Covenant and Ethics – Working out God’s Kingdom in Medicine
James J Rusthoven
Originally published March 2014
THE CONTEMPORARY SETTING
Biomedical ethics has become a required part of training in the health sciences. Students are taught basic principles of ethical awareness in an effort to improve and foster ethical sensitivities of trainees both in their research and at the bedside. One would wonder why such talented and presumably sensitive trainees would have to take courses to improve ethical awareness. The initiation of such courses reflects a time in the recent past when medical science threatened to move aside or even replace the human relational character that had defined the discipline for centuries. In the early days of Christianity, care of the afflicted and needy became a distinguishing mark of Christian virtuous activity. Indeed, it has been written that one of the greatest impacts of Christian witness on pagan society in the early centuries of Christianity was the willingness of Christians to remain behind to care for the plague- ravaged neighbours while most of the population fled the blight.1
Medicine has become professionalized and increasingly defined by scientific evidence of health and disease that has led to culture- changing improvements in prevention, treatment, and overall health. Similarly, training programs have increasingly taught good medical practice as precise diagnostic acumen and therapeutic implementation balancing risks and benefits but with less emphasis on developing relational sensitivity and mindfulness. Like other areas of ethics, biomedical ethics has tended to be a reactive discipline; changes in ethical expectations usually occur only after there has been a crisis or tragedy that might have been averted had ethical behaviour or norms been proactively considered. Such reactive behaviour led to the formation of the Food and Drug Administration in the 1930s after deaths of individuals who ingested a new but inadequately tested sulfa drug. The Nuremberg trials after World War II tried to make physicians and others under the Nazi regime accountable for injustices involving experiments on those condemned to death just for being classified as ethnically undesirable by the regime. In more recent times, a Harvard anesthetist boldly reported in the prestigious New England Journal of Medicine that reputable researchers were engaging in ethically dubious or inappropriate behaviour involving human subjects in their clinical research.2 From such revelations, the Belmont Commission was constituted by the United States Congress to establish ethical principles that could be followed by such investigators.
The commission deliberated regularly and intensively over four years, calling in high-profile philosophers, theologians, physicians, psychologists, and others to find generally agreed-upon ethical principles to which researchers could adhere when relating to human subjects. In its 1978 report, the commission identified three such principles: respect of persons (soon known more generally as autonomy); beneficence, and justice. These principles have formed the framework for many courses in biomedical ethics and at very least provide a foundation of linguistic commonality among caregivers and researchers wrestling with bioethical issues in a society of culturally, linguistically, and religiously diverse peoples. Over the last three decades they formed the nidus of a principles-based approach to biomedical ethics promoted by James Childress and Tom Beauchamp.3 This approach has been heralded by some as the ethical thread that joins us all in common moral likeness, but assaulted by others as a minimalist, content-poor approach to an increasingly complex area of human ethics. Criticism and frustration has been voiced by some medical trainees when they begin to associate with patients and their needs. Such principles may help researchers become aware of and avoid unethical practices such as violating informed consent or succumbing to financial enticements from commercial interests. However, bioethics courses can be wanting in showing how these principles can be helpful at the bedside and during clinic encounters in relating to patients the options involved in complex diagnostic and treatment decisions.
One response to such concerns and perceived inadequacies of a principles-based approach to the ethics of practice has been a call to improving relationships within medicine. The Enlightenment age promoted the elevation of reason and rational capacity as the means by which ethical behaviour can be implemented. In that spirit, Robert Veatch proposes a triple contract theory by which patients, caregivers, and families produce verbal or written contractual pledges to follow principles of ethical practices that would serve the self-interests of each of the parties.4 Such an in-depth approach to ethics has been lauded as one of the few attempts to reconcile the moral inadequacies of principles-based ethics at a fundamental level. Others, however, have bemoaned the imposition of a contractual ethos and its particular expressions in settings of managed care wherein utilitarian efficiency and profit-making motives intrude into the minds and activities of practitioners. The result can divert the focus and telos of medical care away from its normative roots of care for the needy toward self-interest and gain.
APPEALS TO COVENANT AS A RELATIONAL NORM FOR MEDICINE
In an effort to correct such contemporary assaults on the profession, calls have rung out from various quarters to develop an ethos of medical practice akin to that embodied in the concept of covenant. The Patient-Physician Covenant was published in the Journal of the American Medical Association in 1995 by prominent medical leaders in the US.5 The authors are reacting against managed care that has been driven more by self-interest and profit than clinical excellence and sacrifice for the sake of serving the needy patient. Susan Coffey,
a nurse, has presented a covenantal model for nursing care. She acknowledges the idea of covenant in the ancient Greek medical tradition but also the role of Christian bioethicist, William F. May, in the resurgence of covenant as a prescriptive model for relationship in medicine. Medical educator, Jeff Nisker, appeals to a covenant model for the medical educator-student relationship. He bemoans the contractual model that often formalizes mutual self-interests rather than establishes trust and generous offerings of time and expertise beyond expectations. These caregivers and others appeal to a renewed focus on patient trust and caring through covenantal relationships, some appealing to Hippocratic notions of covenant and others to modeling relationships grounded in Judeo-Christian teachings of covenant.
In the history of biomedical ethics, some Christian bioethicists have tried to incorporate covenantal relating in medical practice. Paul Ramsey appeals to covenantal love as enlightened unselfishness, to ensure that patients are protected from more powerful caregivers and researchers. For Ramsey, agape love is the ultimate norm to which principles that give direction for moral action are subordinate. While Ramsey stresses loyalty and fidelity of trust in medical relationships, with a particular focus on ensuring informed consent for patients in his early writings, he later was more explicit about the importance of covenantal relating. However, his emphasis on moral rules and principles diminished the relational character of his moral teaching. It took a successor in his faith tradition, Protestant bioethicist, William F. May, to more openly appeal to covenantal relating in contrast to contractual means of relating and to stress the gift-giving core within the Christian notion of covenant based on the Word of God. In his book, The Physician’s Covenant, May is critical of Christian and Jewish ethicists for suppressing references to the religious convictions that ground their medical ethics, as if medicine was confessionally indeterminate.6 With admirable boldness, Roman Catholic bioethicist, Edmund Pellegrino writes about the need for a philosophy of medicine that secures relational trust between caregivers and patients. His philosophy of medicine grounds the profession in the relationship of beneficence-in-trust between caregiver and patient, embodied in an overarching principle of love for God and fellow human beings wherein caregivers develop character emboldened with the virtues of love, faith, hope, perseverance, etc. It is the renewal of such virtues by medical practitioners that gives the distinctive Christian character to his philosophy of medicine.7
KEEPING COVENANT AS A CHRISTIAN MODEL FOR MEDICINE
Like other areas of life, medicine needs to be understood through the spectacles of biblical teaching about the created order and our place in it as special creatures created as image-bearers of God. However, as exhorted in 1 John 4, Christians also need to discern the spirits of our age, sometimes expressed through modernist or postmodern worldviews that may give direction to life exclusive of God’s covenantal promises and our obligations within that covenant.8 These are two sides of the same coin of Christian living. We must both understand the powers that can lead us away from God and His kingdom plan while gaining understanding about the particulars of Scriptural discernment that speak to the normativity of our relationships and to the meaning of our daily lives. Christian caregivers in the Netherlands have explored such discernment in terms of recognizing the structural make-up of God’s creation as applied to medicine and the directional options that give meaning to such recognition.9 That is, while we can study the physical, biotic, psychical, social, and ethical aspects of human existence and activity that impact our healthy and unhealthy states, we also need to understand their integrated meaning in the relational context of human interactions that constitutes care for the needy and vulnerable. Is the meaning of such relationships grounded on the biblical notion of neighbourly love or is it distorted by self-interest bred by inherent caregiver power? Is it the Holy Spirit or some spirit of human reason and overconfidence that provides the integrating force behind the actions of daily medical practice? Elements of a Christian concept of medical practice include recognition of the inherent structures that constitute medical practice or research, the moral agents who interact within that practice, and the spiritual and religious direction that motivated and gives meaning to those daily interactions.
EXPRESSIONS OF COVENANTAL ETHICAL RELATING IN PRACTICE
So what is a covenantal disposition toward patient care? Unlike contractual agreements wherein the self-interests of each party are legally protected, covenantal relations have a primary focus on meeting needs through gift-giving. One or both parties give to the other, sometimes beyond expectation, as a gesture of love. In teaching, this could mean exploring key issues to a depth beyond the curriculum or incorporating more hours than required to help students with difficulties. In practice, it could mean spending more time with patients in the clinic or advocating for more government resources where care is being compromised. Unlike contracts, covenantal relations need not be time-bound. However, covenantal obligations to patients should also be tempered by relational obligations outside of practice, by relationships with family, church, and other societal ties. Developing an ethos of covenantal relating is complex and is defined by its giving nature and its attention to factors that may jeopardize providing optimal care to vulnerable fellow human beings.
Is a covenantal ethic relevant for medical practice settings today? If so, how might it be helpful in carrying out the goals of practice? Relating to others in the practice of medicine is becoming increasingly complex with the advent of new types of caregivers. Once a single primary care provider such as a family physician supervised and implemented most of the care for a person or family. With the rapid increase in the knowledge of diseases and their diagnoses, new treatments and treatment strategies are emerging as a dizzying rate, resulting in a differentiation of care into numerous specialists and subspecialists who make up a matrix of professional caregivers in specific areas of health care. Besides physicians, nurses are also becoming more specialized. Nurses and nurse practitioners are taking more and more responsibilities once carried out only by physicians in special hospital units and clinics. Similarly, physician assistants have also become a distinct profession with a unique set of roles in practice settings. All of these have been necessitated by the growing knowledge of human health and disease and the limits of the human capacity to absorb and apply much of this knowledge to practice.
One can envision a growing network of caregivers, patients, and support persons. Citizens enter this network to get advice and treatment for disease prevention through healthier life styles, vaccines, etc. Patients with existing medical needs seek advice and authorize management of medical problems requiring diagnosis and treatment over time. With such differentiation of care come increased risks of care. Caregivers must learn to communicate effectively to each other and to patients to coordinate care activities that were once limited to a few individuals. Communications may involve care providers who might be considered outside of mainstream medicine but who are trusted by patients as valid providers of therapeutic options. In addition, there continue to be for-profit groups associated with health care products, such as pharmaceutical companies and those that manufacture medical devices, who may claim to be care providers themselves.
Such claims may raise ethical questions about the influence of such groups whose primary goal, stated or implicit, is to generate corporate profits for shareholders. Resistance to the intrusion of such groups into practices has led to attempts to directly influence patient choices by direct-to-consumer advertising. Such intrusions attempt to by-pass the interpretive corrective that caregivers provide in balancing claims of safety and efficacy made by marketing departments against evidence provided in peer-reviewed books and journals. These intrusions also divert caregiver attention from their primary task of patient care to combatting sometimes dubious claims of efficacy and safety available on public media such as the internet.
In light of these realities of contemporary medicine, a covenantal ethical approach to medicine can help to discern and correct such diversions and intrusions into practice. It can keep practitioners alert to factors that can compromise optimal patient care and the relational integrity so essential to the basis of medical practice.
For their part, patients need to develop a trusting relationship with caregivers but in accepting the gift of their care, empathy, and expertise, they also have obligations to understand their illness, be co-partners in diagnostic and therapeutic decision-making, and be compliant with carrying out mutually agreed-upon care plans. Covenantal commitments need not be formally established but new patients could be introduced to the idea of such a relational understanding, being informed about its advantages and its limits.
For Christians, human relationships should be modelled after our relationship with God. As His image-bearers, we need to relate to fellow human beings, both to those close to us and those who are strangers. In the Old Testament, the Lord reminds His covenant people to treat the alien and the stranger kindly and under the same law to which they themselves are subjected, for they were aliens in Egypt once themselves.10 Likewise, Christ advises His followers to be kind to strangers, reminding them that they may be entertaining angels and that heeding to the needs of strangers will have its kingdom rewards.11 God offered His covenant with us at creation and has kept it despite our repeated failing to keep it as sinful creatures, even to the point of offering His own Son in a new covenant. Being granted such graciousness and patience, we must keep covenant with those whom we serve in His name, as a reflection of His mercy and righteousness.
James ( Jim) J Rusthoven is a part-time medical oncologist in Brantford, ON. He also enjoys teaching bioethics to high school, university, and post- university students as well as through public lectures. He and his wife, Thea, will be moving to Moncton, NB in April 2014 where Jim has accepted a position at Vice-President, Academic Affairs at Crandall University, a Christian university. Jim did his PhD on Covenantal Ethics as an Alternative to Principles-based Ethics.
1 Ferngren, G. Medicine & Health Care in Early Christianity. Baltimore: The Johns Hopkins University Press, 2009, 115-123
2 Beecher, H. K., “Ethics and Clinical Research,” New England Journal of Medicine 1966; 274: 1354-1360.
3 Beauchamp, T. L. and J. F. Childress. Principles of Biomedical Ethics. 7th ed. Oxford: Oxford University Press, 2013.
4 Veatch, R. M. A Theory of Medical Ethics. New York: Basic Books, 1981.
5 Ring, J. J. et al., ‘The Patient-Physician Covenant,’ Journal of the American Medical Association 1995; 274:1265-1266.
6 May, W. F. The Physician’s Covenant. Philadelphia: Westminster Press, 1983.
7 Pellegrino, E. D. and D. C. Thomasma. The Christian Virtues in Medical Practice. Washington, D. C.: Georgetown University Press, 1996.
8 I John 4:1: “Dear friends, do not believe every spirit, but test the spirits to see whether they are from God ….” (NIV)
9 Glas, G. “Persons and Their Lives: Reformational Philosophy on Man, Ethics, and Beyond,” Philosophia Reformata 2006; 71: 31- 57; Jochemsen, H. “Normative Practices as an Intermediate between Theoretical Ethics and Morality.” Philosophia Reformata 2006; 71: 96–112; Hoogland, J. and H. Jochemsen. “Professional Autonomy and the Normative Structure of Medical Practice.” Theoretical Medicine 2000; 21: 457-475.
10 Lev 19:33, 34; Lev 24:22; Ex 22:21.
11 Heb 13:2; Mtt 25:35.