Mr. H is 82 years old and has many serious medical problems, including ischemic heart disease, hypertension, and diabetes mellitus. He has had a series of debilitating strokes that have left him severely disabled and unable to communicate his wishes. His healthcare providers feel that he would not benefit from resuscitation attempts if he were to suffer a cardiac arrest and suggest to his family that a do-not-resuscitate (DNR) order be placed on his chart. The devoutly Baptist family are quite upset and reject this suggestion. They believe that God could still heal their husband and father, and they accuse the healthcare providers of trying to “play God.”
“Protestant” is a term applied to many different Christian denominations, with a wide range of beliefs, who trace their common origin to the Reformation of the sixteenth century. Protestant ideas have profoundly influenced modern bioethics, and most Protestants would see mainstream bioethics as compatible with their personal beliefs. This makes it difficult to define a uniquely Protestant approach to bioethics.
When Martin Luther first challenged the teachings of the Christian church in the early sixteenth century, few could have predicted the tumultuous consequences. The Reformation was founded on the idea that salvation could not be earned through human effort or bought through indulgences, concepts that were prevalent in the church at the time. The reformers preached that it is by God’s grace alone that people are saved. They challenged the authority of the Pope and encouraged their followers to read and interpret the scriptures for themselves.
Today almost 30% of the world’s Christians belong to a Protestant church. From their European origins, Protestants churches have spread throughout the globe: approximately 30% of Protestants live in North America, 25% in Africa, 20% in Europe, and 10% in Asia (Barrett et al., 2001, p. 12). A wide variety of Protestant denominations have grown out of the common roots of the Reformation (Eliade, 1987), and while divisions and new visions have created many new branches, there have also been notable unions and reunification. Some of the larger and better-known denominations include the Anglican and Episcopalian, the United Church and United Church of Christ, Lutheran, Presbyterian, Baptist, Pentecostal, and Charismatic.
Describing a distinct “Protestant bioethic” is difficult, for a number of reasons. Much of the contribution that Protestant thinkers have made to modern bioethics has occurred subtly, over hundreds of years, as part of the larger Protestant influence on Western culture. The value of autonomy is a good example of this. Protestants have played an important historical role in articulating and promoting this concept, but it is now so widely accepted that it would not be considered a unique feature of a Protestant bioethic.
A second important factor is the secularization of Protestant thought and behavior (Bruce, 1990). Mainstream Western values and institutions reflect the culture-building role of Protestant churches. Most Protestants would see mainstream bioethics as compatible with their personal values and beliefs.
At the same time, there is tremendous diversity within Protestant thought and theology. Some Anglican churches are very close theologically to the Catholic Church, while others have adopted different positions on a variety of issues. Many smaller Protestant denominations are notable for their contributions to society, attention to social inequities (the Salvation Army), or their unique culture (the Mennonites). The full spectrum of beliefs and practices can be demonstrated by the positions different Canadian Protestant groups have adopted on a variety of issues. The United Church of Canada (a member of the World Council of Churches) is at the liberal end, as evidenced by their ordination of women and their acceptance of homosexual clergy. By comparison, many Baptist and Pentecostal churches, and advocacy groups such as the Evangelical Fellowship of Canada (a member of the World Evangelical Alliance), generally hold conservative positions on such issues as abortion and homosexuality.
Sectarian Protestantism describes groups with Protestant origins that have developed distinct theology or practices (Reich, 1995). Some have grown to be so different from other Protestant groups that they may question or even reject the label of Protestant; examples include Jehovah’s Witnesses, the Church of Jesus Christ of Latter-Day Saints, Seventh-Day Adventists, and the Church of Christ, Scientist. Many of these groups have specific doctrines or beliefs related to illness and medical care.
Because it is so difficult to define a “typical” Protestant approach to bioethics, we will instead identify common Protestant beliefs and highlight concepts that have emerged from the Protestant tradition that are particularly relevant to bioethics.
Protestants share some fundamental beliefs with other Christians, and most Protestant denominations have common features that reflect their shared origins. Protestants have traditionally believed in an omnipotent, omniscient God, as described in the Bible. They believe that every person has been “made in the image of God” but has been tainted by sin. Protestant theology places a particular emphasis on Jesus Christ, the human incarnation of God’s love. Through faith in Jesus Christ, believers establish a personal relationship with God that transforms them. Jesus’ death on the cross and his resurrection provide a way for people’s sinful nature to be forgiven and for believers to be reconciled to a Holy God. When believers die, they will spend eternity with God in heaven.
Protestants particularly emphasize that it is through grace that believers are reconciled with God. It is not something they deserve or earn. This does not mean that they do not concern themselves with good deeds or acts of charity. One of the key assertions made by the early Protestant reformers was that all believers are to be ministers or servants to one another and that their beliefs should find an outward expression. A true faith in Christ will give rise to virtues such as love, joy, peace, and patience in the lives of believers (Galatians 5:22–3).
Protestants have traditionally viewed the Bible as their primary source of direction and guidance (Eliade, 1987). New Testament writings are particularly emphasized, and Jesus Christ is considered the ultimate role model. Biblical principles are understood and applied to daily living through prayer and through discussion with fellow believers.
Some Protestant themes or ideas are particularly relevant to the practice of medicine and the field of bioethics (Reich, 1995). A key Protestant belief is that God is sovereign and that believers can trust in God’s goodness and faithfulness. This is an idea associated particularly with John Calvin, one of the early reformers. When faced with illness and pain, many people question God’s existence and benevolence. A Protestant perspective asserts that God is in control and that there is a greater meaning or purpose in illness of which we may not be aware. Even in death, families may take comfort in their belief that God has “conquered death” and their loved one is with God in heaven (Lammers and Verhey, 1987). Some Protestants pray for miraculous cures as a sign of God’s authority. Most believe a miracle could occur but also believe that God works through human ingenuity and technology to cure illness and relieve suffering. Believers are cautioned against a form of idolatry that invests physicians and medical interventions with more power than they have. Ultimately it is God who is in control (Reich, 1995).
A second Protestant theme is the value of individual freedom. One of the foundational ideas of the Reformation was that earthly authorities are fallible and that believers should read and understand the scriptures themselves. This historical Protestant emphasis on personal freedom has contributed to the establishment of respect for persons or autonomy as a foundational concept in modern bioethics (Veatch, 1997). However, significant differences exist between secular and Protestant conceptions of autonomy. Many secular formulations emphasize personal freedom and argue that autonomy is best served by minimizing restrictions on individual choice. Protestants would argue that autonomy can be fully expressed only in the context of a relationship with God, and that individuals must account for their personal relationships and their responsibilities to the larger community (Gustafson, 1981).
Protestant ideas about work and vocation have important implications for how the physician–patient relationship is viewed. In rejecting the traditional church structure, early Protestants asserted that all believers should be “ministers” to one another. God’s love and compassion are revealed in many different jobs, not just the work of the priest. Medicine is seen as a calling, and the language of covenant is used to describe the relationship between doctor and patient (Ramsey, 1970). Physicians are to be more than “hired guns” or technical experts. They are called to empathize with their patient’s suffering and to establish relationships of care and respect that allow them to enter into their patient’s world (May, 1983).
Many religious traditions rely on historical precedence or guidelines to encourage uniformity of belief and practice. In the Jewish tradition, it is the Torah, Talmud, Codes, and Responsa. Casuistry helps serve this purpose in the Catholic Church. These practices shape the way followers of these religions approach bioethical concerns and dilemmas. In contrast to these highly articulated procedures, one finds a diversity of methods used in Protestant churches.
The influence of Protestant scholars on modern bioethical thought is pervasive. Twentieth century ethicists Paul Ramsey, Joseph Fletcher, and James Gustafson have been particularly influential (Jonsen, 1998). Ramsey (1970) described a deontological approach to bioethics in which he articulated “unexceptionable moral principles.” He wrote on a variety of topics, and his ideas on the value of the individual and the “canon of loyalty” that exists between physician and patient have had a significant impact on subsequent work in the field. Fletcher (1966) advocated a situation ethic that closely resembles act-utilitarianism, in which the consequences of an action are used to assess whether the action is morally right or wrong. Fletcher (1960) was an Episcopalian who emphasized the need to understand moral issues from the patient’s perspective and felt that human freedom and choice were of the utmost importance. Ramsey and Fletcher represented the opposite ends of the polarities of principles versus situation, deontological versus consequentialist, and norms versus context. Gustafson (1965) helped to move the debate forward. He focused on the agent and emphasized the web of human relationships in which the actors are situated. The starting place for his ethical reflections was ordinary human existence rather than church doctrines or scriptural passages. After describing a situation in terms that do not presuppose distinctive religious teachings or authority, Gustafson (1974) then asked how religious beliefs and presumptions might influence how a situation is being described, and what weight should be assigned to different values and consequences. Gustafson provides useful guidance for understanding the thought patterns of many Protestants in the clinical setting.
Patients want their physicians to respect their spiritual beliefs, and they feel better cared for when this important part of their life is recognized (Daalman and Nease, 1994; King and Bushwick, 1994; Ehman et al., 1999). Including a spiritual history is particularly important when assessing a serious or terminal illness or when making significant treatment decisions.
Because of the influence that Protestant thought has had on Western culture, and the secularization of Protestantism, most physicians (religious or not) will find that they share many values and beliefs with the majority of their Protestant patients. Examples include the importance of respecting patient’s wishes and the value of a caring, empathic relationship between physician and patient.
Physicians should be particularly sensitive to their Protestant patients’ beliefs when dealing with end of life issues, concerns about consent and refusal of care, and beginning of life issues such as abortion, genetic testing, and the use of assisted reproductive technologies. Physicians should also recognize that certain Protestant groups and denominations, particularly those with conservative beliefs, might have different approaches to making decisions and unique treatment wishes. Understanding how to identify these wishes and to respond appropriately will enhance patient care and minimize conflict. In these cases, the physician should inquire about the patient’s personal beliefs and their relationship to their faith community. This discussion will help physicians to identify the particular needs or desires of the patient that the physician may not have anticipated. It also will identify areas of potential conflict that physicians can address before they arise. A withdrawal of treatment may be more easily negotiated if a family’s views are understood beforehand. Great care must be taken not to stereotype or generalize. There is a great diversity of Protestant beliefs and a variety of expression of these beliefs. A chaplain from the same denomination as the patient may be an invaluable resource.
Most Protestants are comfortable with a wide variety of life-sustaining treatments and will want them when indicated. Faced with little hope of recovery, most Protestant patients and families understand why healthcare providers suggest a withdrawal of aggressive interventions and often are in agreement. Many Protestants draw strength from their belief that their loved one will go to Heaven when he or she dies. At the same time, Protestant beliefs have played a role in cases in which families have been reluctant to withhold or withdraw treatment (Cranford, 1991; Sawatzky v. Riverview Health Center Inc., 1998). The families in these situations argued that healthcare providers should not be “playing God.” In one case, the family was hoping that a miracle might occur and that their loved one would be healed (Cranford, 1991). Although the reluctance to withhold or withdraw treatment may be the exception rather than the rule, physicians should listen carefully to the family’s wishes and proceed cautiously (Weijer, 1998). In cases that have gone before the courts, judgments have consistently stated that the wishes of the substitute decision maker be respected.
When faced with important decisions, many devout Protestants seek to determine God’s “will” for their lives through prayer, reading the Bible, and consulting with other believers. Healthcare providers who do not understand this decision-making process may question their patient’s capacity to make decisions or feel that friends or church leaders are coercing their patients.
Physicians should not assume, however, that such a process is invalid or inappropriate when it leads to what they see as negative consequences. In an often-cited Canadian case, Malette v. Shulman (1990), a physician caring for a woman severely injured in a motor vehicle collision felt that she required a blood transfusion to save her life. He knew she had a signed card asking that no blood products be given because of her religious beliefs, but chose to give the blood anyway. He was sued for battery, and the judge found in the plaintiff’s favor.
Although physicians must respect a competent adult’s informed decision, this is not the case with dependent minors. An important rationale for respecting adult’s religious beliefs is that they may be carefully considered and deeply held. Young children are not seen as capable of this same kind of careful consideration and should not suffer harmful consequences as a result of their parents’ beliefs. Courts have affirmed this in many cases. In cases involving older children and teenagers, courts may decide that they are mature enough to make their own decisions and allow them to reject care on the basis of their own beliefs (Rozovsky and Rozovsky, 1992).
Protestant views and practice are particularly diverse when it comes to the issue of abortion. Conservative groups are among the most active in the pro-life movement, as many believe that life begins at conception. Some liberal denominations are pro-choice: they believe that principles such as the right to life and the freedom to choose must be applied and weighed by taking into account the particular circumstances, and that, during the first trimester, the decision to have an abortion should be between a woman and her doctor.
Protestant attitudes toward postconception genetic testing are similarly diverse and often linked to the individual’s views on abortion. If there is no situation in which a person would consider an abortion, they may refuse this type of testing. Although some Protestants may object to in vitro fertilization because of the potential for embryo wastage, many would consider this an option if they were infertile.
In response to the family’s objections, the physician does not write the do-not-resuscitate (DNR) order for Mr. H. She arranges a family conference, and the family’s pastor is invited to attend. It becomes apparent that the family is not really expecting a miracle to happen. They are concerned that their father is not receiving enough rehabilitation services. They feel that the healthcare team is giving up on their father and that the suggested DNR order is evidence of this. The family is reassured that the healthcare providers are committed to their father’s rehabilitation and that the DNR order would not affect the level of care he receives. A discussion about the resuscitation process helps the family to understand that the healthcare providers may be “playing God” just as much by trying to resuscitate Mr. H as by letting him die. The family is able to reaffirm their belief that it is God who will determine when their father dies, not the resuscitation team. They subsequently agreed to a DNR order.
An earlier version of this chapter has appeared: Pauls, M. and Hutchinson, R. C. (2002). Protestant bioethics. CMAJ 166: 339–43.