Bioethics by the Bedside
Principles for Pastoral Care
by Christina M. H. Powell
Bioethics — the equitable distribution of limited health care resources, research policies governing human subjects, and bans on reproductive cloning — often involves choices that affect society as a whole. Yet sometimes the practice of bioethics involves conversations shared around a bedside, involving the patient, his or her family, doctors, and minister. In this case, applying the guiding principles that undergird bioethics as an academic discipline becomes intensely personal. Principles that are easy to articulate with clarity in a seminary classroom may appear to conflict and suddenly a haze of uncertainty can cloud the hospital room.
Putting bioethical principles into practice involves understanding what guidelines apply to the situation at hand, defining any principles in conflict, and assigning appropriate weight to each principle to achieve a balanced and sound decision. Pastors and chaplains encountering bioethical issues during bedside ministry may find themselves coveting Solomon’s wisdom as they seek a comforting word to share with the family. Knowing the four basic principles of bioethics, however, helps ministers understand the way doctors approach ethical problem solving. We respect these four principles for autonomy (letting the patient or his health care proxy decide), nonmaleficence (protecting the patient from harm), beneficence (improving the well being of the patient), and justice (being fair to all patients). Here are the first three principles that deal with the needs of an individual patient.
Letting the Patient Decide
When doctors diagnosed my maternal grandfather with lung cancer in 1953, many physicians believed doctors should not tell patients they had cancer since there were few effective cancer treatments available. Physicians tried to protect the patient from feelings of shock and loss of hope. Instead of informing the patient of his diagnosis, the doctor spoke with close family members. My grandmother, my mother, and her two brothers and three sisters learned of my grandfather’s diagnosis directly from the doctor. This left my grandfather uninformed until he eventually surmised the truth of his condition on his own. Today we would call such an approach to medicine paternalistic.
As medical research in the 1960s and 1970s brought significant progress in cancer treatments, early cancer diagnosis and treatment became important for patient survival. By the end of the 1970s, physicians had shifted from paternalism to shared decision making between patient and physician. When doctors diagnosed my father with head and neck cancer in 1995, the physician disclosed the diagnosis directly to my father. The doctor could disclose information about my father’s medical condition to my mother and me only after he obtained my father’s written permission.
Today, doctors try to emphasize the importance of advanced directives (living wills and durable power of attorney for health care decisions) to allow patients with incapacitating medical conditions to continue to have a voice about the course of their treatment. Yet, many patients fail to have important discussions about their medical wishes with family members while they are still in relatively good health. Pastors can encourage patients to have such conversations to ease the burden for family members who may face difficult decisions should the patient’s condition deteriorate.
Another situation in which pastors can promote healthy communication between patient and family members is when cultural and family dynamics create a clash between well-meaning adult children and their aged, yet fully competent, parent. Adult children may desire to protect their aged parent from medical information they feel will be detrimental to their parent’s emotional well-being. The principle of patient autonomy includes the possibility of a patient deciding how much information he can handle and how much he would rather have shared with a close family member. The doctor, however, must determine that the patient is making a decision about how much information to receive without any coercion from family members.
Chaplains and pastors can provide valuable assistance in such circumstances by helping well-meaning, but potentially misguided family members, understand that a competent individual has the right to choose how much medical information he receives and to make decisions about his health based on that information. Additionally, a minister might be able to help a patient sort through his feelings about the type and extent of medical information he is comfortable receiving.
Protecting the Patient From Harm
The paternalistic approach to medical care that convinced physicians in the 1950s to withhold information about a cancer diagnosis from their patients arose from the desire to protect patients from harm, which is another basic bioethical principle. The phrase, first do no harm, is central to understanding the covenant relationship between a physician and patient. When a physician is unable to cure a patient, the physician must be careful not to place unnecessary burdens on the patient that would result in more harm than benefit. Today we often find application of this principle in discussions of medical futility and the doctrine of double effect.
With the shift away from paternalism to a consumerist approach to medical care, patients and their decision-making surrogates may demand treatments that a physician views as having little benefit. By labeling such treatments as futile, particularly those that prolong the dying process, physician authority regains the ground lost to patient autonomy. While a caring physician can offer a needed perspective that prevents modern technology from prolonging suffering of an imminently dying patient, the danger exists that cost management or value judgments about the patient’s quality of life drive such determinations.
A pastor can help family members understand how respect for sanctity of human life applies to the medical situation at hand. When grief and guilt issues motivate family members to continue to seek treatment that may not be in the best interest of the patient, the wise words of a discerning pastor may help resolve the conflict between the family and medical professionals.
Improving the Well-Being of the Patient
In addition to seeking to do no harm, a physician must endeavor to improve the well-being of a patient. Sometimes the physician must choose between bringing neither benefit nor harm to a patient and administering a benefit that contains a foreseen harm. In such circumstances, the physician resolves the dilemma by employing the doctrine of double effect.
The doctrine of double effect describes situations when a good action, such as administering medication to relieve a patient’s pain, leads to a bad effect, such as hastening the patient’s death. The physician must determine if the benefits of pain relief outweigh the detriment of shortening the patient’s life. If so, then the good of easing the patient’s intolerable pain outweighs the need to protect the patient from the harm of a shortened lifespan.
Pastors can help prevent unwarranted feelings of guilt in family members by helping them understand this doctrine. The concept of double effect also applies to procedures such as treatment of an ectopic pregnancy. When an embryo implants outside a women’s uterus, there is not enough room or a proper environment for the embryo to develop into a baby. If doctors leave an ectopic pregnancy in a fallopian tube untreated, both the woman and the developing embryo will die. Although termination of the ectopic pregnancy destroys the developing embryo, loss of one life prevents the loss of both lives. Understanding this doctrine may ease the grief experienced by a woman over the loss of an ectopic pregnancy.
The bioethical principle of beneficence also applies to mental health and pastoral counseling. Suicidal patients may need to be hospitalized against their will for their own protection. The benefit to the patient of preserving his life outweighs the principle of patient autonomy.
While ministering by the bedside of a parishioner whose future hangs in the balance of the correct application of bioethical principles, a pastor’s words carry great meaning for the patient and his or her family. My prayer for every pastor and chaplain who enters a hospital room is that Psalm 37:30 will spring to life in your ministry: “The mouth of the righteous man utters wisdom, and his tongue speaks what is just.” May proper preparation and the guidance of the Holy Spirit combine together to help you comfort those experiencing difficult times.