Faith, Covenant, and Medical Practice
J. I. Packer
Originally published in March 2014. Selection excerpted from: “Faith, Covenant and Medical Practice”, originally printed in Christian Character, Virtue and Bioethics, Proceedings of the 1996 Clinical Bioethics Conference, Dr. Edwin C. Hui, ed., pps. 11-24. Copyright ©1996 Regent College. (Used with permission)
The following article is an excerpt from a presentation made by Dr. J.I. Packer at a 1996 Clinical Bioethics Conference in Vancouver that was jointly sponsored by CMDA Canada and Regent College. It is reprinted here because of its timeless applicability to the practice of Christian medicine and dentistry according to the covenantal model, and as a tribute to its author.
… [Faith]… gives us our Christian identity, that of being believers, and it is faith that gives us our basic attitudes to God, to humankind, and to things – or perhaps I should say here, to all created realities that are not distinctively human, including all lesser and simpler forms of life, both animal and vegetable, plus all those entities that have no biology. To be more specific:
First, faith gives us our attitude to God, the Father, the Son, and the Holy Spirit, the Three-in-One whom we acknowledge as Creator and Sustainer, constantly active in providence and grace. This is the God whom we recognize to be in every way transcendent and majestic; yet whom we trust and love and adore, because “His name to us is love,” and He has stooped in love to make friends with us, and to assure us that He values our company now and for eternity. This is awesome, if anything ever was, yet by faith we know it to be true, and rejoice accordingly.
Second, faith gives us our attitude to ourselves, weak, silly, and sinful as we are. By faith we know ourselves as redeemed and regenerate sinners, called now to worship and serve the God who has saved us, is saving us, and will save us. In all that we do we are to honour Him and seek to advance His praise and glory, knowing that as we do so we shall find within ourselves a sense of fulfillment and delight that is not attainable any other way. Living thus, our contentment grows, and our Christ- likeness also.
Third, faith gives us our attitude to other people. In general, we are to see everyone with whom we have any contact at all as our neighbour, to be respected, loved, helped, and served according to what need he or she has and what power we have to assist. Then within this frame we are to give priority to fulfilling our obligations to family members and to fellow-believers and to any to whom we have committed ourselves by the bonds of explicit promises, or to whom we a re bound by our or their position in society. We shall return to this shortly, when we reflect on the physician’s covenantal commitment to his or her patients to seek the best for them.
Fourth, faith gives us our attitude to what was once called the created order and is nowadays called the environment. By faith we learn that God made our race stewards and managers of the environment, to develop and use it according to His scheme of values in our culture-building, which includes, of course, health care and all the technology and technique that we devise for that purpose. All important for faith is the preservation of the God-given scale of values as a permanent frame for technical and experimental developments. The sanctity of life, the worth of the individual person, and the maximizing of well-being, which includes health, as an expression of neighbour-love, are three basic values to which faith holds, and must hold, tenaciously.
What, then, is faith in itself ? Though often reduced, even in church circles, to orthodoxy without relational commitment, or else to optimism without cognitive warrant, faith is in fact a whole-soul intellectual and volitional response to a revelation of God that calls for a totally new mind- set, relationship, and way of life. Here is how the Westminster Confession states the matter, in its chapter fourteen titled “Of Saving Faith”:
The grace of faith, whereby the elect are enabled to believe to the saving of their souls, is the work of the Spirit of Christ in their hearts, and is ordinarily wrought by the ministry of the Word, by which also, and by the administration of the sacraments, and prayer, it is increased and strengthened.
By this faith, a Christian believeth to be true whatsoever is revealed in the Word, for the authority of God himself speaking therein, and acteth differently upon that which each particular passage containeth; yielding obedience to the commands, trembling at the threatenings, and embracing the promises of God for this life, and that which is to come. But the principal acts of saving faith are accepting, receiving, and resting upon Christ alone for justification, sanctification, and eternal life, by virtue of the covenant of grace.
Faith, in other words, is knowledge plus responsive action. It is formed by the impact of its object through the agency of the Holy Spirit. Its overall object, speaking broadly and inclusively, is everything that the canonical Scriptures communicate as from God. Its focal object, speaking now with evangelical precision, is twofold: it is the Lord Jesus Christ, the incarnate Son of God, in the fullness of His mediatorial ministry and it is the gracious promise of a gracious heavenly Father based on Christ’s work of redemption and reconciliation on the cross. Faith is the ear and eye of the soul perceiving the Christ of the Scriptures, the arms of the soul embracing Him as the living Saviour and Lord, and the feet of the soul following Him as He summons us to do. Older theologians analyzed saving faith as notitia (knowledge about Jesus Christ), assensus(acknowledgement that this Christ is for real, and this Gospel is true and good), and fiducia (trust in Christ, and confidence that one is accepted through Him, in Him, and by Him)-and this is as true and full an analysis as one can find anywhere.
Faith, then, makes the Christian – indeed, defines the Christian; and the first requirement for fulfilling the role of a Christian physician is actually to be a Christian, one who has received and now follows Jesus Christ, seeking to practice love of God and love of neighbour according to Christ’s teaching and example. Neighbour-love for the glory of God will therefore be the category into which Christian physicians will see their professional work fitting, and this will determine their spirit and attitude in tackling it. Which brings us to the second of the topics on which I was asked to address you, namely covenant, and the sense in which the physician-patient relationship should be regarded as covenantal.
COVENANT
Covenant is the generic biblical word for any sort of bonded and bonding relationship that carries obligations and expectations on both sides. Scripture knows of covenants between 
husband and wife, between friend and friend, between conqueror and conquered, and between king and subjects. Also, and from one standpoint primarily, in the Bible’s account of God’s saving activity His redemptive commitment to His people is regularly described as His covenant with them; so we read of the old covenant established at Sinai, and of the new covenant inaugurated by Jesus’ blood-shedding; and in prophecy and promise we repeatedly encounter what we can call the slogan of God’s covenant in both its old and its new forms- “I will be your God; you shall be my people.” Encountering this promise, we are meant to understand that the commitment expressed by the pronoun in the phrase “your God” is a guarantee of privilege, protection, and endless enrichment to the redeemed, up to the limit of God’s resourcefulness in gracious giving; and we are also to understand that the obligation expressed by the pronoun in the phrase “my people” is to serve God and seek His praise in everything that we do, both in our direct worship and in our treatment of each other; and the third thing we must understand is that this obligation rests equally on every member of the group to which the promise is made – old Israel, that is, the genealogical seed of Abraham, in the days before Christ, and new Israel, the community of Christian believers who are the spiritual seed of Abraham, in the era that Christ’s redemptive ministry began.
The phrases “old covenant” and “new covenant” for the two successive forms of God’s conveyance of saving mercy to mankind, and the concept of “covenant theology” as a name for the systematic spelling out of these redemptive arrangements, are no doubt familiar to us all; but most of us would probably have to admit that our thinking about the covenantal dimensions of life stops there. However, Karl Barth, that most powerful of twentieth-century theologians, based his ethical thinking on the premise that all human life as such, under God and before his face, is covenantal, in the sense that as the Creator’s blessing has already been received in the very fact that we are alive at all, so obligations to God and to our fellow human beings are, so to speak, built into our existence and must be consciously recognized and acknowledged as creational facts. The ethicist Paul Ramsey followed Barth in this, and I should like to quote his very clear account of the principle in the preface to his landmark exploration of medical ethics, titled The Patient as Person. Here, then, is Ramsey’s statement:
At crucial points in the analysis of medical ethics, I shall not be embarrassed to use as an interpretative principle the Biblical norm of fidelity to covenant, with the meaning it gives to righteousness between man and man . . . I hold with Karl Barth that covenant-fidelity is the inner meaning and purpose of our creation as human beings, while the whole of creation is the external basis and condition of the possibility of covenant. This means that the conscious acceptance of covenant responsibilities is the inner meaning of even the “natural” or systemic relations into which we are born, and of the institutional relations or roles we enter by choice, while this fabric [the means, everything around us, our environment, circumstances, and milieu] provides the external framework for human fulfillment in explicit covenants among men. The practice of medicine is one such covenant. Justice, fairness, righteousness, faithfulness, the canons of loyalty, the sanctity of human life, hesed [Hebrew word for loving-kindness or steadfast love] agape or charity are some of the names given to the moral quality of attitude and action owed to all men by any man who steps into a covenant with another man by any man who . . . explicitly acknowledges that we [he means, we who make up the human race] are a covenant people on a common pilgrimage.
Ramsey then states his agenda.
The chief aim of the chapters to follow is, then, simply to explore the meaning of care, to find the actions and abstentions that come from adherence
to covenant, to ask the meaning of the sanctity of life, to articulate the requirements of steadfast faithfulness to a fellow man.1
Exactly! This is the track on which medical ethics must ever travel, in this conference as in all other times and places. Surely the Barth-Ramsey anchoring of the concept of covenant in the created order, which in effect exhibits neighbour-love as natural law, and turns into genuine theology the Kantian axiom that a human being must never be treated merely as a means, but always as an end, is a line of thought that we should accept and build on for ourselves as we seek to pick our way through the thickets of the doctor-patient relationship.
There has been some discussion as to whether covenant or contract is the term that best expresses the appropriate ideal for this relationship in today’s Western world. Some might wonder whether there is any deep difference of meaning between these words, and for some moderns there may not be, but for the Christian who accepts our reasoning thus far, covenant and contract are not the same thing at all. A contract is seen
as a negotiated arrangement between humans in which mutual liability
is limited by agreement, while a covenant is seen in terms of the line of thought just set out, as a divinely imposed relational bond, rooted in the reality first of creation and then of redemption; and in a covenant liability is limited only by the known need of the other party and the possibilities of service that the actual situation and role-relationship of the parties allow. Covenant, we might say, is from above, contract from below, and Christians will not use the first of these terms as a synonym for the second, but will reserve it for the expressing of this higher meaning.
Let us now look more closely at the arguing that goes on here. In favour of the contract idea it is maintained that:
- the category of contract eliminates authoritarianism from the physician-patient relationship, since it inhibits the physician from behaving like a parent, priest, or mystagogue who has on his hands an immature and unintelligent child, and instead displays the relationship as one of free voluntary agreement between adults, in which full exchange and discussion of relevant information at each stage of the diagnosis and treatment is mandated;
- the category of contract eliminates exploitation and injustice from the relationship, by providing recourse under the law for the patient to make the physician accountable under the contract for the quality of service rendered;
- the category of contract eliminates condescension from the relationship, by moving it away from any supposed basis in social superiority or inferiority. As William May phrases it, “a contract does not rely on the pose of philanthropy or condescend as ‘charity.’ It presupposes frankly that self-interest governs people. When the two parties enter into a contract, they do so because each cuts a deal that serves his or her own advantage.”2 The contractual focusing of self-interest on both sides is held to bring realism into the understanding of what goes on when a physician is professionally consulted.
There is obvious substance for the correcting and avoiding of abuses in each of these three arguments, and I have nothing to say against them. The only point I wish to make is that for the Christian physician the contractual understanding of the relationship with the patient, along with all other aspects of the relationship-didactic, technical, instructional, and whatever else-must be set within a covenantal frame, in which the physician’s obligation to render the best service he or she can in matters concerning the life, death, health, and well-being of one who is God’s image bearer is primary. In other words, medical service as a social reality must be understood and undertaken as, quite precisely, neighbour-love. Contract within covenant must be the concept that guides; a contract intended for the fulfilling under God of covenant obligations to one’s neighbour should be the Christian physician’s constant view of the bond that operates in his or her professional commitments to each patient. To think through one’s professional life and work in these terms may mean some swimming against the intellectual stream that flows here and there within the guild-Christian teachers in the public school system have similar problems-but it is a necessary discipline if one’s professionalism is to be in truth service of God…
In a secular society, Christian physicians are precious people, and it is important that they not lose their edge. Covenantal professionalism will keep one’s edge keen. To commend it, as I have been doing is a privilege and a joy. By it humans are blessed, and God is glorified: may there then bemoreofitastheyearsgoby.Thisisthewaythatwemustgo,foritis truly the path of faith and love, whereby the physician serves and follows our Lord and Saviour Jesus Christ.
J.I. PACKER, MA, DPhil (Oxford) became Professor of Systematic and Historical Theology at Regent College in 1979. In 1989, he was installed as the first Sangwoo Youtong Chee Professor of Theology. In 1996, he became Board of Governors’ Professor of Theology. He still holds that title even though he has retired from teaching. He has written in excess of 200 books including the classic Knowing God. J.I. Packer has preached and lectured widely in Great Britain and North America, and is a frequent contributor to theological periodicals. He is a member of the Editorial Council of Christianity Today. He was General Editor of the English Standard Version of the Bible, published in Fall 2001.
ENDNOTES
1 Paul Ramsey, The Patient as Person (New Haven, Conn.: Yale University Press, 1975). xii-xiii.
2 William F. May, The Physician’s Covenant: Images of the Healer in Medical Ethics (Philadelphia: Westminster Press, 1983), l 17.