The Church, the Medical Profession, and Applied Ethics

For the wise men of old the cardinal problem had been how to conform the soul to reality, and the solution had been knowledge, self-discipline, and virtue. For magic and applied science alike the problem is how to subdue reality to the wishes of men: the solution is a technique; and both, in the practice of this technique, are ready to do things hitherto regarded as disgusting and impious…

~ C. S. Lewis, The Abolition of Man

We live in an era where medicine possesses an ever-increasing technical power over the body. The use of this power in more extreme forms, as Lewis predicted, has not been limited in its creation of new realities, nor has it been overly enthusiastic in embracing created order. As a people who value the fallen yet sacred embodied world, one which God inhabited and is redeeming, we have a duty to witness to this objectivity. Haley Baumeister put it well in her essay Why It Is Difficult to Talk About Ethics of the Body: “faced with massive disembodiment, sexual disorder, and bodily desecration, we need a coherent vision of the human person to share with the world. Let us show—and not just tell—that another creaturely life is possible.”

Yet, the subjectivity that causes reality to be viewed as something to subdue is ever increasing in the West. It is complicated by the lack of recognition that the Enlightenment project of secular morality has failed to produce a comprehensive ethic that informs the purpose and limits of medicine. Twentieth-century medical atrocities, highlighted by evils like Nazi experimentations and the Tuskegee experiments, demonstrate the horrors that can be committed in the name of medicine.

These events, combined with the rapid advancement of medical technologies such as life support, organ transplantation, and reproductive treatments, led to the formalization of bioethics as an academic discipline which drew both from philosophical and theological traditions. And while the field has generated significant scholarly output, policy change, and formalized work in clinical ethics, a troubling deficiency in the telos of medicine and the telos of the human body persists.

How does the Church testify to the goodness, as well as the limits, of embodiment? As a practicing physician and lay elder at a local church, I propose a vital piece, perhaps the missing piece, of offering a content-full Christian body ethic to the world is in the formation of our medical professionals through a theology of vocation, particularly in the way the Church forms professionals in knowledge, self-discipline, and virtue. The Church can help her members who practice medicine to recover the profession, and thus its ethic, by forming them as such - a people committed to an ethos who practice the Gospel through their vocation.

The Professions and Covenant

Forming professionals requires recovering the ethos of the vocations once called “the professions.” Professions are vocational groups with a particular set of skills and a code of ethics oriented toward an internal morality. Though the term profession can be applied to many fields, it traditionally invokes the helping professions - law, ministry, education, and medicine, which are oriented toward achieving specialized knowledge in order to help the vulnerable. This convention demonstrates the professions have a telos, an end, such as ensuring justice, saving the lost, enlightening the mind, or, as in the case of medicine, restoring health.

The relationship between professionals and the vulnerable they serve requires trust. We are dependent on these professions because they relate to core aspects of our humanity. The risk of exploitation is significant. Codes of ethics are adopted to ensure fidelity to the ends of the profession. The Hippocratic oath is a well-known example: honor the learning and teaching of specialized medical knowledge, use such knowledge beneficently, do no intentional harm, and have fidelity to the moral community of medicine. The physician and ethicist Edmund Pelligrino, who espoused the aforementioned points, argues that the constellation of virtues required to practice a profession ethically produces an “‘internal morality’—a grounding for the ethics of the professions that is in some way impervious to vacillations in philosophical fashions, as well as social, economic, or political change.”

Moral community is fostered by the professional’s commitment to obtaining specialized knowledge in order to serve man. The community’s faithfulness to its internal morality creates a covenant. It is bound by an agreement amongst members to subject themselves to the standards of their community so that they can serve and love those dependent on their care.

Transaction and the Erosion of Professions

The most corrosive force against the professions is the change from a covenant-centered ethos to a transaction-centered one. Farr Curlin and Christopher Tollefsen explain how the profession of medicine has lost its moral roots due to the rise of the Provider of Services Model (PSM) of medicine. With the transactional model, the professional ethic is now defined by “…three norms: what the law permits, what is technologically possible, and what the patient wants.” In the PSM, the medical professional is reduced to a “purveyor of medical goods,” goods sought out to meet a patient’s desires. The ends of medicine are now defined in consumeristic terms. The medical profession is simply a means to those ends. Within the Provider of Services model, the profession’s internal morality is now centered on fulfilling this transaction.

The PSM is often not a significant factor in routine medical encounters. Blood pressure is managed, cancers are treated, and appendixes are removed by well-meaning doctors whose patients rely on their expertise. Nevertheless, the PSM is grossly apparent in the advancement of the ethically problematic areas of medicine, fueled by societal desire, legal acceptability, and technological feasibility. In quieter, although more pervasive ways, the PSM has been bolstered by the advent of online and consumer clinics which prescribe hormones, sex-enhancing medicines, and “biohacking” treatments, in a nearly unregulated manner. Though the traditional areas of bioethical contention - reproductive control and abortion, euthanasia, and body modification - are still main issues, the access the average person now has to body-altering treatment (looksmaxxing for an example) is unprecedented. This is medicine as a pure provision of services. It is unbridled autonomy with the professional entirely removed, and it further serves to diminish the need to either act as a professional in medicine or for society to seek out a medical professional.

Autonomy as Sicut Deus

The diminishment of healthcare workers from “professionals” to “purveyors” coincides with the rise of autonomy as the overriding principle of medical ethics. Autonomy is a core principle of medical ethics, and yet as a principle it is frequently vexing and challenging. At its core is the respect for the dignity of human beings, made in the image of God. It demands the honoring of a patient’s values and beliefs when considering the uses of medicine. Autonomy is traditionally weighed in light of the other three prima facie principles of medical ethics - beneficence, non-malfeasance, and justice. The worst twentieth-century scandals of medical ethics consisted at least partly in denying autonomy to patients. As well, autonomy is core to our liberal political project. Life, liberty, and the pursuit of happiness are all enshrined as unalienable rights.

A superficial consideration of autonomy reduces it to the right of self-determination. But, at its foundation, the autonomous individual still has to choose an authority to inform his or her decisions. As Carl Trueman and many others have argued, the desires of the self (formed by sociopolitical, psychological, and sexual forces) most often assume this authority. But this subverts the good of autonomy and leads to the misguided version that creates the problematic pseudo-ethic of the provider of services model. This is the world of the Conditioners, which Lewis says ultimately abolishes man.

As Christians, we should not be surprised by this corruption of autonomy. It is a continuation of the original sin of the fall - exchanging the Imago Dei with the sin of becoming like a god. Dietrich Bonhoeffer calls this sicut deus (‘like God’):

…God’s truth pointing to my limit, the serpent’s truth pointing to my unlimitedness—both of them truth, that is, both originating with God, God against God. And this second god is likewise the god of the promise to humankind to be sicut deus. God against humankind sicut deus; God and humankind in the imago dei versus God and humankind sicut deus. Imago dei—humankind in the image of God in being for God and the neighbor, in its original creatureliness and limitedness; sicut deus—humankind like God in knowing out of its own self about good and evil, in having no limit and acting out of its own resources, in its aseity, in its being alone.

Bonhoeffer succinctly captures how autonomy is corrupted. To be god-like in the view of self is a natural inclination of fallen man. The advent of new technologies which provide god-like power only serves as a compounding factor. An eroded profession of medicine is defined by this ceding of professional responsibility to becoming an agent of sicut deus.

The Church and the Formation of Professionals

Showing the world how to think of the body ethically through the use of medicine as a sign of the Kingdom to come requires a medical profession formed by members who have a high view of the profession, an understanding of its internal morality informed by an eschatological teleology, and the deforming influences that are undermining it.

C. S. Lewis concluded his novel Out of the Silent Planet, “What we need for the moment is not so much a body of belief as a body of people familiarized with certain ideas. If we could even effect in one per cent of our readers a change-over from the conception of Space to the conception of Heaven, we should have made a beginning.” The conception of Space treats man as sicut deus, subduing creation to his own glory. By contrast, the conception of Heaven is man reflecting the love of God through vocational gifts to a broken but beautiful world. This is where a recovery of Christian professions must start if there is hope to recover an unswayable internal morality. This work begins at the granular level of the local church with medical professional parishioners.

Grand philosophies and generational cultural changes may seem out of the grasp of the local church. Yet, ideas only gain traction when they become practiced. The Tower of Babel was once a misguided thought experiment until the bricklayers were convinced to build it, the Conditioners as Lewis would call them. The applied ethics of medicine are no different. Prior to any ethical issue gaining front-page attention, multiple smaller, though no less important, decisions were made in laboratories, conference rooms, administrative meetings, and shared decision-making discussions with patients. In a country where well over half of the population would claim some form of Christian belief, surely Christians have at least some influence.

The way Christian medical professionals guide Christian laity to engage in medicine has tremendous influence on the field, particularly one that functions under the provider of services model in which what is permissible is defined by what is desired. The everyday counseling of a couple considering IVF, the spouse deciding whether to end life support, a young woman considering being a surrogate for an infertile relative, or simply the patient considering the use of peptides or hormones for a variety of indicated or non-indicated reasons, are the pebbles which change the course of the river of ethical course of medicine.

Perhaps even more important is the way medical professionals shepherd their patients through suffering by placing limits on medicine. These considerations are complex and unique; any experienced ethicist knows paradigmatic cases exist which make rigid prescriptions hard and which all the more require a Spirit-filled professional grounded in a thoughtful professional ethic to determine boundaries and define the good. In contrast, modern society likes to take paradigmatic exceptions and make them a license to push boundaries of permissibility. This must be resisted by the professional as well. The intentionality in which the Church teaches medical professionals to understand creation, fall, redemption, and new creation informs the grace, mercy, and limits of their ethic.

Doing so requires no special expertise in areas of medicine or bioethics on the part of the Church but rather an engagement with their medical parishioners to assess understanding of basic theological elements of the doctrine of creation, a biblical anthropology of man, and a theology of vocation. Secular appeals to natural law and the restoration of virtue are good recovery points, but they are insufficient in themselves since they appeal to nothing greater for validity.

Medical professionals must have a Christian ethic. Philosopher Oliver O’Donovan argues this ethic must arise from the Gospel: “Creation and redemption each has its ontological and its epistemological aspect. There is the created order and there is natural knowledge; there is the new creation and there is revelation in Christ.” He provides a good starting framework of how this eschatological orientation informs the telos of medicine in Begotten or Made:

Christians should at this juncture confess their faith in the natural order as the good creation of God. To do this is to acknowledge that there are limits to the employment of technique and limits to the appropriateness of our “making.” These limits will not be taught us by compassion, but only by the understanding of what God has made, and by a discovery that it is complete, whole, and satisfying. We must learn again the original meaning of that great symbolic observance of Old Testament faith, the Sabbath, on which we lay aside our making and acting and doing in order to celebrate the completeness and integrity of God’s making and acting and doing, in the light of which we can dare to undertake another week of work. Technique, too, must have its Sabbath rest.

Deeper thinking must be encouraged amongst the medical community within the church through vocational groups guided by those in the profession of ministry. In turn, the local church should allow itself to be ministered to by its theologically informed medical professionals so as to help shape how it engages ever-advancing medical technology.

Is such formation and thinking better suited for specialized para-church organizations like the Christian Medical Dental Association, or think tanks like the Center for Bioethics and Human Dignity? While they do invaluable and important work which greatly bolsters and encourages the profession, they are not integrated gospel communities where one can know and be known to a large cross-section of the laity, nor do they have pastoral responsibility in the way the Church does. Organizations as such should be enthusiastically embraced, though professional formation should not be outsourced to them.

The Church’s mission is to preach the Gospel of Jesus Christ. This message shapes the way we live in God’s beautiful world, one subjected to the fall, awaiting final resurrection. The expression of the profession of medicine, as well as others, should reflect the Gospel for the Christians who practice it. While theological work around bioethics and the theology of the body is of crucial importance, ensuring Christians have a theological vision of the medical profession will be equally as necessary to make the ethics of the body effective in the decades to come.