Strategies for Moral Decision-Making: Confessions of a Moral Underling

H. E. Clifford, FRCS, FRACS
Jack W. Provonsha Lectureship
The Alumni Postgraduate Convention
Loma Linda University
February 24, 1990

A STORY

Two young people who worked in service departments of the Sydney Adventist Hospital were friendly-a little too friendly! Presently the girl was noticeably pregnant, and this intelligence was reported to Administration. What was to be done? We did nothing-a favored administrative strategy. But pregnancies are expansive. The circle of the informed and the concerned also grew, and demands to do something became compelling.

A discipline committee decided the couple should leave, and to my everlasting shame I accepted the decision. I did not, of course, implement the decision. That was delegated to an officer of the personnel department. Delegation is another administrative strategy-not particularly suited to moral enterprise. I did not know then that neither young person had anywhere to go. They both came from broken homes. At one home they were declared unwelcome, and the other no longer existed.

The couple decided that together they wanted to make a go of things because they loved each other. They consulted a church pastor for help and requested marriage. He referred the matter to the church board. The board decided they could be married subject to formal censure, a measure which was designed to place the church's position on premarital relations on record. The plan was dropped because the young man did not want his partner to receive or accept blame. At this stage (I remain amazed) the couple returned to the hospital. We have a beautiful little chapel, and they asked to be married there. We granted their request, but imposed certain restrictions. There was to be no confetti, no petals; the ceremony had to be completed by a certain time. There were not to be too many friends and guests. "We have no friends," they said. In the end our chaplains mustered a few staff members to witness the ceremony. Can you have a wedding without guests? I suppose it defeats the main purpose, that of public declaration of commitment.

For some time I received reports of the couple's progress. There were three in the family now. They were struggling to make ends meet, but otherwise they were doing well. Their love endured. It is a story that ended well. Was this because of, or in spite of, our excursion into moral discipline? Might it not have concluded otherwise-with, say, a discreet abortion or, with so much rejection on all sides, even a suicide?

Reflection on this incident lies behind a change in my thinking about the exercise of moral responsibility. It seems to me now that self-interest was significant in my motivation:

• I had removed a source of offense and embarrassment, and for those persons in the community whose major claim to piety was the keeping of a watchful eye on others, a preoccupation. You know how distracting things like this can be in institutional life.
• I was seen to act decisively. Opportunities for leadership to demonstrate capacity of that sort are not to be lightly passed over.
• I was seen to be a defender of standards. Nothing could be more impressive in the setting of a religious community than for a leader to appear assiduous in that role.
• My action therefore tended to enhance the image of leadership and to preserve the solidarity of the group-administration bonanza!

My determination was also highly idealistic:

It reflected the world as I felt it ought to be. In an ill-defined way I may have considered my action as a witness to that world and therefore in some sense evangelistic.

My action did not, however, account for the reality of the world as it is. Virtue seas taken for granted. There was no provision for default.

Most importantly, in the name of a higher cause my action failed to address the clamant needs of the case at hand.

We can then construct two platforms or worlds of presupposition for ethical enterprise:

EGO/IDEAL

The first I shall call the world of the ego/ideal. By ego I mean simply self. By ideal I mean the highest aim or good. This is the abstract world of ideas, values, interests and beliefs.

ALTER/EXISTENT

The second is the world of the alter/existent. By alter I mean simply other. By existent I mean life as it is lived. This is the concrete world of event, encounter, circumstance and contingency.

This description is, of course, another illustration of the Platonic dichotomy which has for so long plagued and corrupted human thought: the division between idea, form and substance, body and soul, mind, spirit and matter and so on. It runs through philosophy and theology. So we have phenomena and noumena; transcendent and immanent; realized eschatology, future eschatology; kingdoms on the left, kingdoms on the right. (We sometimes forget that the kingdom on the left, i.e., the civil/secular, is God's also.) There are divisions of other kinds: Bertrans Russell observed that human history has been determined by two great opposing forces; prudence and passion. There are the distinctions between profession and practice, intention and action, and so on. There is no need to enlarge on this vast dichotomy; it is inevitable and perhaps necessary in a broken world. St. Paul, with his predilection for the broad canvas and flair for the master stroke, foreshadowed that at the right time God would bring all things together(1).

The point we must make is that the whole of moral enterprise is necessarily grounded in another world falling between and incorporating the two-the world of ambiguity:

Dilemma

Ego/Ideal

Ambiguity

Alter/Existent

Tension

We use ambiguity in the sense not only of two-sidedness by of the unclear, the problematic and the controversial. We are speaking of a world of many shades of gray. It is the world of dilemma and tension in which decision-making must take place. For us, there can be no high moral ground, a platform on which we decision-makers may stand either pretentiously or complacently. It is not that there is no right or wrong, no good or bad, no criterion or standard. The problem is not in anything around us. As we suggested in the beginning, the weakness lies in ourselves. In his book The Puzzles of Childhood (2) the celebrated Australian historian Manning Clark paints a picture of his father, a minister of religion, a man of impressive piety who professed much. The son observed, however, that while the father fervently preached forgiveness (a favorite topic) he could not forget. The picture painted by the son is, in the words of one critic, that of a man who was "all morality and no charity.'' Sadly this is a common contradiction.

My contention is that recognition of the ambiguity which pervades the human condition provides a key to strategy for moral decision-making.

In any strategy that attempts to address problems in an ambiguous world there must be openness. We can and do have commitments. These must be combined with openness-openness to the recognition of our biases.

Philip Wogaman, in his book A Christian Method of Moral Judgment, has pointed out that not only are our presuppositions (those important points of departure) subject to bias, but every step in the decision-making process:

the questions we ask the methods we follow the priorities we establish the solutions we propose. Complete detachment and objectivity are impossible (and perhaps undesirable). The stronger our conviction the less likely we are to be a fair judge of our impartiality.

For those of us who have religious commitments, it is important to recognize that understanding of what it means to be true to Scripture has also undergone considerable development. We remain persuaded that Scripture does speak to our time, but how? How do we move from the historic witness to discover God's will for the present, or from the present to find His will in the historic witness? Of the numerous models which have been elaborated for the use of Scripture in ethics, two seem especially helpful: The formation of character model (B. C. Birch and L. L. Rasmussen). The concept here is that our faith through its stories, images and symbols conditions our perceptions and commends certain values. Internalization of these values and the images and symbols that go with them shapes our attitudes and intentions and in turn our pattern of response. Ultimately these dominant values determine our priorities and inform our decisions:

FAITH (stories, images, symbols)

perceptions,

values attitudes,

intentions,

character disposition

decision

ACTION

There is, according to this thesis, an inextricable relationship between the ethics of being and the ethics of doing. There is consistency between the good person and the right action. The moral principle model (A. von Harnack) proposes that the most fitting application of Scripture in ethics is at the level of moral principle. Certain general principles may be discerned in our foundation sources which can be applied to a variety of concrete situations:

PRINCIPLES

guidance

rules, codes, imperatives

decision

ACTION

This is not to say that Scripture may not provide more specific direction. At the lower levels in this functional hierarchy, however, cultural factors and circumstances of time and place become increasingly influential. This is where problems of interpretation can he very difficult.

The strength of these approaches is that they do justice to persons as intelligent and free moral agents. To speak of ethics and morals without agency or freedom is a contradiction. These models are also responsive to the need for Christian ethics to address ever-changing situations. They do not, however, remove from us the inconvenience of having to work out how to be Christian in the late twentieth century, and they do call on us to expose our accepted patterns of response to examination and to change them if necessary. (see table at bottom)

Of course, not all will agree with our choice of model or principle or that we have applied them appropriately. This should not disturb us. Scripture is rich in its diversity. Certainly differences should not divide us. It is more important to preserve our agency and to cherish our freedom. We must remain open.

An interim ethic may be necessary, if finality cannot be achieved. It is difficult for a medical practitioner to admit on occasion that little can be done-so much is expected. We have sometimes nurtured unrealistic expectations, thereby undermining acceptance of greater individual responsibility for health. This is one of the criticisms of modern medical practice.

It is likewise difficult for a Christian who fervently believe in the all-sufficiency of his faith to accept that one may not have answers to some questions, or that one's recommendations may not be accorded the priority they seem to deserve. In matters of faith, too, unrealistic expectations may undermine acceptance of responsibility.

I was impressed with this when exploring the possibilities for response to the AIDS problem with a group of church and community representatives in New South Wales. To the church group the solution seemed so obvious: immediate return to the principle of fidelity. Exclusive permanent heterosexual union was the complete answer, and this was the propitious time for it. The group was incredulous when others, one of whom was a leading judicial figure, seemed unimpressed. Confidence in the prospect of a universal mass reform movement of this kind is unrealistic-to the point of naiveté. And we can be naive.

The question is therefore, what do we do now? The ideal cannot be realized, the infection continues to spread, and the numbers of sufferers continues to grow everywhere. Can we support simple interim measures to control transmission-safer sexual practices and syringe exchange programs? Can we still accept responsibility?

To proclaim an absolute ideal and proffer nothing else to those unable to attain the absolute is a denial of charity, an abdication of ethical responsibility and an exercise in Pharisaic elitism... In a broken world, second best is better than none... J. McPherson, Ed. Aids and Compassion, Canberra, St. Marks. 1988(4).

The respected John Howard Yoder, in his book The Politics of Jesus(5), makes the radical suggestion that participation in the suffering of Christ (i.e., the taking up of one's cross) does not mean simply the denial of a selfish way of life. It means quite specifically the abandonment of legitimate ends if they cannot be achieved by legitimate means. I make a further proposal (which Yoder declined to make) that following in the way of Christ may sometimes mean the giving up of the most legitimate means in favor of a worthy end. This is particularly important in the context of human welfare and the saving of life. I am inclined in such circumstances to support Fletcher, who argues, if from a different standpoint, that "Any disvalue in the means must be outweighed by value gained in the end"(6).

In an ambiguous world, an interim ethic may be necessary if we cannot achieve finality. We must continue to care when we cannot be correct (by being correct I mean conforming to a code or standard-personal, professional or religious).

To continue to care when we cannot be correct is an immense challenge. Our natural reaction under those circumstances is to withdraw, to dissociate ourselves from compromise. A patient in our hospital had developed an acute postoperative complication. His own surgeon could not be contacted. I requested another visiting surgeon in the hospital at the time to see the patient. To my surprise he declined, declaring that on ethical grounds he could not see another doctor's patient without a direct request from him. (It is true that referral by formal notice is entrenched in Australian medical protocol.) The doctor was correct, very correct, but did he really care?

In the earlier years of the AIDS epidemic there was a reluctance among many health-care professionals and agencies to accept and to admit seropositive patients. Fear was a factor, but there was also disagreement with health authority policy on confidentiality and testing, and there was distaste for the perceivedly less-than-correct circumstances under which many patients contracted the infection. There is also a wider movement, admittedly a strongly opposed one, to restrict therapeutic options in the case of self-inflicted illness, illness resulting from, for example, self-indulgent lifestyles. The employment of a culpability index has been suggested for this purpose. Where would one stop? If we have come to terms with the ambiguity in the world (an ambiguity in which we ourselves participate) we will continue to care whatever the circumstances. This is what I think of as world responsibility. It is the reverse side of the coin of world evangelism.

The concept "world responsibility" implies an awareness that the world is in sin and will remain in sin for the time being. It implies that the community of believers is unable to abandon it in spite of that unalterable fact. It implies that the community is called upon to participate in God's determination to assume responsibility; for the world, to suffer its present state, . . . to keep the doors open for a total renewal at all times. (Nurnberger. Theological Ethics, UNISA. 1980.) (7). I further suggest that responsibility must take precedence over evangelism.

I have referred to a change in my thinking. What would this change mean in terms of our original story-if I had a second chance? I think I would call the couple involved, perhaps even call on them. I would tell them that I had learned a little of what had happened and that I was anxious to help in any way. When I discovered that they wished to keep the baby I would tell them how pleased I was about that. I would ask more about their plans. When I learned that they wished to marry I would discreetly try to prepare the ground for them. I would consult the minister of the church of their choice and ask him, in the name of the Sydney Adventist Hospital, to be helpful. I would explain what I knew of the background to the situation and what the hospital was prepared to do. I would indicate to the couple that they would be welcome to continue work at the institution. We would offer job security for the mother, who would need some leave of absence. When I learned that they had few friends, I would assure them that we, the administration and staff, were all their friends. I would ask about their accommodation and needs and assure them that any reasonable help that could be afforded would be given. I would ask them to report to me again.

All of this would cost the hospital very little. It should, however, go beyond a commitment to world evangelism to acceptance of world responsibility, to a keeping of the doors open until the time when, in Paul's words, "God will bring all things together"(l).

ENDNOTES

1. St. Paul, Eph. 1:10.

2. Clark, Manning. The Puzzles of Childhood. Melbourne: Viking. 1989.

3. St. Paul, 1 Cor. 15:39.

4. McPherson, J. (Ed) AIDS and Compassion. Canberra: St. Marks. 1988; p. 198.

5. Yoder, J.H. The Politics of Jesus. Grand Rapids: Eerdmans, 1977; see esp. Ch. 7 and 12.

6. Fletcher, J. Humanhood: Essays its Biomedical Ethics. New York: Prometheus 1979; pp. 148-159.

7. Nurnberger, K. Theological Ethics. Pretoria: UNISA. 1980; p. 313.

Application of Principles to Some Contemporary Ethical Problems

PROBLEMS (by case number)

1. Life support

2. Organ transfer

3. Animal welfare/ experimentation

4. Status of women

GUIDING PRINCIPLES

1. reverence for life (creation) acceptance of temporarily (fall)

2. privileged place of the body in acts of love (incarnation, Eucharist, passion)

3. cultural mandate (domination, stewardship)

4. equality, complementarity (creation, justification)

RESOLUTIONS

1. optimum rather than maximum support

2. giving and receiving taking and getting selling and buying

3. respect and responsibility for all (sentient) life

4. all forms of discrimination are cultural only

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