(Re)-Emerging Challenges in Christian Bioethics: Leading Voices in Christian Bioethics.

This is the third installment in a Christian Bioethics series that gathers leading voices in Christian bioethics to examine the themes and issues they find most pressing. The papers address fundamental theoretical questions about the nature of Christian bioethics itself, long-standing ethical issues that remain significant today, including physician-assisted suicide, euthanasia, the definition of death, the allocation of scarce resources, and finally, more futuristic questions regarding transhumanism. The contributions underscore the enduring significance of Christian engagement in bioethics.

I. Introduction

This is the third installment in a Christian Bioethics series that gathers leading voices in Christian bioethics to examine the themes and issues they find most pressing. The papers address fundamental theoretical questions about the nature of Christian bioethics itself, long-standing ethical issues that remain significant today, including physician-assisted suicide (PAS), euthanasia, the definition of death, and the allocation of scarce resources, and, finally, more futuristic questions regarding transhumanism. The contributions underscore the enduring significance of Christian engagement in bioethics.

II. FUNDAMENTAL QUESTIONS: WHAT IS CHRISTIAN BIOETHICS AND WHAT SHOULD IT BE?

As a founding coeditor of the journal and a scholar who often has examined broad theoretical issues, B. Andrew Lustig appropriately examines the question of how Christians should engage in bioethics, what the character of Christian scholarship in bioethics should be, and how Christians should engage each other and the secular world with respect to bioethics. He joins a long line of vibrant contributors to Christian Bioethics over the years who have advanced the understanding of the field (see, e.g., Cozby, 2005; Engelhardt, 2005; Verhey, 2005; Waters, 2005; O’Mathúna, 2014; Beckwith, 2019). Lustig is especially interested in understanding what it means or should mean for Christian scholarship to be nonecumenical, an orientation that could encourage divisiveness or that could foster the discovery of common ground through the study of difference. Lustig looks back to past scholarly contributions and, in looking ahead, challenges authors and journal editors to pursue

a disciplined discourse that honors the requirements of a shared forum: viz., academic dialogue that respectfully acknowledges differences, that makes a case for why they matter, and that appreciates that such conversations require attention to what one might call the “tools of the trade,” namely, the recognition of certain basic patterns that inevitably structure theological conversations both within and between communities. (2022, 17)

Here, Lustig draws a parallel between differences among Christians and differences in secular ethical theory. He points to efforts in secular clinical ethics to secure common ground to resolve differences at a practical level despite background disagreements. Christians, he thinks, can learn from those efforts. Thus, he argues for an optimistic and fruitful understanding of “non-ecumenical” scholarship in Christian bioethics, one that leads us “to search for commonality across apparent differences of ethos and culture” grounded in the “recognition that God is the single source of all truth” (2022, 23).

Lustig’s hope is that through the exploration of differences, Christian bioethics scholars will find common ground. He charges authors, readers, and editors with a responsibility to do that. Given the vast differences among Christians today on topics ranging from abortion, research involving human embryos including embryonic stem cell research, PAS, and euthanasia, to understandings of sex and gender, even the most sincere efforts to fulfill Lustig’s charge likely will reveal limits in their shared approach to a range of challenging issues (see, e.g., Waters and Cole-Turner, 2003; Delkeskamp-Hayes and Imrényi, 2013; Bader-Saye, 2019; Cherry, 2020; Dozier et al., 2020; Ford, 2020; Franks, 2020; Savage, 2020; Watt, 2020; Keown, 2022).

III. NEW TWISTS ON OLD TURNS: LONG-STANDING ISSUES IN CHRISTIAN BIOETHICS

Physician-Assisted Suicide and Euthanasia

In the face of ever-expanding support for PAS and euthanasia, John Keown makes an important contribution to understanding how Christians approach these practices. Keown critically engages calls by two prominent Anglican leaders, Desmond Tutu and Lord George Carey, to legalize various forms of physician-assisted death. Keown argues that they fail “to engage with the arguments, both principled and practical, against legalization,” and that those principled and practical arguments should matter to any Christian taking up this issue (2022, 25). His carefully argued paper offers a substantive, point-by-point refutation of Tutu and Carey’s defense of these practices. I highlight only a few here.

Keown argues that some of what Tutu and Carey focus on in advocating for euthanasia is irrelevant to the question at hand. In their statements supporting the so-called “right to die,” for instance, both Tutu and Carey object to the idea that life should be prolonged as much as possible. They seem to assume that rejecting a commitment to the mere prolongation of life necessarily commits one to supporting euthanasia. Keown shows that this does not follow and that such a claim is a distraction, since

The Christian moral tradition and professional medical ethics have long held that human life is not the supreme good; that it is not the role of doctors to preserve life at all costs; that the patient has the primary responsibility to make decisions in relation to his or her health, a responsibility that should be respected by the doctor; that it is proper for a competent patient to refuse treatments that are either futile (i.e., offer no reasonable prospect of therapeutic benefit) or excessively burdensome (as being, for example, too painful or expensive) or, if the patient is incompetent, for a physician to withhold or withdraw such treatments. (2022, 30–31)

Christian scholars have distinguished between licit decisions to withhold or withdraw life-sustaining interventions and killing (see, e.g., Lavery et al., 1997; Engelhardt, 2000, ch. 6; Flannery, 2011).

One area of particular concern for Keown is what he sees as Tutu and Carey’s failure to distinguish often-maligned slippery slope arguments from logical slope and practical slope arguments. In rejecting slippery slope arguments against various “right to die” practices, Tutu and Carey fail to realize that there are relevant practical and logical slope arguments against these practices that should concern Christians. He illustrates these concerns with a series of events in some jurisdictions with permissible “right to die” laws that Christians should find objectionable. Well-intentioned concern with compassion and suffering can lead people, including Christians, to “misguidedly . . . support . . . a campaign that would radically undermine the sanctity of life, one of the most fundamental principles of Christian ethics, professional medical ethics, and criminal law” (Keown, 2022, 37). In addition to reports of nonvoluntary euthanasia, reports of euthanasia in Belgium and the Netherlands for patients who do not fit the conditions used to justify the laws permitting euthanasia, namely, unbearable suffering where there was no potential for improvement, concern Keown. In the Netherlands and Belgium, euthanasia has been approved for conditions including tinnitus (Yuill, 2015), alcoholism (“My alcoholic brother chose euthanasia,” 2016), and various mental health problems (Bostaz, 2016). Precisely, because of concerns about the practical slope, some authors argued against efforts to expand the Dutch law to recognize euthanasia requests from persons who are “tired of living” (see, e.g., Florijin, 2018).

Finally, Keown’s elegant analysis can be read as a warning about the ways in which terms and themes such as dignity, mercy, and compassion are used in radically different ways to justify opposite positions. Appreciation and awareness of this may help Christians to resist the corruption of fundamental Christian virtues and commitments and prevent them from being misled into supporting euthanasia or PAS.

When Are the Dead Dead?

Patrick Lee continues an important discussion among many Roman Catholic thinkers, including Jason Eberl (2015, 2020), Melissa Moschella (2016, 2019), and Josef Seifert (2018), regarding how to understand death, particularly the use of neurological criteria to define death. Lee focuses on how a Roman Catholic understanding of the human person and the soul informs an understanding of death. His contribution is particularly timely, given the vibrant debate in the current literature and public policy settings regarding the definition and diagnosis of death. At the time of this writing, we are awaiting the decision of the Uniform Law Commission (ULC) regarding establishment of a Drafting Committee to revise the Uniform Determination of Death Act. In July of 2020, the ULC Committee appointed a Study Committee to assess the need for a revision to the law (ULC, 2020). At issue are a number of factors that have been the subject of extensive debate in the medical, legal, and bioethical literature for years, including the “lack of uniformity in the medical standards used to determine death by neurologic criteria, the relevance of hormonal functions, and whether notice should be provided before a determination of death” (ULC, 2020). Numerous concerns with the existing law or application of it, as well as proposals for revising the UDDA, have been published in recent years (see, e.g., Lewis et al., 2019; Shewmon, 2021).

In his contribution to this issue, Lee defends the use of neurological criteria to define death on his understanding of what it is to be a human being. Contrary to Seifert’s (2018) objection to Lee and Grisez’s (2012) previous work on brain death, Lee argues here that his defense of “brain death” does not reflect a reductionist view of the human person. Rather, it is grounded in a particular understanding of the nature and connections among the human being, human person, soul, and brain:

Conscious sensation in human beings presupposes brain activity. In human beings conscious sensation is an activity that requires the brain as part of the bodily organ of that activity. So, if an entity lacks a brain, and lacks the capacity to develop a brain, then it lacks the radical capacity for conscious sensation, and the radical capacity for rational action. It follows that a brain-dead body—which lacks both a brain and the capacity to develop a brain—lacks the radical capacities for conscious sensation and rational action, and so a brain-dead body is not a rational animal, not a human being. (Lee, 2022, 43)

Amidst ongoing secular debates regarding neurological criteria for death and the diagnostic criteria that should be applied to diagnose death, Lee’s analysis elucidates some of the differences among Roman Catholic thinkers on this matter in helpful ways.

Allocating and Rationing Scarce Resources

Maura Ryan (2022) explores long-standing ethical issues related to resource allocation, the rationing of scarce resources, and access to health care more generally as they arose in pandemic. Resource allocation refers to the distribution of resources. This includes decisions to dedicate resources to health care versus other areas of spending, such as education or transportation, as well as decisions to allocate resources to particular types of health care. When resources are scarce, they are rationed, that is, some people who could benefit from a resource will be excluded and denied access to the resource in question.

In her contribution to this issue, Ryan connects this inquiry into decision-making regarding resources during the pandemic to larger questions about how Christians understand the purpose of health care and obligations to the ill and dying among us. Ryan’s piece challenges readers to examine allocation and rationing decisions with an honest, critical eye to see which lives are “de-valued” and how implicit assumptions about social worth and quality of life shape them. As states and institutions developed crisis standards of care during the COVID-19 pandemic, some patients were deemed ineligible for treatment or de-prioritized so much that they would be unlikely to receive treatment. Although allocation decisions often are described as grounded in the “best available objective medical evidence,” Ryan demonstrates that such judgments often are said to be “not entirely objective.” In the context of the COVID-19 pandemic, claims that allocation decisions were based on “objective medical evidence” were especially problematic, given the lack of evidence available and the significant amount of unreliable information that was treated as “evidence.”

Allocation decisions and policies during the pandemic, Ryan argues, reflected often-unacknowledged social worth judgments. Such judgments are not new to health-care allocation decisions. The Seattle “God Committee” on dialysis is a familiar example of applying social worth criteria to allocation decisions (Alexander, 1962). The literature on allocating other scarce resources, such as organs for transplantation, also addresses the role of explicit and implicit value judgments in decision making (Frank, 2014; Cahn-Fuller and Parent, 2017). Even where there are no concerns about rationing, that is, allocating scarce resources, other routine practices and recommendations in medicine may reflect similar judgments. For instance, decisions to recommend prenatal genetic diagnosis or prenatal testing for particular conditions and not others may reflect views about lives of persons with certain disabilities and judgments, what kinds of lives are worth living and which ones are not (Iltis, 2016).

Drawing on the long history of thinking about allocating health-care resources and rationing scarce resources in the Roman Catholic tradition, Ryan argues that secular utilitarian reasoning problematically informs many efforts to justify particular distribution schemes. Moreover, distribution decisions get an inappropriate amount of attention. They should not be the ultimate focus of inquiry and assessment in bioethics. She situates such choices in the broader context of “tragic choices” and argues that the obligations we have to those who receive low priority or are deemed ineligible for aggressive treatment merit serious consideration. The obligation to care does not end when treatment is denied.

IV. THE FUTURE OF BEING HUMAN

Jason Eberl examines Transhumanism, “a cohesive movement guided by a particular set of tenets articulated in the ‘Transhumanist Declaration’ (2012)” and identifies “fundamental differences between Christianity and Transhumanism” that render them incompatible (2022, 76). He also distinguishes Transhumanism, which he sees as a “quasi-religion,” from “human enhancement using biotechnological means” and argues that some “moderate forms of human enhancement using biotechnological means” are licit within the Christian context, even though Christianity and Transhumanism are incompatible (Eberl, 2022, 76). The central tension between Transhumanism and Christianity arises from “their respective anthropologies—that is, their diverse understandings of whether there is an essential nature shared by all human persons and, if so, whether certain features of human nature may be intentionally altered in ways that contribute how each views human flourishing” as well as their “competing concepts of the future for both humanity and the cosmos” (Eberl, 2022, 77–78). Their competing views of the relationship between children and parents underlying Christianity and Transhumanism also puts them at odds. Eberl notes that “Christianity views children as a ‘gift’ from God, whereas Transhumanism allows for children to be viewed as a ‘product’ to be fashioned” (2022, 79). Finally, Christians and Transhumanists have different understandings of the future. Whereas “Transhumanists seek to make the future by shaping the actualization of human potentialities and those of nature more broadly . . . Christians live in hope of the coming of God’s Kingdom . . .” (Eberl, 2022, 78). This hope and focus, he notes, “does not entail passivity” or a rejection of the application of science to promote human flourishing; rather, it involves an orientation to God and a fulfillment of His Kingdom that Transhumanists lack.

Although Christianity and Transhumanism are incompatible, Eberl demonstrates that not all human enhancement is properly situated under the umbrella of Transhumanism and that Christianity is compatible with and might even call for certain forms of human enhancement. He examines Roman Catholic and other Christian accounts of enhancement and human flourishing and argues in favor of some forms of human enhancement. Eberl draws on a number of authors, including H. Tristram Engelhardt, Jr., in beginning to elucidate the Christian constraints on human enhancement:

Any account of the proper use of genetic engineering will need to be embedded in Christianity’s rich knowledge of the meaning of the universe, human history, and the moral significance of human nature. Central to all reflections in this matter is the circumstance that God created human nature as good and appropriate, and that this very nature, albeit fallen, was taken on by Christ and redeemed. (Engelhardt, 2008, 80 in Eberl, 2022, 79)

Eberl sums up a Christian understanding of limits on human enhancement this way:

The normative limit on forms of human enhancement is to ensure that the subject of enhancement remains human and is not transformed into a “posthuman” whose self-identity, needs, interests, and teloi (both natural and supernatural) are so fundamentally altered as to be unrecognizable to the subject prior to enhancement. (2022, 85)

Human enhancement should aim at the human ideal and not at creating entities that are different from human beings.

In addition to articulating limits on enhancement, Eberl opens up the possibility that on some Christian views, certain forms of enhancement are to be encouraged. Permissible and perhaps even laudatory forms of enhancement are to be “aimed at appropriate teloi oriented toward the actualization of natural human potentialities relative to our existence as living, sentient, social, and rational animals” (Eberl, 2022, 85). Among the examples Eberl offers are “increased memory capacity, a more robust immune system, alleviation of moderate social anxiety, and elimination of certain cognitive biases that contribute to poor practical reasoning and subsequent unethical behavior” (2022, 85).

Eberl’s contribution comes at a time when the possibility of new forms of human enhancement through future applications of genome editing are growing ever closer. The parameters Eberl establishes for permissible human enhancements from a Christian perspective will leave questions. Nevertheless, his contribution here advances a framework for future elaboration and application.

The contributors to this special issue of Christian Bioethics grapple with pressing issues facing Christian scholars, practitioners, and individuals. The writers contribute to ongoing debates in public policy settings and in the bioethics literature, as well as fundamental questions about the shape and character of scholarly contributions to the field. Each essay fosters thoughtful Christian dialogue and advances our understanding of long-standing and emerging topics.