Science in Christian Perspective
Some Ethical Decisions
In the Practice of Medicine
J. RICHARD BURTON*
From: JASA 14 (September 1962): 79-81.
Before beginning a discussion of the issues involved, I wish to say that these views may not be representative of those of other physicians. They may not even represent those of the author in subsequent years since they will be continually influenced by his experience in the daily practice of medicine. The paper will not cover all of the ethical problems in medicine but will touch on those encountered chiefly by the physician in the practice of internal medicine. Finally, the question of ethics with reference to Christianity will be made as the various topics are discussed.
The practice of medicine has followed many codes of ethics during the centuries but the one most frequently quoted and best known is the Hippocratic Oath. In this we find the tone of warmth for one's fellow man as well as a concern for unselfish service by the physician. If the oath is well understood, the problems based on ethical grounds usually become clear and solve themselves.
Medicine however, has changed since the time of Hippocrates. Broader interpretations now can be given this oath to which we all ascribe. In the past, medicine was a healer's discipline. Now it encompasses that of both healer and scientist. In the present day, the physician must not remain only a scientist with his objective indifference, but he must also retain the personality of the healer. He must still maintain the confidence of the patient and be a willing listener to his complaints. Modem medicine combines the compassion and understanding of the healer with the exacting standards of the scientist so that both disciplines are effectively used. If one views the patient without regard to his personality, family, or environment, he will have difficulty in effectively treating the patient.
The close interpersonal contact established in the doctor-patient relationship often surpasses that of the minister or priest. It is in this regard that the physician also
*Dr. Burton is in private medical practice at the Earl Clinic in St. Paul, Minnesota. He also serves as the school physician of Bethel College and Seminary.
has a high responsibility. A Christian physician may be the only source of spiritual contact that a patient has. If so, he is responsible for the presentation of a Christian witness and for leading the patient into thoughts of spiritual concern.
The critical decisions encountered in the practice of internal medicine relate chiefly to those involving the patient recently diagnosed as having a malignant disease process, the question of prolongation of life in the incurably ill cancer patient, and the use of new, untried medical therapy on human beings. The internist may also be consulted on questions regarding genetics by patients with family histories of inheritable diseases. He may be called upon to render a medical evaluation and recommendations in cases of possible therapeutic abortion. Other situations requiring critical judgment involve the method of securing post-mortem examination permission and one's relationship to his fellow physicians.
The question frequently arises as to whether or not a patient should be informed that he has a malignant disease. An occasional patient is reluctant to ask and some physicians believe that this information doesn't have to be volunteered unless they ask. Some who are extremely anxious, can be gradually brought to the point of knowledge of their disease. This can be done by stating the likely possibility of malignancy which may be subsequently diagnosed by means of x-ray or surgical exploration. I feel that the patient must be told concerning his illness so that he has some time to settle his business affairs and especially for the non-Christian, to settle his spiritual affairs as well. Many patients already suspect their disease and in the light of the close doctor-patient relationship will accept the diagnosis without a great emotional upheaval. In the event the patient is not told of his illness, the subsequent days become increasingly more difficult, since all treatment and consultation is based on falsehood and the relationship may then deteriorate into distrust and despair.
For the Christian physician this time gives him an opportunity for witnessing since, probably for the first time, the patient will begin to think on spiritual things and his future destiny. A relationship characterized by sincerity and honesty will help greatly during these times.
The thing that frightens many patients the most is fear of the unknown. This fear, according to the Bible, is the certitude of Divine judgment (Prov. 11:4) and is not necessarily that of shortening the present life or of an uncertainty about the future. The Christian physician can counsel here and help his patient in his reconciliation to God through Jesus Christ. Following this, giving him scripture passages of reassurance helps him along in his illness, since he is no longer fearful.:,
Fortunately, many malignancies are "curable" for a period of time if detected early enough and treated.
Even here, however, there may be an opportunity to inquire about the patient's relationship to God.
The question of prolonging life once an incurable disease, either a malignant process or severe illness, has been determined, is a much greater problem. The state of illness at this point is when all possible medical therapy has been applied without results and the patient continues to be in an incapacitated, comatose, or suffering condition. In other words, he is in a hopelessly incurable state. For such a patient there is no escape except by death, yet he lingers on in a condition of suffering and helplessness. For this patient in the pre-antibiotic era a superimposed infection, such as pneumonia or kidney infection, would bring an end to his suffering. Now, with antibiotics, steroids, and vasopressors, we are able to manage these patients, return many to their 11 previous state," and prolong their life further. Frequently, relatives request that medical heroics will not be used and further pressure is then applied indirectly by them on the physician's clinical judgment.
Recently, this question was again raised at the American Medical Association meeting in Chicago. Subsequent newspaper comments indicate that the majority of physicians concur that the use of heroic medical therapy in this type of illness is not recommended. This does not mean that the end is hastened by any specific therapy, but it means that the end may occur earlier as a result of a superimposed disease process. Also, this doesn't imply that supportive and symptomatic medical care is withheld. These are continued, and the patient is reassured that he will be kept as comfortable as possible.
The physician's role here, once the condition is determined and responsible relatives as well as the patient have been consulted, is to keep the patient as comfortable as possible. The risk of drug addiction is usually not heeded since the benefits are great and the end is not very far away. The Christian physician has the opportunity here to be a continual witness to the non-Christian patient or a spiritual friend of the Christian patient. He can also give the patient spiritual comfort (Joshua 1:9, 11 Corinthians 12:9); assurance (John 5:24, 1 Corinthians 15:19-21); and hope (II Timothy 4:7-8, John 14:2-3) .2 1 do not believe that this type of care is contrary to Biblical teaching or that it places the physician in the role of God regarding the destiny of his patient.
A more recent question of growing importance is that of using human beings with known, non-operable cancer as study patients for new anti-cancer therapeutics. Before entering such a program these patients are totally informed of the type and purpose of the study and must consent to it. I believe that the physician, as a scientist, should not deny the trial of these drugs since one someday may prove beneficial. This type of treatment, however, should be carried out at an academic facility where all means of evaluation are available, where large series can be obtained rather quickly, and where the patient usually doesn't have to bear the cost. The practicing physician in the community should be aware of these experimental drugs but not use them until they have been thoroughly studied.
I see no controversy here with medical ethics. For some patients it presents a challenge since by it they feel that they are contributing to medicine and thus gain some personal satisfaction. Cooperation is voluntary on their part. It may result in the prolongation of life and, therefore, additional suffering, but it may also give the possibility of temporary arrest or permanent cure. These patients, in contrast to those above, usually aren't as severely ill with their disease, even though their outlook is just as poor. I believe that the Christian physician can also ascribe to this therapy because there is always the hope of improvement. In properly structured studies any deleterious effect is noted early without much subsequent distress to the patient.
In problems of genetic importance, the physician should be well informed of all of the implications concerning the disease state and the possible influence on the marital partners and their offspring. The involved couple should be counseled cautiously and conscientiously; marriage should be discouraged if the possibility of a certain inheritable disease state is strong.
When the question of therapeutic abortion is raised, the ethical lines are more tightly drawn and every standardized by some groups. The internist may be called upon to evaluate some underlying cardiac or renal pathology and thus render an opinion which will influence the judgment of the obstetrician. Many feel that a therapeutic abortion in any sense is a means of destroying one life to save another and that stress of surgery often is just as great as completion of the pregnancy itself. Others feel that the welfare of not only the mother but also the father and other children is at stake and that when these are considered, a mother capable of carrying on her household work is much better than one who becomes more disabled or even dies. This problem remains difficult, is different in each situation, and requires the consultation of several physicians for the most appropriate solution.
Another area frequently encountered by all physicians as well as the internist is that of obtaining permission for post-mortem examination when the patient has expired. This is usually done during an emotionally stressful period and frequently encounters many variable responses. Many misinterpretations by laymen regarding the procedure have to be dispelled before one can deal effectively with them. This period has been used by some physicians to cajole the reluctant relatives by every possible means to sign the permission. I believe that a quiet, reassuring, and explanatory counseling session at this time is most rewarding in obtaining permission from reticent relatives. Here again, the physician as a scientist can equip himself better only if he knows the total disease process of his patient and thus is enabled to serve his other patients more effectively. The ethical decision here is, I believe, to what extent we can go to obtain permission from reluctant relatives. If the facts are quietly and firmly given and permission refused, then it is better to abide by the family's decision.
Medical ethics involves the interchange which takes place not only in a doctor-patient relationship but also in the physician's relationship to his colleagues. One must always strive to speak well of his colleagues even though some may not be practicing the same quality of medicine as oneself. This policy, too, has been set in the oaths of the past where it was common for physicians always to help one another and be willing teachers of the younger physicians. To speak disparagingly of another physician to a patient will break down that patient's regard for his own doctor. If a physician is practicing poorly, it isn't long before his hospital or a county or state board of ethics will investigate his practice.
Finally, in view of all other areas of ethical conduct, the Christian physician finds himself in no different role from that of the Christian businessman, professor, scientist, or laborer. Each must have his own standard of ethics; if these are deviated from, only he can then account for himself. As a physician deals with other people he must be intellectually honest with himself and his patients. He must also remain objective in his treatment of disease and attempt always to do what is best for his patient's welfare. When problems as discussed above are met, each situation becomes new and relative to that individual patient. Its solution is not found at a single moment in time, but it results from the development of many facets, including the disease process itself and the total patient himself, physically, mentally, and spiritually.