Eunice Burton tackles some current issues in medical ethics from the viewpoint of a Christian professional

IF YOU LISTEN to Radio 4’s Programme “On This Day” you learn (or are reminded) of life in Post-War Europe 50 years ago. In the intervening years, Science, Technology and Medicine have progressed at an incredible rate, so that situations undreamed of then are commonplace now - but advances have occurred at a rate faster than our consideration of the moral implications, and Christians seeking guidance on specific modern issues find the Bible is silent. ‘New Directions’ implies more than progress in widening fields, but also changes of direction into hitherto unexplored areas with possible partial or complete rejection of old guidelines. To many of our contemporaries this has meant discarding Judeo-Christian ideals, which shaped European thinking until eroded by the Age of Reason, and accepting a Post-Christian culture, where no absolutes are acknowledged, autonomy dominates and decreased value is placed on human life : the claiming of “rights” now characterises behaviour, so that duties, care, compassion are considered less important.

Before applying Biblical principles to issues such as Abortion, Euthanasia, Genetic Manipulation, may I introduce myself as a recently retired obstetrician and gynaecologist with 25 years’ experience in Consultant practice. My training years (1950s - 1960s) were in an exciting era - antibiotics were simple, new hormones were rapidly developing into more sophisticated Contraceptive Pills and Hormone Replacement Therapy, and infertility treatment was minimal (but Artificual Insemination by Donor, using donor sperm, was available). The 1967 Abortion Act was passed 3 years before I was appointed as Consultant, and I had vivid memories of attending inquests on women who had tragically died of infection following ‘back street abortions’. But I was able to take a conservative stand against ‘social’ abortions without much difficulty , as the prevailing attitude was of respect for human life and Christian principles.

The situation is very different now! - with the good things (safer childbirth and surgery, early diagnosis of cancer and more effective treatment, availability of scans, alleviation of childlessness) have also come the possibilities of abortion (in practice, ‘on demand’), ‘living Wills’ (advance directives) and discrimination against Healthcare Staff re job prospects if they do not accept society’s norms, where the criterion of valuation is ‘Quality of Life’. Patient participation in decision-making was long overdue (and has proven benefits regarding outcome of treatment) but now counselling must be ‘non directive’ and any Christian guidance is unacceptable or considered “paternalistic”. Limited resources in the N.H.S. have meant choices which militate against the individual, especially the handicapped, in favour of greater good for the community (utilitarianism). Teaching in Medical Ethics has developed from medical “etiquette” (doing good, doing no harm, respecting confidentiality and non-advertising) to regarding certain members of society as Non-persons - these are the foetus, neonate, some handicapped, Alzheimer’s disease and senile dementia patients who have no ability to make decisions for themselves (no autonomy) and therefore have no “rights” and do not merit reciprocal duty of care.

Contrast the Christian viewpoint, which regards all human beings as specific creations of God (“in His Image”), so that human life has an intrinsic value and does not exist only because of survival of ‘selfish genes’ (Richard Dawkins). This, together with respect for the Biblical commandments not to kill and to care for the helpless and needy, will determine our views on :

(1) Contraception (within marriage)

If it is accepted that fertilisation results in the full genetic complement and that subsequent implantation of the fertilised ovum into the lining (endometrium) of the uterus provides the environment for development of the mature baby, then methods which interfere with this potential by preventing implantation may be regarded as unacceptable by some Christians, e.g. the Coil (I.U.C.D.), ‘morning after’ pill and sometimes the progesterone only pill (‘minipill’). Often Christians use them and Christian doctors prescribe them on the grounds that the motive is contraception and not early abortion, and this can be important in illiterate or poor communities where one cannot rely on consistent use of the combined pill or barrier methods.

(2) Abortion

The law allows abortion up to 24 weeks if two doctors agree that the continuation of the pregnancy involves risk to the mother’s life, grave permanent injury to her physical or mental health, or risk of injury to the physical or mental health of any existing child(ren) of her family, and now up to 40 weeks (full term) if the baby is expected to be born with serious mental or physical handicap. Cases where the mother’s life is endangered, the pregnancy is the result of incest or rape, or the foetus has an abnormality incompatible with life form a very small proportion of the 150,000 Terminations of Pregnancy (T.O.Ps.) which are done in the U.K. each year - the vast majority are for “social” reasons causing “depression”, such as the pregnancy was unplanned, contraception was not used or failed, the relationship has broken up or the pregnancy would interfere with career prospects. Research on foetal sentience suggests that the foetus can feel pain from 20-22 weeks, but displays reflex action much earlier. But it is not sufficient for Christians to condemn the sexual freedom given by the pill and the ready availability availability of abortion without also trying to help alleviate the enormous amount of heartache and need which lies behind most requests for T.O.P., especially among teenagers (2% are aged under 16). Non Christians justify abortion as in the “best interests” of mother and child, but cannot we show an even better way?

(3) Prenatal Diagnosis of Foetal Abnormality

Tests may be biochemical, checking chromosomes (amniocentesis) or using scans. Ultrasound scans are particularly useful antenatally as they also monitor the growth of the baby and give warning of placental site abnormalities or foetal conditions which are treatable. For example, a foetus with a known heart defect can be delivered in a specialist hospital with facilities for cardiac surgery and a neonatal intensive care unit. But for the majority of congenital malformations there is no cure, and the latitude is that abortion is the better option, so avoiding suffering for baby and family, and the parents can have another child later who will be normal in most cases. (“Sexing ” of the foetus is permitted only in families carrying the risk of sex linked diseases and not for cultural reasons. Some members of the Warnock Committee, however, fail to see any moral wrong in parents with several children of the same sex ensuring that the next child is of the opposite sex.) No one should underestimate the cost of caring for a handicapped child, both to the parents and siblings, especially emotionally, and also to the State financially, but where is the place of Christian support for these families?

(4) Assisted Conception

It is wonderful to be able to fulfil the desires of the infertile couple, but should this extend to the use of donor gametes (sperm and ova) or surrogacy? As I write this, a girl born without a womb has been able to have 3 genetic sons by surrogacy, but another woman has refused to give up the baby who is not genetically hers to the “parents” who entered into a financial arrangement with her. The Human Fertilisation and Embryology Authority does not recommend surrogacy generally in the interests of the child, but public opinion is veering more in its favour because of “hard cases”. Assisted conception techniques may result in “excess” embryos - it is not easy to get the desired 2 or 3 in vivo as every woman’s reaction to stimulating drugs varies, and “large numbers” (for example, Mandy’s 8) are likely to abort naturally if selective abortion is not undertaken in order to save 2 or 3. In “in vitro” techniques, it is uncertain how many ova will be successfully fertilised, so only 2 or 3 of the resulting batch will be implanted and the rest frozen and stored : these can be implanted at a later time, donated to another woman, used for research or destroyed (this is obligatory after 10 years now). Research is allowed up to 14 days when the primitive nervous system is developing - usually excess embryos from infertility treatment are used with parents’ consent, but ovarian tissue can be donated for research in the U.K and used for the creation of embryos in order to perfect techniques for clinical use.

(5) Genetic Manipulation

Genetic manipulation is widely used in horticulture and animal farming, but the whole area is fraught with danger signals, especially since the cloning of “Dolly” has made us realise that cloning of humans is not such an impossibility as we had complacently thought. One has to distinguish between Somatic Line Therapies, where body cells with genetic abnormalities in a given individual are replaced by cells with normal genes (e.g. inhalation therapies in cystic fibrosis) and Gene Line Therapies where defects in the gametes are corrected - in the latter group the descendants of the treated individual would be born free of inherited familial disease, which sounds plausible, but who decides which genes should be altered, what is abnormality rather than natural variant, and does this, at its lowest level, pose an abuse of eugenics and intrusive threat to human dignity? To the Christian, attributing personality and propensities solely to our genes gives little room for acknowledging “God’s Image” in us and our need of salvation.

6. Resuscitation : Extreme Prematurity : Permanent Vegetative State

Very premature infants and adults surviving Road Traffic accidents and strokes are given resuscitation (often placed on ventilators) in the hope of improving the chances of recovery. If subsequent tests, e.g. Ultrasound Scans, E.E.G.s, show such severe brain damage that spontaneous heart beat and respiration are absent, turning off the ventilator is only acknowledging that death has already occurred. But this must be done with dignity and compassion for the relatives, and may provide an opportunity of offering Christian comfort. Permanent Vegetative State is more difficult to diagnose - only the brain stem, controlling heart beat and breathing, is functioning, but no consciousness, recognition or response other than reflex is present, although the patient may grunt and grimace. He/She is not “dying”, and can survive in this state for years given good nursing care and possible antibiotics, e.g. Tony Bland, and life can only be terminated by actively withholding fluids and food (combined with sedation) if a Court agrees with the relatives that the ‘quality of life’ makes further supportive care inappropriate. Do fluids and food count as “medical treatment”, even if given by a tube for convenience as these patients may have problems with swallowing adequately? Also, late recoveries or mistakes in diagnosis make it imperative that no treatment is curtailed for at least 2 years, and that specialist opinion is obtained.

7. Euthanasia

This literally means a “good death”, and is classified as voluntary, nonvoluntary or involuntary. People fear extreme disability following strokes and the indignities associated with senility, so make “living Will” (or advance directives) refusing “medical treatment” should such an event occur and they be unable to communicate their wishes. Refusal of resuscitation is often meant rather than ‘ceasing treatment’ for existing medical conditions while there is hope of recovery, so the wording needs to be precise. Advance refusals are not binding on doctors at present, but there is a growing popularity in theory for “Physician Assisted Suicide”, and we should monitor the situation carefully in Holland, parts of the U.S.A. and Australia, where it seems that “consent” is not always obtained in cases of “voluntary” euthanasia! Giving a lethal drug to cause cessation of life abruptly is not the same as giving a pain-relieving drug in cases of terminal cancer where increasing doses are needed to control symptoms. Palliative care is widely available (Hospices) and it is accepted that analgesic drugs may secondarily shorten the dying process by a few hours or days, while ensuring patient comfort. Voluntary euthanasia is open to abuse by pressure on the elderly to consider themselves a “burden”, and although exercising choice while capable may seem sensible, Christians have hope of eternal life beyond death and believe that no person is ‘worthless’ while God allows life. However, caring is extremely taxing on strength and emotions, and Christians need to give very active support to those involved.

Non Voluntary Euthanasia applies to neonates or others unable to make their wishes known, when it is presumed that they would not wish to go on living under circumstances of extreme disability. Involuntary Euthanasia is perpetrated against the person’s wishes, as in the elimination of handicapped under totalitarian regimes. Euthanasia poses an incipient threat to the freedom of staff to refuse involvement, and we should learn from the “legalisation” of abortion.

Legislation : Laws are designed to prevent wrongdoing and to protect the community, but no longer do they determine public opinion : rather they are framed or modified to reflect society’s norms, hence there is a descending spiral regarding what is permissible as moral standards decline. Imprecise wording leaves loopholes as in the Abortion Act. When there are opportunities for public consultations, a positive and constructive Christian voice should be heard, and legislation regarding Euthanasia may soon give such a chance. We acquiesce by our silence - Christian principles should not only be privately held opinions but also permeate public life.

The Challenge to Christians to refute modern devaluing of human life is obvious, but protest will only be creditable if accompanied by the compassion Christ showed and an active caring of the needy, which will be costly. Joshua’s challenge to Israel “Choose you this day whom you will serve” (Joshua 24. v 15) is still relevant, just as is God’s promise to Joshua, “I will not fail you or forsake you...... be strong and very courageous” (Joshua 1.)

Suggestions for further reading : 1. Truesdale, Al. : “Preface to Bioethics - Some foundations for a Christian Approach to Bioethics”; Perspectives on Science and Christian Faith, 48:4, Dec, 1996. 2. Cook, David : “Patients’ Choice : A Consumer’s Guide to Medical Practice”, Hodder Stoughton, 1993. 3 Beer, M. Dominic (ed.) : “Christian Choices in Healthcare”, CMF/IVP, 1995

Eunice Burton is a recently retired obstetrician and gynaecologist.