The Cambridge textbook of bioethics

Mrs. G is an 85-year-old resident of a Jewish long-term care facility who has vascular dementia, controlled heart failure, and diabetes mellitus. She is bed bound and occasionally recognizes her daughter with a slight smile. The gastrostomy feeding tube she received two years ago has begun leaking and needs to be replaced. Her daughter, who has become her surrogate since the recent death of Mrs. G’s husband, has indicated that if the tube were to come out, she would not consent to the insertion of a new tube: a decision she feels would be in accord with her mother’s wishes. She would not, however, request that the tube be deliberately removed. The staff are concerned that, by not replacing the tube, they would be failing to maintain the current level of treatment, and she would starve. They feel that this would amount to taking the mother’s life, without any substantial decline in her clinical condition. The daughter acknowledges the concern and devotion of the staff and her mother’s unchanged clinical status, but reiterates her belief that her mother would prefer to be allowed to die rather than be force fed through a gastrostomy tube.

What is Jewish bioethics?

Judaism

Judaism is the religion of the Jewish People. Judaism is a 3500-year-old tradition based on foundational stories in the Pentateuch – the five books that make up the Torah. In the first book, Genesis, the Jewish people become defined as the descendents of the

monotheists Abraham and his wife Sarah. The Torah chronicles the people’s covenant with God, deliverance to the holy land, exile and slavery in Egypt, acceptance of the laws of Moses at Sinai, and ends as the people are delivered back to the promised land of Israel. The rest of the Hebrew Bible (Tanach/Old Testament) tells of many centuries of prophets and kings, tribal rivalries, and conflicts with neighbors, as well as the temple in Jerusalem and the priests who kept the holy books. It ends with another story of exile and return, this time from Babylonia. In the ensuing centuries, from 500 BCE on, temple ritual and sacrifice evolved into syna- gogue-based communal prayer and study. With the temple’s final destruction in 70 CE, ancient oral traditions became written in the Talmud. The practice of seeking wisdom through ongoing study of the holy books became a central feature of Jewish existence that persists and thrives today. In the past century, the Jewish people have suffered the trauma of losing six million people to Nazi genocide, and the joy of returning to full nationhood once again when the State of Israel was established in 1948.

Jewish bioethics

Although discussions of medical ethics have been recounted in Jewish writings since ancient times, modern medical technologies have placed new challenges before interpreters of Jewish tradition

(Green, 1985; Feldman, 1986; Rosner, 1986; Rosner and Bleitch, 1987; Novak, 1990; Meier, 1991). The zeal with which these questions have been addressed has given rise to the field of Jewish medical ethics, which has developed since the 1960s. In keeping with Jewish ethics generally, Jewish bioethical inquiry appeals to the principles found in Jewish scriptures and commentaries and applies them to clinical decision making. In doing so, it takes a duty-based approach rather than the predominantly rights-based approach characteristic of some contemporary secular bioethical approaches. As the late Benjamin Freedman (1999) pointed out, ethical deliberations that are focused on rights often help in solving the procedural question of who gets to make a decision, but they do not necessarily offer guidance as to what that decision ought to be. Framing a dilemma in terms of the duties owed to those involved can clarify the issues and suggest a satisfactory course of action.

Interpersonal behavior in Judaism is traditionally conceived as the execution of duties within the context of one’s relationships with other humans and with God. Accordingly, a preoccupation with rights implies, firstly, the relative isolation of individuals making claims upon one another and, secondly, an implicitly or overtly adversarial relationship. In a ‘‘regime of duty,’’ participants seek to enable each other to satisfy the obligations inherent within relationships (Freedman, 1999), including professional relationships. Judaism urges one to perform mitzvoth (good deeds); that is, to act in accordance with one’s duties, and this applies in the healthcare setting no less than anywhere else. The clinic thereby provides a relatively new arena in which mutual obligations between patients, healthcare providers, and families can be explored. Such explorations inevitably begin with the established norms of Jewish law and behavior, collectively known as Halacha (literally, ‘‘the way’’).

A variety of approaches

Traditional Jewish legal and ethical thinking is based on reading and interpreting three main

sources, each of which is vast, varied, and complex. The oldest and most authoritative is the Hebrew Bible, which includes the five books of Moses (the Torah), the Prophets, and the Writings. The second source is the Talmud, which is composed of multilayered commentaries on biblical texts and oral traditions by learned rabbis of the second to fifth centuries CE. To make the voluminous Talmud more accessible, several great codifications of Jewish law emerged that attempted to summarize the Talmud’s primary teachings (Karo, 1965; Asher, 2000). One of the most notable, the Mishne Torah, comes from Maimonides (1962), the noted twelfth century physician and scholar. The third main source of Jewish legal authority is the Responsa literature, in which prominent Jewish scholars through the centuries have given opinions on contemporary matters as interpreted through the Hebrew Bible and Talmud (e.g., Waldenberg, 1990; Feinstein, 1994). Responsa are the continuation of a 2000-year-old interpretative tradition, which creates an intellectual link to the past, helping to keep the law relevant and vital to the present. (Descriptions of codes and Responsa can be found in Freedman [1999] and Rakover [1994], or in any general guide to the sources of Jewish law.)

Bioethical questions are treated by Jewish scholars in a variety of ways, which reflect different orientations toward Judaism and degrees of strictness in the interpretation of Talmudic texts and cases. Pioneering work in contemporary Jewish medical ethics in the 1960s and 1970s came primarily from Orthodox Judaism, in which the authority of God, as expressed through the Torah and Talmud, underlies the deliberative process ( Jakobovits, 1959). Much Jewish bioethics literature comes from this perspective, which assumes that, through the proper interpretation of Talmudic texts and commentaries, answers to the most difficult questions can be discovered. In practice, the rabbi whose opinion is sought for an ethical answer serves as an ‘‘expert counselor’’ to physician and patient, interpreting Halachic law for the situation in question. A local rabbi or chaplain may, in turn, consult more learned Halachic authorities in difficult cases.

Inspired by these Orthodox sources, Jews from the more liberal Reform and Conservative movements have also made contributions to contemporary bioethics (Feldman, 1974; Borowitz, 1984; Maibaum, 1986; Dorff, 1990). The interpretative method and texts used are basically the same, but their rulings are often more flexible than those provided by Orthodox rabbis. Even within Orthodox Judaism, there exist multiple interpretations of most texts, with a resultant variability of rulings. Jews of the Reform movement are often more open to ‘‘extra-Halachic Jewish ethical analysis’’ (Grodin, 1995), in which Halacha becomes only one of several sources of moral authority.

Common principles

Although traditional Jewish scripture expresses many principles worthy of ethical consideration, there are a few foundational tenets that ground much of the Jewish bioethical tradition. One commentator identified three main principles: ‘‘human life has infinite value; aging, illness and death are a natural part of life; and improvement of the patient’s quality of life is a constant commitment’’ (Meier, 1991, p. 60). Other important concepts are that human beings are to act as responsible stewards (Freedman, 1999) in preserving their bodies, which actually belong to God (Davis, 1994), and that they are duty bound to violate any other law in order to save human life (short of committing murder, incest/adultery or idolatry). Compared with secular values, these principles suggest a diminished role for patient autonomy. When a treatment is efficacious (refuah bedukah) there exists a duty to seek or preserve health, which overrides any presumed right to refuse/withhold treatment or to commit suicide. However, when the efficacy of the treatment is uncertain (refuah she’einah bedukah), then the individual is permitted to decide and possibly refuse (Flancbaum, 2001).

The problem faced by Jews in end of life decisions is not usually in determining the appropriate Halacha; a greater challenge is determining the

moment when hope for continued life is lost and the process of death has begun. Jewish law is relatively clear that life is not to be taken before its time. It is equally clear that one is not to impede or hinder the dying process once it has begun (Feldman, 1986). Lenient rulings in such cases may be based on the same texts as strict rulings; one authority may see continued treatment as prolonging life, where another may see it as prolonging death. Working through this dilemma is a common feature of Jewish end of life decision making. Both the duty to treat and the duty not to prolong death must be considered in light of the more general duty to care for one’s parents in old age or ill health.

Why is Jewish bioethics important?

Today approximately 13 million Jews live in many parts of the world. Israel’s population of more than six million is over 80% Jewish, and a similar number live in the USA. Russia and France have large Jewish populations, followed closely by Argentina, Canada, and the UK. While the majority of Jewish people have secularized to varying degrees and adopted the language and customs of their local countrymen, a significant minority remain committed to upholding the laws of the Torah through prayer, study, adherence to tradition, and commitment to the covenant with God.

To traditionally minded Jews, Jewish bioethics is a subset of Halacha, which guides all of their activities. To more secular Jews seeking guidance in difficult decisions about their health, Jewish bioethics offers helpful lessons and considered opinions from the sages. Many non-religious Jews welcome traditional views to help to ease the uncertainty inherent in difficult ethical decisions, even though they may not live according to traditional religious practice.

An understanding of Jewish bioethics can help anyone, Jewish or not, who wishes to explore the many ways people think about difficult ethical issues. Even without accepting the authority of the Hebrew Bible and the Talmud, healthcare professionals

may benefit from seeing how principles or norms can be derived from authoritative texts, how minority opinions can be incorporated into such deliberations (the Talmud consistently records these), and how grappling with tough questions in this structured way can increase sensitivity to ethical and decisional nuance. Perhaps the most important lesson to be learned is that there are few easy answers to complex problems. Jews do not have a guidebook that explicitly tells them what to do in every situation. Rather, their guidebook is cryptic and requires them to consider thoroughly the range of possible answers to ethical dilemmas. It is a tradition of continued and ongoing questioning rather than one of absolute theological law passed down from above (Fasching, 1992). Furthermore, familiarity with Jewish bioethics would give the practitioner the perspective to consider ethical dilemmas through the lens of duty rather than of rights, asking the question, ‘‘What are the obligations of each of the parties involved in this discussion?’’ Although the rabbis of the Talmud would have appreciated the procedural question of who gets to decide, they were more concerned with finding the best course of action for the particular case at hand, irrespective of the participants’ wishes.

whom have significant psychological associations stemming from traumatic experiences.

Patients who are religious may doubly appreciate hospital attire that preserves modesty. Some Jewish patients may also appreciate brief periods set aside for prayer or other ritual obligations.

A practitioner treating a Jewish patient should not make assumptions about the extent to which the patient would like his or her care to be guided by Jewish tradition. It would be perfectly appropriate to ask a patient whether Jewish opinions are considered in the decision-making processes, and to consult with a rabbi – a specific one if so requested – when the patient wishes to explore the tradition’s wisdom on a particular matter.

In general, traditional Judaism prohibits suicide, euthanasia, withholding or withdrawal of potentially beneficial treatment, abortion when the mother’s life or health is not at risk, and many of the traditional ‘‘rights’’ associated with a strong concept of autonomy. For example, an observant Jew would not consider it his or her right to seek physician-assisted suicide as a way to avoid present or future suffering from metastatic carcinoma. Exceptions to these prohibitions are sometimes made in extreme circumstances.

How should I approach Jewish bioethics in practice?

Both Jewish and non-Jewish healthcare professionals can benefit from being acquainted with Jewish bioethics in caring for patients and their families when issues related to Judaism are raised. Table 53.1 summarizes essential points to keep in mind when providing care to Jewish patients.

The patient’s life history might have some bearing on the type of treatment approaches he or she requires. Older Jews not born in Western nations might be more likely to appreciate a rabbi’s input, as they are often more traditional than their children. Also, there are still a significant number of Holocaust survivors in most Western cities, some of

The case

Mrs. G’s daughter is undoubtedly trying to respect her mother in not consenting to the insertion of a new gastrostomy feeding tube, but she will find it difficult to get rabbinical support for reducing or withdrawing treatment that would result in her mother’s death without a prior serious decline in Mrs. G’s overall condition. How best to respect her parent is not easy to determine, but usually Judaism teaches that prolonging life is more respectful than assuming an incompetent patient wishes to end her suffering prematurely.

There is a clear duty to ‘‘cause to eat’’ (Freedman, 1999) in the Jewish tradition, which her daughter should not, according to the Halacha, violate unless Mrs. G is deemed to be a goses (a person in

the throes of dying), in which case treatment or feeding that would hinder the dying process would not normally be allowed. Even as death approaches, performing duties as articulated by Jewish law is the essence of traditional Jewish life, a source of joy and fulfillment for both patients and families, and Jewish bioethics suggests that the articulation

and performance of such duties be the focus of clinical decision making. The daughter agrees to have the gastrostomy tube replaced. She and the healthcare team determine conjointly the basis for future care within a palliative care framework. Mrs. G succumbs comfortably to pneumonia some months later.

REF EREN CES

Ben Asher, J. (2000). Tur Shulkhan Aruch. (No English translation available but explanation at www.shamash. org/lists/scj–faq/HTML/faq/03–38.html) accessed August 2006.

Borowitz, E. (1984). The autonomous self and the commanding community. Theol Stud 45: 34–56.

Davis, D. S. (1994). Method in Jewish bioethics. In Religious Methods and Resources in bioethics ed. P. F. Camenisch. Dordrecht: Kluwer Academic, pp. 109–26.

Dorff, E. (1990). A Jewish approach to end-stage medical care. Conserv Judaism 43: 3–51.

Fasching, D. (1992). Narrative Theology after Auschwitz. Minneapolis, MN: Fortress Press.

Feldman, D. M. (1974). Marital Relations, Birth Control, and Abortion in Jewish Law. New York: Schocken Books.

Feldman, D. M. (1986). Health and Medicine in the Jewish Tradition. New York: Crossroad.

Feinstein, M. (1994). Darash Moshe I: A Selection of Rabbi Moshe Feinstein’s Choice Comments on the Torah. Brooklyn, NY: Mesorah.

Flancbaum, L. (2001). . . . And you Shall Live By Them: Contemporary Jewish Approaches to Medical Ethics. Pennsylvania: Mirkov.

Freedman, B. (1999). Duty and Healing: Foundations of a Jewish Bioethic. New York: Routledge.

Green, R. M. (1985). Contemporary Jewish bioethics: a critical assessment. In Theology and Bioethics: Exploring the Foundations and Frontiers, ed. E. E. Shelp. Dordrecht: Reidel, pp. 245–66.

Grodin, M. A. (1995). Halakhic dilemmas in modern medicine. J Clin Ethics 3: 218–21.

Jakobovits, I. (1959). Jewish Medical Ethics. New York: Bloch. Karo, J. (1965). Shulkhan Arukh. New York: MP Press. Maibaum, M. (1986). A ‘‘progressive’’ Jewish medical

ethics: notes for an agenda. J Reform Judaism 33: 27–33. Maimonides, M. (1962). Mishne Torah. New York: MP Press. Meier, L. (ed.) (1991). Jewish Values in Health and Medi-

cine. New York: University Press of America.

Novak, D. (1990). Bioethics and the contemporary Jewish community. Hastings Cent Rep 20: 14–17.

Rakover, N. (1994). Guide to the Sources of Jewish Law. Jerusalem: Library of Jewish Law.

Rosner, F. (1986). Modern Medicine and Jewish Ethics. New York: Yeshiva University Press.

Rosner, F. and Bleich, J. D. (eds.) (1987). Jewish Bioethics. Brooklyn, NY: Hebrew Publishing.

Waldenberg, E. Y. (1990). Responsa Tzitz Eliezer. [Contemporary rabbinic responsa covering the corpus of Jewish law.] Jerusalem: Rabbi Elizer Y. Waldenberg. [No English translation available.]

Related websites

The Gemara (Talmud): www.acs.ucalgary.ca/ elsegal/TalmudMap/Gemara.html

Jewish Law: www.jlaw.com

Judaism 101: www.jewfaq.org/toc.htm

Page from the Babylonian Talmud: www.acs. ucalgary.ca/ elsegal/TalmudPage.html

Physician-assisted suicide: www.jlaw.com/ Articles/phys-suicide.html and www.jlaw.com/ Articles/suicide.html

The right to die: a Halachic approach: www.jlaw. com/Articles/right.html

Risk: Principles of Judgment in HealthCare Decisions: www.thebody.com/iapac/freedman. html

Shulchan Aruch: www.torah.org/advanced/ shulchan-aruch

Jewish populations world wide: www. jewishvirtuallibrary.org/jsource/Judaism/ jewpop.html#top

The Thirteen Principles of Jewish Medical Ethics: http://members.aol.com/Sauromalus/index. html

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.’’

What is Protestant bioethics?

Origins of Protestantism

‘‘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.

Beliefs

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.

Concepts relevant to bioethics

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

432M. Pauls and R. C. Hutchinson

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.

Why is Protestant bioethics important?

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.

How should I approach Protestant bioethics in practice?

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.

End of life care

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.