by Dr. Richard C. Eyer

In the years in which I served as a hospital chaplain, from 1974 to 1995, medical ethics changed dramatically. In 1974 physicians understood ethics to be about etiquette more than about moral issues. In the matter of a physician's etiquette he was conduct himself in a professional manner. This was often interpreted as maintaining proper bedside manner as much as it was living an honorable life. In 1974 the Hippocratic Oath was still recognized as the standard of ethics and the Oath dealt with matters so commonly accepted as right by the physician that they went unchallenged. The prohibitions of the Oath against abortion, euthanasia, sexual indiscretions, and expectations of maintaining confidentiality had been the main stream of medicine for two millennia. But those medical students entering medical school in the 1970's were about to experience changes in the practice of Hippocratic medicine.

In 1973 the Supreme Court upheld the right of a woman to seek an abortion. Consequently, by the late 1970's many medical colleges had modified their use of the Hippocratic Oath to comply with the spirit of the times and the increasingly liberal interpretations being made in the courts. In medical schools, changes likewise began to appear. Abbreviations of the Hippocratic Oath, contemporary versions of it, and out-right deletion of the traditional Oath became common. As postmodernism overran the culture Hippocratic medicine suffered the fate of a terminal illness and died a quiet death after 2,400 years of practice. Although the Hippocratic Oath is still used at graduation ceremonies in some schools today (the Medical College of Wisconsin is one), its use is ceremonial and symbolic of a bygone tradition rather than efficacious as a pledge.

THE AGE OF HIPPOCRATES

When Hippocrates practiced medicine in the 5^th century BC he spoke as a minority voice in the culture of medicine. He speaks as a minority voice once again today. In his day, the state of the art of medicine uninhibitedly included the practice of abortion, infanticide, suicide, and euthanasia. Let us look for a moment at the content of the Hippocratic Oath and its structure.

The Oath is set in the context of the pantheon of the gods: Apollo, Aesculapius, Hygeia, Panacea and others. Although Hippocrates challenged the prevailing view of his day which claimed that illness was sent by the gods as punishment, and proposed instead that illness had natural causes, the Oath was nevertheless framed in the context of allegiance to the gods. There is no separation of medicine and religion in the origins of the Hippocratic tradition. Listen to how the physician called on the gods to bear witness to the physician's promise and how the oath concludes with calling on the gods to reward or punish the faithful physician or transgressing physician accordingly:

"I swear by Apollo the Physician, by Aesculapius, by Hygeia, by Panacea, by all the gods and goddesses, making them my witness, that I will carry out, according to my ability and judgment, this oath and this indenture."

And skipping over the body of the Oath for the moment we read in the conclusion of the Oath:

"Now if I carry out this oath, and break it not, may I gain forever reputation among all men for my life and for my art; but if I transgress it and forswear myself, may the opposite befall me."

Between these bookends of accountability and in the context of the pantheon, lies the body or content of the Oath. The body of the Oath describes first the relationship between physician as teacher and physician as student. We will pass over this part today. We will focus on physician's obligations to the patient. These obligations are framed as prohibitions,

"I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrongdoing. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. Similarly, I will not give a woman a pessary to cause abortion . . . Into whatsoever houses I will enter, I will enter to help the sick, and I will abstain from all intentional wrongdoing and harm, especially from abusing the bodies of man or woman, slave or free. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets."

As Christians entered the practice of medicine, the Oath was found to be compatible with the beliefs of the Christian faith. The names of the gods and goddesses were replaced with the name of God the Father, Son, and Holy Spirit. There were modifications in expression over the centuries, but the Oath, as intended by the Hippocratic tradition, remained intact until this century. The aim of medicine is, according to the Oath, to heal and not to kill.

The Oath made clear what it means to "do no harm." The meaning of "injury or wrongdoing" was named specifically as abortion, euthanasia, sexual abuse, and breach of confidentiality. In contrast, in postmodern medicine the interpretation of what constitutes "harm" lies in the eye of the beholder. The Kevorkian spectacle has illustrated this. Jack Kevorkian was acquitted in one of his many trials on the claim that he was doing good, not evil. In one of his many trials the judge charged the jury not to make its decision on the basis of whether or not Kevorkian contributed to the death of the patient, but rather on the basis of whether or not his aim was to relieve suffering. The jury accepted Kevorkian's defense that he was only aiming at the relief of suffering and he was set free. No one pointed out the obvious that the means used to relieve suffering was to kill the patient. This case, along with others that followed, contributed to the deconstruction of Hippocratic medicine and the subsequent promotion of postmodern medicine; moving the profession of medicine away from the aim of healing and into the murky waters of relief of suffering through assisted suicide and euthanasia.

POSTMODERN MEDICINE

Three things characterize what I will call postmodern medicine:

1. first, the shift from moral to ethical medicine,
2. second, the shift from community to autonomy, and
3. third, the shift from healing to relief of suffering.

I will unwrap each of these and show their presence proudly displayed in the American Medical Society postmodern Code of Ethics which has replaced the Hippocratic Oath.

During the period of the Enlightenment, ethics experienced a shattering blow. Ethics, once understood to be centered on the Aristotelian notion of character, began to give way to the postmodern notion of ethics divorced from character. We have recently seen this played out in the White House. Hence, Americans did not like the President's actions, but refused to call into question his moral character as a serious consideration for removal from office. By definition and context the word ethics, eqich in Greek, was understood to be about the practice of virtue toward the aim of the development of moral character. Classical Greek ethics which spawned Hippocratic medicine was, in fact, concerned with the goodness of the physician. It was not until the eighteenth century that Hume, the father of feel good ethics, suggested to the modern world that good and evil, right and wrong, are nothing more than the likes and dislikes of people labeled as moral and immoral. Hume, an emotivist, and his contemporary Kant, a rationalist, introduced the notion of autonomy in modern ethics. In medicine today, the autonomy of the patient's self-legislating will is recognized as the methodology of ethics. Morality, the business of right and wrong, the very content of ethics, has been banished and ethics as method or procedure is promoted in health care institutions, medical schools, and textbooks on ethics today. Today one cannot speak of morality and ethics in the same breath. There are no "moral committees" in hospitals, only Ethics Committees. Morality has come to be associated with "personal opinion" rather than with the objective of character and the common good. Ethics committees (and I speak as one who founded the ethics committee at the hospital I served) do not concern themselves with moral questions of "right and wrong." Ethics Committees concern themselves with appropriate medical protocol, legalities, and court precedent. For this reason hospital ethics committees are often dominated in their thinking by a member of the committee who is also an attorney.

Finally, the Code of Ethics of the American Medical Association illustrates the divorce between moral and ethical, that is, from the judgment of right and wrong to adherence to proper procedures. This can be seen most clearly in the matter of the sexual conduct of the physician promoted by the Code. In a final break with Hippocratic tradition the section of the AMA Code entitled, "Sexual Misconduct in the Practice of Medicine" virtually permits sexual activity so long as sexual activity and the "physician-patient relationship is not concurrent." The Code warns of "sexual misconduct" but falters on the definition of misconduct. "What constitutes sexual misconduct? Not the nature of the sexual activity itself, but the nature of the relationship of doctor to patient. The AMA Code says that sexual activity between patient and doctor may "detract from the goals of the physician-patient relationship, may exploit the vulnerability of the patient, may obscure the physician's objective judgment, . . . and ultimately may be detrimental to the patient's well-being." It is not unacceptable because it is morally wrong, but because it has certain utilitarian disadvantages. The Code goes on to say that sexual activity is permitted if the physician-patient relationship is terminated. This ability to move in and out of relationships with little more than signing off the case is postmodern in itself. It must be assumed here that the doctor-patient relationship has become a matter of contract rather than of covenant as has been the tradition of medicine as a profession. Covenants imply promises that are not dissolved except through faithlessness. Medicine according to the AMA Code is no longer a covenant profession; it is in fact referred to in the Code as a business arrangement. Promiscuity outside the doctor-patient relationship is no longer a moral issue for a doctor according to the Code even when the physician continues to be a physician to others. (It must be said to the credit of physicians that about half the doctors in the country are no longer members of the AMA.)

The bible of postmodern ethics is Principles of Biomedical Ethics by Childress and Beauchamp, published in 1979. The four principles of medical ethics now accepted as the basis for biomedical decision-making are: autonomy (self-determination in medical decision-making), beneficence (do good), non-maleficence (do no harm), and justice (equal access to health care). The principle of autonomy dominates and shapes the other three. This shift from the good of the community to the good of the individual by virtue of emphasis on autonomy is characteristic of postmodern medicine. The aim of classical ethics focused on the individual finding his fulfillment in what was good for the community. In postmodern ethics, the individual attempts to find his fulfillment in governance of self for his own benefit. Consequently, for the past several decades, medical ethics has been reduced to a discussion of individual rights: the right of the patient to withdraw life support, the right to seek a second opinion, the right to die, and so on. In citing these examples I am not suggesting that these are not important issues to be dealt with, but I am citing them to illustrate how familiar it sounds to speak of rights and how uncomfortable we are as a society in speaking of what is morally right and wrong.

THE SHIFT FROM HEALING TO THE RELIEF OF SUFFERING

Finally, the shift in medical ethics from healing to relief of suffering has increased the intensity of the quandaries that plague us today. Whereas the Hippocratic Oath was clear about what was right and wrong in the practice of medicine, the current state of Nietzschian postmodern medicine aims at the elimination of all such moral distinctions. This can be seen most clearly in the American Medical Association Code of Ethics. Although the AMA Code of Ethics claims to follow in the tradition of the Hippocratic Oath it is clearly a diversion from it. We read in the AMA Code,

The AMA's Code of Ethics today is a constantly evolving document that serves as a contract between physicians and their patients. Responding to current trends, the code is developing new boundaries for the business of medicine.

Some interesting speculations arise from this statement. First, that the standard of behavior cited by the Code of Ethics should change according to "current trends" makes one wonder whether doctors are expected to abide by the Code or whether the Code is to abide by the practices of doctors. If the Code is a standard to live by it seems a strange matter to revise the Code to conform to the behavior that is obviously beyond the limits set by the Code itself. The quote continues saying that " the ethics which govern [the AMA] must keep pace with progress." How interesting that the deletion of moral consideration and changing behavior in medicine should be identified as "progress."

A further evidence of the shift in emphasis from healing to relief of suffering can be seen in the issue of euthanasia. Euthanasia is addressed in the Code as unacceptable. However euthanasia is so narrowly defined as to reduce euthanasia only to "the administration of a lethal agent . . . for the purpose of relieving the patient's intolerable and incurable suffering." Lutheran Ethicist, Gilbert Meilaender, tackles the problem of identifying whether a doctor is practicing euthanasia and when he is not by defining euthanasia as whenever a doctor "aims at the death of a patient" either by active or passive means. The AMA Code dispenses with the issue of euthanasia in 18 lines, concluding that "to engage in euthanasia would ultimately cause more harm than good." Does this imply that it might cause some good in the penultimate sense? Is the implication here that euthanasia is not so much a moral issue as it is a practical one. The practical issue, it is implied, is that it might confuse the role of the doctor as healer with the role of doctor as killer and we have not yet decided what to do with that.

The most obvious example of the shift from emphasis on healing to killing is found in Oregon where assisted suicide and euthanasia has become legal. Reports after the first year show that abuse is already rampant. Although the Oregon guidelines limit killing to voluntary euthanasia, documented reports show otherwise. The leading role in investigating this abuse in Oregon is not being taken by an ethics committee, but by the FDA since the drugs used to kill have not been authorized for such use in this country. Although Oregon has passed a law permitting assisted suicide and euthanasia, reaction both within the state and in Washington D.C. is that the matter is not yet settled and is sure to be challenged.

A BIBLICAL RESPONSE

How are Christians to respond to this shift in the ethics of medicine today? How are we to respond to the culture that has produced it? Are we to make an attempt at changing the culture? Perhaps! Are we to withdraw from the culture into a sect of Christian health care, doctors, and hospitals? Tempting, but un-Lutheran. Are we to become politically active and fight trends toward euthanasia as we have abortion? Probably, but only for us, as Lutherans, in a characteristically Lutheran way of understanding the individual in vocation rather than collectively as a political force. The path that seems most appropriate is to begin with recognizing the distinctiveness, in our case, of a Lutheran Christian worldview. This worldview is biblical. It is a worldview that invites us to be "in the world, but not of the world."

Our distinctiveness in the world and in the culture is to approach ethics in medicine from the holy perspective of Law and Gospel, and the theology of the cross. All ethics outside the Christian faith are ethics founded on Law. Since natural law comes from God, written on the heart, this is not a bad place to start in secular debate over the needed guidelines for a responsible morality in medicine. But as Christians we know the inadequacy of the Law to truly address the underlying cause of our struggle with issues of morality and ethics. We know, as people of the Word, that Law ultimately always accuses us of failure. So we defend the rule of Law in ethics along with Plato, Aristotle, Kant and other secular thinkers.

But our distinctiveness is in the biblical worldview that invites us to hear the Gospel in all its richness and applicability to life. If the Law, simply defined in ethics as what we must do for God, then Gospel in ethics is the good news of what God has done for us. On the one hand we are familiar, as Lutherans, with proclamation of Gospel as forgiveness of sins covering our wrong choices in ethics and the sin enmeshed therein. But on the other hand we are less familiar with the Gospel as the power that comes through forgiveness to transform our lives. This is not a power we use, but a power of God that works in us and on us. This transformation of how we see the world and respond to it is the work of the Holy Spirit. Our task is to repent daily, to hear the Word, and walk by faith not by sight.

Repentance itself is no easy task. Repentance means looking into the mirror of the Law and seeing ourselves as we really are, confessing those things we have hidden from ourselves and try to hide from God. Our resistance to seeing the world through eyes of faith and our natural tendency to assimilate to unbiblical cultural ways of thinking is a weakness of faith supported by our sinful human nature. Repentance means laying aside the defensiveness motivated by, among other things, our fears and not our faith. When we take on the mind of Christ we see what God has done to save us in the dilemmas we construct for ourselves.

The Gospel is the good news of what God has done to deliver us from choices we need not address because he has addressed them for us. For example, assisted suicide and euthanasia play to our fears of helplessness and loss of control in the face of life threatening disease or disability. But God has addressed these fears at the cross. Jesus Christ, "being in very nature God," did not grasp for control through his own divinity, "but made himself nothing . . .a servant . . . He humbled himself and became obedient to death, even death on a cross." This is not the language of Law telling us what we also must do. It is the language of Gospel, telling us what God has done to take away the fear of helplessness and loss of control. We have the cross as evidence that God is our help and that his control has becomes ours, even though we die.

Finally, the Christian response is not to fear the culture and the changes taking place in medical ethics today. Ours is the calling to speak the Word of truth to empty lives that believe the lies which say there is no right or wrong, or that there is nothing more than the autonomy of the individual at stake. We are a people who have the one thing needed in a world that has lost everything and we need to share it.