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Case Study on Biomedical Ethics in the Christian Narrative

Case Study on Biomedical Ethics in the Christian Narrative

 

Part 1: Chart

Medical Indications

Beneficence and Nonmaleficence

In order to make a diagnosis and determine treatment options, there is a need to assess medical indications exhibited by a patient. Beneficence refers to a health professional acting with best intentions to provide care to patients whereas non-beneficence encourages care providers not to do harm (Gillon, 2018). As per the case study, the surrogates of James acted in the best interest of the patient even the medical condition of James would still be worse even when treated.

Patient Preferences

Autonomy

Autonomy refers to the right of patients to express their choice or make a decision of care yet to be administered to them (Gillon, 2018). Even though James is an underage child, his right to autonomy must be upheld. The parents ought to have consulted the patient before making a decision on care.  The physician had limited influence to alter the decisions made by the parents.

Quality of Life

Beneficence, Nonmaleficence, Autonomy

In the healthcare setting, quality of life entail the medical features of a patient after a therapy has been administered (Gillon, 2018). As per the case study, the health condition of James was worst but improved significantly after dialysis. Conversely, the patient needs a renal replacement therapy involving a kidney transplant to improve the quality of his life. His brother can donate to him his kidney but his father has an opinion to rely on faith regarding the health status of James. The parents, however, should consult James regarding the issue because the last time they relied on faith his condition worsened (Gillon, 2018). The parents should act in the best interest so that the brother can donate the kidney to optimize the quality of health for James.

Contextual Feature

Justice and Fairness

Medical decision can greatly be influenced by familial and social factors as well as legal considerations. In the case study, James’ parents relied on faith when making decision for the health status of their son (Gillon, 2018). They focused more on religious beliefs for healing rather than receiving kidney from his bother. However, the conflict of interest arose when there was a mismatch of cells between James and his brother meaning that the latter could not donate his kidney. This made the parents were therefore willing to donate the kidney and even appealed for the goodwill of well-wishers to offer this vital organ.

 

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Four Principles most Pressing according to Christian worldview

In the Christian perspectives, beneficence emerge as the principle with the most pressing issue pertaining to the health of a patient.

Case Study on Biomedical Ethics in the Christian Narrative

Case Study on Biomedical Ethics in the Christian Narrative

The argument is guided by the premise that James’ parents made decision in the interest of their ailing son. They blindly believed that James would be healed with the support from their daily prayers (SSorajjakool et al., 2017). In this context, the parents relied more on prayers rather than providing kidney to support the life of James. Other than medical support, the parents had faith that prayers also work. No one can criticize their approach and perception in life considering that they made attempts to address the health of their son despite his deteriorating health (Hubbell, Kauschinger & Oermann, 2017). They were also against the idea about the brother donating one of his kidneys to the ailing James. All these actions affirm that the parents cared for the health status of their children. In fact, when the health status of James deteriorated while receiving homecare, they took him back to the care facility for further examination. With this, the parents aimed at addressing the health of their son despite wrong decisions that they sometimes made with regard to his care.

How a Christian might rank the Priority of the Four Principles

In an approach of health, a Christian can give priority to the four principles by starting with beneficence as it is based on one’s goodwill regarding the health of others. According to Christian teachings, parents need to provide love to their children and this is consistent with the principle of beneficence (SSorajjakool et al., 2017). The second priority goes to nonmaleficence which points as doing no harm to patients. Christian parents should not intend or initiate activities that harm their children. The principle is based on the Christian teaching that human life is sacred and that it should be protected by everyone. Justice and fairness are ranked the third as they ensure that health service delivery is provided without preferential treatment to anyone. In Christian teaching, every human being is equal before God and this should be demonstrated during provision of care. The last ranking on the list will be autonomy which ensures that patients make decisions on medical services provided to them. Christians need to allow their patients to choose their option of care and this decision must be respected (Hubbell, Kauschinger & Oermann, 2017). The premise ensures that the dignity of every person is upheld so that one receives quality service to improve on their well-being.

Part 1: Graph

By categorizing the data from the case study according to the important principles of biomedical ethics: autonomy, beneficence, nonmaleficence, and justice, this chart will formalize the four principles and four boxes approach and the four-boxes approach.

Part 2: Assessment

This section contains questions that must be answered in a total of 500 words and describe how principlism would be applied from a Christian perspective.

Remember to use the relevant study materials to back up your answers.

Although the use of the APA style is not compulsory, good academic writing is anticipated.

PHI-413V-RS-T3ApplyingFourPrinciplesCaseStudy.docxPHI-413V-RS-T3T5CaseStudyHealingAndAuton

Study of a Case:

Autonomy and Healing
Mike and Joanne are the parents of identical twins James and Samuel, who were born eight years ago. James is currently in kidney failure due to acute glomerulonephritis. James was admitted to the hospital after experiencing difficulties from a strep throat infection. Kidney failure resulted from the spread of the A streptococcus infection. James’ illness was critical enough that he needed to be treated right away. Acute glomerulonephritis caused by strep infection usually improves on its own or with antibiotic treatment. James, on the other hand, had high blood pressure and a significant amount of fluid buildup that necessitated temporary dialysis to alleviate.
The attending physician advised that dialysis be started right away. Following considerable discussion with Joanne, Mike informs the doctors that they will skip dialysis in favor of putting their confidence in God. Mike and Joanne had been inspired by a sermon their pastor had given a week before, and they had also seen a close friend regain mobility after a terrible stroke when she was prayed over at a healing service. Instead of putting James through numerous rounds of dialysis, they decided to take him to a faith healing session right away. Nonetheless, Mike and Joanne agreed to return to the hospital after the faith healing services later that week in the hopes that James would be healed.
The family returned two days later, and James’ condition had deteriorated to the point that he needed to be put on dialysis. Mike’s decision not to treat James sooner confused and disturbed him. Was he lacking in faith? Was it God or James who was being punished? To make matters worse, James’ kidneys had degenerated to the point where dialysis was no longer an option and a kidney transplant was required. Mike and Joanne, distraught and desperate, offered to donate one of their kidneys to James right away, but they were incompatible donors. During the next few weeks, some of their close friends and church members offered to donate a kidney to James, despite the fact that he was on dialysis every day. None of them, however, were tissue matches.
Mike and Joanne were contacted by James’s nephrologist to set up a private appointment with him. Given daily dialysis, James was stable, but he would need a kidney transplant within a year. Given the urgency of the situation, the nephrologist notified Mike and Joanne of a potential donor—James’ brother Samuel—who was an ideal tissue match but had not yet been evaluated.
Mike is undecided about whether he should have his other son Samuel lose a kidney or wait for God to perform a miracle this time around. Perhaps this is where his faith will be put to the ultimate test? “This time, it’s a question of life and death,” Mike explains. What could be more faith-testing than that?”

J. Hoehner, J. Hoehner, J. Hoehner (2020). Practicing Dignity: An Introduction to Christian Values and Health-Care Decision-Making http://lc.gcumedia.com/phi413v/practicing-dignity-an-introduction-to-christian-values-and-decision-making-in-health-care/v1.1/#/chapter/3

Biomedical Ethics in the Christian Narrative

Introduction

Bioethics is a subfield of ethics that concerns the ethics of medicine and ethical issues in the life sciences raised by the advance of technology. The issues dealt with tend to be complex and controversial (i.e., abortion, stem cell research, euthanasia). There have been several approaches to the theory and methodology of ethical decision-making in bioethics, but this discussion will focus on what is likely the most influential approach called principlism, which stresses the application of four moral principles to all ethical decisions in health care. A practical tool, commonly used by ethicists and hospital ethic committees, known as the “four-boxes approach” will be introduced as a way to organize hard cases and appropriately apply the four principles. Principlism and the

four-boxes approach will be used and interpreted in light of the Christian worldview and the overarching narrative presented in the Bible.

Principlism

Principlism is often referred to as the “four-principle approach” because of its view that there are four ethical principles that are the framework of bioethics. These four principles are the following, as spelled out by Tom L. Beauchamp and David DeGrazia (2004):

  1. Respect for autonomy – A principle that requires respect for the decision- making capacities of autonomous
  2. Nonmaleficence – A principle requiring that people not cause harm to
  3. Beneficence – A group of principles requiring that people prevent harm, provide benefits, and balance benefits against risks and
  4. Justice – A group of principles requiring fair distribution of benefits, risks, and costs. (p. 57)

While these principles will guide ethical decision-making, they only provide a general and abstract framework for thinking about particular ethical cases. Other information is required before one can make a concrete ethical decision. First, one must specify the particular context and details of a case or dilemma in order to concretely apply these principles and arrive at concrete action-guiding results (i.e., individuals need to know how to apply these principles to specific cases and circumstances).

Second, one must figure out how each of the four principles ought to be weighed in a particular case. One needs to determine which of the four principles deserves the most priority in any given case, especially in cases in which there are conflicts between the principles. The details of a specific case as well as the way in which principles are

 

weighed and prioritized necessarily involves discussion of worldview. This is because a patient’s preferences will involve his or her worldview, and because different worldviews would rank the importance and priority of principles differently. Thus, one might approach the four principles from a Buddhist perspective, or an Islamic perspective, or an atheistic perspective and achieve vastly different results. When one utilizes the principlist approach to bioethical dilemmas, it will always also incorporate broader worldview considerations and never be purely neutral or unbiased. In order to understand how the Christian worldview would apply the principles, it is important to understand the grand story told in the Bible that Christians believe describes reality.

The Christian Biblical Narrative

While it is not possible to survey every possible religion, the description below will at least attempt to do justice to the biblical narrative and Judeo-Christian tradition.

The Bible is a collection of 66 books written over thousands of years in several different languages and in different genres (e.g., historical narrative, poetry, letters, prophecy), yet there is an overarching story, or big picture, which is referred to as the Christian biblical narrative. The Christian biblical narrative is often summarized as the story of the creation, fall, redemption, and restoration of human beings (and more accurately this includes the entire created order). Concepts such as sin, righteousness, and shalom provide a framework by which the Christian worldview understands the concepts of health and disease.

Briefly, consider the following summary of each of the four parts of the grand Christian story:

Creation

According to Christianity, the Christian God is the creator of everything that exists (Gen. 1-2 NIV). There is nothing that exists that does not have God as its creator. In Christianity, there is a clear distinction between God and the creation. Creation includes anything that is not God—the universe and everything in it, including human beings.

Thus, the universe itself and all human beings were created. The act of creating by God was intentional. In this original act of creation, everything exists on purpose, not accidentally or purely randomly, and it is good. When God describes his act of creating, and the creation itself as good—among other things—it not only means that it is valuable and that God cares for it, but that everything is the way it is supposed to be. There is an order to creation, so to speak, and everything is how it ought to be. This state of order and peace is described by the term Shalom. Yale theologian Nicholas Wolterstorff (1994) describes Shalom as, “the human being dwelling at peace in all his or her relationships: With God, with self, with fellows, with nature” (p. 251).

The Fall

Sometime after the creation, there occurred an event in human history in which this created order was broken. In Genesis 3, the Bible describes this event as a fundamental act of disobedience to God. The disobedience of Adam and Eve is referred to as the fall, because, among other things, it was their rejection of God’s rule over them and it resulted in a break in Shalom. According to the Bible, the fall had universal implications. Sin entered into the world through the fall, and with it, spiritual and physical death. This break in Shalom has affected the creation ever since; death, disease, suffering, and, most fundamentally, estrangement from God, has been characteristic of human existence.

Redemption

The rest of the story in the Bible after Genesis 3 is a record of humanity’s continual struggle and corruption after the fall, and God’s plan for its redemption. This plan of redemption spans the Old and New Testaments in the Bible and culminates in the life, death, and resurrection of Jesus Christ. The climax of the Christian biblical narrative is the atoning sacrificial death of Jesus Christ, by which God makes available forgiveness and salvation by grace alone, through faith alone. The death of Christ is the means by which this estrangement caused by sin and corruption is made right. Thus, two parties, which were previously estranged, are brought into unity (i.e., “at-one-ment”). For the Christian, salvation fundamentally means the restoration of a right and proper relationship with God, which not only has consequences in the afterlife, but here and now.

Restoration

The final chapter of this narrative is yet to fully be realized. While God has made available a way to salvation, ultimately the end goal is the restoration of all creation to a state of Shalom. The return of Jesus, the final judgment of all people, and the restoration of all creation will inaugurate final restoration.

Summary: The Christian Ethical Approach

While the principlist approach may be used by the Christian as a general methodological tool for bioethical reflection, the general contours of a Christian approach to ethics (not only bioethics) include the principles and rules found in the Bible, as well as the example of Jesus Christ (Rae, 2009, p. 24). The way in which Christianity answers the worldview questions will be in the context of the above narrative. Similarly, a Christian view of health and health care will stem from the above narrative and God’s purposes. Of course, the pinnacle of this framework is the person of Jesus Christ. Thus, for Christianity, medicine is called to serve God’s call and purposes, and everything is done in remembrance of, and in light of, Jesus’s ultimate authority and kingship.

The Four-Boxes Approach

The four-boxes approach is a practical tool developed by Jonsen, Siegler and Winslade that helps clinicians identify ethical issues in medical cases and reach reasonable a conclusions that lead to ethical actions (Jonsen, Siegler, & Winslade, 2010). This approach introduced four topics that describe the way in which the four principles of principlism actually apply to a certain. These topics include (1) medical indications, (2) patient preferences, (3) quality of life, and (4) contextual features.

Medical indications refer to “those facts about the patient’s physiological or psychological condition that indicate which forms of diagnostic, therapeutic, or educational interventions are appropriate” (Jonsen et al., 2010, p. 10). This topic concerns the professional judgment of the physician and involves the concrete application of the principles of beneficence and nonmaleficence.

Patient preferences refer to “the choices that persons make when they are faced with decisions about health and medical treatment…[which] reflect the patient’s own experience, beliefs and values as informed by the physician’s recommendations” (Jonsen et al., 2010, p. 47). This topic primarily involves the concrete application of the principle of respect for autonomy.

Quality of life refers to “that degree of satisfaction that people experience and value about their lives as a whole, and in its particular aspects, such as physical health” (Jonsen et al., 2010, p. 109). This topic is difficult to define, and it involves the concrete application of beneficence, nonmaleficence and respect for autonomy. However, it seems that the most important principle here is an aspect of the principle of beneficence. Beneficence is not only acting in ways that help other persons in need by way of treating or curing illness, but it also involves “acting in ways that bring satisfaction to other persons” (Jonsen et al., 2010, p. 109). Thus, it is also part of beneficence to attempt to improve a patient’s life such that they are satisfied with their quality of life.

Contextual features refer to the context in which a particular case occurs, which includes “professional, familial, religious, financial, legal and institutional factors” which influence clinical decisions (Jonsen et al., 2010, p. 161). Thus, for example, an influential contextual feature in a case in which the medical indications for a person include a blood transfusion, would be if a patient were of the Jehovah’s Witnesses religion. This is because blood transfusions are considered to be immoral according Jehovah’s Witnesses teaching.

When considering a difficult ethical case in medicine or health care, the relevant information of that case is arranged into four boxes which correspond to the four topics above and aligns them with the key ethical principles (Jonsen et al., 2010):

  • Medical Indications (Beneficence and Nonmaleficence)
  • Patient Preferences (Autonomy)
  • Quality of Life (Beneficence, Nonmaleficence, Autonomy)
  • Contextual Features (Justice and Fairness)

The four-boxes approach is a useful tool to make sure that you have gathered all the relevant data (or as much data as possible) so as to come to an ethical decision and plan of action. Keep in mind that many times in clinical ethics, there may not be a single right

 

course of action, but there are certainly better or worse options. This does not mean that there is no such thing as right and wrong (i.e., relativism), but simply that real life is messy and imperfect.

Applying the Principlism and the Four-Boxes Approach

Consider the following analysis from a Christian perspective of the case study, “End of Life and Sanctity of Life,” in the American Medical Associations Journal of Ethics, included in the topic readings (Reichman, 2005). That case is analyzed from a Jewish and Buddhist perspective by different commentators. This case will be analyzed by addressing the four principles in the principlist approach, and then that data will be considered in light of the Christian worldview in order to recommend a course of action in accordance to Christian values and biblical principles. As practice, begin filling the four boxes based on the information provided by the case itself, as well as the analysis below.

Depending on the case, different principles will come to have greater prominence in deciding an ethical course of action. At times there may be conflicts among the principles themselves, in which it will have to be determined which principle will have the greater priority. For example, a common conflict is that between a patient’s autonomy and what a physician considers to be beneficent, or in the best interests of the patient. A physician might see that a particular course of treatment will be beneficial for a patient (beneficence), and yet the patient refuses the treatment (autonomy).

Should the physician simply allow patients to choose for themselves a course of action that will knowingly bring them harm? Is it right for the physician to coerce or force a patient to undergo a treatment against his or her will and violate autonomy, even if it will bring about some medical benefit?

How do the four principles apply to the case of 82-year-old Mrs. Jones as described by Reichman’s case study (2005)?

Autonomy: In this case, Mrs. Jones is incapacitated; she has been unconscious for two days and has no ability to communicate her desires for or against treatment. This is further complicated by the fact that she left no advance directive (a legal document that details her wishes for or against certain kinds of medical treatment should she ever become incapacitated such as a living will or a health care power of attorney). While Mrs. Jones’s family and the physian disagree about the appropriate treatment for her, it seems that determining what Mrs. Jones would have wanted is not possible. Thus, while her autonomy is certainly to be respected, in this case, it is not something that is able to be obtained given her condition (she would technically be considered incompetent and unable to exercise autonomy in her current condition).

Beneficence: Dr. Rosenberg believes that it will be in Mrs. Jones’s best interest medically to be put on temporary dialysis. He believes it to be the beneficent course of action: that which will bring about her good. Mrs. Jones’s family believes that dialysis will be a cause of undue suffering for her, and, thus, do not consider it to be the

beneficent course of action. The fundamental disagreement lies here. Two parties, who are not Mrs. Jones herself, and who presumably do not have information about how she would have decided for herself, disagree about whether or not an action is truly beneficent for her. The principle of nonmaleficence is closely related.

Nonmaleficence: Not only does Dr. Rosenberg have a moral duty to promote Mrs. Jones’s good, but he has a corresponding negative duty to not inflict evil or harm upon her. Mrs. Jones’s family believes that to place her on dialysis would inflict harm and suffering on her. Dr. Rosenberg believes it to be his duty to place her on dialysis and that to not do so would be harmful to her. Dr. Rosenberg’s dilemma involves the belief that withholding treatment that has a good chance of restoring Mrs. Jones back to health with little risk is immoral.

Justice: Questions of justice usually come to the forefront in terms of the equal and fair distribution/allocation of medical goods and services (i.e., organ donation, health insurance. In this case, this principle does not play a major role. It might be said that it is unjust or unfair for Mrs. Jones to not decide for herself. But in the terms of this course, that concern would more appropriately be a question of autonomy, beneficence and nonmaleficence.

The above discussion sketches out how each principle would be relevant to or apply to Mrs. Jones’s case. But notice that you do not automatically have an answer to this dilemma. What should be done ethically? To answer this question, it is necessary to consider the four principles in light of an overarching worldview. Thus, how ought a Christian think about this dilemma?

To begin with, it is important to note that the Bible holds that all life is sacred (Gen. 2:7; Ps. 139:13-16; Exod. 20:13). Thus, whether a life is at its beginning or end, it is valuable and sacred.

The dilemma in Mrs. Jones’s case is directly related to her perceived quality of life. Her family (presumably if they are being honest) does not desire that she remain alive and suffer. They perceive it better for her to stop living than for her to continue living in a poor quality of life in which she would suffer. Dr. Rosenberg believes that her life is sacred and that her quality of life is not so bad as to warrant ending her life early, if it can be saved with reasonable effort and low risk. For the Christian, while quality of life certainly matters, it does not determine the value of a life, or the worthiness of living for a person.

You might ask why exactly Mrs. Jones’s family is so ready to give up on a treatment modality (temporary dialysis) that will likely succeed? Meilaender notes the importance of taking care of those in need and accepting their dependence upon those who love them and vice versa, accepting your own dependence when you are incapacitated, upon those who love you (2013, pp. 85-88). The reticence on the part of Mrs. Jones’s family seems to communicate a lack of willingness to deal with her care. It seems as if they want it to be over with, instead of fulfilling their duty to care for her and be active partners with Dr. Rosenberg in deciding what is in her best interest.

From the Christian perspective, it would be true that if Mrs. Jones had a personal relationship with Christ, her quality of life or existence would be improved dramatically were she to enter into God’s presence directly by way of her earthly passing. However, it would be radically mistaken to believe that it is up to someone other than God when that time would be. Does a refusal of dialysis constitute a reasonable decision? Or does it constitute a decision that functionally denies the opportunity for healing and, thus, denies God’s prerogative? It seems more likely that it is the latter.

In brief, it seems that Dr. Rosenberg is justified in his refusal to withhold reasonable and low-risk treatment for Mrs. Jones. Ultimately, it seems that Mrs. Jones’s family does not want to take responsibility for her care and is, instead, opting to determine her worth or value based upon a perceived quality of life.

Conclusion

In your own case study, consider how each of the four principles apply and analyze those facts in terms of the Christian worldview. All ethical decision-making takes place within a worldview. The content of a worldview will determine what is valuable and what is not, as well as how a person would engage in decision-making given those values.

References

Beauchamp, T. L., & DeGrazia, D. (2004). Principles and principlism. In G. Khushf (Ed.), Philosophy and Medicine: Handbook of bioethics: Taking stock of the field from a philosophical perspective (Vol. 78). Dordrecht: Kluwer Academic Publishers.

Jonsen, A. R., Siegler, M., & Winslade, W. J. (2010). Clinical ethics: A practical approach to ethical decisions in clinical medicine (7th ed.). New York: McGraw Hill Education/Medical.

Meilaender, G. (2013). Bioethics: A primer for Christians (3rd ed.). Grand Rapids, MI: Wm. B. Eerdmans Publishing Company.

Rae, S. B. (2009). Moral choices: An introduction to ethics (3rd ed.). Grand Rapids, MI: Zondervan.

Reichman, E. (2005). End of life and sanctity of life. American Medical Association Journal of Ethics (formerly Virtual Mentor), 7(5), 342-351. Retrieved from http://journalofethics.ama-assn.org/2005/05/ccas2-0505.html

Wolterstorff, N. (1994). For justice in Shalom. In W. G. Boulton, T. D. Kennedy, & A. Verhey (Eds.), From Christ to the world: Introductory readings in Christian ethics (pp. 251-253). Grand Rapids, MI: Wm. B. Eerdmans Publishing Company.

 

 

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