Review: Religious and Secular Medical Ethics: Points of Conflict (Georgetown University Press 2012)

[1] Robert Veatch, is professor of medical ethics at Georgetown and author of numerous books on bioethics including his classic Transplantation Ethics. This book is a revision of his Gifford Lectures at the University of Aberdeen. The book combines historical, philosophical, and theological analysis to make a strong argument for why the ethical codes propagated by professional societies such as the American Medical Association, cannot serve as morally neutral or universally acceptable codes of ethics. These codes cannot serve as neutral guidelines for professional practice since some medical practitioners adhere to faith traditions that have their own teachings on how adherents should value, evaluate, and interact with human life.

[2] The book’s first chapter is a fascinating history of the Hippocratic Oath, from what can be known about its origins to contemporary attempts to use the code as a “universal ethic” for medical practice. Veatch notes the oath’s religious roots, since its oldest forms invoke Greek gods to ground its authority and claims, and seems to have led one as an initiate into a cultic practice. Yet, he argues that even when one removes these references to the gods as is often done at medical school graduation ceremonies, it still cannot provide a sound ethic for contemporary medicine. Some of its claims seem oddly outdated, including its prohibition on surgery given the rise of technology. Other claims made by the oath seem out of character for the ways contemporary societies view the role of the physician. For instance, in the era of the Health Information Portability and Privacy Act, the Hippocratic Oath’s claim that the physician can make the decision about what information and to whom it should be disclosed seem paternalistic.

[3] In addition to the Hippocratic Oath’s religious roots, Veatch shows that the code was never widely used. Thus, claims that the oath had wide acceptance as a basis for ethical medicine are untrue. Christian commentaries on Hippocratic medicine before the Middle Ages make little reference to an “oath”. Some medieval commentators modified the oath to bring it into harmony with Christian beliefs. Yet, Veatch argues that the fact that communities needed to modify the oath to bring it into harmony with religious views proves that the oath is not theologically neutral. In the Christian tradition church fathers such as Jerome and Gregory distinguish Christian medicine from “Hippocratic medicine.”

[4] Veatch’s next chapter looks at the Hippocratic tradition, and finds that while there is sporadic discussion of it in both England and on the European continent during the Renaissance, there is no indication that it was universal. In fact, he shows that rather than relying on a code of ethics determined only by the medical profession, physicians were often in conversation with philosophers and theologians about ethical matters. Not only does that mean that codes of medical ethics were not generated simply by physicians; it means that earlier physicians realized that they needed to be in conversation with other moral traditions and thought systems. Hence, common claims by some that medicine has its “own internal ethic” without reference to outside religious traditions are less convincing.

[5] Yet, the Hippocratic Oath was taken up, at least in some form by early American medical societies. (The American Medical Association was founded in 1847.) Veatch argues that this early code was paternalistic, consequentialist, and individualistic, in ways that contemporary medical ethics, and indeed much of American society would find problematic. One of the weaknesses of Veatch’s book is that it does not recognize cultural differences in what is considered ethical interactions between patients and physicians.

[6] From this survey of the Hippocratic oaths, Veatch turns to the issue of oath taking, which is to say, the practice of publically committing to a value system imposed by a professional organization upon students. The book argues that taking an oath or making a pledge to a professional society’s ethical statement causes one to forgo the moral and ethical traditions from outside the tradition that brought one to the professional practice in the first place. For instance, the American Medical Association may say that abortion is legal, while a devoutly Catholic physician who believes that life begins at the moment of conception, may feel that it is not based on the values and ways of viewing life that one brings from a religious community. Veatch questions the wisdom of having individuals leave one set of moral understandings behind so early in their careers, to swear an oath to which they are not committed.

[7] As a Lutheran ethicist, I was wondering what Luther’s two-kingdoms doctrine might say about the role of the physician and medical ethics. Which hand of God’s does the physician belong to? Even if one could decide this question, it is unclear what rules and procedures a “Gospel-based medicine” would allow or not allow. As Veatch notes, even religious values can be problematic in medical encounters because the patient might (and often does) come from a religious tradition and system of values that is different. Besides, given that Scripture gives so little specific guidance on medical decision making, what is the role of reason, as opposed to revelation in making medical decisions in contemporary contexts?

[8] Indeed, Veatch argues that professionally generated codes are problematic, since what constitutes health, healing, and flourishing are often moral decisions made from non-medical sources, not decisions made internal to medicine. He states, “Insofar as the license to practice medicine proves a socially conveyed authority, it seems reasonable that the society, not the profession, should be the authority to determine whether it is acceptable for licensed health professionals to provide services.” (p. 86) He then goes on to discuss three issues that some physicians are involved in that religious traditions can find problematic: capital punishment, surrogate motherhood, and giving or withholding artificial nutrition and hydration to patients in various states of consciousness.

[9] Veatch’s next chapter argues that religious values can serve as a foundation for medical ethics. He argues that expertise in medical science does not make one an expert on the application of moral norms to that science, and that such norms need to be applied in discussions with experts in moral theory. I’m wondering though, based on my experience, if one needs training in both ethics and medicine to apply the rules well. The converse of Veatch’s arguments are true, especially in context cases, one cannot simply apply moral norms to science if one does not understand the science involved.

[10] Religious truths can conflict with Hippocratic medicine and Veatch notes, “t​he Hippocratic Oath’s claim that knowledge of the group is esoteric, potent, and secret, leads to the historical claim that only members of the group can know what is morally required for its members. These claims, however, are directly in conflict with similar claims made by advocates for religious traditions that believe in the religious relation of moral truths.” (p. 107) He explores the work of Karl Barth and Stanley Hauerwas to show the ways in which they claim that religious revelation has direct bearing on the practice of medicine. This chapter also contains as short discussion of the Lutheran tradition of Medical Ethics, and I think that Lutheran readers will find it both wanting and inaccurate. Veatch uses Luther’s views on the ability of a reader to understand Scripture fused with a notion of the priesthood of the believer to make an argument for what a “Lutheran” approach to a medical records department might look like. One wishes he could have turned to Luther’s statements on suffering or what Lutheran thought might say about topics of medical ethics. He notes too that for Roman Catholic physicians who adhere to medical traditions based on natural law and church authority, it would be illogical to surrender to a professional code that claims makes ethics without recourse to the narratives, principles, and understandings that make the Catholic tradition coherent and distinctive.

[11] The book then turns to the ways that secular philosophical schools might generate a common morality for medical practice from outside the tradition. This brief tour of complex figures like John Rawls and Immanuel Kant does raise interesting points, but philosophically informed readers will probably feel that the discussions are simply too short to do justice to these figures relation to medical care.

[12] Finally, the book closes by arguing for points of convergence between the schools. He argues that the only hope for a common medical ethic is for an overlapping consensus. Religious people can bring what they believe to be known by revelation and non-religious people bring what they can know by sense or experience in hopes of finding common ground. I am not sure that such an ethic would solve the problems of the conflict between religious and non-religious views of human life at the very beginning and end of human life. Indeed where the knowledge overlaps, there is no conflict between physicians and religious people. But the book concludes that individuals should be able to find like-minded doctors who share their commitment to revealed truth, and allow them to practice medicine in accordance with those truths, instead of in accord with the imposed norms of professional societies.

Aaron Klink

Aaron Klink is Chaplain at Pruitt Hospice in Durham, North Carolina.  He received his MAR is Systematic Theology from Lutheran Theological Seminary at Philadelphia, his M.Div. from Yale and a ThM with a concentration in Ethics from Duke Divinity School.