Discussion Topic/ Principalism
Biomedical Ethics in The Christian Narrative
Introduction
The reality of religious pluralism (the view that there are many different religions with different teachings) does not logically imply any sort of religious relativism (the view that there is no such thing as truth, or that everything is a matter of opinion). There are genuine distinctions between religions and worldviews. Given this fact, it is imperative that one be tolerant of differences and engage civilly with those of different religions or worldviews. It might be tempting to think that one is being tolerant or civil by simply rolling all religions into one sort of generic “spirituality” and to claim that all religions are essentially the same. But this is simply false. Once again, there are genuine and important differences among religions; these differences are meaningful to the followers of a particular faith. To simply talk of some sort of a generic “spirituality,” while maybe properly descriptive of some, does not accurately describe most of the religious people in the world. Furthermore, this terminology often reduces religion to a mere personal or cultural preference, and it ignores the distinctions and particularity of each. The point is that such a reductionism is not respectful of patients. It should also be noted that atheism or secularism are not simply default or perfectly objective (or supposedly scientific) starting positions, while religious perspectives are somehow hopelessly biased. Every religion or worldview brings with it a set of assumptions about the nature of reality; whether or not a particular view should be favored depends upon whether or not it is considered true and explains well one’s experience of reality.
Biomedical Ethics
Bioethics is a subfield of ethics that concerns the ethics of medicine and ethical issues in the life sciences raised by the advance of technology. The issues dealt with tend to be complex and controversial (i.e., abortion, stem cell research, euthanasia, etc.). In addition, bioethics usually also involves questions of public policy and social justice. As such, the complexities of bioethical discussion in a pluralistic society are compounded. There have been several different approaches to bioethical questions put forth that have to do with the theory behind ethical decision making. Three positions have been prominent in the discussion principalism (also known as the four-principle approach), virtue ethics, and casuistry. For this lecture, it will be useful to outline principalism and to describe the general contours of a Christian approach to bioethical issues.
Principalism is often referred to as the “four-principle approach” because of its view that there are four ethical principles that are the frame work of bioethics. These four principles are the following, as spelled out by Tom L. Beauchamp and David DeGrazia (2004):
1. Respect for autonomy − A principle that requires respect for the decision-making capacities of autonomous persons.
2. Nonmaleficence − A principle requiring that people not cause harm to others.
3. Beneficence − A group of principles requiring that people prevent harm, provide benefits, and balance benefits against risks and costs.
4. Justice − A group of principles requiring fair distribution of benefits, risks and costs.
(p. 57)
For every bioethical question, one must seek to act according to these principles. For each case there will be details, circumstances, and factors that must be considered. The process of applying these principles to each unique case is referred to as specification and balancing. That is, these principles in and of themselves are abstract with no content or concrete application. One must specify the context and details of a case or dilemma to concretely apply these principles and arrive at concrete action guiding results (i.e., individuals need to know how to apply these principles to specific cases and circumstances). But secondly, the task of balancing involves figuring out how each of the four principles ought to be weighted in a case. One needs to determine which of the four principles deserves the most priority in any given case, especially in cases in which there are conflicts between the principles.
Though there is disagreement and diversity about whether or not principalism is the best theory and method of addressing bioethical questions, these four principles and this methodology have become foundational for bioethical reflection. One common misunderstanding about these principles, and most other bioethical methodologies or theories, is that they can stand on their own and comprise a neutral or secular system of solving ethical issues. However, this is a serious misunderstanding. Though these principles describe well much of the current cultural consciousness about right and wrong (and so describe what Beauchamp and Childress call the “common morality” that all human beings ought to hold to), they do not have enough moral or concrete content on their own apart from prior assumptions and worldview considerations.
Thus, one might come at the four principles from a Buddhist perspective, or an Islamic perspective, or an atheistic perspective and achieve vastly different results. The moral content and concrete application of the four principles would not simply depend on the particular details of a case, but also on the worldview from which one is approaching the moral question to begin with. The same is true of causitry as well. The point is that when one utilizes the principalist approach to bioethical dilemmas, it will always also incorporate broader worldview considerations and never be purely neutral or unbiased.
The Christian Narrative
While it is not possible to survey every possible religion, the description below will at least attempt to do justice to the biblical narrative and Judeo-Christian tradition.
The Bible is a collection of 66 books written over thousands of years in several different languages and in different genres (e.g., historical narrative, poetry, letters, prophecy), yet there is an overarching story, or big picture, which is referred to as the Christian biblical narrative. The Christian biblical narrative is often summarized as the story of the creation, fall, redemption, and restoration of human beings (and more accurately this includes the entire created order). Concepts such as sin, righteousness, and shalom provide a framework by which the Christian worldview understands the concepts of health and disease.
Briefly, consider the following summary of each of the four parts of the grand Christian story:
Creation
According to Christianity, the Christian God is the creator of everything that exists (Gen 1-2). There is nothing that exists that does not have God as its creator. In Christianity, there is a clear distinction between God and the creation. Creation includes anything that is not God–the universe and everything in it, including human beings. Thus, the universe itself and all human beings were created. The act of creating by God was intentional. In this original act of creation, everything exists on purpose, not accidentally or purely randomly, and it is good. When God describes his act or creating, and the creation itself as good, among other things, it not only means that it is valuable and that God cares for it, but that everything is the way it is supposed to be. There is an order to creation, so to speak, and everything is how it ought to be. This state of order and peace is described by the term “Shalom.” Yale theologian Nicholas Wolterstorff (1994) describes Shalom as, “the human being dwelling at peace in all his or her relationships: With God, with self, with fellows, with nature” (p. 251).
Fall
Sometime after the creation, there occurred an event in human history in which this created order was broken. In Genesis 3, the Bible describes this event as a fundamental act of disobedience to God. The disobedience of Adam and Eve is referred to as the Fall, because, among other things, it was their rejection of God’s rule over them and it resulted in a break in Shalom. According to the Bible, the Fall had universal implications. Sin entered into the world through the Fall, and with it, spiritual and physical death. This break in Shalom has affected the creation ever since; death, disease, suffering, and, most fundamentally, estrangement from God, has been characteristic of human existence.
Redemption
The rest of the story in the Bible after Genesis 3 is a record of humanity’s continual struggle and corruption after the Fall, and God’s plan for its redemption. This plan of redemption spans the Old and New Testaments in the Bible and culminates in the life, death, and resurrection of Jesus Christ. The climax of the Christian biblical narrative is the atoning sacrificial death of Jesus Christ, by which God makes available forgiveness and salvation by grace alone, through faith alone. The death of Christ is the means by which this estrangement caused by sin and corruption is made right. Thus, two parties, which were previously estranged, are brought into unity (i.e., “at-one-ment”). For the Christian, salvation fundamentally means the restoration of a right and proper relationship with God, which not only has consequences in the afterlife, but here and now.
Restoration
The final chapter of this narrative is yet to fully be realized. While God has made available a way to salvation, ultimately the end goal is the restoration of all creation to a state of Shalom. The return of Jesus, the final judgment of all people, and the restoration of all creation will inaugurate final restoration.
The Christian Ethical Approach − An Outline
While the principalist approach may be used by the Christian as a general methodological tool for bioethical reflection, the general contours of a Christian approach to ethics (not only bioethics) may be described as a mix of deontoogy and virtue ethics (Rae, 2009, p. 24). Given the reality that there is a God who exists and has created the world with a moral structure and and purpose, what is truly right and good is a reflection of the character and nature of the God of the Bible. The ethic that follows from the holy and loving nature of God is deontological because it will include principles and rules regarding right and wrong.
These principles can be known in two main ways: in the form of divine commands, as recorded in the Bible (take for example the 10 commandments), and in the structure of the world, from which a natural law (about right and wrong, not legal matters) can be detected. The biblical ethic will also involve elements of virtue ethics. The perfect man and moral exemplar (though much more than only a man and an exemplar) in the Christian tradition is Jesus Christ himself. The Christian is to not only obey God’s commands, but to be transformed into his image. Jesus Christ is the perfect representation of such a life; Christian’s thus ought to embody the virtues and character of Jesus himself. The attaining of these virtues will not only be a matter of intellectual knowledge of right and wrong, but an active surrender and transformation by means of God’s own Holy Spirit. Furthermore, the wisdom to navigate all the complexities of ethical dillemas and apply biblical and natural law principles appropriately will be a consequence of a person’s character and the active guidance of the Holy Spirit.
Worldview and the Christian Narrative
The way in which Christianity will answer the seven basic worldview questions will be in the context of the above narrative. In the same vein, a Christian view of health and health care will stem from the above narrative and God’s purposes. Of course, the pinnacle of this framework is the person of Jesus Christ. Thus, for Christianity, medicine is called to serve God’s call and purposes, and everything is done in remembrance of, and in light of, Jesus’ ultimate authority and kingship.
Reference
Beauchamp, T. L., and DeGrazia, D. (2004). “Principles and principalism” in Philosophy and medicine vol. 78. Handbook of bioethics: Taking stock of the field from a philosophical perspective. Dordrecht: Kluwer Academic Publishers.
Rae, Scott B. Moral (2009). Moral choices: An introduction to ethics. (3rd ed.). Grand Rapids, MI: Zondervan.
Wolterstorff, N. (1994). “For justice in Shalom.” In W. G. Boulton, T. D. Kennedy, & A. Verhey (eds.), From Christ to the world: Introductory readings in Christian ethics. Grand Rapids, MI: Wm. B. Eerdmans Publishing Company
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