Written by Heather Zeiger

The government doesn’t take the Hippocratic Oath, but maybe it should.

As I was researching for this article, I easily found the over 2,000-page House bill on health care (H.R. 3962), and downloaded it over our high–speed Internet connection without a problem. I glanced at the Table of Contents, made some notes, and tried to go back to the previous page when my browser came crashing down. It could be that the size of the file gave Firefox some problems. Actually, it was fine at first, but when I realized that this monster was too cumbersome, I tried to get back to a page that was easier to navigate only to find that going back within this huge bill is not as easy as downloading it.

If I can use my experience in retrieving this bulky bill as being symbolic of anything, it would be that if passed, we will find the changes to our health care system confusing and unwieldy. And like my problems with trying to go back to an easier page, once we’ve realized what we’ve gotten ourselves into, it may not be easy to undo what has been done. There are many areas of concern in this legislation that raise ethical red flags, but I want to address a very fundamental issue in health care—that of authority and accountability.

The health care reform bill that has been passed by the House and its Senate counterpart  (deliberations began November 30), both bring to light several key bioethical issues: government funding for abortion, defining end–of–life care, who makes rationing decisions, and our obligation to the weak and infirm, to name a few.  Many aspects of our lives can fall under the umbrella of health care, so this bill has the potential to affect almost every aspect of society. Another contentious (and constitutionally questionable) feature of  the bill is the government requirement that everyone purchase health insurance, which marks the first time in history that the federal government has required everyone in society to enter a particular marketplace (car insurance is state–, not federally regulated).

I want to address the nature of health care specifically. Generally, the person administering health care is dealing with someone who finds themselves in a vulnerable state. That is why people, Christian or not, resonate with the idea that doctors take an oath to “Do No Harm.” The essence of the Hippocratic Oath, even before it was Christianized, is that of a covenantal relationship between the physician, the patient, and God (or, in 400 BC, the Greek gods){1}. This recognition of a deep obligation of the physician to the patient in his or her time of vulnerability has been a vocational standard for the industry for centuries. Granted, after the 1950’s these standards began to change into something far more utilitarian and consumer–driven and the Oath is rarely recited at medical graduations anymore. Nonetheless, doctors and patients today still operate under the assumptions of the Hippocratic Oath that the doctor is to “do no harm.”

But back to the point of the recently passed House bill and the ongoing debate on the Senate bill . If both of these bills pass and are approved by President Obama in their current form, the government is going to exercise a large amount of fiscal and, therefore, regulatory control over the health industry. The Hippocratic Oath was a vocational agreement, but now the government is in the position of holding an individual’s health in its hands. The government makes no such promise to “do no harm” to the individual patient.

In actuality, the very idea of health care for all represents a distinct and debatable worldview. The language being used to argue these bills represents, at best, an attempt to do the greatest good for the greatest number of people. It no longer speaks on an individual level, but on a societal level.  And while individual doctors agree to avoid harming patients, the government views its job as seeking what is best for society at large. That is a very different commitment at a fundamental level. In the United States, the governmental commitment is contractual,{2} while in the Hippocratic tradition, the doctor-patient relationship is covenantal. (See the wording for the Oath of Office and the Hippocratic Oath, below.)

Doing what seems best for society on the whole is fine when we are talking about national security and protecting our borders, or when we are talking about how best to implement and regulate interstate commerce, or even in creating boards that enforce common standards for pharmaceuticals, such as the FDA. This protects society, and protects the individuals within that society. But when it comes to an individual making a decision for his personal health or for his dependents, what is best for society as a whole is not the appropriate ethic. This is called utilitarianism, which is generally defined as an ethic that prioritizes “the greatest good for the greatest number of people.”{3}

Utilitarianism has a limited place, but seeking the greatest good for society should not be the highest calling. This view elevates society and social good to a higher level than the individual, meaning that what is best for the greatest number of people, or society as an aggregate, may be at the expense of certain individuals. However, medicine deals with helping the weak, the infirm, and the vulnerable, which concerns the individual. Hence, the covenantal nature of the doctor/patient relationship. This care for the individual springs from the idea that all people are made in the image of God. Therefore we cannot value some individuals more than others, even if we (fellow human beings) deem them more or less useful to society.

As Dr. Kathy McReynolds, a bioethicist and professor at Biola University and public policy director for the Christian Institute on Disability says about the health care bill, “I am concerned that decisions regarding patient care will be made by someone other than the patient and physician working together. A disinterested politician is not going to have a connection to that patient or be able to identify intrinsic factors about that person’s disability.”{4}

Link: Senate Healthcare bill: help.senate.gov/BAI09A84_xml.pdf

House Bill: The bill, the Affordable Health Care for America Act—H.R. 3962

www.pbs.org/wgbh/nova/doctors/oath_classical.html

I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art—if they desire to learn it—without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.

I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves.

What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.

Importantly, the major feature of the traditional version of the Hippocratic Oath is that the doctor recognizes that he is dealing with a patient at a vulnerable time and will do everything with the patient’s best interest in mind. He enters into a covenantal agreement between himself, the patient, and the deity.{5}

Oath of Office:

www.senate.gov/artandhistory/history/common/briefing/Oath_Office.htm

I do solemnly swear (or affirm) that I will support and defend the Constitution of the United States against all enemies, foreign and domestic; that I will bear true faith and allegiance to the same; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will well and faithfully discharge the duties of the office on which I am about to enter: So help me God.

The distinguishing feature of the Oath of Office is that of protection of those principles found in the Constitution of the United States. While this may protect the citizens of the U.S., this is not a personal obligation towards an individual with the individual’s best interest in mind. In this sense it is a contractual relationship between the citizens of the U.S. and their representatives or armed forces.

Notes

1. Cameron, Nigel M. de S., The New Medicine: Life and Death after Hippocrates, 1991, Crossway Books, Wheaton, IL.
2. For some foundational philosophy on Political Theory, see the works of Jean-Jacques Rousseau (The Social Contract), John Locke, and Thomas Hobbes (Leviathan).
3. For an interesting look at the history of utilitarianism, see the Internet Encyclopedia of Philosophy on “John Stuart Mill,” www.iep.utm.edu/milljs/#SSH2d.ii; also, Kerby Anderson, Christian Ethics in Plain Language, Nashville, TN, 2005, Thomas Nelson, Inc., pps. 15-17.
4. Joni and Friends, www.joniandfriendsnews.com/docs/091125_healthcare.pdf
5. Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943.

© 2009 Probe Ministries

Utilitarianism is an ethical system that determines morality on the basis of the greatest good for the greatest number. A modern form of utilitarianism is situation ethics. Kerby Anderson examines the problems with this ethical system, and evaluates it from a biblical perspective.

 This article is also available in Spanish.

You have probably heard a politician say he or she passed a piece of legislation because it did the greatest good for the greatest number of citizens. Perhaps you have heard someone justify their actions because it was for the greater good.

In this article, we are going to talk about the philosophy behind such actions. The philosophy is known as utilitarianism. Although it is a long word, it is in common usage every day. It is the belief that the sole standard of morality is determined by its usefulness.

Philosophers refer to it as a “teleological” system. The Greek word “telos” means end or goal. This means that this ethical system determines morality by the end result. Whereas Christian ethics are based on rules, utilitarianism is based on results.

Utilitarianism began with the philosophies of Jeremy Bentham (1748-1832) and John Stuart Mill (1806-1873). Utilitarianism gets its name from Bentham’s test question, “What is the use of it?” He conceived of the idea when he ran across the words “the greatest happiness of the greatest number” in Joseph Priestly’s Treatise of Government.

Jeremy Bentham developed his ethical system around the idea of pleasure. He built it on ancient hedonism which pursued physical pleasure and avoided physical pain. According to Bentham, the most moral acts are those which maximize pleasure and minimize pain. This has sometimes been called the “utilitarian calculus.” An act would be moral if it brings the greatest amount of pleasure and the least amount of pain.

John Stuart Mill modified this philosophy and developed it apart from Bentham’s hedonistic foundation. Mill used the same utilitarian calculus but instead focused on maximizing the general happiness by calculating the greatest good for the greatest number. While Bentham used the calculus in a quantitative sense, Mill used this calculus in a qualitative sense. He believed, for example, that some pleasures were of higher quality than others.

Utilitarianism has been embraced by so many simply because it seems to make a good deal of sense and seems relatively simple to apply. However, when it was first proposed, utilitarianism was a radical philosophy. It attempted to set forth a moral system apart from divine revelation and biblical morality. Utilitarianism focused on results rather than rules. Ultimately the focus on the results demolished the rules.

In other words, utilitarianism provided for a way for people to live moral lives apart from the Bible and its prescriptions. There was no need for an appeal to divine revelation. Reason rather than revelation was sufficient to determine morality.

Founders of Utilitarianism

Jeremy Bentham was a leading theorist in Anglo-American philosophy of law and one of the founders of utilitarianism. He developed this idea of a utility and a utilitarian calculus in the Introduction to the Principles of Morals and Legislation (1781).

In the beginning of that work Bentham wrote: “Nature has placed mankind under the governance of two sovereign masters, pain and pleasure. It is for them alone to point out what we ought to do, as well as to determine what we shall do. On the one hand the standard of right and wrong, on the other the chain of causes and effects, are fastened to their throne. They govern us in all we do, in all we say, in all we think: every effort we can make to throw off our subjection, will serve but to demonstrate and confirm it.”{1}

Bentham believed that pain and pleasure not only explain our actions but also help us define what is good and moral. He believed that this foundation could provide a basis for social, legal, and moral reform in society.

Key to his ethical system is the principle of utility. That is, what is the greatest good for the greatest number?

Bentham wrote: “By the principle of utility is meant that principle which approves or disapproves of every action whatsoever, according to the tendency which it appears to have to augment or diminish the happiness of the party whose interest is in question: or, what is the same thing in other words, to promote or to oppose that happiness.” {2}

John Stuart Mill was a brilliant scholar who was subjected to a rigid system of intellectual discipline and shielded from boys his own age. When Mill was a teenager, he read Bentham. Mill said the feeling rushed upon him “that all previous moralists were superseded.” He believed that the principle of utility “gave unity to my conception of things. I now had opinions: a creed, a doctrine, a philosophy; in one among the best senses of the word, a religion; the inculcation and diffusion of what could be made the principle outward purpose of a life.”{3}

Mill modified Bentham’s utilitarianism. Whereas Bentham established an act utilitarianism, Mill established a rule utilitarianism. According to Mill, one calculates what is right by comparing the consequences of all relevant agents of alternative rules for a particular circumstance. This is done by comparing all relevant similar circumstances or settings at any time.

Analysis of Utilitarianism

Why did utilitarianism become popular? There are a number of reasons for its appeal.

First, it is a relatively simple ethical system to apply. To determine whether an action is moral you merely have to calculate the good and bad consequences that will result from a particular action. If the good outweighs the bad, then the action is moral.

Second, utilitarianism avoids the need to appeal to divine revelation. Many adherents to this ethical system are looking for a way to live a moral life apart from the Bible and a belief in God. The system replaces revelation with reason. Logic rather than an adherence to biblical principles guides the ethical decision-making of a utilitarian.

Third, most people already use a form of utilitarianism in their daily decisions. We make lots of non-moral decisions every day based upon consequences. At the checkout line, we try to find the shortest line so we can get out the door more quickly. We make most of our financial decisions (writing checks, buying merchandise, etc.) on a utilitarian calculus of cost and benefits. So making moral decisions using utilitarianism seems like a natural extension of our daily decision-making procedures.

There are also a number of problems with utilitarianism. One problem with utilitarianism is that it leads to an “end justifies the means” mentality. If any worthwhile end can justify the means to attain it, a true ethical foundation is lost. But we all know that the end does not justify the means. If that were so, then Hitler could justify the Holocaust because the end was to purify the human race. Stalin could justify his slaughter of millions because he was trying to achieve a communist utopia.

The end never justifies the means. The means must justify themselves. A particular act cannot be judged as good simply because it may lead to a good consequence. The means must be judged by some objective and consistent standard of morality.

Second, utilitarianism cannot protect the rights of minorities if the goal is the greatest good for the greatest number. Americans in the eighteenth century could justify slavery on the basis that it provided a good consequence for a majority of Americans. Certainly the majority benefited from cheap slave labor even though the lives of black slaves were much worse.

A third problem with utilitarianism is predicting the consequences. If morality is based on results, then we would have to have omniscience in order to accurately predict the consequence of any action. But at best we can only guess at the future, and often these educated guesses are wrong.

A fourth problem with utilitarianism is that consequences themselves must be judged. When results occur, we must still ask whether they are good or bad results. Utilitarianism provides no objective and consistent foundation to judge results because results are the mechanism used to judge the action itself.

Situation Ethics

A popular form of utilitarianism is situation ethics first proposed by Joseph Fletcher in his book by the same name.{4} Fletcher acknowledges that situation ethics is essentially utilitarianism, but modifies the pleasure principle and calls it the agape (love) principle.

Fletcher developed his ethical system as an alternative to two extremes: legalism and antinomianism. The legalist is like the Pharisees in the time of Jesus who had all sorts of laws and regulations but no heart. They emphasized the law over love. Antinomians are like the libertines in Paul’s day who promoted their lawlessness.

The foundation of situation ethics is what Fletcher calls the law of love. Love replaces the law. Fletcher says, “We follow law, if at all, for love’s sake.”{5}

Fletcher even quotes certain biblical passages to make his case. For example, he quotes Romans 13:8 which says, “Let no debt remain outstanding, except the continuing debt to love one another, for he who loves his fellow man has fulfilled the law.”

Another passage Fletcher quotes is Matthew 22:37-40. “Christ said, Love the Lord your God with all your heart and with all your soul and with all your mind. . . . Love your neighbor as yourself.’ All the Law and the Prophets hang on these two commandments.”

Proponents of situation ethics would argue that these summary verses require only one absolute (the law of love). No other universal laws can be derived from this commandment to love. Even the Ten Commandments are subject to exceptions based upon the law of love.

Situation ethics also accepts the view that the end justifies the means. Only the ends can justify the means; the means cannot justify themselves. Fletcher believes that “no act apart from its foreseeable consequences has any ethical meaning whatsoever.”{6}

Joseph Fletcher tells the story of Lenin who had become weary of being told that he had no ethics. After all, he used a very pragmatic and utilitarian philosophy to force communism on the people. So some of those around him accused him of believing that the end justifies the means. Finally, Lenin shot back, “If the end does not justify the means, then in the name of sanity and justice, what does?”{7}

Like utilitarianism, situation ethics attempts to define morality with an “end justifies the means” philosophy. According to Fletcher, the law of love requires the greatest love for the greatest number of people in the long run. But as we will see in the next section, we do not always know how to define love, and we do not always know what will happen in the long run.

Analysis of Situation Ethics

Perhaps the biggest problem with situation ethics is that the law of love is too general. People are going to have different definitions of what love is. What some may believe is a loving act, others might feel is an unloving act.

Moreover, the context of love varies from situation to situation and certainly varies from culture to culture. So it is even difficult to derive moral principles that can be known and applied universally. In other words, it is impossible to say that to follow the law of love is to do such and such in every circumstance. Situations and circumstances change, and so the moral response may change as well.

The admonition to do the loving thing is even less specific than to do what is the greatest good for the greatest number. It has about as much moral force as to say to do the “good thing” or the “right thing.” Without a specific definition, it is nothing more than a moral platitude.

Second, situation ethics suffers from the same problem of utilitarianism in predicting consequences. In order to judge the morality of an action, we have to know the results of the action we are about to take. Often we cannot know the consequences.

Joseph Fletcher acknowledges that when he says, “We can’t always guess the future, even though we are always being forced to try.”{8} But according to his ethical system, we have to know the results in order to make a moral choice. In fact, we should be relatively certain of the consequences, otherwise our action would by definition be immoral.

Situation ethics also assumes that the situation will determine the meaning of love. Yet love is not determined by the particulars of our circumstance but merely conditioned by them. The situation does not determine what is right or wrong. The situation instead helps us determine which biblical command applies in that particular situation.

From the biblical perspective, the problem with utilitarianism and situation ethics is that they ultimately provide no consistent moral framework. Situation ethics also permits us to do evil to achieve good. This is totally contrary to the Bible.

For example, Proverbs 14:12 says that “There is a way which seems right to a man, but its end is the way of death.” The road to destruction is paved with good intentions. This is a fundamental flaw with an “ends justifies the means” ethical system.

In Romans 6:1 Paul asks, “Are we to continue sinning so that grace may increase?” His response is “May it never be!”

Utilitarianism attempts to provide a moral system apart from God’s revelation in the Bible, but in the end, it does not succeed.

Notes

1. Jeremy Bentham, An Introduction to the Principles of Morals and Legislation, printed in 1781 and published in 1789 (Batoche Books: Kitchener, ON Canada, 2000), 14.
2. Ibid.
3. John Stuart Mill, “Last Stage of Education and First of Self-Education,” Autobiography, 1873 (New York: P.F. Collier & Sons, 1909-14).
4. Joseph Fletcher, Situation Ethics: The New Morality (Philadelphia: Westminster, 1966).
5. Ibid., 70.
6. Ibid., 120.
7. Ibid., 121.
8. Ibid., 136.

© 2004 Probe Ministries