Love it or hate it, an understanding of ethics is essential to practising medicine effectively. Wherever you turn, there are decisions to make. How should we approach them? Christians want to do what God says is right. But how do we know what that is? Many great thinkers, including Christians, have devised ethical principles, but there are so many differing opinions that it can be confusing!

where are we to go?

In summer 2010, I posed these questions and began answering them by looking to the Bible as God's revelation of himself and his will, and thus our final authority as Christians. (1) We saw that the triune God, 'continually pours himself out between the persons of the Godhead, in unceasing communication, love, friendship, and joy'. (2) Being made in God's image, we are beings who 'ceaselessly pour ourselves out', centred on God. In the fall this 'all-of-life worship' became misdirected. We 'worship and serve created things', (3) and pour ourselves out to someone or something other than God.

As we looked at the four biblical 'episodes' of human history (creation, fall, redemption and restoration), we saw throughout that God reveals himself in promises of grace that provoke the restoration of 'all-of-life worship' in terms of total dependence on, trust in, and obedience to God.

Thus, we saw the 'worship-ethics' held in the teaching of the Bible, with its central principle that, we are made to image God by centering our lives on him in all-of-life worship. But now for the really key question: when faced with decisions, what do we actually do with that?

How does 'all-of-life worship' respond to a patient's request for contraception, or an abortion? Or any of the other questions we might face each day?

A number of implications arise from the central principle of 'worship-ethics' which I hope will go some way to helping us answer these questions in practical terms. we are made...

First, any application of the Bible to ethics has to recognise that we, our patients, their families, and anyone else involved are made by God, whether we, or they, accept it or not.

This has two implications:

1. all lives have been designed

Recently, I received a fruit-branded smart phone. It came with few instructions, but a key one was: 'not to be used under water'. I can't imagine needing to use my phone on the seabed, but was reassured to know someone was keen that I knew the 'best way' to use it! My phone is designed for use in non-marine situations, and it won't work right if I ignore that design.

Having a designer implies a 'best way' to live according to the designer's intentions. Our decisions, relationships, and use of time and money, will work better if God is our first priority. The Bible is God's revelation of both his original design and his plan to restore us to this design. These two threads unify in Jesus who is both the means of restoration, (4) and the perfect image of God (5) - a perfect revelation of what 'all-of-life worship' looks like.

When we don't live according to God's design, things often don't go so well. I'm not suggesting that the Bible teaches that 'bad things happen to bad people, good things to good people' in every situation. Even a superficial reading of Job would show that to be false! The first two chapters make clear Job's innocence in his suffering. (6)

But generally speaking, life works better when lived according to the designer's plan – and things go wrong when we ignore that design. (7) In Romans 1, Paul teaches that God has 'given us over' to sin and its effects. This reveals his anger, and our need for rescue. (8) In Luke 13 Jesus is asked about an example of suffering: was it a case of 'bad things happening to bad people?' No, but it is an example of life in general not being 'right' as a result of human rebellion against God's design. Rather than illustrating the victims' rebellion, it highlights our own as part of the human race. We are supposed to see our need for rescue and restoration. (9) Therefore, as we see the bad effects of not following God's design, we should understand that both the design, and more importantly the designer, are good and worth following. We are supposed to be driven to seek forgiveness.

For example, studies repeatedly show that children of married couples do better than children of co-habiting or unmarried couples – who are just over three times more likely to have 'self-esteem' problems, and on average perform worse academically. (10) Undoubtedly these statistics are a generalisation, and for many children this would not be the case, but that's the point: the statistics show that in general life works better when lived according to the designer's plan. Gently pointing people to the fact that there is a good design to life, and a good designer is, to put it simply, caring.

Example: A 16 year old girl walks into her GP's surgery requesting contraception, having recently started sleeping with her boyfriend. How would the implication that we are all made by God, and that he designed the best way to live influence the GPs actions here?

The GP would need to remember that this girl was made by God (whether she believes this or not). Sex itself is not bad, but sex outside of marriage is a good gift used out of right context, and elevated above the giver who stipulated its design. The patient is worshipping something other than God, whether that's the pleasure of sex itself, the approval of her boyfriend or friends, or something else.

She is also damaging herself, her boyfriend and (perhaps especially) possible future relationships she might have. The GP would be right to gently point this out, and counsel that abstinence until marriage is better for her, both physically and emotionally.

'Worship-ethics' demands that we point to the greatness of the original design for life, and beyond that to the greatness of the designer.

2. BUT... we are accountable to God alone

People who do not live according to God's design, and do not centre their lives on him, will ultimately be held to account by God alone.

Too often as we try gently to point people towards God's design for life, we reduce Christianity to morality dressed in biblical language. We cannot set ourselves up as judge, (11) or suggest that God accepts us if we live by his rules. Instead we need to point people to the good designer who knows their failure to live according to his design, and calls them to respond to his offer of grace in Jesus.

As we see problems in society bringing suffering, and even hurts in our own lives, we are supposed to make the connection: things have broken down because humans have rejected God's good design. Though we can teach that living according to that design may well bring good things in this life, we must strictly avoid teaching 'salvation by morality'.

Example: Back to our consultation... How would the implication that we are all made by God, and so answerable to him alone, influence the GP's actions here?

The GP needs to remind himself that no-one will ever be declared right with God by practising biblical sexual ethics! His consultation with this patient needs to 'always be gracious, seasoned with salt'. (12) 'Worship ethics' demands that we recognise God's power and authority to both judge and save by grace alone.

to image God...

Secondly, we must recognise that we, our patients, their families, and anyone else involved are made by God, in his image, whether we, or they, accept it or not. There is huge value invested in human life.

Value can be determined in two ways: either intrinsically, bound up with the very substance of the thing (such as the 24 carat gold making up a ring) or extrinsically, because of one feature or another (such as its beauty).

Imagine you wanted to create a valuable painting. You probably wouldn't start by randomly drizzling paint over a canvas. You'd probably find it to be about as valuable as a ruined canvas! It has no extrinsic value because it is not particularly beautiful, and no intrinsic value because at the end of the day it's just a mess! Yet, one of the most expensive paintings ever purchased is entitled 'No. 5' by Jackson Pollock, at $140 million, which he made by seemingly randomly drizzling paint onto a canvas!

Pollock's painting is extrinsically valuable because people think it beautiful. At first glance it has little intrinsic value until one recognises that, since Pollock is a famous artist, the fact that his hand drizzled the paint adds a deep level of intrinsic value.

Something only valuable for extrinsic reasons can lose its value easily, if someone disagrees about its beauty, or it loses one quality or another. Intrinsically valuable things can never lose their value because the value is bound up with their very existence.

This principle is important to the value of human life. In recent years ethicists have insisted on the variability of the value of human life. We are valued according to our 'ethically relevant characteristics' such as ability to relate to people, or reason, or the value ascribed to us by others in terms of their relationship with us (family, for example). (13) Loss of these characteristics produces a less valuable (and therefore expendable) life. This extrinsic view of life's value is alien to the Bible.

Genesis states that humans are made 'in God's image'. (14) As God created human life, he wove intrinsic value into its existence. This value cannot vary. We need to be careful to avoid defining the 'image of God' as simply human characteristics – like creating, or reasoning. It is possible to agree that these traits are 'like God' and therefore could be part of God's image in us. But they cannot be the full definition, otherwise it could be suggested that the Bible actually teaches 'ethically relevant characteristics' - that the image of God and value of life could be lost!

Rather, being made in the image of God means that we're like God in every way that we're like God(!) We pour ourselves out in every aspect of life, whatever our abilities. There is no possibility this likeness can be lost. Life is intrinsically, immensely valuable.

In our 'worship-ethic' we aim to be centred on God in all-of-life worship, making him first in everything. When we see his image in humanity, a high view of God will lead to worship by treating his image with utmost respect, whatever the abilities or characteristics of the image-bearer(s) in front of us.

Example: The next patient in surgery is accompanied by his mother. He has a complex degenerative condition. He's in pain, and is becoming more frail. His mother is distraught: 'You wouldn't treat a dog like this. Why can't we just relieve his suffering?'

How would the fact that we are made in God's image influence the doctor's response? An extrinsic view of this son's life might conclude that his value as a person has decreased. Many ethicists would advocate euthanasia in this circumstance, especially as his mother seems to support it.

Yet this patient, despite his frailty, is an immensely valuable image-bearer. He is worth far more than the 'dog' his mother mentions. Which is her point, but misdirected. Vets treat animals as they do because they are less valuable than humans. Time, money and compassion should be invested in caring for both him and his mother. The GP's view of God's image in his patient should lead to sadness that such a valuable being could be reduced to suffer in this way, but his 'worship ethic' will lead to practising costly, compassionate, medicine in caring for fellow image-bearers as far as he possibly can.

centering our lives on him in all-of-life worship

This is where 'the rubber really hits the road' in our actions as Christian medics. God designed our lives to be centred on him, and he is supposed to be first priority in all our decision making, ethical dilemma or not. But we have all 'exchanged the truth of God for a lie' and 'worship and serve created things rather than the creator'. (15)

Any Christian approach to ethics must be realistic about the reality of universal sin. 'Those controlled by the sinful nature cannot please God'. (16) We need to be realistic not just about the sin 'out there' in the lives of others, but also the sin in our hearts. We do not want to centre our lives on God. We do not want his approval above any other. Instead we are prone to put ourselves first, or seek approval in idols of popularity, or professional success, or whatever they may be.

To respond rightly to any situation, we must recognise, first, that the only reason we have any inkling of the sin in our hearts, and any desire to overcome it, is because of God's work in us by grace. We were dead in our sin. (17) Second, we must see that until we reach heaven (where God's work of restoring us to his original design will be complete), there will always be a part of us that worships other things.

So we must examine our hearts, and ask God to shine the light of Scripture on them by his Holy Spirit. We need to question our motives at every step: 'Who am I seeking to please? Who am I fearing first?' We need to ask: 'Who, or what, am I worshipping?'

This is never more important than when we are challenged in our understanding of the Bible and our approach to ethics. All-of-life worship means centering our lives around God. The only reason we know what God says, or thinks, is because of his self-revelation in the Bible. At times this revelation is hard to understand, but this shouldn't surprise us - God is complex! It is not his revelation that is deficient; it is our understanding, blinded by sin as we are. So, we need to work hard to understand his revelation, and be humble to accept that we might not have the best understanding yet. All the while we need to ensure our first priority is God's opinion. Any other priority, even 'what my pastor or parents or CMF friends think' is idolatry; worshipping something other than God.

Example: After the GP's morning surgery, he discusses prescribing contraception to unmarried people with a Christian partner over lunch. They disagree on the right course of action...

How can these two GPs talk in a way that ensures they are centering their practice, their friendship and even this conversation on God?

These colleagues need humility. The only reason they have any desire to live according to God's design is because he has acted to change their desires. Remembering this will change the entire flavour of a conversation that could have been filled with self-righteousness. They will listen to one another's disagreement, while gently challenging each other to ensure God, and his word are central. How often we need other Christians to help us see where we are putting other things first!

This will also allow ongoing discussion and mutual hard work in understanding the Bible, which may even lead to resolution of the disagreement. The friends can allow themselves to be challenged by one another, knowing they are both seeking to honour God in work as part of their all-of-life worship.

conclusion

Sometimes ethics is hard. Christians can be guilty of pretending it's not. But find a Christian doctor who has been working for a few years, and they will tell you that sometimes doing what the Bible teaches feels difficult. In the face of a suffering patient asking for a quick death, or a suffering woman asking to be relieved of the further burden of a baby it can be tempting to agree to their wishes and see the problem 'go away'. At almost every turn, this is tempting because it's the 'easiest' option. 'Worshipethics' above all, calls us to image God in all-oflife worship by practising costly medicine with compassion: 'suffering with' our patients just as God in Christ suffered with and for us.

In our ethics we need to start and finish with the gospel of grace: God made us to image him in all-of-life worship, and has acted to restore us to that image through the person and work of the Lord Jesus. It is the only remedy for the idolatry of our hearts, and the hearts of our patients and their families. We can point them to God's law, and design all we want. We can explain how valuable they are as his imagebearers. But underlying it all, we must be praying for them to meet the God this all points to for themselves.