To cut or not to cut: the circumcision wars

 

The American Academy of Pediatrics recently revised its policy on male infant circumcision. Its former policy, formulated in 1999, held that there were “potential” benefits to circumcision, but not enough to recommend it routinely. The new policy, drafted after a review of the most recent medical studies, states that the potential benefits of circumcision outweigh the potential risks, and that “the procedure’s benefits justify access to this procedure for families who choose it.” The benefits are not strong enough to recommend universal circumcision; the policy states that the decision should be left to parents.

Is this a major ethical issue? There are many groups that ardently believe it is. Anti-circumcision groups (“Intactivists”) have raged against the policy statement. Listening to the argument from both sides is like a primer on ethical theory.

One side appeals primarily to consequentialist or utilitarian arguments: the overall benefits outweigh the overall risks, so it’s ethically permissible. The other side responds to the consequentialist arguments (“You overstated the benefits and understated the risks!”), but uses primarily deontological arguments: to do a medically unnecessary procedure is always wrong. Genital integrity is a human right. From a virtue ethics viewpoint, circumcision proponents have portrayed the decision to circumcise one’s infant son as an example of virtuous parenting, and I can imagine an “intactivist” group asking, “What kind of doctor (or parent) would do that?”

The argument has also been couched in the language of The Four Principles. Some appeal to non-maleficence: to circumcise risks causing harm, so it should not be done. Others appeal to beneficence: circumcision might do some good, so it is justifiable. Others cite autonomy as the most important principle: an infant cannot consent to a circumcision, so it should not be done before adulthood and only if the patient consents. There are even appeals to justice; a recent article in the Archives of Pediatrics and Adolescent Medicine estimated that the avoidable medical costs to the US medical system caused by the decline in circumcision rates could exceed $4.4 billion.

On the surface, the current debate over circumcision is unresolvable, because the argument isn’t about verifiable scientific data; the different sides are speaking different ethical languages. Depending on which ethical calculus one uses, either side could be understood to have the more compelling position. The debate also highlights the glaring weakness of appealing to the Four Principles to resolve ethical differences: there is no inherent hierarchy for which principle is more important, and in the case of infants the usual recourse to “Autonomy trumps everything else” doesn’t work well.

I am personally agnostic on the question. I perform circumcisions, so I suppose that excludes me from the “intactivist” camp. But I do not advocate for or against circumcision; I find that most parents come with an idea of what they want to do, and nothing I say in the informed consent changes that. I think the vehemence of some on either side is misplaced; on a topic of such “un-clarity,” a charitable tone is far more appropriate than incriminating rhetoric.

Reflections on mowing the lawn (and bioethics)

The other day I was mowing our lawn and since mowing doesn’t require a lot of thought I had some free time to think. My wife says it isn’t normal, but when I have time to think I commonly think about why things are the way they are or why I do the things I do. So since I was mowing and thinking I began to think about why I mow the yard. I decided that I had a biblical foundation for lawn mowing which was found in Matthew 5:9 in which Jesus says “blessed are the peacemakers.” As I probed my deepest motivations for lawn mowing I realized that I do it primarily for my neighbors with whom I desire to maintain peace. If I had no neighbors or if they all placed lawn mowing as low on their list of priorities as I would if left to myself, my lawn would suffer. But in every place my wife and I have lived we have had at least one neighbor who saw lawn care differently. The very first house we lived in had a neighbor across the street whose lawn was so well manicured that the maple seeds stood up vertically when they fell so he could pick them out by hand. As I reflected further I realized that those neighbors have a different biblical foundation for the care they give to their lawns. It is found in Genesis 1:28 in which God blessed the first humans and charged them with being the stewards of the earth. They manifest human dominion over the earth in the property around their home. I mow so they don’t rescind the welcome we received when we moved into the neighborhood. We have different motivations, but we accomplish the same task (almost).

Those who have read this far may be wondering what this has to do with bioethics, but I wasn’t finished mowing or thinking. Before I had gone out to mow I was grading assignments for an online bioethics class I teach. One of the case studies involves the ethical dilemma faced by a couple that I knew in which the wife discovered she had breast cancer early in a pregnancy and had to decide whether to abort the fetus to be able to receive the most effective treatment for her cancer or to limit the treatment to what could be done without harm to the fetus, but lessen her own chance to survive. I ask the students to reflect on what they would do in her situation and why. I get a number of different responses with a number of reasons for why they have made their choice. For those who say they would choose as our friend did to limit treatment to allow her daughter to be born unharmed, there are two primary reasons. One fits the way I think and tend to teach, which is to analyze the ethical issues and find the moral principles involved to decide which of the options is morally permissible and which is not. The other simply says “my love for my unborn child would be so great that I could never do anything to harm her.” Their response helps me remember that God has not made us all to think the same way. My wife says that our living together for 37 years should have taught me that by now.

God knows how he has made us and the variety he has in his creation. He knows how to communicate his moral truth to us in that variety. Just as my neighbor and I have different reasons for why we mow our lawns, we can have different ways to get to the same moral truth that is grounded in the nature of our God who is good.

Bonhoeffer and ethical principles

I just finished reading Eric Metaxas’s excellent biography of Dietrich Bonhoeffer. Two weeks ago I wrote about how Bonhoeffer’s upbringing led to his unique ability to combine reason and faith in his theology and his life. This week I would like to reflect on his understanding of ethical principles.

Dietrich Bonhoeffer was raised to believe and live by strong moral principles, as were many in German society. Early in Hitler’s ascent to power Bonhoeffer recognized that Hitler’s desire to exclude those of Jewish heritage from participation in German society was a serious violation of the principles of justice and the universal value of human beings long before Hitler began his mass murder of the Jewish population. As Hitler sought to limit the participation of Christians with Jewish heritage in the German national church, Bonhoeffer saw that as a violation of the principle of the unity of the church that was foundational to the gospel. That violation of principle was sufficient reason for him to be a founder of the confessing church in Germany that claimed that such a foundational violation of Christian principles meant that the national church was no longer a valid church and that true Christians could no longer be a part of it.

However, Bonhoeffer also saw that there were limitations to ethical principles. Many of the leaders in the church in Germany and many of the military leaders in Germany who were devout Christians had as one of their basic moral principles that they should be subject to the government of their nation and not violate its laws or disobey military orders. When they found themselves serving a government and national leader who were doing things that violated their moral principles of justice they had a moral dilemma that they had much difficulty resolving. Hitler was able to use the principles of his opponents who sought to be law-abiding citizens and obedient soldiers for his advantage.

Bonhoeffer himself faced an even greater ethical dilemma. After years of standing up for the moral principles of biblical Christianity and those churches who were willing to hold to the truth of scripture against those who sought to destroy those things, he learned that there was a group of military leaders that included his brother-in-law who were plotting to assassinate Hitler and bring down the Nazi government. They desired for him to be a part of their conspiracy and he had to choose whether he should be a part of killing a ruthless and evil dictator. By that time Bonhoeffer was aware of the mass murders of the mentally disabled and Jews that many in Germany and the rest of the world did not know about. He understood how evil Hitler and his followers were, and yet he also understood how wrong it is both to kill another human being and to assassinate the leader of one’s own country.

Bonhoeffer’s answer to this dilemma was found in his theology and his personal faith in Christ. He understood that to be a Christian was to be obedient to the call of Christ. He understood that moral principles were grounded in the goodness of God, but that there are times when moral principles can fall short of being able to guide us. At those times obedience to God is more important than anything else. He was clear that God had called him to do all he could to put an end to the evil of Hitler’s reign, so he joined with the conspirators and was hanged just before the end of the war for his part in their failed attempts to kill Hitler. Although I would hope that none of us ever face anything like what Bonhoeffer faced, we can learn from him. As we face the bioethical issues of our day we rely on ethical principles based on our understanding of God’s revealed truth to know what is right. That is good. However, it is not the principles, but God himself who is good and who is the foundation of all we believe and the guide for how we live.

Faith and reason: Bonhoeffer and bioethics

I am currently reading the biography of Dietrich Bonhoeffer written by Eric Metaxas. As I have been reading about his early life, I have been struck by how his family impacted his development as a theologian. He inherited from his parents a brilliant mind and a gift for music. From his father who was a prominent psychiatrist/neurologist, research scientist, and professor in Berlin he learned a rigorous use of reason and appreciation for truth. From his mother he learned a deep personal faith in God expressed in music and worship. All the Bonhoeffer children were very capable and great things were expected from them all. His oldest brother was an eminent nuclear physicist. Dietrich surprised his family with his choice of theology as his field of study. He surprised even more as he forged his own path very different from that of the prominent theologians of Berlin as he completed his PhD by age 21.

Bonhoeffer pursued an intellectually rigorous study of the truth about God. Unlike his professors who saw the Bible from the prevalent view of historical textual criticism as something that was man-made and in need of being torn apart and put back together, Bonhoeffer saw the Bible as God’s revelation of the truth about himself to us. His study of theology combined reason and logic with a personal relationship with the God who he studied. He astounded the leading theologians of Germany with a well-reasoned position that they had to respect even though it totally contradicted their own positions, and yet he was very capable of expressing that truth to children that he taught as an associate pastor.

Reading about Bonhoeffer’s life has made me think of how we combine faith and reason in bioethics. Application of God’s moral truth to the complex issues of medicine and biotechnology requires us to reason clearly and rigorously, yet our pursuit of bioethics is not just an academic endeavor. The reason that we are concerned about what is right and wrong is that we know and worship God who is by his nature good and desires his children to live according to what is good. He desires for us to care for those who are hurting and to protect the weak and oppressed. He wants us to have his heart for them. We should be as academically rigorous as young Bonhoeffer’s challenge to the theologians of Berlin and as compassionate as his caring for the lives of the boys he taught in the toughest part of inner city Berlin.

Prayerfulness on the Hospital Ward

As I have visited a family friend in the hospital the last two weeks, I have been reminded of the importance of a spirit of prayer when working or visiting at a hospital.  Aside from all our impressive technology and reams of laboratory data, there is a lot that is unknown and beyond our control.

In times past, prayerfulness went hand in hand with medical practice for two reasons.  First, medical cures were much more limited than they are today.  In the days before antibiotics and anesthesia, there was a lot less the physicians of that era could do compared to the doctors of today.  It was only natural to regularly turn to prayer to entreat the One on high for healing.

And, secondly and most notably, in times past hospitals were Christian endeavors.  The chaplain was the daily partner with the physician in caring for the sick.  The very foundations of these hospitals were laid with the knowledge that all healing ultimately comes from the One who is the Great Physician and who left us a record of what a healing ministry looks like.

Ethical uncertainty

A few days ago I sensed that the students in my medical ethics class left feeling frustrated. We had been talking about whether it was ethically permissible from a Christian worldview to use in vitro fertilization for treatment of infertility. We agreed that the creation of excess embryos that would not be implanted was not permissible and that there were serious concerns about conceiving a child by the use of donor eggs or sperm and by the use of a surrogate mother. We had difficulty agreeing on whether IVF itself without any of those things was permissible.

We could see that some people would see IVF as a reasonable way to treat the problem of infertility and find it permissible as long of the other things we had concerns about were avoided. We also saw how others would see that there were things inherent to IVF that would make them think that it was not permissible. Those things included the separation of conception from the natural expression of love in a marriage, the instrumentalization of the body, treating the making of a child like a manufacturing project, and destruction of embryos in the development of the process of IVF and by those who practice IVF even if not done in this specific instance. The question was whether those things were significant enough to override the good of having a child.

We were not able to resolve this. That left the students feeling uncomfortable.

For many of the things that we face in life it is clear what is right. Our biggest problem is actually doing what we know to be right. But there are some times when it is not so clear what is right. Even Christian ethicists whom we respect may not agree on some issues. Learning how to deal with uncertainty is a difficult thing to do. It takes a fairly high level of maturity to learn how to make the best choices we can and trust God to help us find our way when things are uncertain. Life is not always clear. I hope that one of the things my students can learn is that we can trust God even when it is difficult to see clearly what the right choice is in a specific situation.

A place for common morality

Although the weather in the Midwest does not seem as much like winter as it usually does at this time of year, I just received the winter edition of Dignitas from CBHD. In the lead article Erik Clary makes the astute observation that when those who have been trained as Christian theologians abandon their Biblical foundations and use the methods of secular philosophy, the ideas that they propose lose their Christian distinctiveness. He traces the loss of influence of Christian thought in bioethics to those who have identified themselves as Christian theologians, but have left that biblical foundation.

His examples are James Childress, who paired with philosopher Tom Beauchamp to introduce principilism to bioethics, and Joseph Fletcher, who introduced a capacity based concept of personhood to bioethics. In Fletcher’s case he abandoned the biblical foundations of Christianity to the point that he eventually rejected Christianity altogether. The concept of capacity based personhood has extensively undermined the theological concept of the inherent dignity of human beings based on being made in the image of God.

It is true that there are problems with Beauchamp and Childress’ principle based system of bioethics. Their concept of common morality lacks a solid foundation. That probably comes in part from an abandonment of biblical authority on Childress’ part and a desire to appeal to everyone in a multicultural society. Because of the lack of solid foundation there is the ability to emphasize various principles as one desires to support one’s own biases. But there is something about the use of common morality that should appeal to Christian bioethicists.

While we need to be solidly grounded in the Bible as the source of moral truth, and never drift into ethical concepts that contradict that truth, we also need to find ways to communicate the theologically grounded moral truth that we have to those who do not yet realize the value of what God has communicated to us in the Bible. That’s where common morality comes in. As a Christian I understand that God has communicated his moral truth both specifically through scripture and more generally through what he has written on the heart of every human being deep in our conscience. Although Beauchamp and Childress do not seem to understand the foundation of common morality, they understand that it is there. Recognition of the presence of basic moral truths that are known to all who are willing to reflect seriously on them no matter what culture they belong to is a beginning point to understanding that there are objective moral values that go beyond personal reasoning and societal culture and point to an authority beyond us.

An understanding of the existence of common mortality can lead to knowing that there must be a source of moral truth and the need to be reconciled to that source. Until people see that, the Christian message of God sending his son to redeem the world doesn’t make sense. Common morality can be one step along the path to a relationship with God.

How nonmoral beliefs impact our moral decisions

When people try to support a belief in cultural relativism they often point to the diversity of moral practices in different cultures. One of the ways to explain how that diversity can exist even if morality is really based on objective moral values that are universal is to show how two cultures with similar basic moral beliefs can have different moral practices due to differing nonmoral beliefs. The treatment of the elderly by Eskimos is a common example. However a recent discussion in my medical ethics class reminded me that differing nonmoral beliefs can lead to differences in the ethical judgments we make as individuals as well.

The class was discussing the case of a patient with ambiguous genitalia who sought care at age nineteen wanting to know why she had never menstruated. The physicians discovered that even though the patient had a generally female body type and had been raised as being female this person had no female genitalia and was genetically male. We were discussing whether it was permissible for the physicians to withhold the information that the patient was genetically male. The class was divided with some saying the whole truth needed to be revealed and others saying that to do what was in the best interest of the patient it was permissible to withhold that information.

As I reflected on how the students had supported their positions it became clear that there was a difference in the nonmoral beliefs between the two groups of students that led to their different moral positions, even though they all had very similar basic moral beliefs. Some of the students believed that gender was determined by genetics and this patient was truly male. They were the ones who said it was not permissible to withhold the information that the patient was genetically male. The other group of students believed that there were other things besides genetics that entered into the determination of gender (such as the influence of hormones on fetal development at certain critical times in development and socialization based on the assumed gender from body type). They were the ones who thought it was permissible to withhold the information.

I had intended for the case discussion to be focused on what it means to tell the truth and whether that always needs to include the whole truth. The students’ responses reminded me how important our nonmoral beliefs are in making moral decisions.

Costly grace and bioethics

I am currently reading Dietrich Bonhoeffer’s book, Discipleship, and thinking about how what he said relates to bioethics. One of the significant concepts in this book is the idea of costly grace. Bonhoeffer wrote “It is costly, because it calls to discipleship; it is grace because it calls us to follow Jesus Christ. It is costly, because it costs people their lives; it is grace, because it thereby makes them live. It is costly, because it condemns sin; it is grace, because it justifies the sinner. Above all, grace is costly, because it was costly to God, because it costs God the life of God’s Son – “you were bought with a price” – and because nothing can be cheap to us which is costly to God. Above all, it is grace because the life of God’s Son was not too costly for God to give in order to make us live.” (45)

One of the difficulties of Christian ethics (including Christian bioethics) is that when we focus on doing what is right it can seem like we are saying that doing what is right is necessary to gain God’s favor and that we are negating the foundational Christian doctrine of salvation by grace. That was a significant issue in Bonhoeffer’s Germany. The established church had taken a position which Bonhoeffer called cheap grace. They were saying that since God’s grace is freely given and we can do nothing to earn it, we should not try to do what is right, but should conform to the standards of society to show that our salvation is entirely free and not related to any effort of our own. That led them to conform to the Nazi regime’s practices that were engulfing their country and not to oppose them.

Bonhoeffer helps us to see that Jesus has paid the price for our salvation and that we can do nothing to earn it, but that God’s grace calls us to be disciples of Jesus. As we seek to follow him by the power of his Spirit and his transforming grace, we will seek to live by his standards. The moral reflection of Christian bioethics helps us to understand how God would have us live in response to his grace in our increasingly complex world.

Bonhoeffer, Dietrich. Discipleship. Minneapolis: Fortress Press, 2003.

Bioethics and Christmas part 3

Over the last two weeks I have been reflecting on how Christmas relates to bioethics. My thoughts were focused on how Jesus’ incarnation helps us understand the inherent moral value of every human life and particularly the value of unborn human beings. But I think there is another way that Christmas relates to ethics that may be even more significant.

One of the problems with ethics in general and bioethics in particular is that none of us lives up to even our own ethical standards. All of us, whether Christian or not, understand that there are ethical standards that we ought to live up to, but we are not able to do it. Ethics by itself raises the problem of our being unable to live up to ethical standards, but it doesn’t give us a good solution. One way to respond to our inability to live up to ethical standards would be to give up in despair. Jesus’ incarnation gives another alternative, hope.

When the angel announced Jesus’ birth to the shepherds outside of Bethlehem, the message was “I bring you good news that will cause great joy for all the people. Today in the town of David a Savior has been born to you; he is the Messiah, the Lord.” (Luke 2:10-11 NIV) The joy in that message is based on the hope it provides. The angel gave us the answer to the problem raised by ethics. Since we all fall short of both our own standards and God’s, we need help. The angel announced that the help we need is the Messiah who has come to be our savior. Instead of despair at our inability to live up to moral standards there is hope, hope that begins with the arrival of God in the form of a baby born in a stable and lying in a manger.

Glory to God in the highest!