How Shall We Then Practice?
What is medicine? Is it a science? Is it a profession? Is it an industry? What has the Christian tradition to say about medicine? And does what the Christian tradition says really matter in the end? In hopes of beginning to address these questions, this essay explores three Christian metaphors which apply to the practice of medicine, namely medicine as gift, medicine as power, and medicine as vocation. For each metaphor, I will attempt to identify errors and blind spots toward which we are prone, point to resources within the Christian tradition for correcting our mistakes, and suggest some very preliminary steps toward what I hope is the way forward.
MEDICINE AS GIFT
In what sense might we say that medicine is a gift? We can start with an uncontroversial claim in this setting, namely, that medicine, like all of creation, comes from God, the giver of all things. We have not created medicine, however much we have advanced the powers which it may apply. Medicine has not emerged of its own accord without reason or purpose. It is not ours by our own merit—we have not purchased it any more than we have purchased the life and health which it seeks to preserve.
If medicine is gift, what implications follow? The most basic implication is that medicine is good, even—in the language of the Bible's first chapter—very good. We might go so far as to ask on what other grounds medicine can be considered good, if not on the grounds of God’s own goodness.
Recently, I spoke with a prominent Christian physician about a talk that he was preparing. The title of his talk posed this question: “Does faith have a place in scientific medicine?” It seems to me that putting the question that way gets us off on the wrong foot. We might better ask, "Why should we practice medicine at all? Why should we care for the sick?"
Here religious believers concede too much too quickly. How sensible is it in the end to care for the sick and weak if our primary concern is the evolutionary fitness of the human population? Indeed, Why should the selfish gene care for anything that diverts us from the task of generating genetic offspring? And why should we invest our time and resources in caring for the debilitated if our aim is to maximize our own temporal autonomy. The sick really are rather a bother after all. Is it not the case that caring for the sick only becomes fully rational, fully defensible, fully and good, in light of the fact that just as we are given life and breath and strength as good gifts from a good giver, so we are also given the means and responsibility to respond to those whose life and breath and strength are threatened or are ebbing away? We find, in other words, that the first implication of medicine as gift is that the goodness of medicine is vouchsafed by the goodness of the God who is its giver.
The second implication of medicine as gift is that medicine has a given order; medicine is not neutral. We are all familiar with the phrase, “Well, that’s a given.” We might say it in response to something like, “The Cubs are going to miss the playoffs." It means, “that is of the nature of the thing, it is intrinsic to it.” Likewise, medicine has a meaning and order that is given in the nature of the thing, one that we do not invent but rather can only to varying extents apprehend, and to which we choose either to submit, to our good, or to ignore, to our peril.
Whether medicine has an intrinsic ethos, or only one imposed by people from outside, has been the subject of at least forty years of debate in the bioethics community. As Christians, we ought to be clear on which side of the debate we stand, because we know that God’s good gifts are all ordered to proper ends and uses. Just as marriage and the church, the family and food and sex have a given order, so also medicine. Yet many Christians in health care seem to conceive of medicine as a relatively neutral, albeit felicitous and powerful, means to the end of spiritual conversation with patients. Medicine is seen as a wedge that opens up the heart inviting dialogue about spiritual matters. The “witnessing” or “ministering” that ensues is thought of as the expression of Christian faithfulness, and medicine becomes one particular tool in or context for that task.
Two problems emerge when Christians treat medicine in this way. The first is that we tend to take for granted that contemporary practices of medicine are good so long as they are not intrinsically evil. After all, the point is not the medicine itself, but the spiritual dialogue to which medicine opens the door. We accept the cake of standard medicine and put a flourish on the frosting, without doing the work to consider whether the cake may be ruined at the core. The second problem is that when we understand medicine as neutral, our efforts to contend for good uses of medicine seem arbitrary. In other words, if medicine is neutral, why should anyone else pay attention to your particular ideas about how it should be practiced? Why should you, in the common idiom, “impose your personal values?" Merriam Webster defines imposition as “an excessive or uncalled-for requirement or burden,” and if values are not central to medicine itself, then such impositions are rightly resisted and understandably resented in a democratic, plural democracy. As Christians, we need to recover the idea that because medicine is given, it is not neutral.
The third implication of medicine as gift is that, as a gift from God to us, medicine expresses truths about God and about us. About God, we learn that he cares for and is concerned about those who suffer in the body. God is the balm in Gilead, the great physician. It is Christ the Lord who heals our diseases and redeems our life from the pit. About ourselves, the gift of medicine reminds us that we are creatures who are, in the philosopher Alasdair MacIntyre’s terms, dependent rational animals. 1 Contemporary medicine tends to unduly emphasize some aspects of these three intrinsic dimensions of the human experience and to ignore other aspects.
Humans are, the conventional reasoning tells us, the only rational animals, and therefore human dignity (or personhood) inheres in our rational capacities. In other words, human dignity is developed with and dependent upon capacities that a mere human may or may not possess, and which that human organism must in some real sense demonstrate in order to make moral claims on the rest of us. That rather ironically puts the burden on the weak to demonstrate that they have what it takes to justify that they be cared for by the strong.
If medicine, along with rationality and life itself, is a gift from God, this approach gets it exactly backward. Christianity teaches us that our dignity is given to us by the one who created us, and is given in the act of creation. For that reason, every creature has a particular dignity, according to its place in the order of creation, and among the animals the dignity of the human organism is highest as that human alone is created in God’s image. Moreover, our dignity inheres in our bodies, not in some disembodied rational capacity. Every human who is bodily present to us, no matter how diminished in capacities, retains the dignity of being part of the human family with God as its head. In fact, just to the extent that our neighbor is vulnerable and diminished in her/his own capacities, that neighbor justly demands, in God’s name, that we care for her/him. What else could Jesus have meant in his claim that what we have done to the least of these, we have done unto him? After all, God cares for us in our utter weakness because we cannot care for ourselves. Here we see the paschal mystery that is foolishness to the world's wise: In the incarnation, Jesus glorifies our created bodies with all of their limitations and dependencies; he dignifies all our suffering by his own bodily suffering, and he triumphs over death by dying. He exposes the lie that our capacities are our salvation. We learn that our worth, however weakened, debilitated, sick, and dying we are, is measured in the currency of his love expressed in his bodily suffering unto death. 2
We humans are rational to a greater and lesser extent, but we are in every way, at all times, dependent upon God and upon one another. One of the errors of modernity, Maclntyre explains, is to always set up the independent agent as the human norm—to see departures from independence as aberrations which are to be expeditiously corrected. Eric Cassell, a prominent bioethicist of the past generation, gives voice to this mindset in his conclusion that the purpose of medicine is to restore our autonomy, to restore, that is, our independence. 3 But when we understand medicine as a gift from God to intrinsically dependent creatures, we see that it is a fool’s errand for medicine to set out to restore that which never really existed. We are never independent from God or one another.
Like the angels and all that is not God, we are dependent upon him who sustains all things by his powerful word. Unlike the angels, we are animals, and so, as all animals, are also limited by the contingencies of being embodied. Here we find another misunderstanding common among Christians who say, in so many terms, that our bodies are just our “earth suits.” This is an error that is cloaked in such wonderful truths that we have allowed it to become something of an axiom. The problem is that such notions suggest that we have bodies only on earth and that like a suit, the body is something which the "real us” can own for a time and then take off. No wonder we find others claiming, “No one has a right to tell me what to do with my body.” In contrast to these ideas, historical Christian orthodoxy holds that humans are embodied creatures, both now and forever. Our existence, now and forever, is bodily existence. We are not spirits who inhabit a body. Christ himself is not God who inhabited a body, but is instead God-man, God in the flesh.
What difference does this Christian dogma make for the practice of medicine? It means that humans are present to us so long as their living bodies are present to us. It means that we should be very careful about saying things like, “Dad is not there anymore" when Dad is in the late stages of Alzheimer’s disease. We should not say of the child with massive injury to the brain, “The real him is gone.” By thinking theologically, we remember that both are still present to us, albeit with drastically reduced capacities and unmitigated dependence. We see, as Jesus taught and Mother Theresa reminded us, that not only are they present to us, but Jesus himself is bodily present to us in them. Can that truth do anything but motivate and enliven our care for the sick and debilitated?
Knowing that medicine is a good gift and has a given order begs the question, what then is medicine for? What is its given purpose (its end)? Let me begin to answer that question by pointing to what many scholars have argued we can know by reason alone, and then complement that by what we as Christians can know by faith. By reason, according to Leon Kass (recent chair of the President’s Council on Bioethics) among others, we can discern that the proper end of medicine is health, which Kass carefully defines as an excellence of the body which is “the well-working of the organism as a whole.” 4
Why the language of organism and body? Isn’t that reductionistic? Isn't that dualistic? Doesn’t that neglect the mind and spirit? No. The focus on the body and the organism is to emphasize that medicine is a practice with limited scope and aims. In a moment we will consider in greater detail some of the problems that emerge when we ignore those limits. Why the term well-working (and elsewhere, flourishing) rather than something more manageable like “the patient’s medical good”? Kass's point is to emphasize that the pursuit of health is for something. Medicine is there to restore what can be restored of health so that the person can continue to seek the fullness of life. Toward that end, a healthy body is a great asset, but the goal is to flourish as a well-working human organism.
What our flourishing entails can only be fully known by the light of faith, wherein we find that the fullness of life is the life of God offered us in Christ. Margaret Mohrmann, a Christian physician and ethicist at the University of Virginia, puts it this way, “Health can never be anything other than a secondary good. God is our absolute good; health is an instrumental subordinate good, important only insofar as it enables us to be the joyful, whole persons God has created us to be and to perform the service to our neighbors that God calls us to perform. Any pursuit of health that subverts either of these obligations of and loving service is the pursuit of a false god. Health is to be sought in and for God, not instead of God." 5
What then is our task as Christians, in light of what we learn about medicine as a gift? It is first to see all of life, medicine included, as a gift. It is second to discern, in the community of the faithful, drawing on the means God has provided, what medicine is by its given nature and its given purposes. Our goal is to understand what God would desire for us to do as stewards of his of medicine in our particular context.
MEDICINE AS POWER
From medicine as gift, we turn to medicine as power and begin with a Scripture oft cited in other settings. In Paul's letter to the Ephesians. he writes (6:12), “For we do not wrestle against flesh and blood, but against the rulers, against the authorities, against the cosmic powers over this present darkness, against the spiritual forces of evil in the heavenly places.” In a book titled, Reclaiming the Body: Christians and the Use of Modern Medicine-a book that I cannot recommend strongly enough—Joel Shuman and Brian Volck argue that perhaps the most important task for Christians today, with respect to medicine, is to recognize and name modern medicine as among the powers and principalities. 6 The following paragraphs attempt to summarize Shuman and Volck’s thesis with respect to medicine as power.
It will not come as any surprise to learn that modern medicine is powerful. Both patients and clinicians experience medicine as, in Shuman and Volck’s words “a mysteriously animated social force." “We find,” they continue, “that medicine creates its own world. Those wishing to benefit from medicine’s power are expected to live in medicine’s world and obey its rules... It is a world with its own language and logic, its own ritual practices, and its own social expectations, and those not initiated into its mysteries cannot hope to understand it.”
By naming medicine as among the powers and principalities, we are not saying that physicians have ill motives, nor that medicine is evil. (Indeed, I have already claimed that medicine is good). Rather, we recognize the particular force that modern medicine exerts as one among the structures and authorities that order our lives, for both better and worse. To know when the influence is for better and when for worse, we have to do what we rarely do with respect to medicine, which is to think with reference to the theological truths of Christianity. And the theological point Shuman and Volck drive home is that medicine, like all of God’s good creation, is fallen and in need of redemption. The powers are good, the powers are fallen, the powers will be redeemed.
First, we know that the powers in their created order are good. Indeed, we cannot live without them. Imagine life without public services, without government, without culture, without printing presses, without transportation systems, without medicine. Our flourishing would not be possible without these powers. The Apostle Paul in Colossians 1:16 tells us, “In [Christ] all things in heaven and on earth were created, things visible and invisible, whether thrones or dominions or rulers or powers—all things have been created through him and for him.” The powers, in their created order, are good.
Yet medicine, like all the rest of creation, is fallen. Shuman and Volck again:
“Medicine primarily functions among the powers, we contend, by occupying a revered social position through which it appears to wield nearly sovereign control over life and death There is no apparent limit to medicine’s ambition to control the circumstances of human life and death by bringing them under human control and few people seem interested in asking whether or to what extent such an aim is appropriate for creatures of a providential God.”
The powers, in their fallen states, make pretentious claims and seductive promises. They offer us what we want, and so we esteem them and yield to them authority that they should not have. After all, as Shuman and Volck remind us, “A denial of our own mortalities and a desire to be in control is very near the center of our own disordered desires.” And how does medicine appeal to those disordered desires? It offers to free us from the limitations of the body.
There is more to say here than space allows, but it is perhaps enough to point to a general pattern with respect to medicine that has emerged with modernity. That is what Gerald McKenny calls “the Baconian Project,” after its principal proponent, Francis Bacon.7 The story is this: Within the Christian tradition, the task we are all to be about is to seek the fullness of salvation, what the Orthodox Christians call “theosis,” connoting participation in the life of God. Within the Christian tradition, therefore, medicine is good to the extent that it frees and enables us in our life of faithfulness, and harmful to the extent it distracts from or otherwise interferes with faithful life. According to McKenny, Francis Bacon and Rene Descartes began with the commitment to subject nature toward the service of one’s neighbor, to make use of it for good. They saw in the natural sciences the engine which might, if rightly harnessed, deliver mankind from its limitations—particularly sickness, weakness, dependency, and death.
Bacon and Descartes’ generic Protestant commitment to helping one’s neighbor was transformed, via Bentham, Mill, and other enlightenment figures, into a more critical stance toward received tradition altogether. In the place of tradition, these thinkers advanced the ideal of commitment to the ostensibly universal morality—those obligations (and only those obligations) which can be known by reason and empirical science. Predictably, the result is a move away from particular and traditional received notions of the givenness of our stations and our obligations, and toward what Charles Taylor, in his book Sources of the Self, describes as the moral project of our day, which is to decrease pain and increase pleasure.8 Taylor writes, “This emphasis on the relief of suffering in turn resulted in a new standard for all remaining conceptions of religious, moral, and legal order: Do they lessen the amount of suffering in the world or contribute to it?” And McKenny adds, “From now on all conceptions of order would have to present their credentials for relieving suffering to gain admission to the moral realm, credentials few such conceptions could produce,”
Of course, without particular moral traditions (i.e. religions) to look to, it is very difficult and perhaps impossible to establish what counts as suffering that should be relieved and what counts as pleasure worth pursuing. The default, not surprisingly, is that suffering and pleasure are what the one experiencing them says they are. Medicine comes to serve the goal of maximal individual control over the contingencies of bodily existence, and toward that end plies the ample technical powers developed by the scientific enterprise. This leads not only to what were traditionally understood to be moral evils, things like abortion and physician-assisted suicide, but also to profound expansions of the range of medicine’s aspirations.
One of the great ironies is that religion, banished from medicine as an undue traditional constraint, comes back to life as a technology that can be employed in our quest to maximize our health. Shurnan and Volck put it this way, “Most of the current literature dealing with faith and medicine seems to suggest that spirituality (or religion) should be brought into the world of the clinic and retooled, when and as necessary, to fit and serve the purposes of that world. Christians, in the meantime, have mostly been content to have their tradition so named and enlisted, grateful for the validation, or at least the attention. Yet we believe this gets matters backward. It is Christianity that ought to be naming medicine, harnessing its power in the service of being a community faithfully witnessing to the work of God in the world. For only as Christians learn properly to name the world and the things in the world, can we make proper use of those things. And only as we make proper use of the world can we hope truly to flourish.”
How then do we respond if we recognize medicine as among the powers which have been corrupted? Our response, Shurnan and Volck tell us, is to name the powers for what they are and therefore take back authority that we have unwittingly and foolishly conceded to them. They continue
“By assuming medicine and Christianity are pursuing the same things—which, coincidentally, happen to be things we want, such as health, the power to choose, and an able-bodied, painless death—Christians transfer even more authority their religious community to medicine, reinforcing one of the least appreciated phenomena in Christianity since the Reformation-the growing amnesia that Christians can and should think, speak, and act differently than the rest of the world.”
By naming medicine among the principalities and powers, we continually remind ourselves that medicine, like all creation, must be subjugated to the pursuit of friendship with God. Ultimately, medicine and all the rest of the powers will be redeemed. Until then, our task is to make use of the powers in pursuit of God while resisting their seductions and exposing and naming their lies.
What we are after is worship rather than idolatry. Idolatry is the practice of treating any particular thing as that which that thing can never be.9 We make medicine an idol when we treat it as the means of deliverance from the contingencies of the body—something it can never be. Worship, on the other hand, teaches us what Saint Augustine called ordered love. We are, Augustine said, to love all elements of creation just in proportion to those elements’ true worth, a worth which is always derivative of and given by God himself.10 We are to love everything in him, the giver of all good things. Christian worship, therefore, is always subversive of the wisdom and powers of this age, and so to worship as we practice, we will stick out. Shuman and Volck cite Flannery O’Conner as saying, “You shall know the truth, and the truth shall make you odd.” But, as they conclude, “If the Christ we claim as savior calls us to be all thumbs, who are we to argue?”
So far I have noted that medicine is a gift from God, and that along with all creation, it is both very good and yet fallen. How then can we participate in God’s work of redeeming the fallen creation, or restoring medicine to its rightful place in the created order? To point in that direction, we move to the third and final metaphor, medicine as vocation.
MEDICINE AS VOCATION
The term vocation, and its contemporary translation, calling, have been put to widespread use to refer to any sort of work done with more than instrumental goals. For the purposes of this essay, I will focus on the concept of vocation that emerged in the Christian tradition. What may come to mind is the contemporary use of the term by the Catholic and Orthodox churches, in which a vocation is a divine calling to a particular and consecrated way of life which is ordered to serve God and the Church through specific, concrete commitments and practices. We think, for example, of vocations to marriage, religious life, priesthood, celibacy, and the like.
For Martin Luther, the concept of vocation was central to the life of every Christian.11 Each of us, Luther taught, is called and set apart to participate: in God’s work through particular stations in life. Luther distinguished stations from vocations, with the latter being the Christian way of living the former. The stations themselves do not effect transformation of the human heart; they do not bring about regeneration in ourselves or others. Even so, Luther notes, “persons who have not taken the gospel to their hearts serve God’s mission, though they be unaware thereof, by the very fact that they perform the outer functions of their respective stations.” Fulfilling our stations in medicine as vocations, therefore, is a way of participating in God’s work of sustaining and preserving creation.
Several important implications follow from seeing the practice of medicine as a Christian vocation. First, medicine as vocation is cooperation and participation in God’s work of caring for others. God is the author of the work, but he works through us to accomplish his purposes. Luther puts it imaginatively, saying,
“God himself will milk the cows through him whose vocation that is. He who engages in the lowliness of his work performs God’s Work, be he lad or king. To give one’s office proper care is not selfishness. Devotion to office is devotion to love, because it is by God’s own ordering that the work of the office is always dedicated to the well-being of one’s neighbor. Care for one’s office is, in its very frame of reference on earth, participation in God’s own care for human beings.”
Second, medicine as vocation specifies for us our relationship within the community of the faithful. With respect to vocation, what one does is dependent on who one is, and who one is is not something one can decide for oneself. We can receive a vocation and live into its requirements, but we cannot make those requirements up. The vocation itself confers on us particular privileges, authority, and obligations. It tells us what our work is in the task of contributing to the good of the community.
Two points here bear some more emphasis. The first is that the particular station or vocation is not incidental but rather a work given by God and ordained to its own given ends for the good of the community in which it is ordered and made accountable. An example may help to drive this point home: Being a husband is a vocation. It is not open for us to invent what it means to be a husband, notwithstanding the regrettable contemporary phenomenon of Christians making up their own marriage vows. We husbands are accountable to the community of the faithful regarding how we fulfill our vocation. Being a husband is not a neutral thing which we make good by praying with our wives, however good it may be to pray with our wives. Likewise, being a physician is not a neutral thing made good by sharing the gospel with our patients. Both vocations are good in themselves and have their own given order and responsibilities which we can apprehend or ignore, but which are not subject to our own creative revisions. C.S. Lewis described this as the difference between the traditional mindset of initiation into an identity and practice, and the modern mindset of indoctrination. What is true, in this respect of being a husband, is also true of medicine.
The recognition that vocation is for and in the life of the body, the community of the faithful, leads Shuman and Volck to say that, properly speaking, as Christians “we never really go to the doctor alone.” The community of the faithful weighs in on and helps us to discern the nature of the gift we have been given in medicine, and how that gift is to be used in a particular setting. In other words, it is not our right to practice medicine according to our own preferences, without the sanction and, if needed, censure of the rest of Christ’s body. Rather, as Shurnan and Volck put it, “Especially when we are sick, we approach medicine as part of a suffering people hoping to remain faithful to our Creator, reserving to the gathered community of which we have been made members the right to judge the aims and means of medical practice in the light of the crucified and risen Jesus we worship.”
In medicine, practiced as a vocation, therefore, by participating in the work of God, within the body of the faithful, thinking theologically, and striving to discern the given nature of medicine and its good uses in our day, we participate in God’s work of redeeming that power and principality which has fallen. We stand as living reminders that the secular vision is not given. It is not to be taken for granted. And we look forward with hope to the day when all will be made right, sickness will be no more, and medicine, like the grave, will be swallowed up in Christ’s victory over sin and death.
In conclusion, through the metaphors of gift, power, and vocation, so richly elaborated in the Scriptures and the Christian tradition, we begin to see how the practice of medicine can and should reflect and embody the Christian story. Creation is good, creation is fallen, creation must be redeemed. Medicine is a good gift. With all creation, medicine is fallen and becomes one of the powers and principalities which order our lives in idolatrous ways. Along with all creation, medicine will ultimately be redeemed in the age to come. In the in-between time, it is our task to happily participate in God’s work by responding to the calling to serve in the vocation of medicine, to make the flourishing of the body our concern so that our patients can return to the task that is given to all, the task of knowing, loving, and serving the Lord.
1 See Alasdair Maclntyre, Dependent Rational Animals: Why Human Beings Need the Virtue (Chicago: Open Court Publishing, 2001).
2 For a powerful explication of human dignity and our obligations to one another in our weakness, see Pope John Paul II’s encyclical The Gospel of Life.
3 E. J. Cassell, “Consent or obedience? Power and authority in medicine,” New England Journal of Medicine, 352:4 (2005) pp. 328-30.
4 Leon R. Kass, “Regarding the end of medicine and the pursuit of health,” Public Interest, 40 (1975), pp. 11-42.
5 Margaret Mohrmann, Medicine as Ministry: Reflections on Suffering, Ethics and Hope (Cleveland: Pilgrim Press, 1995), pp. 15-16.
6 Brian Volck and Joel James Shuman, Reclaiming the Body: Christians and the Faithful Use of Modern Medicine (Grand Rapids: Brazos Press, 2006).
7 Gerald P. McKenny, To Relieve the Human Condition: Bioethics, Technology, and the Body. (Albany, N.Y.: State University of New York Press, 1997).
8 Charles Taylor, Sources of the Self: The Making of the Modern Identity (Cambridge: Cambridge University Press, 1989).
9 I owe this formulation, as best I can remember it, to a lecture delivered by Paul Griffiths, a Catholic moral philosopher at the University of Illinois-Chicago.
10 C.S. Lewis says much the same thing in his book The Abolition of Man.
11 These references to Luther’s thought are owed to: Gustaf Wingren, Luther on Vocation (Eugene, OR: Wipf & Stock Publishers, 2004).
Farr Curlin, MD, is a general internist and medical ethicist at the University of Chicago.