to God’s ways of dealing benevolently with his creation. Jesus cites God’s goodness and benevolence in causing the sun to rise on “the evil and the good” and sends rain on “the just and on the unjust” (Matthew 5:45), indicating the kind of beneficence that ought to characterize his followers. The ultimate role model for health care workers in the New Testament is the Good Samaritan (Luke 10: 30–37). Physicians, nurses, and other health care professionals are called to compassionate acts of charity, kindness, and mercy as they come to the aid of the injured, the sick, and the dying without prejudice of judgment. They are called to relieve, to the furthest extent possible, pain and suffering that is a result of the fall. Comfort care, not just healing, such as offering food and water and maintaining temperature and cleanliness for a dying elderly patient, is also an act of beneficence. Beneficence is also exhibited by comforting patients through a loving presence, palliation, and prayer.

Jesus himself was the example of one who was supremely compassionate and caring, and the sight of a suffering person moved him deeply. The many healing miracles Jesus performed during his ministry on Earth were signs of how the world should be and someday will be. They were a reminder of a broken world and a preview of the future. As the 19th Anglican archbishop and poet Richard Trench (2002) put it,

The healing of the sick can in no way be termed against nature, seeing that the sickness which was healed was against the true nature of man, that it is sickness which is abnormal and not health. The healing is the restoration of the primitive order. (p. 20)

Justice

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Justice is a complex subject and can only be superficially addressed here. Justice is generally defined as rendering what is due or merited with fairness and impartiality. The concept of justice is usually discussed under three headings: 


distributive justice




remedial justice

, and 


retributive justice

. In medical ethics, justice most often refers to a group of principles requiring the fair distribution of medical benefits, risks, and costs. The principle of justice often impacts health care as the profession of medicine has become immersed in the corporate world of business, private insurance, and government regulation. In the context of medical ethics, justice usually refers to distributive justice under conditions of scarcity and competition. Contemporary medicine involves a considerable amount of expensive and not-yet-universally available technology. The way a society determines how much someone should receive of what they want or need, or what someone else wants them to have, continues to be controversial, especially in modern health care.

Most historians of medical ethics trace the academic beginnings of distributive justice to the development and public availability of kidney dialysis machines in the early 1960s. While lifesaving, they were scarce and expensive. When the first outpatient kidney dialysis unit opened in 1962 (Blagg, 2007), the decision about who would receive dialysis was made by an anonymous committee composed of local residents from various walks of life plus two doctors who practiced outside of the field. Many see this as the creation of the first bioethics committee. How these decisions were made required a definition of what distributive justice meant in this situation. The problems encountered by this first bioethics committee remain to this day, as the introduction of many more life-saving technologies outpaces their availability and affordability to the general population.

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Almost all would agree that at a certain level, a decent minimum of medical care is a fundamental need of every person. Clearly, if someone has acute appendicitis, he or she would have a right to an emergency appendectomy, but does that then mean that an infertile couple has an equal right to in vitro fertilization? Deciding what that decent minimum is and how it is to be provided is also a problem of distributive justice.

The principle of justice attempts to answer several other complicated and involved questions about modern health care access and delivery. For instance, what kinds of health care services should be available to society and who will receive them and on what basis? How will the costs of such care be distributed? Who or what will have power and control over those services and their distribution? To say that these are complex issues is an understatement. These are questions that currently have no moral or political consensus. Complicating the issue are multiple competing theories of justice (Beauchamp & Childress, 2013). When comparing countries that seek to provide fair health care access and distribution, none are fashioned entirely on a single theory of justice. Current competing theories of justice each have merits and weaknesses. They can provide models, but none are practical instruments.

This lack of agreement about what constitutes justice stems primarily from differing accounts of what is required for the pursuit of a good life and what people owe one another to enable that pursuit. Although most ethical theories may converge on the conclusion that the moral life is a developed character that provides motivation and direction to do what is right and good, they do not arrive at the same conclusion regarding the content of the right and good. Until one can specify what exactly the right and good entails or identify a single source from which shared judgments might arise, one cannot expect to achieve any real moral consensus or agreement.

On an individual and more personal level, justice refers to respecting the rights and dignity of each human being. Health care professionals must be fair to each patient, respect their rights as a person, and afford the patient, in as far they are able, proper access to health care. States often have a vested interest in protecting the rights and interests of individuals, including the vulnerable. An example of this may be seen in the case of a minor child who is in need of a blood transfusion, but the child’s parents refuse to consent because of their faith as Jehovah’s Witnesses. Most states will readily provide for emergency and temporary state custody to protect minors, and these provisions should be used by health care professionals, who are also their patients’ advocate. In most instances like these, the parents are relieved to relinquish the decision. They have both maintained their faith commitment to the extent of their control without endangering their child’s health.

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The Bible certainly supports the concept of justice. The real purpose of civil law is to guarantee an ordered social coexistence in true justice, so “that we may lead a peaceful and quiet life, godly and dignified in every way” (1 Timothy 2:2). The prophet Isaiah implores Israel to “wash yourselves; make yourselves clean; remove the evil of your deeds from before my eyes; cease to do evil” (Isaiah 1:16). Christian health care professionals have a moral duty to become actively involved with issues of resource allocation and the fair and just distribution of health care. Balancing resource allocation and the duty toward one’s own individual patient can be difficult, and health care professionals need to maintain the primacy of their commitment to their individual patients. Of all people, Christians should also advocate for the underprivileged, the vulnerable, and the marginalized, not showing favor or deference in their treatment or care. Just as God’s love is free and gracious, Christians’ love should reflect this in selfless service to their neighbor. And, as shared in a previous reference, it is especially to the “least of these” (Matthew 25:40) that the Christian’s love should be directed.

Applying the Four Principles

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As discussed repeatedly, the four principles of respect for autonomy, beneficence, nonmaleficence, and justice are too abstract and general to provide direct rules for solving many ethical dilemmas. They all lack specific content and definition when applied to individual cases. Principles also can come into conflict with each other, which is the most common source of ethical dilemmas in health care. Each of the principles must be applied, and it is in their specific application to real cases that they take on a more substantive meaning.

Integral to applying the four principles is the method of specifying what the principles mean in a given case, as well as weighing and balancing each of the principles when they seem to conflict. The judgments one reaches when applying, specifying, weighing, and balancing the principles also must be consistent with one’s foundational moral beliefs and moral reasoning. Coming to a judgment about a moral dilemma that is different from one’s prior foundational moral commitments or moral reasoning is morally and intellectually dishonest. For instance, having a moral foundational belief that all life is sacred, but then approving or participating in a purely elective abortion that is requested for mere convenience may call into question one’s honesty about his or her beliefs, as well as the consistency of his or her moral reasoning.

The process of repeatedly reflecting back-and-forth between one’s judgments about a moral dilemma and one’s moral commitments or intuitions for them to come to a coherent and justified whole is a process referred to as reflective equilibrium.

Specifying

Specifying is the process of reducing the abstract and indeterminate meaning of a principle to more specific and concrete action-guiding content. Discussions of each of the principles can appear vague and theoretical, especially to those used to a more practical and hands-on approach to problem-solving, who are less familiar with philosophical and abstract topics, which may describe many who have chosen a health care or science related profession. The process of specifying brings the principles out of this philosophical and intellectual realm and into practical and direct contact with real-world issues. It is the practical application of defining what these principles mean in this particular case. As Richardson (2000) puts it, defining principles is “spelling out where, when, why, how, by what means, to whom, or by whom the action is to be done or avoided” (p. 289).

The four principles are very general in definition and all need to be supplemented with additional content and meaning when applying them to individual ethics cases because, “the complexity of the moral phenomena always outruns our ability to capture them in general norms” (Richardson, 2000, p. 294). Different moral dilemmas or new circumstances may require further specification of principles already specified, or principles may need to be specified in different ways. Specifying a principle narrows its scope to the individual features of the case or dilemma in question. The goal is to give the principle such a focused meaning that it can provide a useful rule to guide one’s decision or action. Some specified norms may be considered so absolute that they need no further specification. For instance, the rule that one should not inflict unnecessary pain and suffering may qualify as an absolute without exceptions; however, even the firmest of rules may encounter exceptional cases.

Surrogate decision-making is an excellent example of specifying what is meant by respect for patient autonomy. When patients are incapacitated or unable to make autonomous decisions for themselves, how does respect for patient autonomy apply? Specifying would further define the principle of respect for patient autonomy as respecting what the patient would have desired if they were autonomous. Applied to a specific case, respect for patient autonomy would involve discovering some means to assess what that would be, whether through a family member, a health care power of attorney, or an advance directive. Specifying respect for autonomy in this way would further assist in dilemmas in which surrogate decision-makers are not making choices that are in the patient’s best interests or go against good evidence of what the patient would have wanted.

It is very possible that different persons and groups with differing worldviews may specify principles in different ways (Beauchamp & Childress, 2013). Take the example of the permissibility and legality of physician-assisted suicide (PAS). Arguments regarding PAS are often disagreements over the nature of human dignity, benevolence, and respect for autonomy; all general concepts shared by different moral traditions (e.g., cultural, religious, or philosophical); however, individual moral traditions may specify the concepts of human dignity, respect for autonomy, and benevolence differently and arrive at conflicting moral judgments. Those who support PAS often endorse compassionate dying, arguing they are acting benevolently by shortening the suffering of others by assisting them to end their own lives. Human dignity is interpreted as having control over one’s life. Honoring a person’s request for assistance-in-dying (voluntary active PAS) is respecting their personal autonomy. A Christian opposed to PAS also may invoke benevolence to argue that intentionally and actively assisting someone to take their life, even in the face of suffering, is never in someone’s best interests.

The intrinsic dignity and value of a human being is not upheld by assisting someone to commit suicide, even to avoid or eliminate suffering. Every person’s life is valuable, irrespective of one’s physical and mental state, even when that person has ceased to deem life valuable. Intentionally hastening death is an immoral act that involves a misunderstanding of what acting benevolently and compassionately actually entails. In terms of respect for autonomy, a person contemplating suicide may be suffering from such a degree of clinical depression that they are not acting autonomously (Ganzini, 2014). Furthermore, respect for autonomy does not require another person to participate in or assist in an immoral act.

These are by no means the only arguments for or against PAS but are presented as examples to highlight one of the difficulties of applying the four principles. Nothing about specification guarantees that consensus will always be achieved for a given moral dilemma. Conflicting judgments about any given situation can always arise. Because judgments about how principles are interpreted and applied are dependent on more fundamental moral commitments or worldviews, relying on principles alone cannot always get around the difficulties of a pluralistic society.

Weighing and Balancing

Most moral dilemmas originate when two or more principles come into conflict. As previously discussed, the four principles are not hard and fast rules, but are rather prima facie
 binding. In other words, they all should be honored unless they conflict, on a particular occasion, with an equal or stronger obligation. The task of weighing and balancing is to find the greatest balance of right over wrong, given the weights of all competing prima facie
 norms. Simply put, it is to decide what ought to be done after considering all things (Ross, 2009).

Weighing and balancing go together. Weighing is the process of determining the relative importance or strength of relevant aspects of a principle or moral norm. In other words, weighing considers the most significant or most important aspect of each of the competing principles in a particular case. Balancing is the process of finding reasons to support a given principle or moral norm to determine which should have precedence in a given case wherein two or more principles come into conflict. It involves the relative comparison of the different weights assigned to each principle in a particular case in order to justify which one should prevail in coming to a moral resolution.

Prima facie
 duties become actual
 duties when they are weighed and balanced and a moral judgment is rendered. Balancing needs to be supported by good reasons, not merely intuition or feeling, although good reasoning may justify one’s initial intuition. Both weighing and balancing contain value judgments and are dependent on prior moral commitments.

Balancing principles should not be confused with merely rank ordering, but rather it is the process of taking into account the moral considerations of each principle and attempting to support and honor each one the best way possible in a complex situation. Some considerations of beneficence in a given case may require it to take precedence over nonmaleficence, but the principle of nonmaleficence is not merely overridden or neglected. The subordinate principle is still honored to the maximum extent possible given the priorities of a competing principle. When principles compete, some aspect of one principle will need to give way to an aspect of another. But neither principle completely overrides all the aspects of considerations of the other, unless completely necessary. This is the combined role of weighing, deciding what aspects of a given principle are most important in a given case, and balancing, attempting to do justice as much as possible to competing principles, even when certain aspects of a given principle cannot be fulfilled.

A classic example of weighing and balancing is shouting “Fire!” in a crowded theater when there is no fire, potentially injuring or killing many in the ensuing panicked rush toward the exits. Two principles are in competition, the right to free speech, guaranteed by the Bill of Rights in the U.S. Constitution, and the duty not to harm others. A person’s right to free speech is not an absolute right. A person’s individual liberties and rights can be constrained when they harm or can potentially harm others or interfere with the individual rights and liberties of others—this is specifying. The duty not to harm others in this scenario carries more relative weight than this particular instance of free speech, not necessarily free speech in general, because of the severity of the harm and number of people potentially hurt or even killed—this is weighing. One is justified in prioritizing the duty not to harm over a right to free speech in this instance to prevent a potential tragedy—this is balancing. The rule derived from this analysis is that one should not yell, “Fire!” in a crowded theater when there are no fires. From this example, one can see that specifying, weighing, and balancing all go together. Specifying a principle more clearly may change the way it is weighed and balanced against other competing principles. Specifying is concerned primarily with the range or scope of a principle, whereas weighing and balancing are concerned with the strengths, importance, and emphasis that is given to each of the competing principles.

Specifying, weighing, and balancing how principles are to be used does not take place outside the context of individual cases or situations, nor do they take place in a moral vacuum or from some neutral moral stance. The decisions one makes regarding how to specify a given principle, what weight is attached to the concerns of competing principles, and how to balance these concerns is dependent on both one’s moral character and, ultimately, on one’s foundational moral principles as informed by his or her worldview. A Christian view of using the four principles will recognize the importance of the Christian worldview in providing context, definition, and specification to each of the principles (see Figure 3.3), as well as the way they are weighed and balanced in a given situation.

An example of the Christian view of specifying, weighing, and balancing is illustrated in the biblical view that all human beings are created in God’s image, making all human life sacred. The sanctity of human life plays a prominent role in Christian ethics and the rule against killing another innocent human being. For the Christian, the weight of this moral norm that all human life has moral worth informs a Christian view of beneficence and nonmaleficence. It is great enough that it nearly always has priority over other rules or principles, such as respect for autonomy in the case of abortion or PAS. Even then, the rule can be specified in cases of rape, incest, or when the life of the mother is jeopardized in such ways that there may be adequate justification—through weighting and balancing—for an abortion. Christians may disagree on these exceptions depending on the different ways they weigh and balance the principles in each specific case (Meilaender, 2013).

Reflective Equilibrium

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One of the most important aspects of moral reasoning is consistency. Ensuring that one’s moral beliefs are consistent is an important requirement. In other words, one should treat like cases alike and one’s moral commitments should be consistent with one’s moral judgments. The influential political philosopher John Rawls (1999) described a method known as reflective equilibrium for striving toward consistency in moral beliefs.

Figure 3.4


Reflective Equilibrium

Reflective equilibrium is a way toward bringing consistency to one’s moral principles, judgments about specific ethical cases, and moral intuitions and beliefs; it is a method of ensuring that one’s whole system of moral thinking is consistent. The method begins with one’s moral beliefs or, as Rawls (1999) puts it, one’s “considered moral judgments” (p. 47). These are moral convictions in which one has the highest confidence. These can either be moral intuitions (i.e., feelings about what is right or wrong) or as informed by a particular tradition or philosophy (e.g., the Christian worldview and biblical morality).

These moral beliefs about a case are used to generate principles that are then applied to specific cases through the process of specification, balancing, and weighing. The conclusion reached about a given judgment or moral action is then tested against one’s original moral beliefs to see if they remain consistent. If one’s moral beliefs are not consistent with those moral judgments, then something in the cycle must change, whether it is one’s moral beliefs, reformulating the general moral principles, further specifying those principles, or reweighing/balancing competing principles as they apply to an individual case. It could also mean understanding more clearly or discovering additional specifics about the case that may be morally relevant.

The whole process goes back-and-forth, revising, pruning, and adjusting one’s moral beliefs, principles, and specification until one reaches a consistent and coherent whole. The point is not just to maximize consistency in moral beliefs, but also to help people gain a deeper insight into their own moral thinking and come up with better reasons for their moral decisions and actions.

An Example of Specifying, Weighing and Balancing, and Reflective Equilibrium

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Take a common example of a woman presenting to the clinic with a life-threatening ruptured ectopic pregnancy. The medical professional’s moral beliefs inform a principle of beneficence, which means doing whatever is possible to help the woman who will more than likely die if she does not have definitive surgical treatment. Unfortunately, the treatment is to remove the developing embryo to save the woman’s life. The medical professional may simultaneously hold the moral belief that all life, even a human embryo, is sacred and of moral worth. It is an innocent human being with the same moral worth of the mother, and the medical professional believes that no one should ever kill an innocent person, even an embryo. Surgically removing the embryo would be morally equivalent to killing the embryo.

In this case, two moral principles have come into conflict, that of beneficence to the woman and that of nonmaleficence to the embryo. The medical professional’s moral intuition makes not doing anything—letting the woman die—seem morally abhorrent. By means of specification, the medical professional comes to understand that the embryo cannot survive in the abdomen; therefore, in this specific case, the medical professional needs to further narrow down what is meant by nonmaleficence and how it specifically applies to this case. The medical professional can, for instance, say that the principle of nonmaleficence does not apply to the embryo by changing moral beliefs about the moral worth of human embryos. Alternatively, the medical professional could further specify what is meant by nonmaleficence, meaning doing no harm unless that harm is necessary because there is no other alternative to bring about an essential good, which in this case is saving the life of the woman. The medical professional must also weigh and balance the competing principles of beneficence and nonmaleficence. Because the embryo is not viable with current technology, there is no way to save its life. The medical professional can ultimately do no further harm and the weight of this principle is lessened in terms of the embryo. The risk to the mother is very serious, potentially life-threatening, and therefore would carry a good deal of weight. In this case, it seems the balance rests with saving the life of the mother and accepting the death of the embryo, which is inevitable with or without surgery.

Balancing principles does not mean rank-ordering them in that beneficence always takes total precedence over nonmaleficence. Nonmaleficence is balanced by the fact that, in this situation,
 no further harm is being done by the surgery to the embryo, while harm would occur to the mother if surgery were not performed. Both nonmaleficence and beneficence are being upheld in the best possible way in this specific case. In this simple and obvious form of reflective equilibrium, one’s moral intuitions and beliefs are brought into harmony with how particular principles are specified, weighed, and balanced within a given moral dilemma.

The Four-Boxes Approach to Case Analysis

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From the previous discussion, the four principles of respect for autonomy, beneficence, nonmaleficence, and justice were found to be abstract and general concepts until they are actually applied, specified, and given context within moral dilemmas of individual ethics cases. Moral dilemmas in clinical medicine can be complex, convoluted, and challenging, often in the context of considerable medical data, competing individual judgments and values, multiple persons and stakeholders, and complicated situations. Clinical medicine is also intensely practical. When sorting out the myriad issues involved in a typical medical ethics case, it is helpful to have an organizing framework and method to help sort out the pertinent facts and relevant issues into an orderly pattern that will facilitate discussion about ethical problems and potential recommendations.

In their book 
Clinical Ethics, three clinical ethicists, Jonsen, Siegler, and Winslade (2015), developed a framework to organize and work through difficult and complex ethical cases in medicine. The method they use is like a history and physical work-up that all physicians, nurses, and other health care professions learn when they are asked to present a case. In a medical history and physical, the pertinent features of the case are organized and presented in a specific order and under the categories of

1. Chief complaint,

2. History of present illness,

3. Past medical history,

4. Family and social history,

5. Physical exam, and

6. Laboratory studies.

Nursing students also learn an abbreviated form for presenting updates on a patient’s condition, progress, and plans called a SOAP note. SOAP is an acronym for the subjective assessment (i.e., patient complaints), objective assessment (i.e., vital signs, physical exam, and laboratory data), assessment, and plans.

The 


four-boxes approach

, sometimes referred to as the four-topics approach of Jonsen, Siegler, and Winslade (2015), is an organizing device that parallels the way health care professionals think through and organize medical cases. They identify four topics that are intrinsic to most clinical ethics encounters: 


medical indications




patient preferences




quality of life

, and 


contextual features

. Focusing on these four topics organizes the facts presented in individual cases in order to recognize the relevant moral dilemmas and gain insight into how each of the four principles may apply. These four topics must not be confused with the four principles. The four topics are typically arranged in a grid, table, or box, which is why it is sometimes referred to as the four-boxes approach or Jonsen’s boxes (see Table 3.1)

Table 3.1


The Four-Boxes Approach to Ethical Case Analysis

Medical Indications

Patient Preferences

The Principles of Beneficence and Nonmaleficence

The Principle of Respect for Autonomy

1. What is the patient’s medical problem?

2. Is the problem acute? chronic? critical? reversible? emergent? terminal?

3. What are the goals of treatment?

4. In what circumstances are medical treatments not indicated?

5. What are the probabilities of success of various treatment options?

In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?

1. Has the patient been informed of benefits and risks, understood this information, and given consent?

2. Is the patient mentally capable and legally competent, and is there evidence of incapacity?

3. If mentally capable, what preferences about treatment is the patient stating?

4. If incapacitated, has the patient expressed prior preferences?

5. Who is the appropriate surrogate to make decisions for the incapacitated patient?

6. Is the patient unwilling or unable to cooperate with medical treatment? If so, why?

Quality of Life

Contextual Features

The Principles of Beneficence and Nonmaleficence and Respect for Autonomy

The Principles of Justice and Fairness

1. What are the prospects, with or without treatment, for a return to normal life, and what physical, mental, and social deficits might the patient experience even if treatment succeeds?

2. On what grounds can anyone judge that some quality of life would be undesirable for a patient who cannot make or express such a judgment?

3. Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?

4. What ethical issues arise concerning improving or enhancing a patient’s quality of life?

5. Do quality-of-life assessments raise any questions regarding changes in treatment plans, such as forgoing life-sustaining treatment?

6. What are plans and rationale to forgo life-sustaining treatment?

7. What is the legal and ethical status of suicide?

1. Are there professional, interprofessional, or business interests that might create conflicts of interest in the clinical treatment of patients?

2. Are there parties other than clinicians and patients, such as family members, who have an interest in clinical decisions?

3. What are the limits imposed on patient confidentiality by the legitimate interests of third parties?

4. Are there financial factors that create conflicts of interest in clinical decisions?

5. Are there problems of allocation of scarce health resources that might affect clinical decisions?

6. Are there religious issues that might influence clinical decisions?

7. What are the legal issues that might affect clinical decisions?

8. Are there considerations of clinical research and education that might affect clinical decisions?

9. Are there issues of public health and safety that affect clinical decisions?

Note. From 
Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Practice (8th ed.) (p. 9), by A. R. Jonsen, M. Siegler, and W. J. Winslade, 2015, New York, NY: McGraw Hill. Copyright 2015 by McGraw Hill. Reprinted with permission.

Medical Indications

All clinical encounters include a history, diagnosis, prognosis, and treatment options. It also includes an assessment of the goals of care. This topic is the starting point of any case analysis and includes the usual objective content of a medical case presentation, but one focused on the relevant features that will have an impact on the ethical questions.

The topic of medical indications considers the objective aspects of the patient’s medical problem, including the diagnosis—whether it is acute, chronic, critical, reversible, emergent, or terminal—the prognosis with or without treatment, the goals of treatment, and the possibilities of success for any of the treatment options being presented. According to Jonsen, Siegler and Winslade (2015), it is best summarized by the phrase, “How can this patient be benefited by medical and nursing care, and how can harm be avoided?” Notice how the language of this summary links the topic to the principles of beneficence and nonmaleficence.

The four-boxes approach aids in linking the four principles to the relevant aspects of the case, which will be helpful for later analysis, including specifying, weighing, and balancing the principles. Under the topic of medical indications, the principles of beneficence and nonmaleficence are listed. This is not meant to limit this particular topic to these principles alone, but it is a reminder that these principles tend to be the most relevant and applicable to this topic.

Medical indications is not a completely objective presentation of the best treatment option punctuated by the authority of scientific facts. All medical decision-making, deciding on the best treatment option based on an analysis of risks, benefits, and burdens, requires more than just facts. Health care professionals may be able to assign a quantitative number or probabilistic range of numbers to each of these terms based on their medical knowledge and professional judgment. But each of these terms also carries a qualitative component that cannot be quantified. People have different values and beliefs that influence what harm, burden, or risk, means for them. How a person weighs the importance of a certain risk, harm, or burden is subject to their own personal values and beliefs.

For example, being intubated, in which a small tube placed in the trachea to protect the lungs from aspiration and to assist the patient’s breathing, presents a low risk of vocal-cord damage, which may not amount to much for the normal surgical patient undergoing a general anesthetic, as the risk is so low, some anesthesiologists do not even mention it on the long list of potential complications on a consent form. For an opera singer, however, the weight and importance attached to such a potential complication, even if the actual probability of it happening was small, might persuade them to choose a form of regional anesthesia, like a spinal anesthetic, which would avoid needing a breathing tube for the surgery. Even if choosing another type of anesthetic had a higher risk with regard to other complications, these risks may not be weighed as important as something that would risk a patient’s career and livelihood, such as vocal-cord damage would for an opera singer. On the other hand, a college athlete may opt for a general anesthetic over a nerve block for a minor procedure, placing greater weight on the potential for nerve damage to an extremity that would affect his athletic career.

The point is that any clinical 
ought that is represented by this quadrant must remain provisional and not final. The right thing to do is not always a matter of the best medical thing to do. The right thing to do will ultimately depend on a more complete analysis that includes the information presented in the other three boxes.

Patient Preferences

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This topic focuses on the competent patient’s treatment decisions and whether he or she consents to treatment options or refuses. If the patient is not mentally capable and legally competent, it focuses on his or her presumed decision if he or she were capable and competent. In all medical decisions, the patient’s preferences are based on the patient’s own values and personal assessment of the risks, benefits, and burdens of the treatment options. The topic of patient preferences is most closely linked to the principle of respect for autonomy.

This topic is also the place to evaluate whether patients have been properly informed of the benefits and risks of any proposed procedure, have understood this information, and have given their consent. If, for any reason, the patient is unable to provide consent or make their wishes known, the medical professional needs to ask whether the patient has previously expressed in writing or otherwise their prior preferences for treatment and who the appropriate surrogate is to make decisions for this patient. Is there an advance directive—a written statement of treatment preferences and goals, sometimes referred to as a living will—or durable power of health care attorney or proxy—a person designated by the patient in writing to make health care decisions on behalf of the patient based on prior wishes and preferences?

In the absence of an advance directive or designated durable power of health care, surrogate decision-making usually falls to the next of kin in the following order or priority: the patient’s spouse or state registered domestic partner, children of the patient who are not minors, parents of the patient, and adult siblings of the patient, though individual state laws and regulations may vary.

Quality of Life

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All injury or illness, as well as many medical therapies and interventions, threatens patients with actual or potentially reduced quality of life, whether it be through signs and symptoms of their disease, resultant physical and mental disabilities that are a consequence of their disease, or complications of treatments. Under the topic of quality of life, one assesses the prospects for a return to normal life given the various treatment options and the adverse physical, mental, and social effects that a patient may experience even if a given treatment is successful.

Quality of life is a vague term with many different interpretations, but, for the purposes of this topic, it focuses on the patient’s own perceived quality of life in relation to his or her own values, goals, and what they hold to be most important for living a full and complete life. In many cases it is difficult for other persons to identify what a patient’s perceived quality of life is. This leaves room for potential bias and prejudice when a patient cannot make his or her preferences known. For instance, there are some who would judge that a child born with Down’s syndrome has such a reduced quality of life that terminating a pregnancy is justified on quality of life considerations. Yet many Down’s syndrome children and those with other disabilities enjoy a high quality of life despite their physical and mental limitations, are loving and loved, and enjoy life (Newton, 2018). Above and beyond these assessments, a Christian worldview will recognize the intrinsic value, dignity, and respect that needs to be afforded to all human beings as being made in the image of God, with or without mental and physical disabilities (Stahl & Kilner, 2017).

The concept of quality of life, while sometimes vague and subject to caregiver and other biases, remains an important component of ethical analysis and is closely linked to the principles of beneficence, nonmaleficence, and respect for autonomy. Jonsen, Siegler, & Winslow (2015) also include assessments of plans and rationale to forgo life-sustaining treatment, as well as the legal and ethical status of suicide under this topic.

Contextual Features

All clinical encounters occur in the larger context of persons, institutions, and financial and social arrangements. Family conflicts, the law, culture, hospital policy, insurance companies, financial concerns, and confidentiality issues are just some of the issues that can influence the decisions of a patient. Many things can complicate the clinical picture or introduce personal biases and controlling influences.

The topic of contextual features is less defined and more open than the other three topics. It is an attempt to capture all the remaining relevant issues that may not already be considered. In a sense, it is a bird’s eye approach to the entire clinical encounter, health care system, and social context of a case. The principle of justice is the major theme of this topic, although the other three principles can be represented as well. This topic includes myriad issues that may affect clinical decisions and patient welfare that include, but are not limited to, conflicts of interests, limits on patient confidentiality imposed by third parties, financial issues, difficulties regarding allocation of scarce resources, issues of clinical research or education, and public health and safety issues.

The four-boxes approach is meant to facilitate the systematic identification and organization of relevant ethical issues in a clinical ethics case. Sokol (2008) refers to the four-boxes approach as an “ethical stethoscope” (p. 516) that increases one’s ability to ask relevant questions, expose the exact nature of the moral dilemma, and identify all the data relevant to making a justified ethical decision.

More work still needs to be done. Providing reasoned arguments to resolve the moral dilemmas is not strictly a part of the four-boxes approach. It is merely an organizing tool. The four-boxes approach is used with the four principles, along with the associated methods of specification, weighing, balancing, and reflective equilibrium to finally arrive at a decision or recommendation. An example of this combined approach is provided at the end of this chapter.

Case Study: Surrogate Decision to Withdrawal Life-Support

Gerald, a 52-year-old man with diabetes, hypertension, and migraine headaches with a long history of psychiatric disability, including depression, borderline personality disorder, and suicide attempts, presents to the emergency department minimally responsive, profoundly bradycardic, and barely breathing.

Earlier that evening, Gerald sent a goodbye text to a friend, Margie, who immediately called 911. When the paramedics arrived at his home, they found him in bed with several empty pill bottles that contained antidepressants and tranquilizers on his nightstand. In the emergency department, he was intubated and transferred to the intensive-care unit. After being treated for a critical cardiac rhythm disturbance, his condition stabilized. His respiratory depression was presumed to be due to the overdose of medication and would resolve with continued respiratory support. It was anticipated that he would make a full recovery to his baseline medical condition and mental status.

Gerald lived alone and had no close family. Several months ago he completed an advance directive that named his friend, Margie, as his agent and selected from a list of several options the following instructions: “If I suffer a condition from which there is no reasonable prospect of regaining my ability to think and act for myself, I want only care directed at my comfort and dignity, and authorize my agent to decline all treatment, including artificial nutrition and hydration, the primary purpose of which is to prolong my life.” Margie, the patient’s agent, requested that his ventilator support be stopped and that he be allowed to die, believing this is what Gerald would have wanted.

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Case Study: Surrogate Decision to Withdrawal Life-Support Continued

Recommendations

Patients often write an advance directive to indicate what their treatment wishes would be in a situation wherein they are no longer able to make or express those decisions for themselves. They also may name someone as their agent or surrogate to make those treatment decisions on their behalf—also referred to as a durable power of medical attorney—or both. An agent or surrogate is ethically and legally bound to follow the patient’s own wishes as best they understand them.

In the case presented, Gerald has a valid advance directive in which he has named an agent, Margie, and given instructions; however, the conditions of the advance directive do not pertain in this instance because Gerald’s condition is treatable, reversible, and would likely return him to his previous baseline state of health. The autonomous decision-making capacity of Gerald also may be questioned in this case scenario. It is often the case that a suicide attempt, whether irrational or rational, especially when a patient is clinically depressed or suffers from other psychiatric disorders, is viewed as a situation in which the patient’s prior written or verbal request to limit or withdrawal treatment may be overridden.

A patient’s health care agent or surrogate has a very serious responsibility to express a patient’s wishes and to see that they are carried out. When a health care agent or surrogate requests something different from what a patient has previously expressed or written, it may be difficult to decide what the patient truly would want. In the present case, even if Margie, Gerald’s surrogate, were to convince the health care team that she knew what Gerald really meant, her request should be overridden by the precedent of temporarily setting aside the decisions of a depressed and suicidal patient when their condition is reversible.

Questions for Further Discussion

1. If the patient’s condition became such that his prospects of survival were much worse (e.g., irreversible brain injury from a prolonged period of hypoxia), how would that alter the decision-making process?

2. Who has the right to give surrogate consent?

3. How would one go about evaluating whether a surrogate decision-maker is deciding what they want to do rather than representing what the patient would have wanted?

4. Which one takes precedence?

5. What other contextual features could have been present, and how would they have altered the final recommendation?

Table 3.2


Completed Four-Topics Boxes

Medical Indications

Patient Preferences

The Principles of Beneficence and Nonmaleficence

The Principle of Respect for Autonomy

1. The patient has a history of depression.

2. The patient’s respiratory depression was presumed to be due to an overdose of medication and required respiratory support until it reversed.

3. It was anticipated that the patient would make a full recovery to his baseline medical condition and status.

1. The patient was unable to make treatment decisions, but had completed an advance directive earlier that stated: “If I suffer a condition from which there is no reasonable prospect of regaining my ability to think and act for myself, I want only care directed at my comfort and dignity, and authorize my agent to decline all treatment (including artificial nutrition and hydration) the primary purpose of which is to prolong my life.”

2. The patient’s agent, Margie, requested that ventilator support be removed, as this is what she believed the patient would have wanted.

3. The patient gave clear indications that he was attempting to commit suicide.

Quality of Life

Contextual Features

The Principles of Beneficence and Nonmaleficence and Respect for Autonomy

The Principles of Justice and Fairness

1. It was anticipated that the patient would make a full recovery to his baseline medical condition and status.

2. The patient’s condition was reversible.

3. The patient has a history of depression and gave clear indications that he was attempting to commit suicide.

Conclusion

This chapter presented a great deal of material. It began with the Christian worldview as informed by the biblical narrative of creation, fall, redemption, and restoration. Each part of this narrative has much to say about how a Christian should approach medicine, healing, and medical ethics. It then introduced the four principles of medical ethics: beneficence, nonmaleficence, respect for autonomy, and justice. Each of these abstract principles were defined and their application to individual ethical situations was explained in terms of specifying, weighing, and balancing. Finally, a practical tool to aid in actual case analysis was presented. This tool, known as the four-boxes approach, organizes the data of complex ethical cases under the topics of medical indications, patient preferences, quality of life, and contextual features. One could say that this chapter was obsessed with the number four: four elements of a Christian worldview, four principles of biomedical ethics, and four topics in clinical case organization. Combining a Christian worldview, the framework of the four-principle approach, and the four-boxes tool gives the Christian health care professional a solid approach to address many ethical issues in medicine.

The focus of this chapter was on applying the four principles within a Christian worldview. This four-principle approach can be a very useful framework for approaching moral dilemmas in medicine. The four principles, as abstract generalizations, are always informed by a worldview or philosophical position, even if one is not aware of it. This chapter showed how a Christian worldview specifically informs how these principles are to be interpreted and used.

The four-principle approach to medical ethics is not a complete theory, nor is it the only framework available for medical ethics. It is not a pure secular ethical theory because it is always informed by prior worldview or philosophical considerations. Given its near universal presence in current health care ethics, it is imperative that all health care professionals at least understand what it is, along with its strengths and weaknesses. With this understanding, the four principles of beneficence, nonmaleficence, respect for autonomy, and justice can be used effectively by Christians who are firmly grounded in their own worldview to engage and interact in the rapidly growing, exciting, sometimes perplexing, but always rewarding field of biomedical ethics.

Additional Resources

Anderson, T. J., Clark, W. M., & Naugle, D. K. (2017). 
An introduction to Christian worldview: Pursuing God’s perspective in a pluralistic world. Downers Grove, IL: InterVarsity Press.

Beauchamp, T. L., & Childress, J. F. (2013). 
Principles of biomedical ethics (7th ed.). New York, NY: Oxford University Press.

Clouser, R. A. (2001). 
The myth of religious neutrality: An essay on the hidden role of religious belief in theories. Notre Dame, IN: University of Notre Dame Press.

Hauerwas, S. (1994). 
God, medicine, and suffering. Grand Rapids, MI: Wm. B. Eerdmans Publishing Company.

Hoehner, P. J. (2006). The myth of value neutrality. 
Virtual Mentor, Ethics Journal of the American Medical Association, 8(5), 341-344.

Jonsen, A. R., Siegler, M., & Winslade, W. J. (2015). 
Clinical ethics: A practical approach to ethical decisions in clinical medicine (8th ed.). New York, NY: McGraw Hill Education/Medical.

Kilner, J. F. (2015). 
Dignity and destiny: Humanity in the image of God. Grand Rapids, MI: Wm. B. Eerdmans Publishing Company.

Meilaender, G. (2013). 
Bioethics: A primer for Christians (3rd ed.). Grand Rapids, MI: Wm. B. Eerdmans Publishing Company.

Orr, R. D. (2009). 
Medical ethics and the faith factor: A handbook for clergy and health-care professionals. Grand Rapids, MI: Wm. B. Eerdmans Publishing Company.

Schroeter, K., Derse, A., Junkerman, C., & Schiedermayer, D. (2002). 
Practical ethics for nurses and nursing students: A short reference manual. Frederick, MD: University Publishing Group.

Shelly, J. A., & Miller, A. B. (2006). 
Called to care: A Christian worldview for nursing (2nd ed.)
Downers Grove: IL: InterVarsity Press.

Shuman, J. J. (1999). 
The body of compassion: Ethics, medicine, and the church. Boulder, CO: Westview Press.

Steinbock, B., Arras, J. D., & London, A. J. (2003). 
Ethical issues in modern medicine. New York: McGraw Hill.

Sugarman, J., & Sulmasy, D. P. (Eds.) (2010). 
Methods in medical ethics (2nd ed.). Washington, DC: Georgetown University Press.

Key Terms

Balancing: The process of comparing the relative significance or importance of two or more competing principles in order to justify which principles are to be given precedence, finding the greatest balance of right and wrong. It is what ought to be done, all things considered. Balancing is not merely rank ordering but is the process of taking into account the relevant moral considerations of each principle and attempting to support each one as best as possible.

Beneficence: A principle used in a broad sense to include all forms of action intended to benefit other persons. It requires that one prevents harm to others, provides benefits, and balances those benefits against risks and costs.

Biopsychosocial-Spiritual Model: A model of health care whereby wellness is concerned with and defined by not only the physical, but also the emotional, spiritual, and social wellness of human beings.

Contextual Features: In terms of the four-boxes approach to ethical case analysis, contextual features are those features of a case that form the larger context of persons, institutions, and financial and social arrangements that may influence patient care or a patient’s decision, either positively or negatively.

Distributive Justice: The fair distribution of goods, services, and responsibilities in a community.
 Also see justice, remedial justice, and retributive justice.

Four-Boxes Approach: An approach to identifying, organizing, and analyzing the relevant elements of a particular case to assist in resolving ethical problems in clinical medicine using the general topics of medical indications, patient preference, quality of life, and contextual features. Sometimes called the four-topics approach or simply Jonsen’s boxes.

Justice: A principle characterized by rendering what is due or merited according to fairness and impartiality. Also see distributive justice, remedial justice, and retributive justice
.

Medical Futility: A morally ambiguous concept that usually expresses a combined value and medical/scientific judgment about what treatments and interventions are to be considered useless. It can refer to a medical procedure or treatment that has no physiological effect or that will not contribute to the stated goals and values of a patient.

Medical Indications: In terms of the four-boxes approach to ethical case analysis, medical indications include
 the diagnosis, prognosis, and treatment of the patient’s medical problem evaluated in light of the fundamental ethical features of a case. It involves the goals of care and the possibilities for benefiting the patient.

Nonmaleficence: A principle that requires persons to not harm others. It is based on the maxim 
primum non nocere, which means “above all, do no harm” or “first of all, do no harm.”

Patient Preferences: In terms of the four-boxes approach to ethical case analysis, patient preferences refers to what a patient desires to do in a particular case given their own personal goals. Patient preferences are based on the patient’s own values and personal assessment of the benefits and burdens of the treatment plans being offered.

Prima Facie: Loosely translated as, “on the face of it,” “at face value,” or “at first glance.” In the context of the four principles of medical ethics, to say that principles or rules are prima facie binding means that they should be fulfilled unless they conflict, in a given situation, with an equal or stronger obligation.

Quality of Life: A multidimensional construct that attempts to describe the experience of life satisfaction or well-being that includes things besides physical health, including the performance and enjoyment of social roles, engaging in meaningful personal relationships, intellectual functioning, as well as emotional and spiritual states. Quality of life expresses personal values and is sometimes difficult to define.

Reflective Equilibrium: A way toward bringing consistency to one’s moral principles, judgments about specific ethical cases, and moral intuitions and beliefs. Reflective equilibrium is a method of ensuring that one’s whole system of moral thinking is consistent.

Remedial Justice: The correction of past unjust distributions. Also see distributive justice, justice, and retributive justice.

Respect for Autonomy: A principle requiring respect for the decisions of autonomous persons. In health care ethics, it means that patients have a right to hold views, to make choices, and to take actions based on their values and beliefs.

Retributive Justice: The restoration of a right that has been violated by making recompense for that violation. In the context of medical ethics, it usually refers to distributive justice, which is the fair distribution of benefits, risks, and costs, especially involving the distribution of and payment for scarce and/or expensive medical resources or services. It also refers to the impartial and fair treatment of individual patients, respecting the rights and dignity of each human being.
 Also see distributive justice, justice, and remedial justice.

Specifying: The process of reducing the abstract and indeterminate meaning of a principle to more specific and concrete action-guiding content in a given case. It involves further defining a principle, narrowing its scope, and adding content in the context of a specific application.

Weighing: The process of determining the relative importance or strength of relevant aspects of a principle or moral norm in a given situation.

References

Barth, K. (1981). 
Ethics (D. Braun, Trans.). New York, NY: Seabury.

Beauchamp, T. L., & Childress, J. F. (2013). 
Principles of biomedical ethics (7th ed.). New York, NY: Oxford University Press.

Beck, H., & Brown C. (1976). Peace. In C. Brown (Ed.), 
New international dictionary of New Testament theology (Vol. 2, pp. 776-783). Grand Rapids, MI: Regency Reference Library.

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Hastings Center Report, 20(1), 12-16.

Childress, J. A. (1994). Principles-oriented bioethics: An analysis from within. In E. R. Du Bose, R. Hamel, & L. J. O’Connell (Eds.), 
A matter of principles? Ferment in U.S. bioethics (pp. 72-98). Valley Forge, PA: Trinity Press International.

Clouser, K. D. & Gert, B. (1990). A critique of principlism. 
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Cook, E. D. (1995). Relativism. In D. J. Atkinson (Ed.), 
New dictionary of Christian ethics and pastoral theology (Vol. 3, pp. 726-727). Downers Grove, IL: InterVarsity Press.

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Principles of Biomedical Ethics
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Hoehner P. J. (2006). The myth of value neutrality. 
Ethics Journal of the American Medical Association, 8(5), 341-344.

Hoehner, P. J. (2008). The coming bioethics tsunami. 
Today’s Christian Doctor, 39(4), 17-17.

Hoehner, P. J. (2018). Ethical and legal issues of geriatrics. In J. G. Reves, S. R. Barnett, J. R. McSwain, & G. A. Rooke (Eds.), 
Geriatric anesthesiology (3rd ed., pp. 27-51). Cham, Switzerland: Springer.

Jonsen, A. R., Siegler, M., & Winslade, W. J. (2015). 
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Resources

1. New Testament Overview

View the online video, “New Testament Overview,” from the Bible Project, located on the YouTube website (2018

… Read More

https://www.youtube.com/watch?v=Q0BrP8bqj0c

2. Sacrifice and Atonement

Explore “Sacrifice and Atonement” webpage and watch the video, on the Bible Project website (2018).

https://bibleproject.com/explore/video/sacrifice-and-atonement/

3. Explore “The Messiah” webpage and watch the video on the Bible Project website (2018).

https://bibleproject.com/explore/video/messiah/

4. Incorporating Spirituality into Patient Care

Read “Incorporating Spirituality into Patient Care,” by Orr, from 
American Medical Association Journal of Ethics (2015).

… Read More

https://journalofethics.ama-assn.org/article/incorporating-spirituality-patient-care/2015-05