Which ethical basis?

In a pluralist society it is difficult to find moral consensus, because we no longer have a common process for working out right from wrong. We hope our legislators will consider an ethical perspective as they make decisions, but there is no guarantee that their ethics will be consistent with biblical ethics.

Let me illustrate some common ways of making ethical decisions in our community by using the example of abortion.

The most common approach to deciding right from wrong in our society is to judge actions solely by their consequences—that is, the rightness or otherwise of a course of action is determined by looking at the outcome. As I mentioned briefly in chapter 3, this ethical theory is called consequentialism. If you expect a good outcome, then it is a morally good decision. If you anticipate a bad outcome, it is the wrong ethical choice. For example, a consequentialist finds that she has an unplanned pregnancy. She worries that this unwanted baby will have a bad effect on her health, her career, and her general happiness. She reasons that since an abortion would remove these threats to her future and provide a better outcome, then an abortion is the ethically correct choice for her.

Another popular theory involves evaluating choices in terms of an individual’s rights. In the case of abortion, we often hear the classic argument of a woman’s ‘right to choose’ what happens to her body. While there are some recognized lists of rights (such as The Universal Declaration of Human Rights by the United Nations),[1] nowadays many people use ‘rights’ language simply to demand something they really, really want, but which is not actually a valid ‘right’ at all.

In many heated public debates on topics such as abortion, you often hear an argument like this: “If you don’t like abortion then don’t have one, but don’t stop someone else from having one”. This argument is based on a theory called moral relativism. According to this theory, there is no absolute right or wrong, and moral rules are just an expression of personal preferences (influenced by cultural factors). Therefore choosing an abortion is a matter of expressing your personal preferences and values, and does not need any other reason to justify it—just as if you were choosing what to eat for breakfast. Furthermore, no-one should judge another’s choice and ask for abortion to be banned.[2]

Sometimes the ethically correct healthcare for an individual is decided by what is best for the community as a whole—a theory called communitarianism. Consider, for example, when public policy needs to determine what public funds will be spent on, or which procedures will be legal. Some people justify abortion for disabled babies on the grounds that it is better for the community if disabled children are not born, so that they don’t have to be supported, which costs society time and money. Note that you would need to combine another theory with this one, because the main feature of communitarianism is its assumption that what is right for the individual can be determined by working out what is best for the group. (Christian responses to all these arguments are given below.)

Cuts both ways

Note that each of these common ethical theories could also be used to argue against abortion. The consequentialist might decide that missing out on being a mother is a bad outcome, so she may decide against abortion. The rights advocate might consider the right of the baby to life. The relativist might just prefer not to have the abortion, and the communitarian might decide it is bad for the community to allow the devaluing of human life, and decide that abortion is wrong on these grounds. The ethical theory you use is just an instrument that gives you a method to work through the question; it does not necessarily determine what you decide. Your presuppositions (the basic principles that you accept as true—such as believing that life starts at fertilization) will also make a big difference to your conclusion. This demonstrates that, even without using biblical principles, non-Christians will at times agree with Christians on issues of morality, though possibly for different reasons.

Christian decision-making

Serious ethical deliberation involves a logical process of working through basic principles to determine what is the right thing to do. Human reason therefore plays a role in evangelical ethics, but a Christian will not operate without the guiding authority of Scripture. However, because human reason is fallible, and because we don’t all have exactly the same priorities or the same perceptions of the way the world is, it is possible that two Christians will approach the same ethical question and come to different, but valid, conclusions. They would not come to a conclusion that is contrary to Scripture, but there are many issues on which Scripture is silent. For example, given that government is operating under God’s authority (as Romans 13 teaches), what mode of government is correct? While we would probably all prefer democratic government on grounds of human equality, some of us might support a more capitalist version of democracy because it encourages human enterprise, and others might favour a more socialist version because it aims to support the poor and the weak.[3] Both conclusions make sense. That is why there are Christians in different political parties.

In order to make informed and biblical decisions, we really need two things: a clear understanding of the facts related to the decision, and a sound biblical framework for making sense of them and working out what is the right and wrong thing to do. In medical decision-making, many Christians often struggle with the first of these factors—that is, they simply don’t have a good knowledge of the facts, often because of rapidly changing technologies that are emerging. Much of the rest of this book will be concerned with providing this information.

However, knowing the facts is not enough. We also need a clear and applicable biblical foundation on which to base our decision-making. In this chapter, I will introduce one basic approach, but there are excellent accounts elsewhere which provide comprehensive explanations.[4]

All explanations of evangelical Christian decision-making will use the Bible as the moral compass. The Bible contains some specific guidance—for example, we are told to obey God’s commands as an expression of our love for him (John 14:15). We also find some general moral principles in its pages that we can confidently follow (e.g. Matthew 5-7). However, just as important is the Bible’s portrayal of the character of the God we seek to emulate—his goodness, justice, mercy, grace and forgiveness (Exod 34:6-7). There are also numerous lists of the qualities of character (virtues) that we should seek to develop as we grow in godliness (Gal 5:22-23; Eph 4:1-3, 32; Phil 4:8; Col 3:12-13; 1 Tim 4:12, 6:11; 2 Tim 2:22, 3:10-11; Titus 3:1-2; 1 Pet 3:8; 2 Pet 1:5-7). Furthermore, the Bible teaches us the context of our lives—what we are as human beings, what kind of world we live in, and what lies in our future.

As we already began to see in chapter 3, it is also important to consider the whole of Scripture as it unfolds so that our conclusions are not distorted by a partial appreciation of God’s purposes. This will involve reflecting on what is often called ‘biblical theology’—the framework of God’s unfolding revelation in the Bible:

  1. Creation: the world as God originally made it
  2. Fall: the world as it is affected by sin
  3. Redemption: the world in light of salvation through Christ
  4. Future consummation: the world in view of the glorious future awaiting us

So, for example, with regard to the principles for moral behaviour given to Israel in the Old Testament, we need to remember that the biblical revelation is progressive, and that these principles will need to be interpreted in light of the New Testament. Paul tells us in Romans that we are no longer under the law—in fact, we are delivered from the law (Rom 6:14, 7:6)—and so we will look carefully at the validity of Old Testament ethical instruction, using it as a source of Christian wisdom rather than a strict code of law.[5]

As Hill points out, many of the New Testament virtues are related to personal relationship and community—virtues like compassion, kindness, hospitality, gentleness, generosity, peaceableness, truthfulness, humility, patience and forbearance.[6] This reminds us that we are creatures made for relationship, which will be an important consideration in all our decision-making.

So how do we put it all together? Below is a framework that can help us combine the important considerations for any decision and check whether we are indeed following biblical principles.

A model of ethical decision-making for Christians

In any moral choice, we are first moved to act by our motivation, which leads to an intention to achieve a certain goal. We then take action to achieve that goal, and our action will have certain consequences. How does the Bible judge the importance of each of these components of our ethical choice?

We begin by recognizing that we face an ethical decision, and developing the motivation to respond. This will determine not what we are going to do so much as why we are going to do it. Christian motivation is grounded in the summary of the commandments given by Jesus in Matthew 22:37-40: “Love the Lord your God with all your heart and with all your soul and with all your mind” and “love your neighbour as yourself”. For example, if a Christian (let’s call him Tom) sees a woman suffering from unrelieved pain, he will be moved by love and compassion to want to help.

Once we have been motivated to act, we consider what we want to achieve. This is our intention. We begin to consider a particular goal, which will help us to decide on an appropriate course of action. Mind you, good intentions are not enough on their own. Good intentions do not justify wrong actions (as Paul insists in Romans 3:8); nor are good intentions an excuse for doing nothing (as James reminds us in James 2:16). However, if we have bad intentions, this can be as bad as having performed a wrong action (Matt 5:21-22, 27-28).

Both intentions and actions are significant. Jesus told us that our actions are a reflection of what is in our hearts and minds (Mark 7:21-23). We therefore will see some overlap between our intentions and our actions.

To take our example to the next step: having been motivated to help, Tom now decides to try to stop the woman’s suffering by relieving her pain. He has formed an intention, but what action will he take?

In recent times, some people advocate euthanasia—that is, killing those who are in pain and suffering, in the (usually erroneous) belief that it is the only way to stop their pain. However, Tom is aware that there is a biblical prohibition on killing people (Gen 9:6; Exod 20:13; cf. Matt 5:21-22), so he rules out that course of action. The action itself is wrong, even if the intention is noble or good (in this case, compassion for the suffering person). Compassion moves us to act, but does not inform the content of our actions.

Tom decides to give the woman medication to stop the pain. This is a compassionate response that does not violate any biblical principles.

The last aspect of our choice involves examining the consequences of our action. Consequences are important, and we do need to consider them. However, we cannot decide right from wrong by looking at consequences only. There are a few reasons for this. We might remember, firstly, that the end does not justify the means (there are some things we should never do regardless of the consequences, as Romans 3:7-8 makes clear). Moreover, God knows our hearts and minds, and he is concerned by our motivation and intention as well as our actions and their consequences (cf. Matt 5:27-28). Besides, consequences are enormously difficult to predict and to assess—even after the fact, let alone in advance. So in the case of euthanasia, there is on the one hand the consequence of a sick person’s suffering being eased. But on the other hand, there is the distinct possibility that allowing euthanasia will certainly lead to some people being killed against their real wishes. How do we weigh these consequences against one another, let alone all the other possible outcomes and consequences? And can we do so credibly in advance, when we simply cannot predict or control what will eventuate? Consequences alone are an inadequate basis for ethical decision-making.

However, we do need to consider what effect our actions will have, for good or ill. Now, before we go any further, we need to acknowledge that all things are in our sovereign God’s hands, and that we cannot foresee all consequences. God knows this, and we are judged according to those things for which we are responsible, not those things that are out of our control. God’s judgement will be just (Rom 3:19). We should aim for a good outcome, but if a bad outcome intervenes through circumstances beyond our control, we are not morally liable.

That said, Christians will judge consequences in light of gospel values. If we are aiming to love our neighbours and do what is best for them, we will look for outcomes in which suffering is eased, loving relationships are fostered, justice is done, and so on (see Mic 6:8). Sometimes we will need to be creative in considering what options are available to us. Sometimes we will have to choose an option that has a difficult and personally costly outcome. Sometimes we will be surprised by the way God works to bring good out of evil (Rom 8:28). But God has promised that we will never be forced to submit to the ethically wrong but easy way out when we are tempted to give way (1 Cor 10:13). We also need to remember that we cannot control the actions of others, and that we must expect to see troubles in this fallen world (John 16:33).

To return to our example: the consequence of Tom’s action is that the woman’s pain is relieved and her suffering eased. He considers this a satisfactory result by biblical standards.

MOTIVATION Love for God and for our neighbours. Christian character is developed according to the virtues listed in the New Testament.
INTENTION Both intentions and actions should be obedient to God’s word and keep in mind the nature of the creation.
CONSEQUENCES Will be measured according to God’s standards for justice; we will be concerned for the vulnerable, we will be merciful and we will keep in view the future consummation.

Note that to maintain a Christian ethic in decision-making, the following is necessary:

  • study of the Scriptures to identify relevant themes and rules
  • development of Christian character (put on virtues, take off vices)
  • development of a Christian world view by making it our practice to think things through in a gospel context and collecting any extra information we need
  • prayer that God’s spirit will give us wisdom and the power to change.

A retrieval ethic

Sometimes we find ourselves having to choose between two ‘evils’. As Michael Hill acknowledges, the tensions of living in a fallen world mean that love for God and for our neighbours cannot always be sustained as we would like. At these times, we will find that the Bible permits a retrieval ethic—an allowance from God in view of the hardness of our hearts. To justify this approach Hill looks to passages like 1 Corinthians 7:10-16, where God, who hates divorce, will allow it when mutual love cannot be accomplished, as a way of salvaging what good is possible and minimizing harm (cf. Matt 19:8).[7] Sometimes all we can do is try to minimize the damage that results from actions we cannot control.

This needs to be carefully evaluated. A retrieval ethic is not based on a different system of morality to that I have described. Rather, “the same value system [is] operating in two different ways”.[8] As Hill describes it, good and evil remain constant, but where sin has limited the opportunity to act as we would wish, some goods may need to be abandoned and others taken up. His example refers to divorce, where the oneness of marriage is no longer possible if one party leaves the relationship for an adulterous union. However, a cordial relationship may be able to be maintained through legal separation and formal divorce. This is particularly helpful if children are involved.

Decision-making in medical matters

It is difficult to make choices if we are not sure what it is we are choosing between. As mentioned above, one of the challenges of decision-making in bioethics is that we need to understand something of the science before we can start talking about ethics. Christians have at times been discredited for speaking out on scientific issues about which they were ignorant.

I am not saying we shouldn’t speak out until we know every single detail. But we will be taken more seriously in public debate if we know our facts and we know our limitations. This is a challenge for our churches, but we need to trust that God will provide people, if not in our own congregations then in our geographical areas, who can educate us about current controversial bioethical issues.

Responding to alternative ethical theories

At the beginning of the chapter we looked at several ethical theories that are popular in modern society. Having looked at the Bible’s ethical framework, how might Christians respond to these alternative approaches?

Let us start with consequentialism. While the Bible teaches that we should consider the consequences of our actions, it does not support the idea that consequences are the only things that matter, or that consequences should overrule all other considerations. We would therefore reject the argument that a good outcome (such as the mother’s emotional or financial or career wellbeing) justifies abortion on grounds that killing an unborn child is an unjust and immoral action in itself. The mother’s desire to secure her future wellbeing does not justify taking human life any more than, say, inheriting a valuable property justifies killing your parents.

Regarding rights theory, we will be more interested in loving our neighbours than in asserting our rights over them (1 Cor 10:24). We would also point out that the proliferation of ‘rights’ (usually self-claimed) results in impossible conflicts. So, for example, if I have a right to personal happiness or prosperity, what happens when my neighbour’s right to the same thing conflicts with mine? Whose right should have priority? Likewise, why does a woman’s right to control her own body override a baby’s right to life and liberty? In the end, these conflicts are usually resolved by the more powerful trampling on the rights of the weak. The mother decides that the baby’s right to life is not morally relevant or not as important as her right to happiness, and so aborts the baby. And the baby is in no position to stop her.

Moral relativism is often regarded as ‘politically correct’, and necessary for maintaining community harmony. But while it may appear to promote tolerance, insisting that all moral positions are personal and relative is both illogical and impractical. It is illogical because moral relativism is itself claiming to be the correct ethical theory. And it is impractical because no-one ever sticks to it. You don’t have to push a moral relativist very far before they admit that some things are universally good or evil (whether it is racism or sexism or child abuse or whatever). Also, by reducing the abortion argument to ‘Don’t have an abortion if you don’t approve’, moral relativists are avoiding the question of right and wrong entirely and confusing it with personal preference. But for those opposed to abortion, personal preferences are beside the point when you are fighting for an absolute moral value such as the protection of innocent human lives. And personal preferences certainly shouldn’t be the basis for the law that provides the moral standard for a whole society.

With regard to communitarianism, we will always consider the needs and welfare of those around us, and will desire to build strong and loving communities. But working out what is best for a community will depend on one’s vision of the good life, and what constitutes the ‘best’. So whereas supporters of abortion would argue that it is better to abort disabled babies so that the community does not have to bear the cost of supporting them throughout their lives, Christians would say that this is not only a morally wrong action in itself, but is also based on a morally defective view of what makes a good community. In a truly good community, everyone would be treated with love, dignity and respect, not dispensed with if they are weak or disabled or become expensive to care for.

Christians do support communitarianism in that we believe there are absolute moral truths that are the good gift of the God who made the world, and that upholding and living out these truths will be for the benefit of everyone in the community.

For doctors

Medicine has for some time focused on the ‘four principles’ approach to healthcare ethics developed by Tom Beauchamp and James Childress (often called ‘principlism’).[9] The principles they identified as important in this context were:

  1. Beneficence (the obligation to provide overall benefits to patients when balanced with risks)
  2. Non-maleficence (the obligation to avoid causing harm)
  3. Respect for autonomy (the obligation to allow mentally competent patients to make decisions on matters that affect them)
  4. Justice (the obligation to treat patients fairly regarding benefits and risks)

However, the authors never intended this framework to be used as an independent ethical theory. Beauchamp recommended it be used “together with other moral considerations”.[10] In fact, it is extremely difficult to decide what to do using only these four principles.

For one thing, it does not tell you whose autonomy ought to be respected if more than one patient is involved. If you were deciding whether abortion was the right or wrong thing to do, you may consider going ahead if you wanted to respect the autonomy of the woman requesting one. But what of the unborn child whose autonomy is being radically terminated? Moreover, you are denying the unborn child justice by intentionally killing it—an act that can only be described as harmful (maleficent). From this perspective it would be the wrong thing to do. Obviously, further principles are required to work out what to do in this situation. If we consider the principles with regard to the mother, abortion is the right thing to do. If we look at it from the baby’s perspective, it isn’t.

Furthermore, the way the principles are used in medical practice usually makes them a form of consequentialism (deciding right from wrong only on the basis of the consequences of an action). That is, beneficent actions are determined as those with good outcomes; maleficent actions are determined as those with harmful outcomes; and so on. As such, the ‘four principles’ approach suffers from the problems and inconsistencies that all consequentialist moral theories share. We know from Scripture that we are not to decide right from wrong purely by consequences—the end does not justify the means. We need to consider the morality of motive, intentions and actions as well, as we have discussed above. The ‘four principles’ approach will be inadequate on its own to assess morality for Christians.

The usefulness of the principles lies in reminding us that we should aim to do good and not harm, to take into consideration our patients’ wishes where appropriate, and to treat them justly. This is not the complete list of our obligations, but it is a start.

Doctors interested in engaging with medical ethics would do well to do further reading about ethical theories. This will put you in a position not only to formulate and understand your own ethical approach, but also to be able to analyse and interact with the arguments of others. Beauchamp is right when he says that “it is insupportably optimistic to think we will ever attain a fully specified system of norms for health care ethics”.[11] There is no longer sufficient societal consensus for this to happen. I agree with Pellegrino that the most likely candidate to allow development of a unique ‘professional medical ethic’ is virtue theory (which looks at the preferred virtues, or qualities of character, of a good doctor). His writing on this topic is recommended. [12] This style of approach is becoming loosely categorized as ‘Hippocratic medicine’, and you could do a lot worse than aim for that.

Now that we have covered the basics of biology, theology and ethics, we will look at specific areas of the beginning of life that need to be evaluated from a Christian perspective. We will start with contraception.

  1. UN General Assembly, The Universal Declaration of Human Rights, 10 December 1948. 
  2. For a comprehensive refutation of moral relativism in the abortion debate, see F Beckwith, Defending Life, Cambridge University Press, New York, 2007, chapter 1. 
  3. This example is taken from J Stott, New Issues Facing Christians Today, rev. edn, HarperCollins, London, 1999, p. 46. 
  4. For a detailed explanation of ethical Christian decision-making, see M Hill, The How and Why of Love, Matthias Media, Sydney, 2002. 
  5. For further discussion of the place of Old Testament laws in Christian ethics, see A Cameron, Joined-up Life, IVP, Nottingham, 2011, pp. 135-40. 
  6. Hill, op. cit., p. 38. 
  7. Hill, ibid., pp. 132-4. 
  8. ibid, p. 133. 
  9. TL Beauchamp and JF Childress, Principles of Biomedical Ethics, 3rd edn, Oxford University Press, New York, 1989. 
  10. TL Beauchamp, ‘The “four principles” approach’ in R Gillon (ed.), Principles of Health Care Ethics, Wiley, Chichester, 1994, pp. 3-12. 
  11. Beauchamp, op. cit., p. 12. 
  12. ED Pellegrino, The Philosophy of Medicine Reborn, University of Notre Dame Press, Indiana, 2008, chapter 12. 

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