Some context
I was a student in a postgraduate B.A. Honours course in 1988 - Medical Ethics and a Theology of Health - which comprised twelve (12) weekly seminars held each Wednesday.
Half the seminars were devoted to questions of ‘Medical Ethics’ and covered themes which included: the relationship between patient autonomy and a doctor’s responsibility to heal, the theological-ethical issues and criteria involved in procreation, euthanasia and life-support systems, ethical criteria which ought to inform financial resources allocated to medical care, and what it means to tell the truth in a doctor-patient relationship.
The other half of our seminars centred around ‘a Theology of Health’ which included: what are the distinctive characteristics of a Christian theology of health? The significance of the holistic paradigm for understanding health and healing in our context (including dialogue with a biblical perspective, traditional African religion and scientific medicine), faith and the relationship among faith, science and healing, the nature of guilt and its effect on health and the relationship between forgiveness and healing, the theological insights which the Christian faith provides for thinking through the problem of innocent and unjust suffering, and how the Christian tradition understands death and the ways in which this helps in counselling both the dying and the bereaved.
I learnt a good deal throughout this course. To this day I value the content and the kinds of questions we needed to grapple with. I’ve returned to these seminar papers over the years and more especially in more recent times as I have continued to find insights which could support me in my understanding of issues related to Medicine, Science, and Health. I think specifically of the last few years when a so-called ‘Covid Pandemic’ has been forcefully thrust upon humanity across the world, and which has brought into sharper focus many questions and concerns related to (mainstream) medicine, science and health. Even now, four years on, we continue to be bombarded by competing and contested narratives – with a discernible and raging tension between what may be described as Good and True medicine, science and health, as distinct from Bad or Pseudo medicine, science and health.
My focus will now shift to issues covered in the Medical Ethics component of the 1988 course. In separate substacks, I will touch on themes that include: the relationship between patient and doctor (autonomy and beneficence), procreation (abortion and in vitro fertilisation), euthanasia (and life-support systems), and truth-telling in the patient-doctor relationship. In dealing with these themes, I will make very few editorial changes to the original 1988 seminar papers I researched and presented in the course. Now, several decades later, I recognise that each of these themes, and others, requires rigorous examination and critical engagement, especially in light of more recent and ongoing inquiry, research and critical analysis within the medical and health care systems. Hopefully, the content of these substacks offers a helpful introduction to some of the issues which remain important for us today.
My first medical ethics substack can be accessed here: https://rogerarendse.substack.com/p/the-relationship-between-patient
Procreation – the dialogue in theological-ethical context
A fundamental theological premise for Christians is that human procreation is a God-given right, and it reflects human action complementary to the divine will:
All churches would best confine procreation to the marriage relationship between a husband and a wife who love each other and who through sexual intercourse bring about new life. This view stems from the theological foundation that marriage and human sexuality are good and God’s handiwork (Kelly: 37)
However, human conflict arises when human procreation is not possible under these ‘normal’ and ‘God-blessed’ conditions. The theological issues and their ethical implications now turn to the areas of artificial insemination, in-vitro fertilisation (IVF) and abortion. These areas are the focus of this substack. It is here where considerable theological, philosophical and ethical debates and dialogues still rage which are important, not only for “contemporary obstetrical and gynaecological practice,” but also for “all members of society, both professional and lay” (Benatar 1985:86).
A number of theological questions beg answers. At a basic level:
What is human life?
When does human life begin?
Do human-beings have a right to exercise choice or control over nature, or is this the prerogative of God alone?
The dialogue continues beyond these questions:
What is the value of this human life?
What is the difference in value (if any) between the human embryo in its different stages of development, and the fully born child?
What is the status of the human embryo?
Kelly highlights an even deeper level of dialogue:
What kind of reverence/respect is required or demanded for human life?
In this substack, I will explore some major theological views and answers given to these theological-ethical issues raised above. The considerations cannot be exhaustive, though hopefully suggestive for further examination, especially in light of the many complex and potentially divisive areas which confront human beings more than ever today.
The Warnock Report (1984), Nuremberg Code (1947) and Helsinki Declaration (1964)
Each of these were developed as a response to the theological-ethical questions set our above.
The Nuremberg Code: Permissible Medical Experiments
The great weight of the evidence before us to effect that certain types of medical experiments on human beings, when kept within reasonably well-defined bounds, conform to the ethics of the medical profession generally. The protagonists of the practice of human experimentation justify their views on the basis that such experiments yield results for the good of society that are unprocurable by other methods or means of study. All agree, however, that certain basic principles must be observed in order to satisfy moral, ethical and legal concepts:
The voluntary consent of the human subject is absolutely essential. This means that the person involved should have legal capacity to give consent; should be so situated as to be able to exercise free power of choice, without the intervention of any element of force, fraud, deceit, duress, overreaching, or other ulterior form of constraint or coercion; and should have sufficient knowledge and comprehension of the elements of the subject matter involved as to enable him to make an understanding and enlightened decision. This latter element requires that before the acceptance of an affirmative decision by the experimental subject there should be made known to him the nature, duration, and purpose of the experiment; the method and means by which it is to be conducted; all inconveniences and hazards reasonably to be expected; and the effects upon his health or person which may possibly come from his participation in the experiment.
The duty and responsibility for ascertaining the quality of the consent rests upon each individual who initiates, directs, or engages in the experiment. It is a personal duty and responsibility which may not be delegated toanother with impunity.The experiment should be such as to yield fruitful results for the good of society, unprocurable by other methods or means of study, and not random and unnecessary in nature.
The experiment should be so designed and based on the results of animal experimentation and a knowledge of the natural history of the disease or other problem under study that the anticipated results justify the performance of the experiment.
The experiment should be so conducted as to avoid all unnecessary physical and mental suffering and injury.
No experiment should be conducted where there is an a priori reason to believe that death or disabling injury will occur; except, perhaps, in those experiments where the experimental physicians also serve as subjects.
The degree of risk to be taken should never exceed that determined by the humanitarian importance of the problem to be solved by the experiment.
Proper preparations should be made and adequate facilities provided to protect the experimental subject against even remote possibilities of injury, disability or death.
The experiment should be conducted only by scientifically qualified persons. The highest degree of skill and care should be required through all stages of the experiment of those who conduct or engage in the experiment.
During the course of the experiment the human subject should be at liberty to bring the experiment to an end if he has reached the physical or mental state where continuation of the experiment seems to him to be impossible.
During the course of the experiment the scientist in charge must be prepared to terminate the experiment at any stage, if he has probable cause to believe, in the exercise of the good faith, superior skill and careful judgment required of him, that a continuation of the experiment is likely to result in injury, disability, or death to the experimentalsubject.
The Warnock Report, Nuremberg Code, and Helsinki Declaration seek simultaneously to limit human interference in nature in this sensitive area and to allow for meaningful and free decision-making and action by professionals, marriage partners, and the wider society. These ‘guides’ attempt to listen to and accept the scientific, empirical evidence that the embryo is human, genetically complete, and given the right environment free from accidents, it would develop into a full human being (Kelly:72). They also seek, however, to address the human dilemma which arises when normal human procreation is retarded by other negative factors. For example, when couples cannot have children owing to husband or wife infertility, or when research is required to make possible more scientific and medically informed help given these dilemmas, who now decides what is to be done?
Theological perspectives and their ethical implications
The conservative Roman Catholic Church (RCC) represents the extreme theological perspective on the one side of the spectrum. In answer to the questions raised above, the RCC adopts an essentialist position. It argues, like all other churches, that God is the ultimate source of all human life; God gives human life dignity which demands respect (Kelly: 67-69); and “the first right of the human person is life” (Kelly: 70). But Catholicism specifies, more exclusively, that from the moment of conception, the foetus is a “human life with potential,” and therefore must be afforded equal status to that of a fully developed human life (Kelly: 75,77). The necessary outflow from this theological foundation is that any abortion is unethical and immoral.
Related to this is the view that human procreation is an expression of human love which results essentially and supremely from the physical act of sexual intercourse between marriage partners. Therefore, any form of artificial insemination, through the husband (AIH), a donor involvement (AID), or by in-vitro fertilisation (IVF), is theologically and ethically untenable. Human informed consent, even if voluntary and autonomous, and professional responsibility in these matters, must bow to a higher rule. This theological standpoint does not help to resolve the difficult human and ethical problems which arise in actual human experiences. It fails to take seriously enough human emotion and tragedy, and at best offers dogmatic solutions. For example:
What happens if a couple cannot have sexual intercourse because of some severe injury of one or both partners?
What if a couple cannot procreate, even by sexual intercourse because either one or both are r infertile?
What are doctors to do when the mother’s life is seriously endangered during pregnancy, and either she, or both she and the child stand to lose their lives if nature is to follow its course?
Is one to leave such situations in God’s hands, and rely on miraculous grace to bring a positive reversal in this situation?
Most churches, other religions (like Judaism and Islam), and philosophers seek to take seriously the human experience, especially where theological and ethical criteria and current obstetrical and gynaecological practice are in tension. They, like the Roman Catholic view, are essentialist in their acceptance of the primacy of God (or an Ultimate Principle) over human life, and the respect and dignity which all human life, including the human embryro at any stage of development, demands (Kelly: ch 2 & 4, esp. p75). But they tend to be more consequentialist when answering the related questions:
What precisely is the status and value of the human embryo?
Is the human foetus a human-being in the proper sense of the term?
(Kelly: 73)
In the area of artificial insemination, the theological-ethical issue is the ‘rule of love’ “Any responsible use of IVF and reproductive technology must respect the ‘goods’ of marriage itself” (Kelly: 37).
Following on from the other theological issues involved in human procreation – like the value given to the human embryo – a number of different views are evident. For example, the Church of England holds that the embryo “prior to the stage of definite individuation is less than that of a human being in the proper sense of the word” (Kelly: 75). A Jewish view would concur with this position (Benatar ed. 1985:101). Methodists would claim that “value depends on the embryo’s stage of development” (Kelly:75) – the less developed the embryo, the less its value and vice versa.
These views, at the very least, allow for various techniques involved in AIH, AID, and IVF, abortion and experimentation, although these are to be administered according to fundamentally agreed upon theological and ethical premises (see above) and in accordance with the ethical standards for practice specified, for example, in Doctors Talking (Autton: 203-209). A more rigorous code operates when applied to AID, even when AIH and IVF are accepted (Kelly: 147-149). The more stringent boundaries on AID originate from a firm belief in human sinfulness, and the potential for abuse of ‘spare eggs’ or ‘frozen sperm.’ Also they seek to eliminate the inherent dangers of possible ‘genetic alteration’ and ‘cloning. (Note: The last two were still considered ‘remote’ possibilities in 1988 when this seminar paper was first written; though they are becoming greater realities as we move into the 21st century, and require critical engagement).
A radical view, on the other side of the theological-ethical spectrum, comes from the feminist perspective which raises further theological issues which focus on the rights of the woman. Questions include:
Will IVF enable women to be more truly themselves as women?
Cannot women decide autonomously on issues like IVF and abortion?
What right do even the churches or philosphers have in deciding on behalf of women?
(Kelly: 151).
Each of these views: Roman Catholic, other churches and religious groups, and the feminists, have interpreted the “kind of reverence” they would afford human life, and the boundaries that are to be set in human procreation and abortion. Those to the left of the Roman Catholic perspective would argue that “reverence for God’ is demonstrated in different degrees and ways, depending on the practical real-life circumstances (Kelly: 78-81). For these groups, the possibilities for human procreation, even under adverse conditions, are greater, and the role in decision-making of husband, wife and professional, and the value of the child are increased in importance as a result.
Conclusion
I believe that Kelly correctly highlights the failure of churches to offer an adequate rationale for the different options they take regarding the value of the human embryo (Kelly:80). These remain too rigidly bound by particular Christian and biblical perspectives, and take too little account of other human perspectives – theologically, philosophically and ethically.
Kelly (81) asks a philosophical question which casts a critical beam on the theological issues raised by those churches who differ so radically at this point from the Roman Catholic essentialist position:
If an equal respect is not the right of a being with potency, just what kind of respect is due to it by right?
How do the theological-ethical issues raised in this substack relate to other than western cultures? Are theological and ethical values in the area of human procreation absolute and binding on all humanity?
And perhaps, more critical and key to this necessary conversation: What is the value of life? What is sanctity of life?
Reflection and Journalling Exercise
What are your views on procreation, abortion and in-vitro fertilisation?
What theological, ethical, and philosophical arguments support your respective views?
How would you describe “the value of life” and “sanctity of life”?
Do you see genetic alteration and cloning as a threat to or an opportunity for human life moving forward? What reasons do you offer to support your perspective?
References
Autton, N. 1984. Doctors Talking. A Guide To Current Medico-Moral Problems (Warnock Report, Nuremberg Code, Declaration of Helsinki). London: OUP
Benatar, S.R. (ed) 1984. Ethical Issues in Contemporary Medical Practice, Session 3, Report of the Council for Science and Society, Human Procreation, chapter 1. London: OUP
Benatar, S.R. (ed) 1985. Ethical and Moral Issues in Contemporary Medical Practice, Session 3, When does life begin? Abortion and In Vitro Fertilisation. Cape Town: UCT Printing Department
Kelly, K.T. (undated). Life and Love: Towards a Christian Dialogue on Bioethical Questions, chapters 2, 4, & 8. Cape Town: Collins
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Look out for my next substack in my current medical ethics series when I discuss euthanasia and life support systems.
Blessings!