Should we impose our morality?

Nitpickerus: It's all very well for us to pontificate about ethical issues Dionysius. We're Christians. We've got an agreed starting point. But most of our patients don't accept the authority of the Bible. We can hardly impose our morality on them, can we?

Dionysius: It's not our morality Nitpickerus, it's God's.

Nitpickerus: Maybe, but many of our patients don't believe in God either. Are you suggesting that we should dance around the surgery like Old Testament prophets ... 'Doom, doom, repent, repent'?

Dionysius: The idea's not quite as silly as it sounds. The role of a doctor is not unlike that of a prophet. There is a very strong link between lifestyle and disease.

Nitpickerus: That's a very dangerous assertion Dionysius. Isn't disease simply a result of the fact that we are living in a fallen world?

Dionysius: I'm not denying that the whole world has been generally affected as a consequence of man's rebellion against God.[1] It has. Paul tells us that the whole of creation is groaning.[2] We're looking forward to a new world where there will be 'no more death or mourning or crying or pain'.[3] We're waiting for resurrected bodies like that of Christ.[4] But this doesn't mean that we can't at times see a specific link between sin and disease. There often is one. Of course, we must 'test everything'[5] and be careful to 'enquire, probe and investigate thoroughly'[6] before jumping to hasty conclusions. But we must also be honest. This is not to say that there are no innocent victims. There are.[7] Nor is it to claim that all who seem to escape the consequences of sin are thereby free of guilt. They're not.[8] Nor is it to claim that we can always see the link between a specific sin and a specific disease, if indeed there is one at all. We can't.[9] But, this is not to say that specific links don't occur.

Is there a link between sin and disease?

Nitpickerus: So what biblical evidence is there for a specific link between sin and disease?

Dionysius: There are plenty of individual examples in both Old and New Testaments: The Philistines' tumours,[10] Jeroboam's paralysis,[11] Gehazi's leprosy,[12] Zechariah's loss of speech,[13] Elymas' blindness[14]... Ananias' and Sapphira's sudden death.[15] But there are general examples as well. Many of the curses that God said would come upon the Israelites if they disobeyed his commands are actually medical conditions of one kind or another. Read Leviticus 26 and Deuteronomy 28. In the light of current knowledge about the link between behaviour and disease many of God's regulations make perfect sense.

Nitpickerus: For instance?

Dionysius: Take the quarantine laws for contagious disease in Leviticus 13 and 14. The priest, in many ways the modern day equivalent of the physician (!), had a responsibility to protect the rest of the community from infection by isolating affected individuals. Deuteronomy 23:12-14 is a prescription for preventing all sorts of gastroenteritis, and other diseases spread by the faecal-oral route. The guidelines about animal fat consumption[16] are particularly interesting in view of what we know about the aetiology of gastrointestinal disease and atherosclerosis. Then there are the pharmacological effects of alcohol beautifully described by the writer of Proverbs,[17] and the preventive measures for stress-related illness given by Jesus[18] and Paul.[19]

Nitpickerus: Is there anything on sexually transmitted disease?

Dionysius: We've already discussed in a previous issue the disastrous personal and social consequences of people breaking God's rule of one man, one woman, for life.[20] The biblical guidelines for sexual intercourse are detailed and unambiguous.[21] The Moabite seduction of Israel is a graphic example of sexual sin resulting specifically in fatal disease.[22] I wonder what the infective agent was in that case? It certainly makes the HIV virus pale into insignificance.

Nitpickerus: What other diseases described in the Bible can have their root in sexual immorality?

Dionysius: Sexually transmitted diseases can cause infertility. There wouldn't be much of a demand for IVF and GIFT if it wasn't for Chlamydia trachomatis. We know micro-organisms spread by the sexual route are responsible ultimately for an astounding range of pathologies: the papilloma virus predisposes to cervical cancer or 'wasting disease', certain serotypes of Chlamydia trachomatis cause 'blindness', Neisseria gonorrheae produces 'discharges', Treponema pallidum causes a host of afflictions including madness' and 'confusion of mind', lymphogranuloma venereum results in 'festering sores '... not even to mention the various manifestations of AIDS in all these categories and more.[23]

Doctors - Prophets? Priests?

Nitpickerus: So you're saying the Christian doctor should be both a prophet and a priest to his patients?

Dionysius: I'm saying that we have much to learn from these two models. We have the responsibility to warn our patients about the consequences of dangerous lifestyles. If we don't, then we must bear some of the responsibility when they suffer. This is not unlike the role of a prophet to whom God has given special knowledge with the intention that he should use it to benefit others.[24] Like the priest also, we have God-given skills in diagnosis, treatment and limitation of the spread of disease.[25]

Nitpickerus: So doctors have 'god-like' knowledge and power?

Dionysius: Yes they do, and with all knowledge and power comes accountability. Would that all doctors had 'God-like' characters as well.

Nitpickerus: But do doctors have a right to foist their views about lifestyles on patients?

Dionysius: Forget about rights Nitpickerus. Doctors have a responsibility to educate, warn, diagnose, treat and protect. If we are clearly doing it out of concern for our patients and not merely to appease our own consciences, they will usually respect us for it. Even if they don't, it doesn't alter the fact that we have a duty to tell them the truth. of course, we should do it sensitively, at the right time, in the right manner.[27]

Nitpickerus: But we can't force people to act in the right way.

Dionysius: No, God doesn't work like that. He asks people to come freely,[28] and does everything in his power to persuade them that this is the correct course. We should do the same.

Should doctors try to change patients' behaviour?

Nitpickerus: But isn't giving advice about sexual behaviour moralising?

Dionysius: Why? Isn't it just part of responsible health education? Doctors are always trying to get patients to change their behaviour in other areas of life for their health's sake: 'Don't smoke. Cut down on your alcohol. Eat less fat. Get more exercise.' What's so sacred about sex? They can always decide to ignore our advice, but if we don't tell them, aren't we being negligent?

Nitpickerus: But smoking is a high risk behaviour. Everyone recognises that. The bad consequences of sex outside marriage are hardly inevitable.

Dionysius: Granted. Not all fornicators end up with unwanted pregnancies, or AIDS. But not all smokers develop lung cancer either. It doesn't stop us advising them not to smoke. The fact that some manage to get away with it doesn't mean we don't have an obligation to warn everyone of the possible consequences.

Nitpickerus: But you can have safe sex without restricting it to a lifelong heterosexual relationship, just by using a condom.

Dionysius: Condoms don't protect you from emotional hurt and broken relationships.

Aare condoms safe?

Nitpickerus: Maybe, but they're not bad at preventing unwanted pregnancy and sexually transmitted disease. At least they're safe.

Dionysius: Safer than nothing at all but hardly safe! They can split, leak or just fall off. In a recent survey of men attending a South London genitourinary medicine clinic, 53% reported condoms coming off during intercourse, at least occasionally, and 26% complained of condoms splitting.[29] Recent tests on 110 brands of condoms found that over one third had too many holes and failed a strength test.[30] The pregnancy rate associated with condom use is at least 15.7 pregnancies per hundred woman years and an HIV virus can pass through a smaller gap than a human spermatozoon. A study of married couples in which one partner was infected with HIV has shown that 17% of the partners who used condoms for protection were positive for the virus within eighteen months.[31] Those survival odds are little better than Russian roulette... and that's if people actually choose to use condoms.

Nitpickerus: What do you mean? Everybody does nowadays.

Dionysius: They don't. The younger the age of commencing sexual activity, the greater the risks taken, and the worse the outcome.[32] Why do you think it is that an increase in the availability of contraception is often associated with an increase in the abortion rate? In Britain during the past 20 years contraception has never been more freely available irrespective of age, marital status and parental consent, yet the abortion and conception rates continue to rise, especially in young people.[33]

Nitpickerus: Surely this means that we should promote condoms more vigorously. The message is obviously not getting through.

What's the right AIDS message?

Dionysius: Perhaps it's the wrong message Nitpickerus. Have you thought of that? In Africa, governments are exercising more wisdom in AIDS education. The Kenyan campaign posters exhort people to be faithful' to their spouses. The 'AIDS club' in Zambia is teaching 'No sex before marriage, no sex outside marriage'.

Nitpickerus: How are they going to keep their populations under control without condoms?

Dionysius: I think they are far more concerned about what AIDS is going to do to their populations. In the last two years the number of Ugandan people with HIV/AIDS has grown from 1.5 to 1.9 million.[34] There are more effective ways of reducing the birth-rate than condoms. A recent Ethiopian study showed a 50% fall in birth and fertility rates largely as a result of natural family planning.[35]

Nitpickerus: It would never work here.

Dionysius: If a 'modified mucus method' of natural family planning can result in a pregnancy rate as low as 2% among illiterate and semiliterate women in India,[36] I don't see why not. Did you hear that the Polish education ministry is opposing the distribution of the BMA's booklet 'Aids and you'?[37] They say it should emphasize chastity rather than condoms.

Nitpickerus: They would, wouldn't they? Poland is a Catholic country.

Dionysius: France is a Catholic country and they've just slashed the price of condoms by 75%.[38] No Nitpickerus, the reality is that someone's not being honest and responsible. Even the World Health Organization is now advocating 'abstinence' and 'mutual fidelity' as good alternatives in Aids control.[39] The fact that most AIDS educators in this country are still advocating condoms as the only solution is morally indefensible. They are basing their campaigns on two false presuppositions... that condoms are safe and that abstinence outside marriage is impossible. It's dishonest and deceitful.

Nitpickerus: This brings us onto the whole issue of truth.

Dionysius: Yes, but that's to move from the seventh to the ninth commandment.[40] Maybe we'll discuss that in the next issue of Nucleus.