Patients, ethics and power

November 2, 1999

The Body of Compassion: Ethics, Medicine, and the Church, by Joel James Shuman

Joel James Shuman's boyhood hero was his grandfather, a hardworking farmer and woodsman from West Virginia who was faithful to his family, the land, his traditions and his church. Even leukemia did not change his work habits and life patterns. But a surgical intervention meant to arrest the cancer went poorly, and the grandfather died from subsequent complications, "alone in a hospital, hours from home, denied an active role in the last days of his life by a world that was almost completely foreign to him . . ."

Shuman, an instructor in theological ethics at Duke University Divinity School, uses this narrative to unfold the major themes of The Body of Compassion. The isolation, passivity and alienation of his grandfather's experience of dying points to a moral crisis in contemporary biomedicine: its knowledge about the body has come at the expense of knowing and caring for patients as embodied persons. The modern discipline of bioethics, Schuman observes, would have offered little to address his grandfather's need for compassionate care. He criticizes bioethics as a pretentious academic specialization that rests on a mistaken view of ethics.

In his concluding chapters, in which Shuman moves from cultural critic to constructive theologian, he comments that "there was something missing" in the way survivors responded to his grandfather's death. This "something" has much to do with a Christian account of the body that has been buried by biomedicine and bioethics. What Shuman sees as the "tragic" elements of this death lead him to explore ways of being ill and caring for the ill that reflect and witness to the Christian story.

Shuman describes the church as a countercultural community and believes that not only modern culture but its expression in bioethics must be resisted and transformed by Christian practice. Unfortunately, his interpretation of bioethics is badly off the mark. He portrays bioethics' "dominant working assumption" as "helping professional caregivers make morally difficult decisions on behalf of their patients." Yet the history of bioethics is largely rooted in a rejection of paternalistic professional authority and in an attempt to empower the patient as a moral authority in the caregiving encounter.

Shuman's critique makes power the central category of bioethics. Bioethics takes the power to make decisions away from patients and their families and gives it to experts; indeed, "ethicists vie with physicians" for that power. Rather than seeing ethics in Aristotelian terms as discourse among friends about the good life, bioethicists, says Shuman, construct the moral world of medicine as a conflict of wills between strangers, focused on the opposition between expert control and self-determination. Despite bioethicists' pretensions to moral insight, their "'ethics' becomes simply another way of masking coercive power under the guise of knowledge." Yet Shuman never presents any convincing evidence to support his argument.

While it is fair to say that bioethics as a professional discipline does not embody the characteristics and traditions of the Christian community, it is certainly not the slave to modern scientific, political and economic thought that Shuman proposes. Insofar as he has made bioethics a pivotal term in his book and a pivotal culture for Christians to counter, his misdirected critique undermines the bioethical relevance of his theological understandings of modernity, the body and Christian life.

Shuman seeks to illustrate his self-described "polemic" against bioethics through short assessments of the scholarly work of influential ethicists. All of bioethics' expositors fail, in his view, because they uncritically accept the scientific, political and economic assumptions of the modern world. He seeks prophets to witness against modernity and instead finds in bioethicists opportunistic priests with hidden pretensions to kingship. An example of how Shuman's polemic has clouded his analysis is his repeated affirmation that contemporary ethicists not only aspire to replace physicians and patients as the key decision-makers but also hope to present their own decisions with the precision and objectivity that mark modern science.

Yet not one of his three short assessments supports such a conclusion; in fact, all of his exemplars acknowledge an Aristotelian and Thomistic modesty about ethics. Shuman particularly chastises two leading bioethicists, Tom Beauchamp and James Childress, for presuming that "there is nothing wrong with contemporary medical practice that rigorous ethical analysis cannot fix." He misreads the central thrust of the Beauchamp-Childress approach: that bioethics is more about trouble-making (for those in power) than trouble-shooting, more about problem-seeing than problem-solving.

According to Shuman, bioethics is a reflection of modernity, and modernity's essence is the "antagonistic juxtaposition of wills to power." Because modern science has rejected a teleological account of nature and of human life, it makes itself the ultimate savior, with medicine as the mediator. God, meanwhile, is increasingly irrelevant, relegated to those shrinking realms that have yet to become scientifically ex­plicable. In the absence of a human telos, the individual claims moral sovereignty regarding his or her particular good.

This theological, ethical and communal wasteland requires the Christian community to abandon its forms of accommodation and to resist secular hegemony through witnessing to an alternative pattern of life. This requires the assertion of the Christian understanding of ultimate human ends, such as the Thomistic understanding of humanity's friendship with God enacted through a living community and tradition, the church. In this regard, Shuman offers an account of how central Christian practices such as baptism and the Eucharist have a transforming effect on the body.

Shuman rightly maintains that Christian theological discourse on the body presents multiple meanings. There can be no "absolute" distinction, he contends, between a person's own body, the human body of Jesus, the material presence of Christ in the Eucharist, and the social body called church. This intertwining enables Christians to overcome the isolation and inexpressibility of pain and "really share one another's suffering." This proposition promises new theologically and bioethically relevant insights about compassion-insights that this book unfortunately fails to deliver.

Shuman describes baptism as the body-transforming ritual that joins us to the body of Christ. However, he attributes the Christian capacity for compassion to the conviction that our bodily suffering has been experienced by the embodied Jesus. It's not at all clear how these quite different experiential bodies provide a basis for us to claim that we are really sharing in the suffering of another person. The book's promise of some substantive commentary on compassion is not realized.

The concluding chapter does present thoughtful insights into the relation between liturgy and moral virtue and into the central virtues for patients (dependency and constancy) and caregivers (hospitality and presence). Using a story by Flannery O'Connor to illustrate his point, Shuman compellingly argues that a central task of the Christian community is to instruct and exemplify how to be sick and die well, and how to care well for the sick and dying. A valid question is what analogous sources of moral tutoring are available to professional caregivers.

Shuman joins other Christian theologians, such as Lisa Sowle Cahill, Margaret Farley, Gerald McKinney and Gilbert Meilaender, in exploring the theological significance of the body for bioethics. While not as careful in his critical analysis as he should be, he has much to offer to this emerging and important dialogue.