Christian Medical Ethics

1. Christian Medical Ethics A basic exploration of fundamental concepts and a problem solving process

2. Common approaches to medical ethics • Virtue ethics (Existential) • Good = What a good person would do • Look at motives and behaviour • Consequence ethics (Teleological/ Utilitarian) • Good = Aiming at good goal / consequences • Look at facts and consequences • Duty ethics (Deontological) • Good = What the law says • Look at laws, protocols, standards, creeds, norms

3. What is Christian medical ethics? Theological basis: Matthew 22: 37-39 Application: How love our neighbour in healthcare? As a science: Reverent, systematic, analytical and critical thinking about how medical professionals ought to behave. We consider virtues, consequences and duties in loving God and our neighbour

4. Ethics problem-solving flow-chart Define moral problem Develop possible courses of action Determine preferred course of action Deploy planned course of action Deployment evaluated and appropriately handled

5. Case study: Patient requests euthanasia • Christian nursing home, Christian doctor doing rounds with successor • Male patient: • Early sixties, divorced (no contact with ex-wife), three children (no contact with one of them, poor contact with the other two), • Grew up in Christian environment, drifted away as teenager and stayed that way • Poor vascular system, upper leg amputations both sides because of this; still smoking - under supervision because of fire hazard; several large decubitus ulcers • Has requested euthanasia once before. Doctor then explained that it is against the institutional code and against the doctors’ conscience to do so. Patient accepted it at that stage. His family was not informed about his request. • Now complains of severe ongoing pain, feels depressed, sees no future for himself, requests euthanasia again • Doctor reminds patient of earlier conversation; discusses the various complaints with patient; prescribes more potent pain relief protocol; adds that patient will have to move to other nursing home if he persists with euthanasia request; recommends a talk with a pastoral worker • Patient declines pastoral care; promises to think more about the issue

6. In the groups • Appoint persons in following roles: • One person = doctor doing ward round • One person = patient • One person = son who has no contact • Rest = ethics committee members of institution • Define the problem • Develop possible courses of action • Determine preferred course of action

7. 1. Define moral problem • What are the facts of the situation: medical, nursing, legal, economic, social, organisational? • Who is involved? • What does each party think about the situation? • What are their responsibilities in the situation? • What interests do they have in the situation? • What are the underlying world view perspectives? • Is there a moral dilemma? If so, which? More than one dilemma? • What is the scope of the problem? (Micro, meso, macro?) • State the problem as a specific question

8. 2. Develop possible courses of action • Which courses of action could be taken? (including those you would not agree with) • What virtues / consequences / duties are relevant in each of the possible courses of action? • Which virtues / consequences / duties are in danger of being neglected in each of the possible courses of action? • What would each possible course of action mean for each of the key persons involved? • If different underlying opinions / preferences / world view issues are evident, specify.

9. Seven Vices Pride Envy Gluttony Lust Wrath / Anger Greed Sloth Seven Virtues Faith Hope Love Fortitude Temperance Justice Prudence 2.1a General Virtues and Vices Q: What does my conscience say? How become more Christ-like through grappling with problem?

10. Seven Medical Virtues Compassion Mercy Professionalism Integrity Collegiality Justice Prudence Seven Medical Vices Coldness Cruelty Quackery Corruption Rivalry Injustice Carelessness 2.1b Medical Virtues and Vices

11. 2.2 Consequences: A Christian perspective • Purpose: promote health interests of patient • What will consequences be for: • Ethical, religious, legal, economical, social and technical aspects? (? also aesthetic, linguistic and cultural aspects) • Preventive, curative, palliative + terminal care? • Health and well-being of involved parties? • Consider these rules regarding consequences: • Proportionality (benefit / burden analysis) • Subsidiarity (least drastic / burdensome / expensive) • Consider the scope of the consequences: • Micro (personal), meso (institutional) and macro (whole field) • Short term, long term, eternal

12. Christian duties Pro-shalom; not kill on purpose Marriage as safe circle for intercourse, conception and raising children Respect responsibility and freedom of choice of patient Repair of disease as safe circle for genetic manipulation Respect property of another Respect created sexual identity The Law: What does the Bible say? Ten / two commandments Law suited to humans Love is fulfilment of the law Medical Duties Care Respect for life Beneficence (do good) Non-maleficence (no harm) Justice Confidentiality Trustworthiness Informed consent Hippocratic Oath Medical ethical codes Protocols, standards Professional responsibilities + position description 2.3 Duties: A Christian perspective

13. 3. Determine preferred course of action • Dialogue with relevant parties regarding possible courses of action; discuss virtues / consequences and duties of each possibility • Use feedback to improve quality of problem solving • Develop criteria for evaluating the possible courses of action: what is acceptable / exemplary / unacceptable • Which criteria will count the most? • Build convincing argumentation for your choice; refer to virtues, consequences and duties as well as the criteria for evaluating the courses of action • Seek to reach consensus about the preferred course of action. Use negotiation / mediation if required • What protocol to follow if no consensus is reached?

14. 4. Deploy planned course of action • Plan: Make a good plan re course of action: • Consider implications on care plans, treatment protocols, institutional plans and procedures • Who does what by when? • Who is responsible for supervision of which part of the planned course of action? • How will the implementation of the planned course of action be evaluated? • What will consequences be of the evaluation? • Do: Implement the plan

15. Check: Evaluate the course of action as indicated in the plan Act: Use information from evaluation to take appropriate steps towards a better future together 5. Deployment evaluated and appropriately handled

16. Overview of the process

17. Overlap / different interpretations between doctor / patient Virtues Consequences Duties

18. What happened with the patient who requested euthanasia? • Patient satisfied with adequate pain relief and excellent care; withdrew euthanasia request • Condition later deteriorated seriously; this time took advice from successor doctor to get pastoral help • As a consequence: • Reconciliation between patient and God • Reconciliation between patient and lost son • Gratitude expressed towards successor and staff • Patient died in peace just after this

19. Faith • Belief, trust, fidelity, loyalty, conviction • Faith: trust God at His Word

20. Hope • Desire, expectation, reliance, belief • Hope: certainty of better future based on God’s promises

21. Love / Charity • Generosity, benevolence, helpfulness, mercy • Love: desire, choose and act for highest good

22. Fortitude • Strength, courage, endurance, resoluteness • Fortitude: perseverance in integrity; strength of mind to endure adversity steadfastly; perseverance in facing danger for the sake of principle

23. Temperance • Moderation, restraint, self-mastery, frugality, sobriety • Temperance: Self-control

24. Justice • Impartiality, fairness, equity, rightness, dispassion • Justice: regard for fulfilment of obligations

25. Prudence • Wisdom, vigilance, carefulness, thoughtfulness, discretion • Prudence: due regard for one’s own welfare; habitually careful to avoid error / danger

26. Pride • Pride is excessive belief in one's own abilities, that interferes with the individual's recognition of the grace of God. It has been called the sin from which all others arise. • Thomas Aquinas said of Pride "inordinate self-love is the cause of every sin (1,77) ... the root of pride is found to consist in man not being, in some way, subject to God and His rule."

27. Envy • Envy is the desire for others' traits, status, abilities, or situation. • Thomas Aquinas said of Envy: "Envy according to the aspect of its object is contrary to charity, whence the soul derives its spiritual life... Charity rejoices in our neighbour's good, while envy grieves over it." (2, 36, ad 3)

28. Gluttony • Gluttony is an inordinate desire to consume more than that which one requires. • Thomas Aquinas said of Gluttony: "Gluttony denotes, not any desire of eating and drinking, but an inordinate desire..." (2, 148, ad 1)

29. Lust • Lust is an inordinate craving for the pleasures of the body.

30. Anger • Anger is manifested in the individual who spurns love and opts instead for fury. It is also known as Wrath.

31. Greed • Greed is the desire for material wealth or gain, ignoring the realm of the spiritual. It is also called Avarice or Covetousness. • Thomas Aquinas said of Greed: "it is a sin directly against one's neighbour, since one man cannot over-abound in external riches, without another man lacking them... it is a sin against God, just as all mortal sins, inasmuch as man contemns things eternal for the sake of temporal things." (2, 118, ad 1)

32. Sloth • Sloth is the avoidance of physical or spiritual work. • Thomas Aquinas said Sloth is "sluggishness of the mind which neglects to begin good... [it] is evil in its effect, if it so oppresses man as to draw him away entirely from good deeds." (2,35, ad 1)