Saturday, February 23, 2019

The Role of Religious Participation and Religious Belief in Biomedical Decision Making



NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Institute of Medicine (US) Committee on the Social and Ethical Impacts of Developments in Biomedicine; Bulger RE, Meyer Bobby E, Fineberg HV, editors. Society's Choices: Social and Ethical Decision Making in Biomedicine. Washington (DC): National Academies Press (US); 1995.

The Role of Religious Participation and Religious Belief in Biomedical Decision Making

CHARLES M. SWEZEY, Ph.D. Dean of the Faculty, Union Theological Seminary in Virginia
Biomedical decisions usually focus on specific problems or cases, and particular decisions gain standing and legitimacy when they become part of a practice. By practice, I mean standard ways to deal with typical cases that emerge over time and are accepted by medical practitioners and society. Practices are justified by explicitly stated moral values and characteristic ways of understanding and so interpreting illness. Also important are a long history of care, professional training and socialization, and accepted ways of assimilating new knowledge. These and other factors, however, require an ethos of support.

The explosion of knowledge in biology and other fields of inquiry, combined with recent innovations in medical technology, dramatically increase the human capacity to intervene in the natural life process. They also call into question some of the standard ways of dealing with typical cases. Well-known examples are subject to public debate. May physicians assist in actively terminating human lives? Is it permissible to use human fetal tissue in medical research? Under what conditions, if any, should patients receive organ transplants from nonhuman animals? The central issue in these and other questions is whether what can be done technically ought to be done morally. The issue has attitudinal dimensions. We respond to innovations in medical technology with wonder and awe. We are grateful for benefits, yet we fear deleterious consequences, so we search for guidance by exploring possibilities and seeking limits, understanding that limits have their own consequences. To set limits and attain possibilities, of course, are ways of specifying what may be done in particular cases, that is, of redefining medical practice.
The search for guidance does not take place in a vacuum, but in the context of a perceived erosion of confidence. The costs of health care rise amid serious debates about access to care and the adequacy of health insurance. Litigation increases amid important questions about the relation of causal accountability to moral and legal responsibility. Questions about the rationing of care appear just when physicians are charged with overtreating patients. Though all of medical practice is not disputed, the number of significant problems and the lack of consensus in dealing with them set a context for scrutiny by an increasingly broad public. The interacting roles of patient and physician are reexamined; the numbers of ethics committees and review boards grow; pressure groups and lobbies emerge. Medical practice seems to have become everybody's business.
Along with other aspects of life, it becomes increasingly specialized and at the same time seeks legitimation in a democratic forum.
At the heart of these discussions are disagreements about proper modes of treatment. These disagreements are the source of fears that are larger than disputes about individual cases. One fear concerns the possible effects of a lack of uniformity in practices. The desire for uniformity is rooted in part in an understanding of fairness, the principle that similar cases should be treated similarly. When similar cases are not treated similarly, something seems askew morally. Judgments are difficult here, for there is room for diversity. Adult Jehovah's Witnesses, for example, undoubtedly will continue to refuse blood transfusions, a refusal generally accepted as an exception to standard practice. At issue is the amount of diversity a practice will tolerate. The specter which haunts is that the ethos that sustains standard practices will falter. Thus the second fear is that the very practice of medicine will erode, a practice inherited from the past which has served society well. These fears are strong enough to set a context for addressing the issue of the role of religious belief and participation in biomedical decision making. Clearly religion has the potential to erode, sustain, or enrich at least the ethos that nourishes standard medical practice.

FACTORS IN RELIGIOUS BELIEF

The topic this paper addresses is part of the more general problem of the relation of religion to modern society. The pioneering studies of Max Weber and Ernst Troeltsch have been followed by an enormous literature from several fields. Though not unmindful of these studies, the primary intention of this paper is to provide a framework for understanding the relation between religion and biomedical decision making, and it undoubtedly reflects the viewpoint of a mainline Protestant ethicist. I first provide a scheme which points to important dimensions of religious belief. Although this scheme oversimplifies in ways that offend even my own scholarly sensibilities, it draws attention to several important factors. I next sketch the elements of decision making. Interactions are then traced, and a concluding section follows.

The Vision of God

In the traditions of the West, religious beliefs are intellectual constructs grounded in an experience of the reality of God. Piety, faith, and ecstasy, as well as other terms, refer to this experience. A religious object, God, is disclosed, and this object is characterized in different ways, e.g., king, lord, father, steadfast love, shepherd, judge, deliverer. This experience and its corresponding object is a vision of God, and its effects vary. Different sensibilities are evoked, e.g., reverence, wonder, and gratitude. Liturgical performance is elicited, e.g., praise, confession, and supplication. Certain deeds or acts are enjoined or prohibited, e.g., honoring parents or not bearing false witness.
Believers also articulate the character of the religious object in the form of beliefs. This response has multiple roots, e.g., attempts to clarify liturgical practice, efforts to persuade others of the authenticity of a vision, or simply the struggle to better comprehend and explain the deity. Many who formulate these beliefs are aware of the inadequacy and shortcomings of propositional statements. Indeed, a certain poignancy accompanies the work of theologians who are aware of the agonies of excess or defect, or of claiming either too much or too little for knowledge of God. Still the attempt is as important as it is inevitable, for what is believed about God is decisive in specifying God's relation to the world.
One difficulty is that religion is located in an institution, whereas, presumably, God is not so confined. This difficulty is compounded by the complexity of the world. James M. Gustafson, for example, writes about different "arenas" in which God's presence may be discerned-nature, history, culture, and society. To claim that God is present to society and culture, for example, requires that something be said about God's relation to family life, economic institutions, government, technology, the arts, and the sciences. In the face of these difficulties, some theologians affirm that God is absent from the world, or perhaps present as a condemning judge who calls the faithful away to a better life. Others argue that God's governance includes sustaining and ordering powers that may be discerned in each of these arenas. Still others suggest that God as creator provides the occasions for new possibilities and so enables human innovation. Each of these beliefs, and many others, are thematizations. It is a mistake to reduce them to the status of intellectual propositions to which believers give cognitive assent. This move abstracts from important dimensions of religious belief and fails to see them as construals which, by specifying God's relation to the world, interpret all of life in theological dimension. Theological beliefs seek a coherence and consistency which, faithful to the divine reality, make sense in relation to the world.
If the task of theology in a strict sense is to articulate the vision of God in the form of stated beliefs so that the relation of God to the world gains specificity, its larger task is to elaborate this vision by addressing four issues that recur perennially. The four issues are the relation of good and evil, the nature of religious participation, estimates of reliable sources of knowledge, and the character of moral guidance. Each is part of religious belief, and the vision of God becomes clearer as they are answered. If these questions are not always answered explicitly, they are nonetheless present in the lives of believers as implicit, unstated assumptions. Those who do not share a religious vision offer nonreligious counterparts to explicitly religious answers to these questions.

Good and Evil

The first issue is the relation of good and evil. More precisely, the question concerns their location and extent as well as their relation. This problem emerges in everyday life when judgments are made about relative goods. One television program rather than another is watched, an adolescent selects a college to attend, a second career is chosen, and so forth.
A key for understanding the interaction of good and evil is found in human responses to certain events. When college students receive midterm grades, for example, responses range from indifference to overly enthusiastic optimism. These and other moods may occur fleetingly in response to particular events. Over time, however, moods may persist and become attitudes adopted toward the world. With apathy, what one does makes little difference; with cynicism, what others say or do makes no difference; with despair, the exercise of intentions is useless. These and other attitudes develop into patterns of being human, so that life is "staged," for example, with deep resignation or with quiet conscientiousness. Attitudes have roots in human nature, but it is human nature patterned in response to a discernment of good and evil forces in the world.
The interaction of good and evil requires an interpretation which sets particular events in a larger frame. Theology provides an interpretation by construing the world in a particular way, and this construal is part of the vision of God. One result may be a thoroughgoing dualism which assigns definite locations to good and evil forces. For example, the dominant culture or mere physical existence becomes the locus of evil, and the pure religious community or spiritual existence is the locus of good. God is envisioned as judge of the dominant culture or as not blessing physical life, and also as the savior who delivers the faithful into true community or spiritual bliss. Certain patterns of life follow. The perception of evil in thoroughgoing dualisms is neither universal nor radical. Since evil is assigned a rather definite location, it is not all-pervasive or universal. Since forces for good seem relatively exempt from evil, the extent of evil is limited; it is not truly virulent or radical.
Other theological interpretations locate evil more universally and view its extent more radically; they also provide an account of forces for good. The quest genre of literature provides an example. Grasped by a vision of God, a band of pilgrims ventures a journey and sets forth in the world only to encounter pitfalls, dangers, and temptations. Their challenge is to respond to these encounters in ways which faithfully honor the original vision. Those on the journey eventually learn that evil is found not only in the world, but lurks in the heart of each venturer. Moreover, those on the journey inevitably experience moments of grace when, surprisingly, they encounter forces of good outside their own company. The world is thus experienced as an arena of interacting good and evil forces, but without a thoroughgoing dualism. These encounters are means of clarifying the original vision of God who now is perceived as an ordering power who sustains and nurtures human existence as well as the rest of life, and who, as the creator of new possibilities, enables the journey to continue.
To remain with the image of the quest, patterns of life develop which train and equip venturers to deal with the experience of evil. Established ways of living, like the "inner-worldly asceticism" Max Weber attributed to the Puritans, are perduring attitudes adopted toward the world. Because the common experience of believers is that present reality does not exhaust the goodness of God, a way of life can be sustained in the face of truly tragic encounters with evil. What Weber called "the ethical irrationality of the world" is faced, namely, the realization that good results do not always flow from good intentions and that evil persons, despite themselves, may bring benefits. Eschatologies, or beliefs about the way interacting good and evil forces finally play out, are born in these experiences and so expand the vision. So eschatologies are radically dualistic; others are not. The result, in any case, is a vision of God which interprets human existence in the world.
Perceptions of good and evil, including eschatologies, are not confined to theology. For example, discussions of the consequences of genetic interventions in humans often include estimates of the future which strikingly resemble strands of religious beliefs about the interactions of good and evil, and well-known scientists who are not self-consciously religious spin out their own versions of the human prospect. One cannot but wonder about the possibilities of mutual discourse. At issue is what is known scientifically about the natural world and humanity's place in it, and the role this knowledge plays in interpreting the present and conjuring the future. Also at issue are patterns of existence in the world and the sources of knowledge deemed reliable. In any event, religious belief is clearly a source for understanding the relation of good and evil, though it does this in different ways.

Religious Participation

A second factor in religious belief is the relation of those who share a religious vision to those who do not explicitly acknowledge it. This question is part of everyday life for believers and, in larger form, is present to all. How relate to those who differ in some significant respect? Resolutions of the explicitly religious issue are deeply conditioned by the distinctive form of religious association that first emerged in the West. This form of association is called "congregational religion."
According to Max Weber, congregational religion is an association of persons who embody, though imperfectly, belief in a transcendent God. Transcendent here means the conception of a deity who brings the world into existence, stands over against it, and wills a way of life which differs from that customarily practiced. The embodiment of this belief takes place through three interacting provisions, each of which, again, stabilizes and secures belief in communal form. First, standard ways of venerating and so recalling the nature of the deity in a properly religious way are enacted regularly. Thus a cult is created, including sacraments and other forms of worship. Second, belief in God is fixed in a message that serves as court of appeal and authoritative source of knowledge. This takes place by demarcating canonical writings and by enunciating doctrines which state the meaning of these texts. Third, a means is found to recognize and order religious leaders in the association.
The clergy so ordered take up the task of being true to the transcendent God by leading worship and by interpreting scripture and doctrine. They also bear special responsibility for attracting and maintaining followers in the religious association, and they are successful in this calling to the extent that laity participate in the community, share the religious vision, and comprehend the rest of life in its light. Congregational religion emphasizes two primary methods for interacting with the laity who, notoriously, are unwilling to give up customary ways of living and know better than the clergy the meaning of belief. One is preaching and the other is pastoral care. The two are related, and each is suited to clerical tasks. Pastoral care, or attention to the needs of the laity with a distinctively religious focus, requires clergy to attend to matters which concern the everyday life of parishioners. Preaching affords the regular and formal opportunity to respond to these concerns by interpreting the religious message in the context of worship.
The beginnings of a voluntary principle for human associations are properly found in the emergence of congregational religion. In ways just enumerated, religion differentiates from other forms of human association, including the family, the market, and the state. Being located in one realm raises the question of God's relation to these other realms. This issue is compounded in the modern world which, with its growing segmentation, is increasingly aware of autonomous rationales for differing institutions. Different forms of associations serve independent purposes. The dominant purpose of the economic realm, for example, is to produce and distribute goods and services. The political arena provides a system of governance charged with ensuring order in society. The family fosters mutuality and provides nurture for infants. One purpose of medicine is to provide health care. Religion serves none of these purposes, at least not directly. The irony is that one of the largest challenges faced by religion is posed by its own principle of organization. An enduring task of religion is to comprehend and interpret theologically all of life; but by gaining independence as an organization, its relation to other areas of life is called into question, and so the challenge is set.
Weber's colleague, Ernst Troeltsch, argued that congregational religion exhibits three tendencies in relating to the world. The religious association may dissociate from the dominant society by withdrawing in more active or passive ways; it tends more exclusively to its own nurture. The religious community may oppose the dominant society by protest, or by seeking to change or overthrow it. Or the dominant society may be affirmed, as an inevitable necessity, by critical acceptance, or more wholehearted embrace. These tendencies, then, represent three typical patterns of participation.
A new expression of congregational religion, the denomination, appeared with the disestablishment of state-sanctioned religion. For the denomination, the voluntary principle is the organizing feature of congregational life. Persons join, presumably, only when they consent to its norms, that is, to the implicit or explicit consensus that exists in the group. The need to gain the consent of laity introduces a democratic impulse into congregational life and presents a political task to religious leaders who want to attract and retain members. Once the element of democracy is acknowledged and the active consent of laity is present, congregations can become seedbeds of activism.Congregational activities proliferate; new institutions like the Sunday school are formed; alliances with other associations develop. Recent American religious history illustrates that these conditions are an environment for change as in, for example, the emergence of politically conscious evangelicals, the decline of the Protestant mainline, and the growing influence of the Roman Catholic Church. Denominational life is subject to numerous factors, many outside its control. One thinks of the increase in global interdependence; one thinks of the emergence of pluralism and the recognition of different viewpoints and communities; one even thinks of demographic factors. All of these, and more, are conditions to which congregations must respond. H. Richard Niebuhr once commented, ''We are more acted upon than acting," and that may be true of denominations. Still, within whatever limits, denominations retain the capacity to exercise intentions in their many activities. There are different units and levels of participation, including individuals, small groups, congregations, regional bodies, national bureaucracies, etc., and all of these in relation to other organizations and other arenas of existence. Religious participation, then, has many meanings and dimensions.
The basic tendencies noted by Troeltsch illustrate ways in which religious participation takes place in relation to society. Recall that the religious vision grows clearer and God's relation to the world gains specificity with each factor in religious belief. With the factor of religious participation, the relation of God to the community which shares the religious vision is spelled out, and God's relation to the world thereby becomes clearer, that is, God's relation to those who do not explicitly or organizationally acknowledge the religious vision. At least two basic patterns emerge. One pattern identifies God's presence or emphasizes God's relation to the religious association in ways which are not true of God's relation with the larger world. For this pattern, the tendency of the religious association is to oppose the dominant society. On the other hand, the religious community may be viewed as the realm of the conscious acknowledgment of God's more universal presence or relation to the world. The tendency of the religious association in this pattern is to affirm the dominant society.
These patterns have consequences for the vision of God and for the interaction of good and evil. When God is uniquely related to the religious community, it is less likely that the presence of God as an ordering, sustaining, nurturing, and redeeming power will be discerned in the world, which is viewed as the locus of evil. Thus believers tend to oppose the world. If opposition to the dominant society takes the path of changing the world, it is likely that God's positive presence will be selectively identified with certain elements in society, thus modifying the interaction of good and evil. When God's presence is more affirmatively related to the dominant society, discerning the presence of God in the world as an ordering, sustaining, nurturing, and redeeming power is more likely. The location of evil is apt to be viewed as more universal and radical, but enough good is discerned in the world to encourage affirmation, as an inevitable necessity, by critical acceptance, or more wholehearted embrace.
These generalizations are regrettably abstract, and, no doubt, particular historical instances will not conform. They nonetheless draw attention to major patterns of religious participation. In sum, religious participation is multifaceted in depth and breadth.

Sources of Knowledge

The issue for the third factor in religious belief may be posed as a question. What sources of knowledge are reliable, and how are they related? Since answers to any question depend on one or more sources of knowledge, this issue emerges in everyday life. Even the fabled Cynics who rigorously rejected the reliability of all knowledge adopted a stance on this issue, albeit a flatly negative one. Answers in everyday life range from reliance on common sense to disciplined appeals to specialized fields of learning. I concentrate here on sources deemed reliable for morality.
Appeals to sources of knowledge in religion are sometimes more narrow and exclusive, sometimes broader and more inclusive. Sole reliance on an authoritative text illustrates a narrower, more exclusive, answer, which often joins with an appeal to the religious community as the only authentic interpreter of the canonical witness. By contrast, various theories of "natural law" illustrate broader, more inclusive, appeals. They assume that believers and nonbelievers share a common source of reliable knowledge, like perceptions of human nature or a common moral sense. A dominant strand in the Roman Catholic tradition affirms that what is known morally by reason is given by God and universally shared; this knowledge, moreover, is not contradicted by scripture though the latter provides certain commands that go beyond the duties of ordinary living. The so-called quadrilateral of the Methodist Church appeals to four interacting sources of knowledge, namely, scripture, tradition, reason, and experience. It thereby combines more distinctively religious sources with those which presumably are more widely shared. Of course, the exact meaning of each term in the quadrilateral and their relation to each other continue to be debated.
Religious answers to the question about sources of knowledge appeal in some normative fashion to canonical writings. Since the uses of authoritative texts vary, the ways scripture actually functions as a normative source also vary. For example, scripture may be viewed as disclosing knowledge of the reality of God, revealing the relation of good and evil, providing guidance in the form of moral values, engendering attitudes, exhibiting virtues, providing direct answers to moral questions, and so forth. It is important to draw fairly precise distinctions in order to understand particular claims.
Some theologians claim on descriptive grounds that multiple sources of knowledge are inevitably present in decision making. Lisa Sowle Cahill argues that four interacting sources of knowledge are invariably present in religious ethics: canonical writings, the religious tradition, normative accounts of the human, and descriptive accounts of the human. Her argument suggests that the normativity of scripture cannot be upheld in actual use unless brought into conscious relation with other sources of knowledge. Judgments, of course, must be rendered about the number of sources and also about their relation. The point here is that some theologians self-consciously use multiple sources, and arguments for their use are not only descriptive but have theological flavor. It is obvious that recourse to "descriptive accounts of the human" places believers on at least some common ground with biomedical decision makers who may not share the religious vision.
These few examples illustrate the plurality of answers to the question about sources. This factor interacts with others. Recall again that the religious vision becomes clearer when each factor of religious belief is taken into account. When the factor is sources of knowledge, God's relation to the world is specified in reference to the availability of reliable moral knowledge to the religious community and to those who do not share the religious vision. In other words, sources of knowledge clearly interact with the factor of religious participation. I delineate two general patterns.
First, to the degree that God's positive presence is identified more exclusively with the religious community in contrast to the rest of humanity, emphasis is placed on the need of the community to rely on more distinctively religious sources of knowledge like canonical writings. For example, if God is more exclusively present to the religious community as lawgiver or commander, a belief grounded in scripture, believers will be enjoined to obey these laws or commands, e.g., do not resist evil or enter the land of Canaan to conquer and occupy. Again, if a religious community gathers around the personality of a leader and does not yet have an authoritative text, the belief that God is present to the world exclusively through those who follow the leader is grounded in a personality; believers are enjoined to follow the leader's directives. A more comprehensive account requires an estimate of the type of knowledge available to nonbelievers; when such accounts are given, they correlate with perceptions of the location and extent of good and evil in the world. For example, the world may be seen as a locus of evil to the extent that it does not follow the teaching of nonviolence or to the extent that it does not follow the teachings which flow from the leader's personality.
Second, to the degree that God's positive presence is related to the world, some emphasis is placed on sources of knowledge which are shared by believers and nonbelievers, at least in moral matters. If God's ordering power is present to the world in sustaining life through the structure of the family, for example, reliable knowledge about being a spouse or a parent may be given through an "order of creation" ordained by the deity and perceived by reason and experience, that is, sources of knowledge universally shared. A more comprehensive account requires an estimate of the role of scripture as a distinctively religious source of knowledge. This estimate may be that reason and scripture do not conflict in moral matters, but that scripture moves beyond reason in certain ways. A more paradoxical claim is that reason and scripture are both required but serve different functions; reason informs us how to restrain evil in the world and scripture gives us reborn hearts. These and other claims also depend upon perceptions of the interaction of good and evil.
These patterns are again regrettably abstract and, of course, particular historical instances may not exactly conform. Although more detailed analysis would require greater nuance, the generalizations indicate two major patterns. They also show that factors in religious belief interact dynamically. If one is persuaded that multiple sources of knowledge are required and also of the reality of God, for example, then one is forced to give a theological account of how God makes reliable knowledge available to the world, say, in the sciences. In sum, the factors of religious belief interact dynamically and are complex.

Moral Guidance

A fourth and final factor in religious belief also takes the form of a question raised in everyday life. What types of guidance, if any, aid in facing the demands of life? By demands of life I refer to a broad array of matters, like choosing a vocation, raising children, electing surgery, or donating money. Possible forms of guidance are also far-ranging, for example, principles and rules, symbols by which to comprehend circumstances, training in character, and distinctions between relative goods. The religious form of this issue is the type of guidance which flows from or is consistent with a vision of God. Religion offers rich resources with respect to these possibilities, but I concentrate here on guidance in the form of moral principles.
Whether the first requirement of a religious vision is a reborn heart or obedient conduct is a perennial debate, often couched in terms of the priority given to inner or outer dimensions of life. The inner dimension emphasizes a new disposition, the outer stresses good deeds. Though exceptions exist, these options are usually viewed as complementary, not as alternatives. Recurring discussions draw boundaries by identifying "legalism" and "antinomianism" as extremes to avoid. An emphasis on inner freedom to the neglect of good conduct is antinomian or "against the law." Legalism emphasizes proper conduct to the neglect of matters of the heart. These distinctions are more successful in indicating extremes to avoid than in stating a middle ground. An agricultural metaphor poses the issue of relating inner and outer dimensions of life in a pattern responsive to the religious vision. How are the "roots" of a plant related to its "fruits," that is, how are the inner dispositions of a way of life related to conduct? The image assumes that both roots and fruits are required and related.
Moral principles are a means to guide conduct. Their form and content, as well as their use and purpose, stem from a relation between roots and fruits. They are also conditioned by the religious factors of belief which specify God's relation to the world. The relation of good and evil, we have seen, may lead to a thoroughgoing dualism. When the location and extent of evil are more universal and radical, however, this dualism moderates. With the factor of religious participation, tendencies to dissociate or oppose the world stand in contrast with more affirmative stances. With the issue of sources, reliable moral knowledge may be more exclusively available to the religious community or more universally distributed. The religious vision clearly directs these possibilities, but the vision is also shaped by these other factors in belief.
Many combinations of these factors are possible, and I shall indicate two major patterns. In the first, a vision of God with a thoroughgoing dualism which lacks a radical and universal sense of evil links with a tendency to oppose the world. These factors, in turn, join with the tendency for the knowledge provided by God to be more exclusively related to believers. With this pattern, moral guidance often takes the rigorous form of a "higher law." Conscientious obedience is expected, and there is little likelihood of dialogue with persons outside the religious community about the form and content of guidance. The guidance offered may be directed primarily towards the inner religious life, though necessarily cast in outward form, e.g., a vow of obedience to a religious superior; or the guidance may be more overtly moral, though obedience springs from the heart, e.g., not swearing in court.
A variation in this pattern occurs if the tendency to oppose the world takes the form of seeking to overthrow it. The rigorous content of the moral guidance may then become more militant and conscientious obedience is still expected, e.g., launching a violent crusade against an enemy. If the tendency to oppose the world is not explicitly violent, but nonetheless expresses an intention to change the world, moral guidance is likely formed in relation to selected sources of knowledge available in the world.
In the second pattern, the vision of God views the extent and location of evil as more universal and radical. Lacking a thoroughgoing dualism, it includes an affirmative posture toward the world and assumes that moral knowledge is more universally distributed. With this pattern, the form of moral guidance is less rigorous in the sense that it more likely compromises with various aspects of life in the world. Guidance is more responsive to the demands of culture and society, and is directed to both the religious community and the world. Dialogue about the form and content of this guidance is possible in principle and practice. The more explicit purposes of moral guidance depend in part on the virulence of evil in the world and range from the restraint of evil to more positive directives. If evil is so virulent that little positive good can be accomplished, restraint is emphasized; if possibilities for human flourishing exist, more positive forms of guidance emerge.
The well-known debate about "uses" of the law in the sixteenth century illustrates the purposes of guidance in this second pattern. The commandment "Do not kill" is a form of moral guidance with particular content. For John Calvin, its first use is theological, that is, to convict of sin and perhaps prepare the way for repentance. So the command is radicalized to include anger in the heart, an inner disposition. The second use is political, that is, to restrain evil. A murderer is a killer and a menace to society who must be punished by the state, an outward deed. The third use provides moral guidance which is grounded in the heart and expressed in outward form. The positive intention of the prohibition not to kill is to respect human life. More exact formulations come with dialogue. Unlike Calvin, some theologians endorsed only the first two uses; for these latter, the primary purpose of guidance in the world is the restraint of extremely virulent evil. It may be noted that in the pattern of thought where the tendency is to oppose the world, the commandment not to kill may take the form of a "higher law" and stand as a prohibition in the religious community against all lethal violence. If the tendency toward the world is seeking to overthrow it, this command may be superseded by a different form of "higher law,'' namely, the call to violent revolution.
Once again, these generalizations are regrettably abstract, and once again, historical instances do not exactly conform. However, the central points about guidance in the form of moral principles should not be lost. Moral principles in a religious context presume a relation between inner and outer dimensions of existence. Their form and content are likely to be more rigorously conscientious or more responsive to the demands of culture and society. They also serve certain purposes. These three features of guidance, in turn, are informed by the religious vision and conditioned by perceptions of good and evil, estimates of reliable sources of knowledge, and different tendencies in religious participation. The factors in religious belief are complex and mutually conditioning.

Summary

Religion is a way of life grounded in a vision of God, and one response to this vision is articulating beliefs. Believing is part, but only part, of walking a way. To analyze religious beliefs is to discern that a religious vision specifies the relation of God to the world by dealing with four distinct yet related factors. Each is important, and each displays its own qualities. To take religious participation as an example, its roots are found in faith and piety which nurture, express, and condition its shape. It is also influenced by the form of a religious association, e.g., a denominational congregation, and it embodies one of the tendencies which belong to this factor, namely, to dissociate from, oppose, or affirm the world. These characteristics blend to compose the distinctive quality of religious participation. This factor, in turn, conditions and interacts with the other factors, each with its own qualities. When informed by a vision of God, the qualities of these four factors form a more or less integrated pattern. This complex and interacting whole provides resources which are brought to everyday life, including the medical arena. Every pastor and physician is aware that those informed by a religious vision respond out of the resources provided by a way of life, sometimes courageously in the face of tragedy and sometimes in despair.

THE ELEMENTS OF DECISION MAKING

An analysis of religion's role in the medical arena could begin inductively by examining the actual responses of believers to illness and health. This paper, however, inquires about the interaction of religion and morality in the medical arena by first setting forth the elements of decision making. Just as the integrity of religion is not well served if reduced to decision making, so the elements of morality deserve their own consideration. Indeed, to ask about the interaction of religion and moral decisions assumes that the latter stands somewhat independently of the former. Yet differing views of morality are conditioned by perspectives which are either more or less comprehensive, and religion presses for a broader, more comprehensive, view. Morality retains its relative independence, but is conceived broadly enough to interact fully with the factors of religion which, again, have nonreligious counterparts; the wider conception is not a product of a religious view only.
This section of the paper states four distinct but related components of decision making, and together, these elements define the subject matter of morality. I do not mean to imply that all religious persons share this understanding, but stating these elements is a basis for inquiring about their relation to religion. Two of the components, moral values and situational analysis, are the common coin of contemporary moral discourse. A third element, loyalties, is more often neglected. The final element is human agency. These components are formal in the sense that different clusters of content are attracted to each.

Moral Values and Situational Analysis

A strong consequentialism is present in biomedical decision making because interventions in the natural life process are undertaken with the expectation that certain results will follow. But will they? And are the predicted results truly beneficial or good? These questions point to two important issues. One concerns facts and values, and the other concerns the adequacy of the method of calculating consequences for ethics. Consideration of these two issues raises a third, namely, the place of purpose in this component of decision making.
The vast literature about the relation of facts and values illustrates that different types of evidence count in making decisions. A division between facts and values presupposes a model in which one type of evidence consisting of pure moral values is applied to another type of evidence consisting of factually delineated situations. This model is endorsed in the important writings of Paul Ramsey. For Ramsey, when a medical team considers resuscitation, it first "reads the situation" by determining whether the patient is dying or nondying. This assessment is a matter of medical fact, and a patient's condition is such that resuscitation will either restore health or prolong the dying process. Once this situation is comprehended, the moral value of "care, but only care" is applied. Care requires informed consent. Care also requires an intervention to restore health, as may be possible, if the consenting patient is nondying. If the patient is dying, however, the obligation "only to care" does not require resuscitation, which would only prolong the dying process, but a ministry to suffering, pain, and loneliness, and the patient is allowed to die. Whether or not patients are always described adequately as either dying or nondying, the two kinds of evidence posit a division of labor. Medical science provides the facts and morality supplies the values to be applied.
This matter, I think, should be treated more subtly. Are "dying" and "nondying" purely factual terms? Any conception of death includes some notion of what is valued about life which, when lost irreversibly, enables the judgment that a person is in fact dead. Similarly, it may be asked whether "care" is a purely moral value which stands independently of factual material. Kubler-Ross's famous studies of the stages of death, for example, emerged out of value-laden observations about what takes place in the processes of dying, and this material shaped notions of care.
Concepts like justice and stealing include and combine different types of evidence. Notions of distributive justice, for example, are formulated by paying attention to situations in which competition exists for scarce resources. Certain situations which otherwise would not be understood are properly described as stealing. These observations do not erase the conceptual distinction between moral values and situational analysis, though the two may coalesce. Rather each of these components combines different types of evidence. So one comprehends the significance of situations in value-laden ways, and moral values are informed by data from the world.
The second issue is whether to modify or erase consequentialism, a question also introduced by Ramsey who argued that the business of morality is to provide rules of right conduct, not to calculate consequences. For Ramsey, it would be morally wrong to assume that death is always a bad consequence; this would tempt us to seek the better result of preserving life at any cost. As a rule of right conduct which does not calculate consequences, the canon of care does not prolong the dying process but allows the patient to die.
Still, Ramsey's stance presupposes that mere survival is not the purpose of human existence. If the "good" of health is assumed to be mere physical existence, care as a rule of right conduct might well support preserving life at very high costs, even in dying patients. The deep problem here is to understand health in relation to the purposes of human existence. If health is the central purpose of existence, it likely will be identified with survival or mere existence. On the other hand, if health is only one aspect of human purpose and a condition for its other aspects, mere existence is not so highly prized. Understanding the good of health in relation to other human purposes is not determined by moral principles; rather, moral principles are placed in their service, in either more or less consequential ways.
With respect to the question of method, my own judgment is that rules of right conduct and calculating consequences are both necessary. A better way to say this is that human conduct is evaluated by referring to the kind of activity it constitutes and in terms of its consequences. Sole reliance on either flounders, if only because of the former's unwillingness to take into account adequately what can be known about the future, and the latter's ultimate inability to foresee the future.
Human purposes condition each of these crucial elements and their interaction. The evidence for reading situations perceptively varies, and the forms of situational analysis range from intuitive perceptions to highly disciplined inquiries informed by different fields of learning. These forms and their content are judged more or less adequate in terms of their purpose. Again, the evidence which counts in formulating moral values varies, and the forms of moral values also vary, including everything from rules of thumb to ethical principles. The adequacy of these forms, as well as the adequacy of their content, is conditioned by their purposes. In sum, the uses of situational analysis and moral values in decision making inevitably serve human purposes. These purposes are set in relation to human capacities and needs in interaction with the structures of society and cultural norms.

Loyalties

"Loyalties" is shorthand to refer to objects of human desire, expectation, and trust. When affirmed, these objects receive our allegiance, hence the term loyalties. The nation is a potential object of devotion, for example. One may desire to be a citizen of a particular country and actively participate in its civic life. One may expect a country to provide protection and guarantee certain rights, and one may expect to participate actively in the processes of ruling and being ruled. If these desires and expectations are fulfilled in some fashion, enough trust develops that an allegiance is formed. Though the process is more complicated than indicated here, the result is that the loyalty of patriotism emerges, and this, in turn, shapes those who hold it.
Loyalties perform three functions, those of orienting, motivating, and providing a general direction. As orientation, patriotism provides a perspective from which to view and interpret life. As motivation, it provides reasons of heart and mind to participate in civic society. The political form of a country, e.g., a constitutional democracy, provides a general direction for at least one aspect of life.
The exact meaning of particular loyalties is discussed and debated, and different loyalties demand different allegiances which interact in various combinations. For example, the family is a potential object of desire, expectation, and trust, and so may become a loyalty. Parenthood provides orientation, motivation, and direction. Conflict in motivation is experienced if the demands of patriotism fail to agree with the perspective and direction of parenthood. Persons form many allegiances and in turn are shaped by them, e.g., economic prosperity and health, so the adjudication of interacting loyalties is perennial.
Loyalties take institutional form and embody cultural values. For the parent, institutional forms of the family embody the values of parenthood. For the patriot, institutional forms of government embody the values of democracy. For the physician, different institutionalizations of care embody the values of health. For the entrepreneur, institutionalizations of business embody values like hard work and success. These and other loyalties form identity because they are purposive. They exist for a reason, and these reasons are brought to bear on decision making. Why go to war? In part because one is a patriot. Why not go to war? In part because patriotism itself may give reasons to do otherwise. Why nurture children? In part because one is a parent. Why provide care? In part because one is a physician.
The interaction of different institutions with cultural norms helps shape a general ethos which is more or less diverse and demanding. This ethos exists in the present, but is deeply conditioned by recollections of the past and expectations of the future. As background and frame of reference, this ethos itself conditions decision making in society, and when ethos changes, existing practices will erode, gain support, or be enriched.

Human Agency

Stated briefly, assumptions which guide conduct are made about the capabilities of human agents, their motives, and their possibilities and limitations within the courses and workings of nature, history, culture, and society. Human beings are a highly diverse lot equipped with a remarkable range of capabilities. People differ according to their genetic endowment and their psychological development, as well as their settings in time and space, and different people have differing motives and intentions. They have different capacities for action and different inclinations toward moral deeds.
Nevertheless, they share a common nature Human agents are more or less integrated creatures with certain limits and possibilities. Within the context of culture and society, people are formed as their natural endowments develop and interact with the historical formation of dispositions, intentions, and basic convictions. In their varied forms, the motives and intentions of agents are shaped by historic convictions and expressed in conduct. The different motives and intentions of different persons, then, must be taken into account.
Human agency is expressed and embodied in a way of life, one important dimension of which is character. Character refers to the Greek word hexis, as in Aristotle, which was translated into Latin as habitus, as in Thomas Aquinas, and became the term "habit" in English. A habit or disposition is a readiness to act in a consistent manner, like reading or writing, or a persisting tendency to do things in fairly predictable ways, like driving a car or playing the piano. These skills are not endowed directly by nature, but are acquired over time when training and practice are offered by communities like the family, school, or synagogue. When habits are deemed moral, they are called virtues. Honesty, for example, is a disposition which characterizes some people; we observe, "They are as honest as the day is long," which means at least that they are not tempted to steal every time they go through a checkout counter. The acquisition of habits and dispositions forms identity. A child who learns to read is identified as a "reader" just as an adolescent who learns to drive is known as a "driver." Similarly, practitioners of medicine and those who repair automobiles are identified correctly as physicians and mechanics. These and other identities display the character of a social roles, though these admit a wide variety of expression since they are filtered through individuals. Still, physicians are expected to care and auto mechanics are expected to tell the truth. Character is necessary, both individually and in social roles, if agents are to sustain identity over time. Agency may also take corporate forms, but enough has been written to suggest that it is shaped by a variety of factors which are not readily reducible to a concept like freedom.
Assumptions about character as well as other aspects of agency "fit" the other elements of decision making, both in the sense that they influence them and in the sense that these other elements also shape these assumptions. The moral principle "Do not kill" fits humanity; the commands typically given to other animals, like dogs, do not. Situational analysis is conditioned by these assumptions, and differing assumptions about human nature make differences in how situations are described. The apprehension and statement of the purposes of life in the form of loyalties also fit perceptions of humanity. These interactions are reciprocal.

Summary

One neutral way to pose the moral question is to ask, What ought I to do? Answers are given in the form of judgments, acts, and policies. When judgments are made, acts performed, or policies enacted, they may be challenged. These answers to the moral question are then defended or discussed by giving "reasons" which support them, and these reasons take their form and content from the four components of morality.
Should the patient be resuscitated? If the answer is a judgment, "No," and this judgment is questioned, reasons are given to justify it. One reason appeals to situational analysis: The patient is irreversibly in the process of dying and attempts at resuscitation would only prolong the dying process. A second reason appeals to a moral value. The obligation of the medical team is to care for the patient, but only to care. This means that the patient will be allowed to die, but requires that pain, loneliness, and suffering be attended. A third reason appeals to loyalties: Health is a human good, but not an end in itself. Since health is a condition for other aspects of human flourishing, and these aspects are now beyond attainment, there is reason to allow the patient to die. A fourth reason appeals to human agency: Allowing a person to die accords with the finite nature of humanity and, one presumes, coheres with the dying patient's motives and intentions.
The four reasons are distinct, but together form a larger pattern which coalesces with the complex interaction between judgments, acts, and policies. If the judgment is followed by an act, for example, the patient is not resuscitated. We respond to similarly situated cases in the same way, if only because of the demand of fairness. The result is a policy which, when adopted, becomes a practice which defines, embodies, and expresses the meaning of medical care and gains the support of an ethos.
The interacting reasons of the four components of decision making are in turn conditioned and influenced by the factors of religious belief, or if not them, by their nonreligious counterparts. What is the extent, location, and relation of forces of good and evil? How relate to those who differ in some significant respect? What sources of knowledge are reliable? What types of guidance aid in facing the demands of life? To the degree that a vision of God informs answers to these questions, religious belief interacts with biomedical decision making. The possibilities are multiple.

INTERACTIONS

The multiple possibilities are too rich to be explicated fully here. The whole is a complex and dynamic field of interaction in which a vision of God and the factors of religious belief mutually condition each other and each of the elements of decision making and vice versa. I shall illustrate some of these interactions, but first comment on the relation between loyalties and a religious vision.

Vision and Loyalties

The interaction between a vision of God and human loyalties is important, though frequently neglected. Recall that loyalties are objects of human desire, expectation, and confidence which form allegiances like patriotism and parenthood. These are embodied in institutional forms which express cultural values, and so are causes which serve human purposes and shape identify. Loyalties change in content over the course of time, interact with other allegiances, and require adjudication. That is, they are constantly reformulated, related to other loyalties, and so ordered. This ordering is done by a center of value, a perspective which relates the demands of differing allegiances and aids in formulating their content. These interactions have inner dimensions insofar as desire, expectation, and trust are coordinated into a whole; they have outer dimensions insofar as the contending demands of external allegiances are ordered coherently. A result is the formation of identity as a pattern of life which orients, motivates, and directs agents in the world.
When a religious vision interacts with human loyalties, its basic import is to distinguish the ultimate from the proximate by subordinating other allegiances to devotion to God. This matter stands at the heart of religious life as the problem of idolatry. To have no other God does not eliminate other human loyalties; it requires they be apprehended as nonultimate. Proximate values in a religious vision range from those which are not worthy of esteem to causes worth serving even to the point of death, e.g., martyrdom on behalf of one's family. Devotion to God as the center of value orders the relative worth of these proximate allegiances in inner and outer dimension. The inner dimension is that the religious vision elicits human trust, expectation, and desire, and transfers them to God. To use traditional Christian language, they are transformed so that trust as faith in God, expectation as hope in God, and desire as love of God, characterize inner devotion to an ultimate cause. What is believed about God as the object of faith, hope, and love has important external dimensions. As the center of value, these beliefs deal with the contending demands of the world by helping to order, relate, and formulate the proximate meaning of other human allegiances. When these inner and outer dimensions coalesce, an integrated pattern of life emerges which provides identity as orientation, motivation, and direction for walking a way.
The possibilities considered by Paul Ramsey when he wrote about the meaning of care illustrate the interaction between a vision of God, other human loyalties, and the prospect of intervening in the natural life process. For a patient with appendicitis who is not irreversibly dying, for example, a medical intervention is likely to restore health; otherwise, premature death may result. Suppose, however, that intervention is opposed because it "plays God" by usurping the deity's sovereign rule. God is conceived as the direct giver and "taker" of life since the divine presence in the world is identified with the natural life processes of cause and effect. A loyalty to health as physical existence is of little worth when ordered in relation to this center of value.
On the other hand, if an intervention is sanctioned which restores health, God's presence as sustainer of life may be discerned indirectly through a surgical procedure which at the same time mediates God's ordering power. As the center of value, belief in God correlates with a loyalty to health which esteems the gift of physical existence more highly than when intervention is foregone. This latter stance, of course, avoids a "God of the gaps" position in which scientific notions of cause and effect are antitheticallyjuxtaposed with beliefs about the deity. If God is conceived as an active power whose presence in the world is mediated in time and space, then what actually takes place in the world must be related in some way to this belief. Vision, loyalties, and the possibility of intervening are interacting variables; knowledge of God is admittedly conditioned by perceptions of the world, not only ideas about health but also notions of cause and effect.
The case of the patient who is irreversibly dying also illustrates the interaction of these variables and the influence of belief in God as the center of value. A medical intervention prolongs the dying process. This intervention correlates with a conception of health as mere physical existence, for the point can only be to "respect" life by preserving it as long as possible. When the limits of technology are not acknowledged, conceptions of God's power to sustain life transcend or remain independent of cause and effect processes.
If no intervention is undertaken, on the other hand, the patient is allowed to die. Lack of intervention correlates with a conception of health as a condition for other aspects of human flourishing, and when these aspects are beyond attainment, mere existence is not so highly prized. God as the center of value is imaged as the indirect giver of life, and also as an ordering power whose purposive presence is mediated in and through the various arenas of life. When these divine purposes, which correlate with other aspects of human flourishing, are no longer attainable, the importance of health as mere survival diminishes. Moreover, a distinction between God and creaturely existence is upheld. So again, the religious vision is the center of value which orders other human loyalties, and this center gains specificity by the way it interacts with the ways things are in the world, in this case, perceptions of health and notions of cause and effect.

The Other Factors of Belief

Loyalties and the vision of God do not stand alone. Their interaction with possibilities for intervening are conditioned by the factors of religious belief, and these, in turn, influence the other components of decision making and vice versa. A religious stance with a thoroughgoing dualism which opposes the world, uses exclusive sources of knowledge, and offers rigorous guidance to the religious community, for example, differs considerably from one which moderates a thoroughgoing dualism, affirms the world, uses inclusive sources of knowledge, and offers guidance to the world. Keyed to distinctive beliefs about God, these and other stances qualify the components of morality differently.
Some of these differences may be illustrated briefly by reverting to the case of the irreversibly dying patient where attempts at resuscitation prolong the dying process. In respect to good and evil forces, a thoroughgoing dualism could view the end of life as the central locus of evil and set human existence over against death as good. The extent and location of evil are not universal or radical but confined to life and death issues, a position which could be elaborated by an eschatology which protests or rebels against human finitude. With respect to religious participation, opposition to the world could be expressed in a refusal to accept the limits of technological innovations, and with it, a failure to recognize the limitations of the medical segment of society. With respect to sources of knowledge, a more exclusive stance could ignore scientific accounts of cause and effect and object to the statement that a patient is irreversibly dying. With respect to moral guidance, conscientious obedience to a rigorous higher law could instruct the religious community to disregard the limits of technology and foster attempts to always preserve life.
Each of these factors is keyed to a vision of God's power to sustain life which transcends or remains independent of cause and effect processes.
Together, they reinforce the interaction between a vision of God, a conception of health as mere existence, and attempts to preserve life as long as possible. This combination of factors, moreover, counters the moral reasons which would allow a patient to die, though in ways too intricate to enumerate here in detail. Still, health is not conceived as a condition and one aspect of human flourishing, but as physical existence. Human finitude is not accepted but protested. Instead of the canon of care, emphasis is placed on the moral value of preserving life, and instead of saying that the patient is irreversibly dying, it could be said that the patient is temporarily ill.
Allowing an irreversibly dying patient to die, on the other hand, may also be supported by the factors of religious belief. With respect to good and evil forces, a moderated dualism could discern God's ordering presence in the world amid these interacting powers, though the divine purposes of existence in the varied arenas of life are beyond attainment for the patient. The gift of life could be acknowledged as a finite good to be received with a gratitude expressed properly to both its proximate and ultimate sources, a position which could be elaborated by an eschatology which affirms the goodness of God and the value of life even in the face of finitude and death. With respect to religious participation, affirmation of the world could be expressed by accepting the limits of technological innovation, and with it, a recognition of the limitations of the medical segment of society. With respect to sources of knowledge, a more inclusive stance could accept scientific accounts of cause and effect and endorse the statement that a patient is irreversibly dying. With respect to moral guidance more responsive to the demands of culture and society, the canon of care, but only care, could be affirmed.
Each of these factors is keyed to a vision of God as the indirect giver of life and an ordering power whose mediated presence is discerned in the various arenas of life. Together, they reinforce the interaction between a vision of God, a conception of health as a condition and aspect of human flourishing, and a willingness to forego attempts at resuscitation. This combination of factors, moreover, supports the moral reasons which would allow a patient to die in ways which, I hope, are clear in basic outline.
The factors of religious belief do not entail or precisely determine the exact qualifications of the components of moral decision making, which retain their relative independence, yet profoundly condition and influence them. The result is that a vision of God and the factors of belief interact with the elements of morality to form a way of life. The qualities of each of the factors of religious belief, we have seen, join with a vision of God to form a pattern, and these, in turn, link with qualifications of the components of decision making to fashion a way of walking in the world.
The image of a journey draws to attention that a way of life does not always move from a vision and the factors of belief to moral problems, but often the reverse. No journey is complete at its beginning, but continues through encounters with problems which may be viewed as pitfalls, dangers, and temptations. These provide the occasion for seeking guidance, acquiring skills, and forming identity in community. Venturers are thereby oriented, motivated, and directed to walk a way in the world. Depending on the vision, and, no doubt, the character of the travelers, encounters in the world may also be viewed as challenges and opportunities. Perhaps a paradox in the vitality of religious belief is found at this point. The deepest convictions of life are often religious, so there are reasons to hold them firmly. If held defensively, for whatever reason, encounters in the world are viewed only as temptations, dangers, and pitfalls. Yet firmness of belief may also bring something like the ''cosmic optimism" Perry Miller attributed to the Puritans, a certain confidence in the vision which provides encouragement for the journey of life. Venturers are then challenged to respond to encounters as opportunities to clarify the meaning of existence in the world in relation to the vision.

Prophetic Protest, the Status Quo, and Apocalypticism

More could be said about the rich interaction between a religious vision, the factors of religious belief, and the elements of decision making, but enough has been written to provide a partial basis for explaining how religion sometimes functions as a cover for other interests. The essence of the process is an inversion at the point of loyalties so that beliefs about God become a function of other allegiances which are the actual center of value. The phenomenon is as old as Western religion and stands at the heart of prophetic protests against "priestly" religion, that is, the type of religion sometimes endorsed by the leaders of congregational religion. Prophets typically use moral language to criticize false forms of worship, e.g., "I take no delight in your solemn assemblies ... let justice roll down like waters" (Amos 5:21, 24). What is centrally at stake, however, is specifying God's relation to the world with respect to a way of life. In congregational religion priests are responsible for leading worship and interpreting the religious message. Trained by an establishment, these leaders may be conservative in two senses: first, they set forth a religious message from the past in the context of worship, and second, along with influential laity, they have a stake in maintaining the status quo. By contrast, the urgency of a prophetic message objects to liturgical practice when it sanctions a way of life unresponsive to God's active presence and provides moral guidance in the form of moral principles which point to a true way of life in the world.
The religious participation of "priestly religion" opposes any change in the status quo, and its use of moral principles reflects this interest. Repeating an unrevised religious message in a liturgical setting, priests insist that the exclusive source of reliable knowledge is the authoritative tradition in which they have been trained and overlook what is actually taking place in the world. They know with scholastic assurance that true belief is cognitive assent to intellectual propositions. The forces of good are located in the status quo, and evil is defined as threats or challenges to this same order. These priests do not provide a religious construal of existence which leads to a way of life responsive to God's active presence. The heart of the matter is an inversion at the point of loyalties, so that beliefs about God function as a cover for other interests which are the actual center of value.
Prophetic criticism of priestly religion can depart from discerning God's ordering presence in the world and focus more completely on the way the world ought to be in the future. The moral urgency of apocalyptic messages is directed toward a new order. Guidance no longer takes the form of moral principles but endorses those inner attitudes deemed necessary for the emergence of a new world. Religious participation does not endorse the existing order but opposes it by fleeing, protesting, seeking change, or attempting to overthrow it. Reliable knowledge is drawn selectively from authoritative texts and other sources which point to a new order. God's relation to the world is specified in terms of what should be rather than what is, though foretastes of the new order may be seen in the present. Judgments must then be made about whether allegiance to a new order is the actual center of value, so that religion functions as a cover for this interest, or whether belief in God actually demands this proximate loyalty. The criteria used to test these judgments are drawn from the religious vision, the factors of belief, and the components of decision making.

Summary

These comments provide the occasion for a summary which focuses on the link between forms of religious participation and beliefs about God's ordering presence in the world which, in turn, interact with the ethos which supports medical practice. Again, the patterns delineated are regrettably abstract. One pattern of religious participation dissociates from the world. With this pattern, God's active presence is not discerned in the world, and interaction with ethos is minimal; medical practice, in all probability, is ignored and sustained by benign neglect.
A second pattern of religious participation opposes the world. When opposition takes the form of protest, God's ordering power as a positive presence in the world is largely absent. Protest may erode the ethos which supports medical practice or perhaps lead to change. When opposition takes the form of change, God's ordering presence in the world is allied with selective tendencies in the culture. The result creates tension in the supporting ethos which perhaps leads to modifications in medical practice, or, if change is not successful, to erosion. When opposition attempts to overthrow the world, ethos is not supported; medical practice may change, remain unchanged, or erode.
The third pattern affirms the world. When affirmation takes the form of virtual embrace, God's ordering presence is identified with the existing order. Ethos, as well as medical practice, is sustained. When affirmation takes the form of an inevitable necessity, God's restraining order is perceived in a world continually threatened by chaos. The ethos which supports medical practice is endorsed to the extent that it continues to limit threats to chaos. When affirmation takes the form of critical acceptance, God's ordering of the world includes sustaining and judging dimensions, and also prospects for new possibilities. The ethos which supports medical practice may be enriched or modified.

CONCLUDING OBSERVATIONS

I conclude with four observations. First, the conception of religion in this paper presses for a broader, more comprehensive, view of morality. It is uneasy with more restrictive views that split fact from value, focus on applying purely moral principles to purely factual situations, conceive agency as moral only to the degree it is free from historical and other forms of conditioning and neglect the importance of human purposes. The primary reason offered in this paper for a broader view is theological. A vision of God is articulated only when the factors of religious belief aid in specifying the deity's relation to the world, and this vision requires a conception of morality responsive to its concerns. Since the factors of religious belief are not always qualified from an explicitly religious point of view, nonreligious reasons could also be adduced for a broader view.
Second, contributions by religion to biomedical decision making are more likely when religious participation is more affirmative, sources of knowledge are more inclusive, moral guidance is directed toward the world, evil is conceived as universal and radical, and God's active presence in the world is discerned in an interacting field of good and evil forces without a thoroughgoing dualism. There is room for caution even here, however. For example, medical practice has learned from those whose religious stance is quite different about respecting persons who refuse medical treatment.
Third, not the least of God's mercies is that the whole scheme outlined in this paper does not have to be used every time a decision is made. Most decisions in ordinary life are a product of informed intuitions, habits, and practices; an analytical framework certainly does not guarantee better decisions. Moreover, if one's religious stance is more affirmative on participation, more inclusive on sources, more worldly in moral guidance, and so forth, theological reasons exist for not having to articulate an understanding of God for every decision. Indeed, theologians may participate in good conscience in public decision making without referring explicitly to their deepest convictions about God, and my suspicion is that something like this stance is often adopted by theologians who serve on public commissions. Readers of this paper will have observed that the description of the moral components of decision making is not theological, though they could be qualified more directly by religious content than I have indicated.
On the other hand, I am persuaded that the factors of religious belief deeply condition decision making, whether qualified by religious or nonreligious perspectives. When explicit or implicit assumptions about these factors are divisive, which is more often than we usually care to acknowledge, they require explicit attention, and it may well be helpful to call attention to them even when implicit agreement appears to be present. They are, after all, at the heart of some of the deepest of human convictions. One would think, moreover, that theologians who serve on public commissions would be expected to contribute to discussions from a religious perspective.
Fourth, all knowledge is historically conditioned and so perspective in at least two senses. What one sees and knows depends on where one stands, for example, twentieth-century America in contract to first-century China. What one sees and know depends also on the glasses or lenses used to view the world, for example, common sense, one or more of the science, theology, or whatever. Since no neutral standing point or privileged perspective exists, a theologian may be given for observing that a "confessional" dimension inevitably enters discourse. The four factors of religious belief profoundly condition decision making, and no point of view exists from which to qualify them which is not historically conditioned and perspectival
Those persuaded of the reality of historical conditioning are uneasy with notions of what is "public" if they imply the absence of a point of view, as if, for example, religion represents a private domain set over against more publicly accessible knowledge. Even science is not public in the sense that it is unconditioned by perspectives and history. Those trained in physics often use mathematics in ways which are not easily accessible to biologists, and chemists sometimes have difficulty conversing with biologists, not to mention paleontologists. I agree with James M. Gustafson that "there is no scientific public, except perhaps on very, very generalized or abstract grounds." As one historically conditioned point of view among others, religion has its own perspective. Its potential contribution to biomedical decision making is not privileged, of course; judgments must be made on the basis of its arguments, the evidence it cites, its willingness to learn in dialogue from other points of view, and its cogency in open forums.

Footnotes

1. See especially, Max Weber, Economy and Society, 3 vols., ed. Guenther Roth and Claus Wittich (New York: Bedminster Press, 1968), vol. 2, pp. 399-640, and Ernst Troetsch, The Social Teaching of the Christian Churches, 2 vols., trans. Olive Wyon (Louisville: Westminster/ John Knox Press, 1992).
2. James M. Gustafson, Ethics from a Theocentric Perspective, 2 vols. (Chicago: The University of Chicago Press, 1981, 1984), vol. 1, Theology and Ethics, pp. 209-225. Gustafson also mentions "the self." An enormous literature seeks to describe the modern world, e.g., Niklas Luhmann, The Differentiation of Society, trans. Stephen Holmes and Charles Larmore (New York: Columbia University Press, 1982). For suggestive summaries in a theological context, see Max L. Stackhouse, Public Theology and Political Economy: Christian Stewardship in Modern Society (Lanham: University Press of America, 1991), pp. 163-174, and Douglas F. Ottati, "The Contemporary Situation for Mainstream Theology and Ministry," Affirmation, vol. 4, no. 1 (Spring 1991), pp. 1-24.
3. The two basic questions of theology are, Who is God and how is God related to the world? The central traditions of Christianity answer the first question by saying trinity, and the second by saying creator, governor, and redeemer (the term "governor" includes images of ordering, sustaining and nurturing, preserving and restraining, and judging). The first answer distinguishes Christianity from Judaism, but the two traditions share at least some common ground in answers to the second, which in theology is known as the "nature-grace" issue. This paper concentrates on answers to the second question.
H. Richard Niebuhr in Christ and Culture (New York: Harper and Brothers, Harper Torchlight Books, 1951) shows how answers to both questions are related in Christianity, and his reflections are informed by the study of Charles Norris Cochrane, Christianity and Classical Culture: A Study of Thought and Action from Augustus to Augustine (New York: Oxford University Press, A Galaxy Book, 1957). I regret that I am not competent to take into account the literature of Judaism and Islam in this paper.
4. These four issues, along with answers to the two questions in the previous endnote, are elements central to a systematic theology. My treatment of these matters is informed by H. Richard Niebuhr's Christ and Culture, itself a response to Troeltsch's The Social Teaching.
5. Weber, Max, "Politics as a Vocation," in From Max Weber: Essays in Sociology, trans. and ed. H. H. Gerth and C. Wright Mills (New York: Oxford University Press, 1958), pp. 122-124.
6. For examples, see Mary Midgley, Evolution as Religion: Strange Hopes and Stranger Fears (New York: Methuen, 1985) and Science as Salvation: A Modern Myth and Its Meaning (New York: Routledge, 1992); see also James M. Gustafson, "Sociobiology: A Secular Theology" [a review of On Human Nature by Edward O. Wilson], Hastings Center Report, vol. 9, no. 1 (February 1979), pp. 44-45.
7. Weber, Max, Economy and Society, vol. 2, pp. 452-468.
8. Adams, James Luther, "Mediating Structures and the Separation of Powers," Voluntary Associations: Socio-cultural Analyses and Theological Interpretation, by James Luther Adams, ed. J. Ronald Engel (Chicago: Exploration Press, 1986), pp. 217-244.
9. Troeltsch's well-known typology of church, sect, and mysticism, appears in The Social Teaching.
10. See Adams, "Mediating Structures," and his "The Voluntary Principle in the Forming of American Religion," Voluntary Associations: Socio-cultural Analyses and Theological Interpretation, pp. 171-200. See also, James M. Gustafson, "The Voluntary Church: A Moral Appraisal," Voluntary Associations: A Study of Groups in Free Societies, ed. D. B. Robertson (Richmond: John Knox Press, 1966), pp. 299-322.
11. Roof, Wade Clark and William McKinney, American Mainline Religion: Its Changing Shape and Future (New Brunswick: Rutgers University Press, 1987).
12. I cannot locate an exact quotation, but see H. Richard Niebuhr, The Responsible Self An Essay in Christian Moral Philosophy (New York: Harper & Row, 1963), pp. 47-68.
13. Normative and descriptive studies exist. For Protestantism, Paul Ramsey, Who Speaks for the Church? A Critique of the 1966 Geneva Conference on Church and Society (Nashville: Abingdon Press, 1967) initiated a continuing debate. See also, James M. Gustafson, Protestant and Roman Catholic Ethics: Prospects for Rapprochement (Chicago: University of Chicago Press, 1978), pp. 126-137. For Roman Catholicism, a place to begin is Readings in Moral Theology No. 3, The Magisterium and Morality, ed. Charles E. Curran and Richard A. McCormick (New York: Paulist Press, 1982). See also The Crisis in Moral Teachings in the Episcopal Church, ed. Timothy Sedgwick and Philip Turner (Harrisburg: Morehouse Publishing, 1992), and Todd Whitmore, "Reason and Authority in Church Social Documents: The Case for Plausibility and Coherence," Ethics in the Nuclear Age: Strategy, Religious Studies, and the Churches, ed. Todd Whitmore (Dallas: Southern Methodist University Press, 1989), pp. 181-231. Descriptive accounts are found in a number of social studies.
14. Cahill, Lisa Sowle, Between the Sexes: Foundations for a Christian Ethics of Sexuality (Philadelphia: Fortress Press, 1985), p. 5. Cahill's statement should be compared with Gustafson's four sources in Protestant and Roman Catholic Ethics, p. 142.
15. Calvin, John, Institutes of the Christian Religion, 2 vols. (Philadelphia: Westminster Press [Library of Christian Classics, vol. 20, ed. John T. McNeill], 1960), trans. Ford Lewis Battles, vol. 1, pp. 348-366. The impact of these formulations had far-ranging consequences on the Puritans and in America. For a fascinating but neglected study, see David Little, Religion, Order, and Law: A Study in Pre-Revolutionary England (New York: Harper Torchbooks, 1969 [reprint, University of Chicago, Midway Press, 1984]).
16. Four components of decision making are cited by a number of different authors, though in differing forms, e.g., Ralph B. Potter, War and Moral Discourse (Richmond: John Knox Press, 1970), pp. 23-24, James M Gustafson, Protestant and Roman Catholic Ethics, pp. 139-141, and Gustafson, Ethics from a Theocentric Perspective, vol. 2, Ethics and Theology, p. 143. My views are informed by Gustafson though I think he collapses proximate loyalties into his "theological base." The usefulness of the four components for analytical purposes is illustrated in Harlan Beckley, Passion for Justice: Retrieving the Legacies of Walter Rauschenbusch, John A. Ryan, and Reinhold Niebuhr (Louisville: Westminster/John Knox Press, 1992). This latter book, incidentally, shows that theological convictions can be important in formulating conceptions of justice and demonstrates that theologians from different Christian denominations contributed to the "public" moral discourse in twentieth century America.
17. Ramsey, Paul, The Patient as Person (New Haven: Yale University Press, 1970), pp. 113-164.
18. Veatch, Robert M., Death, Dying, and the Biological Revolution: Our Last Quest for Responsibility, rev. ed. (New Haven: Yale University Press, 1989), pp. 15-44. The literature is extensive.
19. Kubler-Ross, Elisabeth, On Death and Dying (New York: Macmillan Company, 1969). See also, Milton Mayeroff, On Caring (New York: Harper & Row, Perennial Library, 1971).
20. See Leon R. Kass, "The End of Medicine and the Pursuit of Health," Toward a More Natural Science: Biology and Human Affairs (New York: Free Press, 1985), pp. 157-186.
21. Augustine's treatment of loyalties remains influential, perhaps especially the nineteenth book of Concerning the City of God Against the Pagans, trans. Henry Bettenson, intro. David Knowles (Baltimore: Penguin Books, 1972), pp. 843-894.
22. John Rawls writes about practices in "Two Concepts of Rules," Philosophical Review, vol. 64, no. 1 (January 1955), pp. 3-32, an article cited by James M. Gustafson in The Contributions of Theology to Medical Ethics (Milwaukee: Marquette University Theology Department, 1975). On practices, see also Alasdair Macintyre, After Virtue: A Study in Moral Theory (Notre Dame: University of Notre Dame Press, 1981).
23. My abbreviated account is informed by Gustafson, Can Ethics Be Christian? (Chicago: University of Chicago Press, 1975), pp. 25-47. Theological construals of human nature inevitably presuppose a philosophical account. Both Mary Midgley, Beast and Man: The Roots of Human Nature (Ithaca: Cornell University Press, 1978) and Melvin Konner, The Tangled Wing: Biological Constraints on the Human Spirit (New York: Holt, Rinehart and Winston, 1982) show that a dualism between nature and spirit, or between phenomenal and noumenal aspects of agency, cannot be sustained in light of contemporary knowledge of biology.
24. My brief account of character is informed loosely by Aristotle, Thomas Aquinas, James M. Gustafson, and Stanley Hauerwas.
25. Niebuhr, H. Richard, Radical Monotheism and Western Culture: With Supplementary Essays (New York: Harper & Brothers, 1943, 1952, 1955, 1960), uses the term "center of value." Both Niebuhr and Gustafson are informed by Augustine as well as Josiah Royce. Gustafson explicitly mentions faith, hope, and love, as well as desire, expectation, and confidence, in Ethics from a Theocentric Perspective, vol. 1, Theology and Ethics, pp. 224-225, and like Niebuhr, distinguishes faith as confidence from faith as fidelity.
26. Augustine, "The Way of Life of the Catholic Church," The Catholic and Manichean Ways of Life, trans. Donald A. Gallagher and Idella J. Gallagher (Washington, D.C.: Catholic University Press, 1966), pp. 3-61, has had an enormous influence in Christianity. The classic delineation of religion as a way of life in sociology is Max Weber, Economy and Society, vol. 2, pp. 399-640. See also, Paul M. van Buren, A Theology of the Jewish-Christian Reality, Part I, Discerning the Way (San Francisco: Harper & Row, 1980).
27. Miller, Perry, The New England Mind, vol. 1, The Seventeenth Century (Boston: Beacon Press, 1961), p. 18.
28. Roof, Wade Clark, Community & Commitment: Religious Plausibility in a Liberal Protestant Church (New York: Elsevier, 1978), delineates "local" and "cosmopolitan" outlooks as variables of religious meaning and belonging. Religion as a "function" of other interests is a wellworn topic in sociology.
29. Observations about a scholastic religious response to modernity are found in Clifford Geertz, Islam Observed: Religious Development in Morocco and Indonesia (New Haven: Yale University Press, 1968).
30. For two discussions of criteria, see Douglas F. Ottati, "Christian Theology and Other Disciplines," Journal of Religion, vol. 64, no. 2 (April 1984), pp. 173-187, and James M. Gustafson, Can Ethics Be Christian?, pp. 130-143. Stackhouse's more intuitive appeal to evidence from "the world" and from "the Word" is of interest; see Public Theology and Political Economy.
31. A literature that began more than thirty years ago stresses the importance of a point of view in science. See Norwood Russell Hanson, Patterns of Discovery: An Inquiry into the Conceptual Foundations of Science (Cambridge: Cambridge University Press, 1965; originally 1958); Michael Polanyi, Personal Knowledge (New York: Harper and Row, 1964; originally 1958); Stephen Toulmin, Foresight and Understanding (New York: Harper and Row, 1961); and Thomas S. Kuhn, The Structure of Scientific Revolutions, 2d ed. (Chicago: University of Chicago Press, 1970; originally 1962). A philosophically aware and clear discussion of these matters is Harold I. Brown, Perception, Theory and Commitment: The New Philosophy of Science (Chicago: University of Chicago Press, 1979). See also, Stephen Toulmin, Human Understanding: The Collective Use and Evolution of Concepts (Princeton: Princeton University Press, 1972).
32. Gustafson, James M., "Response to Francis Schussler Fiorenza," The Legacy of H. Richard Niebuhr, ed. Ronald F. Thiemann (Minneapolis: Fortress Press, 1991), p. 79. My previous sentence is drawn from this article.
Copyright 1995 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK231954

Institute of Medicine (US) Committee on the Social and Ethical Impacts of Developments in Biomedicine; Bulger RE, Meyer Bobby E, Fineberg HV, editors. Society's Choices: Social and Ethical Decision Making in Biomedicine. Washington (DC): National Academies Press (US); 1995. The Role of Religious Participation and Religious Belief in Biomedical Decision Making. Available from: https://www.ncbi.nlm.nih.gov/books/NBK231954/
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Essay 1 Proposal Argument

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