Matters of Life and Death

John Wyatt has been arguing that even non-Christian doctors have been guided by a Hippocratic-Christian consensus. This extract from his new book, published by IVP, shows how this has been eroded.

It was not until around 1850 that the idea of Christian health professionals going from the West to care for the sick and dying in developing countries came to fruition.
At that time it was estimated that there were only between 12 and 15 Christian doctors working in Asia or Africa. But in the following century, more than 1,500 doctors went from Britain alone to work in developing countries, and thousands more missionary nurses and paramedicals went where there were no doctors. Wherever they went, they introduced the Hippocratic Christian ideal. I understand that until the middle of the 20th century, the only professional nurses in the whole of the Indian sub-continent were linked to Christian establishments.
Asia has been the site of several major world religions, especially Hinduism and Buddhism, stretching back thousands of years. Why was it that devout Hindu or Buddhist believers had never set up a system of practical medical and nursing care for the weak and disadvantaged, for the leprosy victims, the outcast and the untouchables? Why did the development of large-scale medical establishments in Asia depend on the influence of Christian doctors, nurses and religious orders? Ultimately, this can all be traced back to the teaching and example of Jesus of Nazareth.

Current debates

This historical dimension provides a different perspective on the current debates about the future of medicine. When we look backwards to see the historical roots of Western medicine, we find Christianity at every turn. The improbable cross-fertilisation between a pagan guild of physicians and a radical Middle Eastern religion led to 2,000 years of proud medical, nursing and healthcare history. Inevitably, the potted version I have provided oversimplifies the story. There have always been tensions and strains in the alliance. Western Hippocratic medicine has often lost contact with practical care for the disadvantaged, for example. In Western society physicians have frequently espoused a social position among the elite. The London Royal College of Physicians was, and to some extent, remains, a highly aristocratic institution. I suspect there was a distinct preference among its wealthy Fellows to hobnob with royalty and the aristocrats of Mayfair rather than frequent the Poor Hospitals in the East End of London, although there are outstanding examples of philanthropy among physicians to royalty. For long periods of our history, the poor could not afford a properly-trained Hippocratic physician. They had to make do with the apothecary, the herbalist or the quack doctor. Despite this, in most Western countries, the Hippocratic Christian consensus remained fundamentally intact until the 1960s. This Christian way of thinking was so much a part of the axioms of medical ethics that it was almost invisible and unquestionable. But, as we have seen, over recent decades, the consensus has been steadily coming apart at the seams. Each of the five trends we explored in chapter 1 has been quietly eroding the partnership of 2,000 years.
It is possible to note five aspects of healthcare which are being destroyed by this erosion.

Motivation

Biological reductionism strikes at the heart of Hippocratic-Christian anthropology. If I am caring for a being made in God's image, I might have a motivation for philanthropy, for enshrining the values of respect and compassion. But if I am caring for a survival machine, for 'robot vehicles blindly programmed to preserve the selfish molecules known as genes', then, logically, why bother? After all, if the mechanisms of this particular machine are grossly abnormal, it lacks the right DNA for the future of our species. Why should we not help it on its way to the rubbish heap?

Values and aims

Technology changes the values and aims of the medical enterprise. We do not have to accept our bodies as they have been given to us, we can improve the structure. Of course, in the days of the old Hippocratic-Christian consensus, this was hardly an issue. Most of the therapies the medical profession had to offer were of little use. The lover of the human could also be a lover of the art. But this was partly because the biological potential of the art was extremely limited. Today we have effective biological technology. We can really change the design. The concerns of the medical technologist thus become the concerns of the Lego constructor: does the new construction work? Is it safe? The original focus of Hippocratic medicine was on healing, and the ban on abortion and euthanasia prohibited many of the manipulative possibilities of the medical art. With the development of technology, seen most clearly in the field of reproductive technology, the original purpose of healing is being supplanted by a range of manipulative possibilities.

Doctors and patients

Consumerism changes the relationship between doctor and patient. In the past, Hippocratic medicine was a collaborative enterprise between the doctor and the patient. The relationship was frequently paternalistic and unbalanced, a parent-child relationship. Despite this, the doctor entered into a covenant with the patient to act solely in the patient's interests, within the ethical constraints laid down by the tradition of medicine. In a paternalistic relationship it was inevitably the doctor's values which were dominant. Now, in many cases, the relationship has been turned on its head. In a consumerist culture it is the consumer who is king. The enterprise becomes a client-technician relationship and it is the client's values which become over-riding. The aims of prenatal screening have been officially described as allowing 'the widest range of informed choice to women and their partners'. This is a remarkable mission statement for modern healthcare. It represents the values of a modern service industry, offering the widest range of choices. 'Got to keep the consumer satisfied', as Simon and Garfunkel sang. It is a slogan that market traders have been chanting since the dawn of time, but now it is becoming official policy in the medical world. The NHS 'internal market' model - forced on to the NHS in the teeth of strong opposition from most of the professionals within it - has further eroded the traditional ethics of medicine and nursing.
The modern concept of non-directive counselling also has affinities with the values of the service industry. Philosophically it is another example of the facts/values distinction. The professional's job is simply to give the client the facts: cold, neutral, objective. What the client decides to make of the facts is up to him or her as a consumer. But genuinely non-directive counselling is a myth. We are all coming from somewhere. Whether atheist, Christian, agnostic or Buddhist, all health professions have some core beliefs, a worldview which influences their perspective and colours the advice they give.

The healing ideal

Resource limitations have eroded the Hippocratic ideal of healing without harming. In a society in which economics becomes increasingly the most influential measure of all human activity, the terrible truth of what I call the 'first law of health economics' cannot be resisted. Antenatal screening and abortion will always be cheaper than medical and social care for the disabled. Euthanasia will always be cheaper than multidisciplinary support for the dying. If we as a society allow the monetary cost of caring to dominate our thinking, we will turn away from Christian ideals. Yet Christian thinking must always be practical and realistic. We cannot ignore the ever-spiralling economic costs of healthcare. How can we enshrine Christian principles in the rationing and allocation of healthcare resources?

Ethics

As we have seen, some modern bioethicists are directly challenging the old Hippocratic-Christian consensus. Nigel Cameron has suggested that the very word, created in the 1970s, symbolised a wholly fresh approach to the values of medicine. 'What appeared at first to be an opening of medicine to scrutiny from the outside . . . has rapidly been transformed into a field of reflections in which medicine itself can only claim a tangential place' (Cameron 1995:3). It is certainly remarkable to see how the bioethical enterprise has increasingly been taken over by philosophers, ethicists and lawyers. Clinicians are generally regarded as having little to contribute to the development of the discipline! By cutting loose the discussion of ethical values from the constraints of the professional Hippocratic tradition, which is caricatured as obsolete and culturally-bound, bioethicists are free to develop their radical theories unchallenged.
We should not be surprised if ethicists from non-Judaeo-Christian religious traditions have rather different concepts of the significance of the body and therefore of medical ethics. Ac-cording to a news report in 1997, the President of the Inter-national Association of Bioethics, Hyakudai Sakamoto of Nihon University, stated his support for genetic enhancement of human beings. Sakamoto said that in Asia, there is no fixed distinction between the natural and the artificial, and that in Buddhist thought, everything is constantly changing. Therefore genetic engineering should be used for what Sakamoto called the 'artificial evolution' of humankind.
Peter Singer has no illusions about the magnitude of the ethic change that is going on in our midst. 'After ruling our thought and decisions for nearly 2,000 years, the traditional Western ethic has collapsed. To mark the precise moment when the old ethic gave way, a future historian might choose February 4 1993, when Britain's highest court ruled that the doctors attending Tony Bland could lawfully act to end the life of their patient' (Singer 1994:1). Singer continues in apocalyptic tone: 'These are the surface tremors resulting from major shifts in the bedrock of Western ethics. We are going through a period of transition in our attitude to the sanctity of human life. How can we communicate and defend the Christian perspective in a pluralist society which has little time for religion as a source of ethical norms?

This is an extract from John Wyatt's book Matters of Life and Death, recently published by IVP/CMF, and used with permission.

An extract from the book Matters of Life and Death showing how the Hippocratic - Christian consensus guiding all doctors is being eroded