Applied Christian bioethics: counseling on the moral edge.

Greggo, Stephen P.

Extraordinary and precedent-setting medical human interest stories consistently break into the news. Media commentators and bioethicists labored over the birthing account of Sharon Duchesneau and Candy McCullough. Both women are deaf. When they determined to become parents, having a deaf child was highly valued. In their community, deafness is not considered a disease or disability that provokes remorse; it is simply a different way of life. Being a lesbian couple, Sharon and Candy sought a sperm donor with five generations of deafness in his family. They were eventually 'successful', as their son, Gauvin, was born deaf. As this family story circulated, it raised multiple questions regarding eugenic definitions, limitations, and choices. Should medical technology be applied to design human beings? Who speaks for the human being created? Should patient autonomy rule in setting the parameters for the usage of available biotechnology (Sandel, 2007)?

On Easter Sunday, March 23, 2008, 18-year-old Stephanie Kuleba, known as "Sunshine," a blond-haired, outgoing, high school cheerleader with a near perfect grade point average tragically and suddenly died. Sunshine was undergoing elective breast augmentation surgery. The year prior in 2007, 347,500 women of all ages had done the same. The decision to medically correct perceived imperfections accounted for her assuming the risk of anesthesia. A rare reaction called malignant hyperthermia resulted in her death. Is there reason to reflect on what drove this woman with so much potential to pursue this enhancement with its indisputable threats (www.TODAYShow.com)?

Newsworthy scenarios receive media attention, while everyday bioethical conclusions contain elements common to the dramatic ones. Specifically, the intersection of personal stories, wishes, dreams, expectations, and motivational forces all combine within the fabric of a social community to form a unique context where determinations are made on the use of biotechnology. Ethics is the identification of the parameters utilized to guide decisions regarding right and wrong (Kilner & Mitchell, 2003). Preface the word 'ethics' with only three letters, B-I-O, to signify that which is alive, and the decisions encompass the weighty matters of life--along with its inevitable partner, death. Bioethics has arisen over the past fifty years as a distinct interdisciplinary field out of medical ethics as health care determinations impacting human lives are no longer exclusively within the professional domain of physicians.

Christian bioethics is the theological and philosophical sub-specialty that explores the implication of health care practice in light of traditional Judeo-Christian medical praxis, expanding technology, legal/medical policy, biblical interpretation, theoretical assumptions and theological definitions of human personhood. An agenda shift in Christian bioethics is evident (de S Cameron, 2004). The initial focus was on the protection of human life (abortion, euthanasia, embryo experimentation). Today discussion centers on ways that biotechnology modifies or manipulates human beings (cloning, genetic modifications, cybernetics). The opening stories illustrate this shift. Christian theology must address contemporary concerns related to critical nuances regarding the dignity of human beings and sanctity of covenant relationships. Conflicting positions are not uncommon. It is imperative that discourse on these matters be transposed from contentious debate on expansive topics into practical parameters that impact how individuals who desire to honor the Lord of Creation can exercise stewardship over medical technology.

Ethics committees are available to assist physicians and medical personnel (Vaszar, Raffin, & Kuschner, 2005). Representatives from such a committee can provide a bedside consult to families or patients in the midst of an urgent concern. Outside of a medical crisis, ethical consultation services are not available to resolve internal and interpersonal dissonance. From an explicitly Christian worldview, insightful analysis of the challenge beyond the level of medical ethics is necessary. Christian bioethicists expose biblical and theological perspectives by speaking out on public policy and medical practice. Still, there may not yet be enough specificity in the literature or explicit guidance to inform routine decisions within a patient's range of available choices (Kilner, in press).

Aulisio (2003) identifies three features of health care that converge to incite bioethical debates: complex decisions, value heterogeneity (pluralism), and the recognition that individuals have the right to determine their own health care (patient autonomy). Whereas standards regarding procedures are thought to reside in medical journals, boards, ethical guidelines, government regulations or perhaps even in Christian academia, it is evident that the consumers of health care services are in the prime position to determine direction. The assumptions bound within a consumer-based health care system are themselves a bioethical concern (Kilner, 2004; Kilner, Orr, & Shelly, 1998). Nonetheless, contemporary biotechnology has brought critical moral challenges into the everyday lives of ordinary people. Who will seriously engage with needy families on the gritty decisions they face in the rapidly evolving array of complex health care choices?

Medical personnel are prepared to describe options, clarify risks, and discuss potential outcomes. Yet, medical language training--inherent and perhaps necessary to the system--has been so infused with protective legal maneuvers that achieving genuine dialogue may be difficult. In certain instances, a subtle suggestion might follow exposure of an ethical dilemma, such as: "well, if I were in your position ..." or "if this were my family member ..." Because the medical sphere prioritizes patient autonomy, pertinent recommendations may be absent altogether. Moreover, it must be said that conversations to uncover embedded ethical conflicts require the luxury of time. Can medical professionals give the gift of listening to the background story with a discerning heart to organize the range of alternatives into the context of a real human life?

Christ followers require assistance to apply theological guidelines in the midst of high tech options and intense personal desires as they handle responsibly the privilege of consumer-based medicine. Dedicated believers are attentive to the reality that a personal deity still governs the universe. Biblical answers regarding the use of healthcare technology are not straightforward; dilemmas can be overwhelming. Christian doctrine does matter (Vanhoozer, 2010; Greggo, 2010). Pastoral care providers can aid in realizing wisdom by representing the relationship between theology and ethical behavior (Gartner, 2010; Greggo & Tillett, 2010). Such counsel should exceed mere declaration of an application based upon doctrinal convictions. Care and conversation ideally furthers prayer, thirst for the Word, attending to the Holy Spirit, and an awareness of the awesome power of a loving and transcendent God. The following insights for clergy were lifted from a theme edition on pastoral counseling in the journal, Christian Bioethics.

In a Traditional Christian context, bioethical problems are only ostensibly moral. Decisions about how to respond to the Divine call to chastity, to the acceptance of numerous children as a gift, to the acceptance of unwanted children as a difficult gift, to the integration of one's desire for health, fitness, and beauty into the overriding pursuit of holiness, to patience in personal suffering, to works of charity in caring for incapacitated family members, to hope for eternal life in the face of temporal death--all these are decisions about how to accept one's personal cross. Taking God seriously when counseling congregants about such bioethical problems involves nothing less than offering them the core spiritual therapy of rendering them receptive to that Divine grace which supports their dying to themselves. (Delkeskamp-Hayes, 2010, pp. 108-109)

Are bioethical matters explored with theological clarification from the pulpit? Is the Christian community growing in fluency to translate doctrinal convictions into medically oriented boundaries? Realistically, how routine and at what depth are the pastoral exchanges that take place? Responses to these questions will vary. This article contends there is a substantial service gap between medical and pastoral care that mental health professionals with a Christian worldview should prepare to fill. The following scenarios are adopted from ordinary stories to illustrate a potential role for MHPs.

Scenario One

Eduardo and Anna are pursuing the American dream. They are first generation immigrants living in a modest home of their very own with three young children. For years, they have been disconnected from their natural parents who live in rural villages back in Guatemala. Eduardo was sent to live with his aunt in America at the age of 11 because he was considered to be bright, strong-minded, and have great potential to succeed. This aunt had come to America as a teenager to serve a family as housecleaner, cook, and nanny. She never married, nor had children. She, along with the support of other immigrants, raised Eduardo through his teen years and two years of community college. Now he is the proud manager of a Burger King restaurant.

Eduardo and Anna live in a prosperous land due to the generosity of a fellow immigrant who pioneered the way. Unfortunately, following a stroke four years ago, Eduardo's aunt entered a nursing home. She does not speak. Her alertness has diminished. Over the last six months, she is barely awake. Due to the depressing nature of her condition and living quarters, visits are few. Anna and Eduardo do not speak about their pain. Each carries substantial guilt for not looking after his aunt under their own roof as earlier cultural lessons had taught was the rule. They will inherit her meager savings and have already taken funds from those accounts to pay for new school clothes. Caring for children in style is costly. Eduardo pushes consistently to be a winner and cannot be distracted by his aunt's struggles. Over the past few months, his aunt has been in and out of the hospital with difficulty breathing connected with congestive heart failure. Evident to all, she is dying. The nursing home repeatedly sends his aunt to the emergency room when death appears imminent. Eduardo refuses to sign do-not-resuscitate (DNR) forms. When consulted, he insists dogmatically that every conceivable medical option be applied to preserve the life of his aunt. Heart surgery remains under consideration if her strength can be sufficiently increased to the point that she has a reasonable chance of survival. Each occasion when the ailing aunt is raced away from the nursing facility in an ambulance is a traumatic and jolting experience. Barely recovered, she is discharged back to the nursing home until the cycle recurs once again.

Anna and Eduardo attend an evangelical church. They fit. Each finds the message and the fellowship to be a blessing. Their hearts are heavy when they pray for their aunt. Christians are pro-life, so these believers advocate relentlessly for their benefactor.

Scenario Two

Don and Debbie are active within a mid-sized but struggling congregation. Don is an elder who has carried the ministry on his shoulders during more than one lean period. He has also brought his wife through her own dark moods as she has fought depressive episodes with good reason. In their late thirties, with ten years of marriage behind them, they finally had--and then lost--a single daughter, Andrea. She had held onto life by the barest of threads for a stressful four-and-a-half months. Prior to Andrea, there had been several miscarriages. Debbie's blood pressure gets overly high during pregnancy and she has difficulty carrying a child to term. Their daughter never left the neonatal intensive care unit after her birth at 27 weeks gestation. Her kidneys never kicked in. Her heart was weak and she had three life-threatening surgeries, not to count a persistent flow of special procedures. When Don and Debbie held Andrea, it was a blessed occasion. They still wonder in their silent pain if everything possible was done to keep her with them.

As they come to terms with Andrea's death, the gnawing notion that she may have been their only biological child fills them with more burden than comfort. Hope might arise from an adoption plan. Debbie tosses this aside. Imprecise knowledge of family heritage or potential genetic flaws cannot be tolerated. A surrogate or gestational carrier is the option seriously under investigation. A gestational carrier does not supply the egg, but donates or is paid a fee for the use of her uterus for delivery. The plan is to use in vitro fertilization (IVF) procedures along with the pre-implantation genetic testing. The sex of the child may be determined and key genetic imperfections reasonably avoided. Debbie regularly becomes despondent over her own health issues and the inability to safely carry a child to term. In the interest of peace, Don buries his disturbing awareness of his wife's propensity towards depression, along with her press for precision and urge to control. Does the shadow of her grief grow darker under the shade of these qualities? Desperate to have healthy children and avoid a reprise of Andrea's loss, potential moral questions fade further into the background.

Will a medical professional, pastor, or bioethicist surface the conflicts and motivations within these families? Who will facilitate the outworking of a Christian identity amidst the myriad of ethical implications blended deep into each decision?

The Complexity of Christian Bioethics

The lines in the medical enterprise have blurred regarding cure or enhancement, medical necessity versus personal desirability, need and choice, and treatment as intervention or directing destiny. There is debate over what constitutes a disease, disability, or individual difference. Perhaps the limits of life are not givens, but baselines to be extended. Biotechnology has created options along with novel predicaments (Mitchell, Pellegrino, Elshtain, Kilner, & Rae, 2007). Globalization has opened new markets for 'medical' tourism. If an advantageous or desirable treatment is unavailable or cost prohibitive in our geographic area, travel can be booked to a destination where the rules are favorable, the price negotiable, and the expertise ready to oblige.

As discretionary medical decisions become common, medicine has to grapple with ethical questions that divulge moral convictions. Applications in health care emerging from non-theistic traditions with no appreciation for priorities derived from Scripture under the supervision of the Holy Spirit have long been the bane of Christians engaged in the psychological domain. One's theological understanding of matters regarding human nature, teleology, destiny, sanctification, and autonomy are influential when conducting a clinical mental health assessment and targeting outcomes. Will the applied therapeutic effort redeem self from the effects of sin or might it, even unwittingly, stimulate sinful self-mastery? Consider a parallel, medical predicament (Kilner & Mitchell, 2003; Meilaender, 1996). Does the selected medical procedure take into account a self submitted to the will of a loving Creator? Or, does the option under pursuit demonstrate a corrupt attempt to deny the Creator's limits by sneaking fruit from the tree of life? How might believers discern the division between God-honoring stewardship and flagrant self arrogance? Do we seek God in suffering or avoid him by lessened or averted pain? Is the transition between life and death placed in God's hands or is life prolonged for every possible second because the hereafter is feared, unknown, and undesirable?

The Christian Association for Psychological Studies (CAPS) has invested over 50 years establishing a credible interface between Christianity (revelation based worldview) and psychology (empirically oriented methodology) (Stevenson, Eck, & Hill, 2007). It is not coincidental that this movement coincides with the rise in bioethics and in particular, its uniquely Christian branch. Values emerge from worldview. Distinctions between the prevailing secular and the Christian sacred are evident throughout all of medicine. Given that psychologically oriented treatment has been perceived in conservative Christian circles as particularly suspect, transparency in the relationship between Christianity and mental health treatment has been central for role integration (Hathaway, 2009). The emphasis in the broader medical field on empirical evidence and 'hard' science may have minimized secular/sacred tensions as bioethical concerns were obscured behind the curtain of 'best practice.' The expanding range of available technology accompanied with a consumer orientation has pulled back this veil and exposed crucial junctures that turn on personal preferences, cultural context, values, and ultimately worldview. The medical sphere is witnessing more overt conflict surrounding the appropriateness of intervention options and a Christian worldview. Interestingly, addressing the roots and ramifications of such strain is inherent in the vision of CAPS and in the activities of its membership.

The intention in these pages is not to articulate the intricacies of how to form or inform a distinctively Christian rubric for bioethics. Rather, the objective is to motivate a sustained interest within Christian MHPs to participate in the pursuit of Christian conventions to obtain wisdom. Organization resources are available such as the Center for Bioethics and Human Dignity (www.cbhd.org); Christian Medical and Dental Association (www.cmda.org); and the National Catholic Bioethics Center (www.ncbcenter.org). There are targeted academic journals: Christian Bioethics and Ethics & medicine: A Christian perspective on issues in bioethics. There are papal pronouncements such as Dignitas Personae (2008). This is an emerging practice area where CAPS members would do well to encourage one another to develop the necessary competencies to serve clients well (CAPS, 2005). Given the attention directed within CAPS to the intersection of professional ethics and empirically oriented treatments with Christian values, likeminded MHPs may be uniquely qualified to venture into bioethical conversations where presenting problems, clinical concerns and spiritual formation are all too closely entwined.

There is an unfortunate vacancy on medical and pastoral collaborative teams that Christian MHPs are in an excellent position to fill. There are critical professional ethical barriers that each applicant will need to address (e.g., informed consent, respecting client autonomy, value clarification versus imposition, and client confidentiality). Counseling to explore a bioethical theme requires that the MHP consider at length the role distinctions between a medical, pastoral, and mental health clinician. A return to the case scenarios will bring out select concerns; then the added value of MHP expertise will be articulated.

Identifying Bioethical Concerns

Eduardo and Anna have the utmost desire to honor the kind person who made their immigration, marriage, and future possible. Eduardo genuinely believes he is applying a pro-life position as their family merges into a local Christian fellowship. Based on an abbreviated review of the details, a pastoral staff member prays with them for the aunt's recovery. Between the nursing home physician and rotating hospital staff, there is no one to engage with Eduardo to deliberate on the ethical aspects of the treatment cycle that is being perpetuated. What does a pro-life position look like at the end of life when medical procedures are futile (Mitchell, Orr, & Salladay, 2004)?

Certainly, his aunt absolutely maintains her dignity as a human being with full personhood for she is created imago Dei (Saucy, 1993). Eduardo does well to reject any suggestion that personhood is lost as the ability to engage with others disappears. Even in her disabled and diminished capacity, she must be treated with the recognition that there is a full human person beneath her ragged skin, relentless sleep, and routine silence. Nonetheless, this could be the opportune moment to consider palliative care. What would be required for her to be as comfortable as possible as she awaits transition into eternal life? Is the persistent game of patient ping pong between hospital and nursing home restoring health, or is it prolonging, even exacerbating, her suffering? These questions may not be impossible for an objective pastor or MHP to entertain. There are ample reasons why Eduardo is not capable of considering such a perspective without compassionate, informed, and engaging assistance. Arriving at a comprehensive understanding with Eduardo of being pro-life and Christian must take into account his past, his personality, and implanted cultural promises. A robust understanding of the term 'pro-life' would never lose sight of eternity with a Savior who has prepared a place for those who are His (I Cor. 15:21-16; Phil. 1:20-21). Christians embrace the reality that in Jesus Christ, death has lost its painful sting (I Cor. 15:55).

Debbie and Don are in the midst of a serious crisis that has multiple layers. The predicament involving the death of a daughter born premature has left their future precarious. As they contemplate their dreams, do they have sufficient support to sustain confidence in the source of their hope? Is their faith in God's hands or might they relentlessly seek medical options to subdue their grief? Medical technology 'failed' them once. Could either feel entitled to medical assistance to realize their goals? Is there a danger of pondering obsessively, eugenic, or 'good genes' as they press on, earnest to attain a picture perfect family? Fertility procedures from artificial insemination to egg donation to surrogacy to gestational carrier are available. These could provide Debbie with exactly what she longs for in terms of a biologically related child. Or, eggs or sperm could be secured or purchased to achieve a child with a predictable combination of beauty, brains, and buffers against illness. If they acknowledge by informed consent the risks involved, there are permissible options. Would such a direction be a Christ-honoring approach that fits Debbie and Don as people of faith? What defines the sanctity of marriage? Is there any separation between what can be done and what should be done? What would happen to unused or imperfect embryos? What are the potential hazards involved with a surrogate or carrier? One underlying risk might be this: given Debbie's temperament, how likely is she to be satisfied with this arrangement and its results in the years ahead? How might additional pain impact this couple weighed down by grief and desperately seeking children? A MHP might wonder and assess if the marriage has the stamina to survive the losses of the past and those that may lie ahead.

Helping Professionals Coaching Christian Conversation

Three basic techniques demonstrate the advantage of having an MHP enter bioethical conversations: 1) listening for central self and relational features; 2) linking to core story themes and values; and 3) leaning into critical personality styles. For clarity, this utilization of such core professional skills is not novel, nor is this a sole method to determine Christian wisdom (Pro. 1:7; Ps. 1:1-3). These are components of a wisdom search that are plainly valuable, but not typically available through the routine services of medical or pastoral staff. These exhibit contributions that MHPs can make to navigate the service gap for Christians striving towards the realization of a Christian identity and grappling with immediate medical choices. A MHP supplements, but does not substitute for, medical and pastoral personnel. The emphasis swings from an abstract bioethical trial to the intrapersonal quandary, interpersonal ties, and transcendent resources.

One fundamental to the supportive consultation process is empathic listening (Egan, 2010). Beginner helpers are taught to start with primary level accurate empathy statements and systematically make meaningful connections. Facts are heard. More importantly, emotionally laden convictions are acknowledged with compassionate feedback. As the conversation deepens, the use of advanced accurate empathy demonstrates comprehension of underlying values, storylines, and the threads that weave together priorities throughout the narrative. For believers, there is the persistent awareness that one's self story is to be under reconstruction as it is woven into God's mission to further the gospel--God's story of creation, fall, redemption and restoration. Thus, helpers respectfully assist in the revision of distorted beliefs and tangled emotional-relational schemas. There is no explicit reason why pastors or medical personnel could not do the same. Conditions related to time, role, and agenda align at cross purposes to bring advanced empathic listening into these conversations.

Reflective listening is designed to identify the potent forces that contribute to decisions. A concise assessment grid, known as the "4 S System" is useful to discern coping resources and influential variables (Goodman, Schlossberg, & Anderson, 2006). The model's headings are situation, support, strategies, and self. The situation variable steers the listener to attend to those triggers, events, or expectations that force change or instigate a life transition that stresses the patient. Support assessment requires a wide angle scan over the convoy of social support, ranging from intimate alliances to distant acquaintances. The counselor should pay attention to any gaps that are apparent within it. Strategies are those engrained coping patterns, assumptions, and notions of what works best based upon past experience and ingrained beliefs. The self factor guides the listener to notice not only the demographic and developmental features, but also the accompanying long-term issues, social preferences, and certainly, personality style. The addition that is critical for our purpose is to add a fifth "S", spirituality. Though spiritual beliefs, relationships, and resources could be treated as a distinct category, my preference is to assume that Christian spirituality permeates each of the other four areas as the Holy Spirit moves. God is at work within the situation, Jesus Christ is an available supportive ally quickening Christian fellowship, and Scripture guides the selection of strategies through wisdom as it moves self toward sanctification and re-creation.

For Eduardo, the strategy to push hard and press ahead into the American dream may need to be brought under review. This has served both him and Anna well. Yet, they may be in a position for a unique season of service. Or, what if assistance could be recruited from within their cultural community to make home care possible? What network of support tied to their cultural past might be available to assist in the present? Does a pro-life approach insist that medical personnel employ every extensive procedure to delay the aunt's progression towards heaven where she will be whole once again?

Given the chance to pour out their hearts, Don and Debbie might reveal a longing for substantial comfort surrounding the loss of their daughter. There is an intense need to network with other couples who face fertility concerns. Most importantly, pastorally oriented input coupled with psychologically astute sensitivity could raise awareness of the indispensable fifth 'S' to help these Christ followers discern once again their spiritual commitments. Don and Debbie are under undue affliction during this season of distress.

Listening well to recognize the full framework provides the MHP with opportunities to link the immediate dilemma regarding appropriation of biotechnology with personal narratives. How does the gospel story mix with their own story? The concept of linking is to connect ethical principles that guide other areas of life to this bioethical concern. In ethical consultation, this is known as following the value path of the patient. Medical decisions make core values transparent. The most common value conflict investigated is one between medical procedure and the value path of a patient. Is this not the precise assumption of Satan when speaking to God about Job's assumed faith? "Skin for Skin!" Satan replied. A man will give all he has for his own life. But stretch out your hand and strike his flesh and bones, and he will surely curse you to your face" (Job 2:4-5, New International Version). From a Christian bioethics perspective, there is intentional effort to link the value paths within patients to the medical options under consideration. When inner values are brought to the surface for examination, the Lord provides grace to evaluate what is excavated. Old self motives may conflict with being a new creation in Christ. Might the desire to apply an alternative, consciously chosen value take precedence? A helping consultant will have words, phrases, and convictions from the hearts of those being coached to blend back into the conversations. In such moments, messages from pastors, phrases from the Word, themes from Scripture and even underlying theological premises discerned by bioethicists as relevant to their dilemma, can be heard and internalized. Feedback can link the medical decisions under consideration to the faith story of their lives in light of the ever relevant good news of the gospel. This provides powerful assistance.

Lastly, the most unique contribution that a professional helping consultant can make in encouraging a deeper contemplation of bioethical issues is to notice how personality patterns influence the direction of the bioethical choices. Aligning the ethical conversation with the dominate personality tendencies is what is meant by leaning into the personality pattern. This fits under the heading of self from the "4 S system." Within a Christian helping framework, picture ways that self and identity is exposed for the sake of transformation. What qualities might the Holy Spirit seek to touch in order to accomplish particular putting on and putting off of these evident characteristics?

Theodore Millon and those investigating his model of personality have demonstrated how personality variables tie to vulnerabilities in physical and mental health issues. Beyond the risk factors associated with personality types, proposals have shown how compliance with medical treatment is improved when personality features are taken into account by medical professionals (Harper, 2004). The material from behavioral medicine on personality is vast and involves the interface of many disciplines and concepts. The intent in this context is to suggest that in approaching conversations regarding bioethical issues, recognition of prevailing personality features may enhance cooperation and ease misunderstandings. When the personality patterns of the client are recognized, helpers can participate with those tendencies in a productive manner.

Eduardo was identified as having an intense and strong will early in life. He certainly has made an impression on health care providers who know that he expects them to keep his aunt alive. Might a competitive, mildly detached, overly self-focused style describe him? If so, does his drive for material success have implications for the health care decisions being made on behalf of his aunt? And if this hypothesis has validity, Anna's views would be crucial to bring balance and perspective. Bringing forward Anna's input might yield cultural perspectives and resources. It may take an authoritative style challenge to slow Eduardo down long enough for him to consider an alternative perspective on his aunt's medical intervention plan. Direct physician attention or straight words from a pastor might be particularly useful. Given that his aunt's remaining lifespan could be short, in what ways can her life of service be honored in her death? Eduardo may benefit from firm and hard reflective questions. These need not be harsh. Penetrating query may be useful to help Eduardo hear what his heart--and perhaps the Holy Spirit--could be telling him.

Debbie is struggling with complicated grief and related depression. In what ways does she persistently blame herself for Andrea's death? This may be best treated in therapy and a referral is indeed warranted. It does suggest that making a critical decision regarding utilization of a surrogate may require vigilant examination given her vulnerability at this juncture (ASRM, 2004). Furthermore, the plausibility of a negativistic personality orientation with chronic discontentment set in an oppositional and resentful posture may be worth considering. Given the overlay of grief tied to the recent loss of a child, thoughts in this direction should move cautiously. Nevertheless, judgment on major decisions will need to be supplemented with wise Christian counsel. If a hypothesis regarding perfectionist and negativistic tendencies has merit, then Don will require encouragement to remain steadfastly committed to his wife. He has done this with his church. He may well benefit from having a consistent support close at his side to permit clear judgment when faced with crucial decisions. Debbie could have a tendency to burn out those who assist; a broad social network within the church may be advisable.

These are samples. There is no intention to insinuate the presence of any entrenched Axis II disorders. A medical situation automatically places stress on personality, bringing out underlying, perplexing, and at times, troubling traits. From a Christian perspective, this is a normal occurrence. The wisdom that the Lord provides promises that these are ripe moments for the development of character, maturity in the faith, and perseverance (James 1:1-12). The strategy for consultation is to apply help that fits with and adequately addresses the personality traits of the person in distress.

Autonomy, Dual Roles and Christian Discernment

A biblical grasp of imago Dei reveals that there is no unrestricted entitlement for individuals to determine how to apply biotechnology based on personal desires alone. Dominion over creation is inherent in our nature according to the Genesis account of human formation (Gen. 1:26-31, Wheeler, 1996). The application of tools, technology, and creativity for populating the earth is a stewardship function reflecting divine authority, will, and interest in human choices. The effects of the fall can be managed or reversed via divine grace filtered through human ingenuity. Like those who sought to build a tower reaching to heaven, human efforts that ignore or defy the Creator by failing to honor him exemplify what can be done but not what should be done. Human beings were created to relate to, rest in, and depend on their Creator. Technology is a gift that arrives in our world as a result of the endowments infused into human creativity and rationality. These characteristics were placed within human beings by our Creator. Thus, their use is to be returned to him as an act of worship and praise. The secular culture and medical profession are not expected to grasp this principle as a criterion for moral action. Those who are ecclesia--called out as wholly his for the purpose of becoming increasingly holy--are to place autonomy, control, and will under a redeemed relationship with the Creator.

This apparent rejection of the standard of autonomy as authorizing the use of biotechnology is admittedly both controversial and counter-cultural. It constitutes a genuine professional ethical crisis, for it raises questions regarding adherence to our professional codes of ethics. Fidelity to the welfare of the patient is paramount and informed consent is a procedure designed to facilitate and protect patient autonomy (Corey, Corey, & Callanan, 2010). The suggested utilization of helping technology tools--identified in basic terms as listening, linking, and leaning--to explore more thoroughly the moral application of biomedical technology could mistakenly be portrayed as exercising dual roles. The MHP who offers consultation to assist the patient must clarify distinctions between pastoral, medical and professional counseling services. In the interest of mutual exploration, there is a need for MHPs to resist the urge to impose the values of a presumed Christian worldview. While this could indeed be a potential concern, it would not necessarily constitute a conflict of interest with confessing Christians who voluntarily seek consultation from an MHP who declares these allegiances in a forthright and direct fashion. The intent of the counseling conversation would be to humbly further a patient's interests by jointly seeking divinely granted wisdom in the midst of tempting contemporary choices. This proposal runs parallel to the recommendations offered by Yarhouse (2004) in conjunction with explicitly Christian therapy for those who experience same sex attraction. Acquiring counseling services to assist one to explore bioethical decisions from the vantage point of Scripture, theology, and the Spirit's enlightenment could be treated as a means to support a commitment to live out a consistently Christian identity. The goal is not only to clarify a person's value path, but to lay that path before the Creator and ask, Lord, is this your way through a narrow gate?

Additionally, a helping professional must be extraordinarily upfront regarding the purpose and the type of input that could be offered. Concern over professional authenticity within this type of consultation assistance is valid. If an MHP presents services as a 'Christian' counselor, additional clarification of informed consent is necessary to separate or define the insinuation that pastoral and professional roles may be combined. Practitioners need to grasp the potential role shift from that of patient advocate, to the prophetic voice of a particular religious community, a cultural representative, or a promoter of spiritual values. Christian counselors recognize variant roles and work towards transparency regarding values exposed (Greggo & Parent, in press).

The ideas articulated in this article are not aimed towards those who serve on formal committees on bioethics. Those committees are designed to assist patients and their families while protecting organizations and professionals (Vaszar, Raffin, & Kuschner, 2005). Committees tend to favor an 'ethics facilitation' model built on a presumed neutral middle ground between imposing a moral agenda on one end (outcome) and promoting arrival at a consensus at the other (process) (Aulisio, 2003). Ethics facilitation seeks a happy medium between an authoritarian approach that lays claim to a predetermined outcome and a model of process facilitation where stakeholders are coerced to arrive at consensus. Institutional ethics committees have their purpose. In order to arrive at a kingdom orientation, the use of psychologically informed, theologically grounded consultations may activate what are ultimately God-honoring conversations.

The accusation could be raised that any effort to apply 'Christian' bioethics would by definition be authoritarian since there is a frank appeal to represent a divine and absolute authority through the application of revelation. Such an objection recognizes a genuine risk but misses the service potential. The intent is to clarify values regarding health care within a Christian moral structure that is informed by Scripture, faith tradition, and the wisdom of the community. Christ followers ponder the nuanced implications of medical choices. Christian discernment empowered by the Holy Spirit can follow. MHP consultations are not promoted to adjudicate conflict (Baylis & Brody, 2003). The goal is to host value-clarifying dialogue in the pursuit of Christ-honoring virtue. Medical professionals can poignantly clarify options and risks. Theologians, biblical scholars, and bioethicists can guide pastors and flocks to recognize biblical limits. MHPs can support those in distress to make God honoring moral choices in the midst of real life.

Vision for Ministry at the Moral Edge

The field of Christian bioethics has alerted the faithful that best medical practice is not solely a matter of clinical guidelines interfacing with what a patient desires or can afford. Our Creator oversees these activities. Scripture offers a perspective on suffering and how to express gratitude for relief. Theologically grounded convictions do impact decisions made in the realm of biotechnology. Yet, believers are not well prepared to enter discussions with health care professionals when armed only with an indoctrinated list of do's and don'ts. It would be better for those on a journey of faith to be equipped to critically apply doctrine with a desire to mature through the ministry of the Holy Spirit. Christians can enjoy the blessings that medical advancements offer as redemptive expressions of grace. And, people of faith persistently recall the promise of eternity where every tear is wiped from the eyes of those who suffer.

Christians who counsel can host conversations that awaken awareness of the Creator regarding the moral edge of bioethics. In order to meet professional expectations regarding competency, every consultant collaborating on bioethical matters will seek to become conversant with medical terms, procedures, ethical principles, and the roles of each shareholder in the decision. In order to represent one's faith tradition, familiarity with kingdom ethics decision models and application to bioethical matters is critical.

Readers of this journal can contribute further through dedicated research and integrative efforts. Survey research is necessary to determine how MHPs with Christian worldview convictions are involved in bioethical dialogue and to identify distinctive views. CAPS publications and conferences could address specific concerns. The Christian psychological literature lacks groundbreaking articles on bioethical topics and input by Christian ethicists. Case discussions in academic settings could raise awareness of the moral edge embedded in medical options. Are cases such as those presented here offered to those apprenticing to enter the profession? Folks like Eduardo, Anna, Don and Debbie would benefit from informed bioethical conversations in their surrounding faith communities and this does include our counseling offices.

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Stephen P. Greggo

Trinity Evangelical Divinity School

Author

Rev. Stephen P. Greggo, Psy. D. is a Professor in the Counseling Department at Trinity Evangelical Divinity School, Deerfield, IL. Dr. Greggo is also Director of Professional Practice at Christian Counseling Associates in Delmar, NY. His interest areas are in counseling and Christian worldview, contemporary clinical practice, groups, supervision and raising up the next generation of mental health professions for kingdom service.

An earlier version of this article was presented at the 2008 Christian Association for Psychological Studies international conference in Phoenix, AZ on April 5, 2008 under the conference theme of imago Dei in the Spirituality/Pastoral Care track. The author wishes to acknowledge research assistant, Lisa Chu, for her support in the preparation of this manuscript. My appreciation also goes out to the anonymous reviewers who contributed valuable insights and suggestions. Correspondence concerning this article should be addressed to Stephen P. Greggo, Counseling Department, Trinity Evangelical Divinity School, 2065 Half Day Road, Deerfield, Illinois 60015. E-mail: <[email protected]>