Teaching Health Care Ethics from a Peacemaking Perspective

Brenda Srof

The Conrad Grebel Review 35, no. 1 (Winter 2017)

The contemporary health care scene is mired in ethical complexities for which the simplicity of the Hippocratic oath’s requirement to “do no harm” is inadequate for addressing today’s dilemmas. Ever-increasing technological sophistication and soaring costs in health care are major factors that create ethical conundrums from which societies struggle to emerge. Societal expectations demand that health care improve the quality of life and the duration of life, contributing to unrealistic expectations of what a health care system can deliver. In this climate, patients and families need to understand ethical reasoning within a modern context, necessitated by a concern for stewardship and public welfare. This paper describes the study of ethics in the Goshen College nursing program, not simply to give a glimpse into its complexity but to invite the reader to participate in a dialogue about health care from a perspective of stewardship and peace.

Development of a Health Care Ethics Course

Goshen College, a four-year liberal arts college, offers undergraduate degree programs, select graduate programs, and a study abroad program. Rooted in the Mennonite Church USA, Goshen describes itself as a community of faith and learning, striving to foster personal, intellectual, spiritual, and social growth in every person.[1] Discussions to open a baccalaureate nursing program at the College began in the early 1940s against the backdrop of a nation at war.[2] The baccalaureate program opened in 1949, at a time when hospital-based technical education was the norm for preparing registered nurses.

The model for education in nursing at Goshen College within the theological context of the peace church was visionary in terms of the ethos of Christian service, and corresponded to a call for a broader context of holistic nursing practice that connected the natural and social sciences.[3] Building on the foundation of the historic peace church as well as a holistic model of nursing care, it was fitting that a health care ethics course be introduced into the nursing curriculum. Professor Anne Hershberger was instrumental in insuring that the content of this course, added to the curriculum in 1990 and cross-listed in Bible and Religion, was informed by an understanding of ethics grounded within a Mennonite worldview. She had dedicated her scholarship in nursing to the study of ethics in health care.

In its earliest form, the ethics course recognized that advances in medical science and engineering required a reasoned approach to bioethics, one that questioned society’s growing love affair with technology, drawing instead from peace church perspectives on stewardship and mutual care in the community context by building on the work of Goshen College campus physician Willard Krabill. In the 1980s and ’90s, a time of prolific scholarship and interest in the discipline of bioethics that focused largely upon ethical dilemmas, Krabill advocated for a theological narrative to challenge and inform the nation’s affinity for technology. [4] Noting fundamental shifts from a natural approach to death to a medically managed death, he supported the palliative and hospice movements as an approach to care at the end of life. Citing factors such as the rise in litigation, the secularization of health, and the growing aging population, he called for congregations and communities to discuss stewardship in health care utilization.

Hershberger, a sibling of Krabill’s, had developed her own expertise in health care ethics by participating in studies in Bioethics and Sexuality at New York University and in Bioethics in Family Nursing at the University of California San Francisco, and by spending a sabbatical year at the Kennedy Center for Ethics at Georgetown University. Her distinct contribution was the beginning-of-life perspective with an emphasis on nurturing healthy families.[5] Krabill and Hershberger’s contributions have extended to the broader community, in the development of health care ethics committees at several facilities in Goshen, and the facilitation of discussion of topics related to health care and bioethics at Mennonite gatherings. In addition, the pair have been important writers and speakers on respecting sexuality as integral to the health of one’s whole being. Hershberger’s edited book, Sexuality: God’s Gift, is a comprehensive study offering insight on sensitive topics within a tenor of celebration for God’s creation.[6]

When I began teaching the health care ethics course in 2001 following Hershberger’s retirement, I built upon the foundation that she and Krabill had laid. Over the course of my tenure, the national landscape of ethics has changed, as has the make-up of the course. While technological advancements have not slowed, there is greater acknowledgement of the value of palliative and hospice care. The enactment of the Patient Protection and Affordable Care Act in 2010 also marks a new chapter for health care in the United States.[7] Organizations such as Physicians for a National Health Program[8] are raising an ever more important voice in support of single payer systems in the US. Pressures for deciding how to pay for health care are mounting in Canada as well, against the backdrop of an aging population and rising costs.[9]

Although the looming crisis of the aging population is not new, the current shortage of nursing professionals juxtaposed with the growing population of the aged makes for an increased shortage of resources to care for persons in the last decades of life. The failure of society to acknowledge the limits of health care resources contributes to the impasse in moving reasonable health care policies forward.[10] And while public opinion regarding physician assisted suicide (PAS) has remained relatively unchanged since 2005, with 47 percent of American adults approving of PAS laws, there is an increasing sentiment that physicians should do everything possible to keep patients alive.[11]

The Goshen College health care ethics course is also changing. In 2014-2015, in an effort to extend it to a broader multi-disciplinary cadre of majors, its designation changed from primarily a nursing course to a core curriculum course—more particularly, a course within a block of offerings in the “Peacemaking Perspective.” The goal of perspectives courses is to provide “an interdisciplinary thread that helps students see how knowledge is created and revised in multiple areas of study.”[12] Using high-impact educational practices such as collaborative learning and intensive writing, the course seeks to build skills in active reflection on ethical issues in health care.

Nursing students are required to enroll in this course, but a small number of students from biology, business, social work, psychology, and even physics have joined the roster and lent their voices to the discussions. By and large, biology students comment on the usefulness of the course in preparing for medical school and a career in medicine. One molecular biology student has made this comment:

Even though I took this class just because I needed a peacemaking perspective course, I realized that the course is going to be one of the most critical courses in my professional life on the first day of the class. In fact, I suggested that this course should be required for every pre-health student. At the beginning of the school year when I began reading Being Mortal,[13] I was very passionate about the end of life theme. The book criticizes the modern healthcare system and suggests a solution. It was such a huge intervention for me because I had never learned anything about end of life decisions and the end of life dilemmas that many people go through. The most important thing I have learned from the course is how important our roles as healthcare providers are going to be at the end of a patient’s life. The course has reignited my ambition of becoming a physician and impacting many people’s lives.[14]

Setting the Stage: Course Premises

For the majority of students, this is their first venture into a health care ethics course. Some who take it have had little or no experience in the clinical setting, while others such as fourth-year nursing students have completed at least five clinical courses and have perhaps been employed in some capacity in the health care industry. For many who tell stories of their grandparents’ decisions at the end of life, this is the frame of reference they bring to the course.

Another evolution of the course pertains to the declining enrollment at the College of students from an Anabaptist faith community perspective. At the same time, there is a growing population of Hispanic students, with this group comprising 20-25 percent of the nursing student body. The diversity of both faith and ethnic make-up is a welcome shift, but it demands that assumptions be made clear when students enter the course. Krabill and Hershberger were well rooted in the Mennonite tradition with its themes of stewardship, social justice, community living, and Jesus as model for life. These basic tenets were, and still are, at the foundation of the course. On the first day of class, I provide students with a list of foundational statements and assumptions, giving them an opportunity to add more points to it. These statements and premises include the following:

  • This course will allow us to learn a common language to process ethical problems.
  • We will learn to listen more carefully and more openly to those with opposing views.
  • We will use a variety of literature on ethical issues.
  • We will primarily use a clinical orientation and use, but not get lost in, philosophical reflection.
  • Health and freedom of choice values will be upheld.
  • Bioethical decisions will be made, if not through careful reflection, then by default.
  • Health care resources are limited, so this will temper our decision-making.
  • Death is a part of life’s experience and not an enemy to be avoided at all costs.
  • Society is attracted to sensational medical treatments.
  • Our moral beliefs are related to underlying worldviews.
  • Examples used in the course focus on real life issues of human significance with which students can readily identify.
  • This course’s greatest contribution to participants will be to help them learn how to think about bioethical problems, know what questions to ask, determine what resources to draw on when facing such issues, not to determine “correct” decisions.[15]

Theoretical Perspectives

The major theoretical perspectives or threads central to the course are two-fold. The first theoretical thread explores what it means to be a person created in the image of God. The second thread centers on relationships of shalom and covenant, calling forth questions of how we are to be in relation to one another in community. These threads are interconnected. Mennonite writers emphasize the centrality of Jesus, the transformative experience of grace, the expression of communal relationship with God, and the expression of faith in discipleship as central tenets in understanding the person in moral community.[16] Similarly, Joseph Kotva elucidates Anabaptist theology as the discernment of Scripture within the context of the faith community and the Gospel stories of Christ’s life and teaching. Kotva observes that “the true church is visible through the transformed lives of its members and their commitment to mutual support and accountability.”[17] With this Anabaptist perspective, the emphasis is on moral responsibility within the faith community. The parable of the Good Samaritan is used in class as a representation of genuine caring presence, challenging the status quo, and practicing Christian beneficence.

The American Nurses Association (ANA) Code of Ethics, Provision 1, states that “the nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.” [18] More specifically, respect for dignity affords protection of persons, such as protection from harm in the course of receiving medical care or participating in research. Also embedded in respect for dignity is the Judeo-Christian concept of the imago dei (the person is made in the image of God).[19] Exploration of what it means to be person is part of the moral education important for students in Christian liberal arts colleges. Students in the Goshen course may experience transformation as they explore, ponder, and dialogue in such a way that the theme of personhood will be meaningful for them in their professional lives.

Course Outline and Methodologies

In the transition of the health care ethics course from a disciplinary offering to a peacemaking perspectives offering, I have sought out meaningful methodologies to connect peacemaking, ethics, and the Anabaptist faith perspective. It is important to me that the foundational elements include philosophical underpinnings, major theories and principles of ethics, and major tenets of the Mennonite faith tradition (discipleship, truth, stewardship, and peace).[20] Building on these components, the broad content categories include: 1) major schools of thought, theories, and principles; 2) ethics in professional relationships; 3) the nature of personhood; 4) ethics considerations across the life span; and 5) the health care delivery system, including allocation of resources. Key assignments flow from the course objectives. Table 1 presents several representative objectives aligned with the assignments and specific questions.

Table 1. Health Care Ethics: Course Objectives, Assignments, and Examples
Given a case study presenting conflicting moral choices, describe the ways in which ethical theories, principles, and decision-making models facilitate thinking about the case in constructive ways. Response Paper Given a case study, describe how the case would be addressed from deontologic and teleologic perspectives.
Using a variety of resources from the ethics literature, critically analyze arguments related to conflicting moral choices in health care. Final integration paper Integration paper that asks the question “What is the interconnection of distributive justice and the ethical practice of peacemaking?” or “How does the code of ethics of your chosen profession inform views and practice of honoring the personhood of others?”
Using a variety of resources from the ethics literature, critically analyze arguments related to conflicting moral choices in health care. Decision-making model application assignment Given a case study, apply a given decision-making model as an approach to addressing the dilemma.
Describe selected ethical problems/dilemmas present in contemporary healthcare practice. Point Counterpoint Student Presentation

Sample questions for debate:

Should truth-telling depend on the patient’s culture?

Should prisoners be allowed to participate in research?

Should public health override powers over individual liberty in combating bioterrorism? (Levine, 2010)[21]

The Nature of Morality: Introduction to Ethics

Meaning is developed when students learn to listen to the varying perspectives of class members. In one model exercise, they are asked to indicate on a continuum how much they agree or disagree with the statement, “Watermelon should only be eaten in the summertime.” This non-threatening first question forges discussion as to the merits of seasonal watermelon consumption versus random consumption. Students are then asked to think about where they would place themselves on a continuum representing their agreement or disagreement with the statement, “There are some things that are simply and absolutely right or wrong.” As they articulate their own positions, they identify their beliefs and values, and explore constructs of moral relativism, metaethics, ethical objectivism, and moral responsibility.

Moral certainty is tested in the video, “What’s the Right Thing to Do?”[22] In this video, Harvard professor Michael Sandel models a framework for moral discourse, using the classic case of a trolley car careening out of control. The trolley car driver must decide if he will continue forward and kill five people standing on the main track, or pull a lever, switch the track, and kill one person on a secondary track. Students in the video as well as those in my classroom engage in active debate on the moral choice. From the first day of class, students recognize that their current moral frameworks may be insufficient for addressing the complex dilemmas in health care. One student stated it this way: “I thought I knew myself and my moral frame, but my classmates and I just can’t stop talking about class last week. The first class session makes my head swim because I am challenged to think about my own thinking.” The Sandel video and student engagement in the chaos of unknowing is a natural prelude to an introduction to the ethics theories (beginning with deontology and teleology) and principles. These theories and principles are themes to which we return in every session.

At first blush, the principles of ethics appear to be without controversy. For example, the merits of such principles as beneficence and non-maleficence are dispositional for health care providers. However, using Beauchamp and Childress’s model, we begin to dissect beneficence, engaging in questions of “obligatory” versus “ideal” beneficence.[23] In this model, health care providers are obligated to render action when such action can prevent harm without significant risks and burdens to the provider, and the benefits are expected to outweigh burdens.[24] Peter Singer, contrastingly, advocates for an altruistic ideal beneficence, a type of beneficence that not only prevents harm but promotes good. He sets a relatively high standard for beneficence, drawing attention to issues of global poverty and society’s obligation to respond in positive ways.[25]

Rosemarie Parse is a nursing theorist steeped in the phenomenological tradition. In essence, her theory is “grounded in the view of the human as unitary (different from the sum of parts) and focuses on optimal well-being and quality of life.”[26] This view contrasts with predominant views in medicine and nursing that see the human as a “mechanistic bio-psycho-social-spiritual being.”[27] Health, according to Parse, is an ongoing process of becoming, composed of the lived experiences of humans engaged in shifting perspectives woven through the fabric of life. Although I don’t review Parse’s theory in class, for me it is a paradigm that beckons ethical perspectives to reach beyond the historically rooted theories of teleology and deontology. In a postmodern society, students quite naturally engage in the phenomenological, seeking an understanding of the patient’s story as central to patient care.

A more holistic view of the person, offered through a narrative theoretical perspective, points to the connectedness of life and the patterns of human becoming in what Parse calls the emergence occurring in “genuine human presence.”[28] I am personally curious about the notion of genuine human presence, and I want students to ponder this construct. Given the traditional patriarchal mores in health care practice, I contemplate how to move students from a mechanistic model to a view of health care provider and patient in genuine presence and mutuality. It is my desire that they commit to the centrality of authentic relationships, and to the sacredness of what Martin Buber calls the “I-Thou,” not the “I-It,” of human relations.[29]

If the sacredness of authentic relationship is normative in health care, what role does developing virtuous character play? To explore this question, I ask students to reflect on the nature of a person who for them represents virtuous character, with the emphasis on virtues as not so much something we do but as characteristics of who we are. W.F. May’s description of the covenant relationship of physician and patient as a sacred consecrated bond between healer and person, noting that genuine relationship requires active engagement, ties in well here.[30] Being a person of virtue requires nurture of one’s character, self-examination, and personal discipline.

Ethics in Professional Relationships

In an increasingly economically stressed health care system risking dehumanization, the ethics of professional relationships must consider the concepts of role fidelity, paternalism, self-determination, and veracity. Numerous case examples demonstrate the conflict between beneficence, paternalism, and role fidelity on the one side, and self-determination and autonomy on the other. In a classic video, Does Dr. Know Best?, prominent figures such as US Surgeon General C. Everett Koop and psychiatrist Willard Gaylin of the Hastings Center engage in a case study of a young woman with cervical cancer who defies recommended treatment modalities.[31] Issues of paternalism, privacy, and self-determination emerge as the case gains in complexity over the course of the video. Inevitably, the student dialogue turns to the language of patient rights versus physician rights. While paternalism is passé in the 21st century, students appreciate the dilemma of preserving the provider’s autonomous rights while simultaneously preserving the provider’s overarching duty to honor the patient’s right to self-determination.

When class discussion begins to meander to the theme of rights, I ask students to take caution. An appeal to one’s rights sometimes makes demands in unhealthful ways. Rather, the expression of moral behavior should manifest itself in our caring for God’s handiwork with gentleness, stewardship, respect, and holistic living.[32] Therefore, addressing moral questions from the perspective of whose rights prevail is limiting, and disengages the discussion from the tenet that we belong to God and are established in community with God from whom we receive life and sustenance.[33]

Given the theme of communal relationship, one student has reflected that “It seems that we are focusing a lot of attention in our society on paternalism versus self-determination and this is troubling to me. I think the focus of the discussion needs to be broader to discuss moral relationships in the context of the broader society.” To this end, I ask students in a written reflection assignment to examine the limitations of individualism as a trump card in ethical decision-making. They reference codes of ethics for their respective professions, for example the right to self-determination articulated in the ANA Code of Ethics, Provision I.[34] But the reflection also calls on them to view the person within the context of the broader moral community with attention to the principles of justice. They are asked to hold in tension these two competing commitments: honoring patient autonomy and promoting broader justice.

Holding this tension in place, we turn our attention to issues such as organ procurement. Steen Jensen illustrates this well in the video Organs for Sale, examining the need and desire of wealthy individuals against the encroachment on, and violation of, persons in poor communities in countries where organs can be bought and sold.[35] Students have mixed responses to this video. Some see no harm in a man from a wealthy country purchasing a kidney from a tenant farmer in an impoverished one. Others see deeper injustices at work that create untenable situations in which persons caught in economic desperation go to great lengths (or take great risks), such as selling kidneys in order to preserve family survival.

Ethicists M.C. Brannigan and J.A. Boss state that we often make cultural definitions of morality based on a desire to maintain the status quo, depersonalizing beings in order to obtain some utilitarian good.[36] Students begin to understand that if we desire the greater good and commit ourselves to work for justice for those oppressed, there may be limits to resource allocation in health care. Others agree that there are such limits.[37] Contrary to the growing view that physicians should employ ever-expanding technology to keep people alive, recognition of the sanctity of life should prevent an ultimate trespass upon the person by extensive use of technological resources in cases of medical futility.[38] Christian authors such as Bouma et al. recognize there are limits such that “health and life of the body are goods that we may and must seek, but they are not the greatest good, and they may need to be risked and sacrificed in the pursuit of other goods.”[39]

The Nature of Personhood

In terms of our response of beneficence to others, I wonder what it is that students must grasp about “being.” Presenting them with a bowl of apples, I ask them to identify the necessary and sufficient conditions of an apple. Typical and expected answers include the fruit’s taste, shape, crunchiness, and color—all attributes and characteristics that could also describe other fruits. At some point, a wise student will finally proclaim the genetic structure as the necessary and sufficient condition. The follow-up question becomes What are the necessary and sufficient conditions of personhood? I then introduce counter-posing definitions of personhood, comparing the writings of Joseph Fletcher[40] with those of Bouma et al.

Fletcher’s seminal work sets a high bar for defining the person as a specific subset of humanity, framing the necessary and sufficient conditions of personhood as minimum intelligence, self-awareness, a sense of time, concern for others, curiosity, control of existence, and ability to communicate. (This is a summary of his total list.) In contrast, Bouma and his co-authors set forth personhood as being created by God, in the image and likeness of God, and caring for persons from the moment of conception, at which time humans are intentionally designed with a special moral status as God’s creation. Whereas Fletcher’s definition implies that those falling outside a specific set of criteria are somewhat less deserving of health care resources, Bouma et al. honor the sanctity of life perspective.

In small groups, students are given cards on which are written each of Fletcher’s characteristics constituting the human profile. I ask them to rank the cards from the most to the least important. In almost every case, self-awareness and neo-cortical function rise to the top of the list. Using the Socratic method to delve into deeper levels of thought, I help students to see that many people could possibly fall outside of the community of persons based on their categorizations: undocumented immigrants, children with trisomy 21 (Down’s Syndrome), or fetuses who have the potential for characteristics of personhood. Fundamentally, how we make decisions about belonging in the club called personhood will continue to shape health care priorities and care responses.

Fletcher’s criteria present a fragmented view, as if one can somehow disentangle the various elements of human existence in order to justify withholding resources from an individual without a proper claim to personhood. The nuances of neurological and physiological functioning that place a human inside or outside the club can lead to serious consequences. Such segregation propagates the language of individual rights, and perpetuates prejudices leading to racism, sexism, and ageism. History is rife with examples of outcomes of limitations placed on personhood, such as the Nazi war crimes of Josef Mengele’s experiments on twins, the gross negligence and disregard for human dignity represented in the Tuskegee trials, and the misinterpretation of utilitarian ideals in the case of early gene therapy research for the 18-year-old Jesse Gelsinger.[41] In the end, the conceptual theme of personhood lends itself to looking outside the individual perspective to a global perspective, thinking about how members of moral communities are moved to the fringes in systematic ways based on race, gender, ethnicity, and socioeconomics. The personhood theme provides a thought-provoking base around which questions of faith, virtue, morality, and professional responsibility can be examined.

Interconnections of faith, virtue, and personhood are evident in responses to an assignment that connects to the students’ affective mode of learning. Upon entering the classroom, they find tables laid out with photos taken from National Geographic.[42] Without knowing the nature of the assignment, they choose a photo that in some way creates an emotional affinity for them. They discuss it with classmates, and make a conjecture as to why it created a personal connection for them. They are then asked to write a short essay answering the question, “What does the photo say to you about personhood?” Some responses typically discuss racial discrimination and denial of health care resources to those refused status as persons, some describe the lack of claim to personhood on the part of refugees experiencing war-zone trauma, and others depict family members consoling one another as they donate the organs and tissues of a dying child.

As well, some responses discuss unfair distribution of resources as a key component for denying personhood, racial discrimination as a failure to recognize the intrinsic worth of, and the importance of understanding the historical narrative of, each person. For this assignment, one student selected a famous photo taken by Steve McCurry on assignment in a crowded Afghan refugee camp in Pakistan. This photo, known almost universally as “The Afghan Girl,” first appeared on a National Geographic cover in 1985. The student, reflecting on the photo and the theme of personhood, wrote:

It is almost hard for me to imagine a life like hers and mine existing in the same plane of time and space, but it does. We are, after all, both people here on Earth. We both have families who we love. We have goals and needs and desires. But how is it that others respect my needs for safety, love, and education, but not hers? Does someone’s value as a human rely solely on other people’s perception of that value? I would like to say no. If you had asked me just three weeks ago how I defined personhood, I would have mumbled something about consciousness and relationships with others. But there are devil’s advocates with tricky follow-up questions. What about those who are comatose, or have severe handicaps? I think I must now revise my definition of personhood to this: the presence of a spirit or a soul. The first provision of the nursing code of ethics talks about “compassion and respect for the inherent dignity, worth, and unique attributes of every person.”[43] So regardless of whether I live in North America with a National Geographic subscription and loving brothers, or in a refugee camp in rural Pakistan with no family at all but the people who hide from the bombers with me, the respect and care I deserve is the same. Though we claim to work for justice, life remains vastly unfair. Isn’t it interesting that so much of what shapes our personhood—our thoughts, relationships, even eyes—lies in the hands of others?[44]

As noted earlier, exploring what it means to be a person is an important part of the moral education for those attending a Christian liberal arts college. Students may experience personal and professional transformation as they engage with the theme of personhood.

Ethics Across the Lifespan

Ethical theory, ethical principles, and the meaning of personhood are applied in the course to topics representative of health experience across the lifespan. For example, questions at the beginning of life include those of eugenics, prenatal genetic testing, and abortion. Ethical issues in childhood and adolescence include mandatory immunization, including immunizations for human papilloma virus. The themes of ethics at the end of life take considerable time and attention. Sentinel cases in modern media dramatize the issues. The Terri Schiavo case dramatizes the debate for decision-making rights at the end of life. This case, beginning with Schiavo’s massive brain injury resulting from cardiac arrest in 1990 and ending with her death in 2015, was wrought with bitter entanglements between husband and parents on the extent of end-of-life care, decision-making authority, and questions about the fundamental nature of the human person.[45] This case reveals that polarization among the public regarding sanctity of life, the right to die, and decision-making rights is counterproductive, and only serves to further trivialize the person. In Schiavo’s case, the communal experience of transformational grace was sadly lacking.

The values of communal relationship and stewardship, not of individual rights, is affirmed by Daniel Callahan, who explores the intensive use of technology at the end of the natural course of one’s life. Callahan advocates for the “taming” of death and the nurturing of societal values that negate the predominant narcissism in our society. As persons face the end of life, “narcissism struggles with altruism; the insistent clamor of desires and wants wrestles with the claims of morality.[46] To tame death, says Callahan, society must return to the circle of family, friends, and children as a supportive group for dialogue when facing end-of-life decisions. When seemingly insurmountable conflicts arise, the responsive health team will facilitate navigation to peaceful resolution.

In the final class assignment students engage in reflective discourse on the foundational themes. In writing about end-of-life decisions and roles of health care providers, a biology student has observed that:

When a patient faces the end of their life due to age or terminal illness, the doctor and the patient discuss the diagnosis and prognosis—an extremely difficult conversation for both parties. Nevertheless, the beauty of being a healthcare provider is having the ability to build relationships with patients and to affect their lives in positive ways. Healthcare providers play a significant role in enhancing the quality during the final days of terminally ill patients. In order to accomplish the role, they should be interpretive rather than paternalistic in order to guide patients to make appropriate end of life decisions and provide palliative care instead of curative care to enable patients to live a normal life with their loved ones.[47]

Witnessing the transformation of students throughout the course is extremely satisfying. In the last class session, I scatter mustard seeds on the desks and read the parable of the mustard seed. As students continue the process of developing virtue and moral character, they can be the mustard seed, growing to great heights and providing shade for the weary.


My approach to teaching ethics bears in mind that ethical decision-making requires affective as well as cognitive involvement.[48] Whereas all theoretical perspectives provide insight into moral dilemmas, the perspective of personal narrative seems most in keeping with understanding the relational aspect of personhood within created humanity. This approach reminds us that we are not disconnected bits and pieces but part of a larger pattern, a human narrative that gives purpose to our lives.[49] The discussion of themes through case studies, open dialogue, and faith exploration helps us remember that sharing in the suffering and burdens of others is central to our communal relation with God.[50] As Anne Hershberger reminds us, “Ethical issues and matters of character pervade all areas of life and thought; therefore, it behooves educators to help students recognize ethical issues and the ramifications of their decisions for themselves and for those with whom one interacts in society.”[51]

Finally, as I reflect on the convergence of factors that led to the current course design, the launching of the nursing program at Goshen College after World War II, the initiation of a health care ethics class in the 1990s, and the evolution of this class into a core curriculum peacemaking perspectives offering, I am awed by the interconnectedness and relevance of it all. Basing health care ethics education on the foundational theoretical perspectives of the person in the image of God, and in relation to shalom in community, remains both a vision to uphold and the subject matter for important dialogue. As students emerge from the health care ethics course, may they continue to grow—and sow seeds of virtue and healthful living.

Brenda Srof is Professor and Chair of Nursing at Goshen College in Goshen, Indiana.


[1] Goshen College, Undergraduate Course Catalog, 2016-2017.

[2] Vicky Kirkton, “Senior Nurse’s Pinning Ceremony Address,” Goshen College Bulletin, September 2013, 3.

[3] M. Patricia Donahue, Nursing: The Finest Art, 2nd ed. (St. Louis: Mosby, 1996).

[4] Willard Krabill, “Death and Dying: Prevailing Medical Perspectives,” in Medical Ethics, Human Choices: A Christian Perspective, ed. John Rogers (Scottdale, PA: Herald Press, 1984).

[5] 5Anne K. Hershberger, “Premature Parenthood: Is it Possible to Prevent Teen Pregnancy?” Mennonite Medical Messenger 44, no. 3 (1993): 40-42; Anne K. Hershberger, “Recognizing Ethical Issues,” in Ethics and the Educated Person: A Teaching-Learning Resource, ed. Anne K. Hershberger (Goshen, IN: Goshen College, 1993).

[6] Anne K. Hershberger, Sexuality: God’s Gift, 2nd ed. (Scottdale, PA: Herald Press, 1999).

[7] Patient Protection and Affordable Care Act, 42 U.S.C.§ 18001 (2010).

[8] This organization’s website is www.pnhp.org.

[9] Susan Lunn, “Ottawa Favours Targeted Health-care Spending over Increased Transfer to Provinces,” CBC News, June 23, 2016, www.cbc.ca/news/politics/philpott-health-accord-1.3649864, accessed Nov. 2, 2016. Shanifa Nasser, “Ontario Budget 2016: Mixed Reaction From Health-care, Student Groups,” CBC News, February 25, 2016, www.cbc.ca/ news/canada/toronto/ontario-2016-budget-reaction-students-hospitals-1.3464871, accessed November 2, 2016.

[10] Daniel Callahan, The Troubled Dream of Life (New York: Simon & Schuster, 1993).

[11] See Michael Lipka, “Americans of all Ages Divided Over Doctor-assisted Suicide Laws,” Pew Research Center, 2014, www.pewresearch.org/fact-tank/2014/10/22/americans-of-all-ages-divided-over-doctor-assisted-suicide-laws/, accessed November 2, 2016; and Pew Research Center, “Views on End-of-life Medical Treatments: Growing Minority of Americans Say Doctors Should do Everything Possible to Keep Patients Alive,” www.pewforum. org/2013/11/21/views- on-end-of-life-medical-treatments/2013, November 21, 2013, accessed November 2, 2016.

[12] “The Goshen Core,” www.goshen.edu/core/, accessed November 2, 2016.

[13] Atul Gawande, Being Mortal: Medicine and What Matters in the End (New York: Metropolitan Books, 2014).

[14] Tae Gyung Hwang, a senior year biology major at the time of this writing (2016), is currently enrolled at the University of Michigan School of Dentistry. Used with permission.

[15] Hershberger, “Recognizing Ethical Issues,” 62.

[16] Roman J. Miller, “Viewing Bioethics Through Anabaptist Eyes,” in Viewing New Creations with Anabaptist Eyes: Ethics of Biotechnology, ed. Roman J. Miller, Beryl H. Brubaker, and James C. Peterson (Telford, PA: Cascadia Publishing, 2005), 87-88.

[17] Joseph J. Kotva, Jr., The Anabaptist Tradition: Religious Beliefs and Healthcare Decisions (Park Ridge, IL: Park Ridge Center for the Study of Health, Faith, and Ethics, 2002), 2.

[18] American Nurses Association, Guide to the Code of Ethics for Nurses with Interpretive Statements, 2nd ed. (Silver Spring, MD: American Nurses Association, 2015), 1.

[19] American Nurses Association, Guide to the Code, 8.

[20] General Conference Mennonite Church; Mennonite Church USA, Confession of Faith in a Mennonite Perspective (Scottdale, PA: Herald Press, 1995).

[21] Carol Levine, Taking Sides: Clashing Views on Bioethical Issues, 13th ed. (Boston: McGraw Hill, 2010).

[22] Michael Sandel, “What’s the Right Thing to Do? Justice with Michael Sandel,” TED video, filmed September 2005; www.ted.com/talks/michael_sandel_what_s_the_right_thing_to_ do, accessed November 2, 2016.

[23] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 7th ed. (New York: Oxford Univ. Press, 2013).

[24] Ibid., 207.

[25] Peter Singer, “The Why and How of Effective Altruism,” TED video, filmed March 2013; www.ted.com/talks/peter_singer_the_why_and_how_of_effective_altruism?language=en, accessed November 2, 2016.

[26] Rosemarie R. Parse, The Human Becoming School of Thought (Thousand Oaks, CA: Sage, 1998), 6.

[27] Ibid., 6.

[28] Ibid.

[29] Martin Buber, I and Thou (New York: Simon & Schuster, 1971).

[30] W.F. May, “Code, Covenant, or Philanthropy,” The Hastings Center Report 5, no. 5 (1975): 29-38.

[31] Ethics in America, “Does Doctor Know Best?” YouTube video from Columbia University Seminars on Media and Society (1989), www.youtube.com/watch?v=1godZGrAq00, accessed November 2, 2016.

[32] Miller, “Viewing Bioethics,” 94.

[33] Gilbert Meilaender, Bioethics: A Primer for Christians (Grand Rapids, MI: Eerdmans, 2005).

[34] Code of Ethics, Provision I., 15.

[35] “Organs for Sale,” video, dir. Steen Jensen (New York: Filmakers Library, 2004).

[36] M.C. Brannigan and J.A. Boss, Healthcare Ethics in a Diverse Society (Mountain View, CA: Mayfield Publishing, 2001), 15.

[37] See Hessel Bouma III, Douglas Diekema, Edward Langerak, Theodore Rottman, and Allen Verhey, Christian Faith, Health, and Medical Practice (Grand Rapids, MI: Eerdmans, 1989); Paul Ramsey, The Patient as Person (New Haven, CT: Yale Univ. Press, 1979).

[38] Ramsey, The Patient as Person, xiii.

[39] Bouma et al., Christian Faith, 44.

[40] Joseph Fletcher, Humanhood: Essays in Biomedical Ethics (Buffalo, NY: Prometheus Books, 1979).

[41] Jesse Gelsinger suffered from an X-linked genetic disease, ornithine transcarbamylase deficiency. His death in 1999 is marked as the first death directly related to gene therapy. See “The Biotech Death of Jesse Gelsinger,” New York Times, November 28, 1999, www.nytimes. com/1999/11/28/magazine/the-biotech-death-of-jesse-gelsinger.html, accessed November 2, 2016. See also Gregory E. Pence, Medical Ethics: Accounts of the Cases that Shaped and Define Medical Ethics (Boston: McGraw-Hill, 2008).

[42] Leah Bendavid-Val, National Geographic: The Photographs (Washington, DC: National Geographic, 2008).

[43] Code of Ethics, Provision I, 1.

[44] Anna Cullar, a junior nursing major at the time of this writing (2016), continues as a student at Goshen College. Used with permission.

[45] Terri Schiavo: The Right to Die, e-book, www.nytimes.com/store/terri-schiavo-the-right-to-die-tb074.html (New York: New York Times Company, 2013), accessed November 2, 2016.

[46] Callahan, The Troubled Dream of Life, 25.

[47] Tae Gyung Hwang, a senior year biology major at the time of this writing (2016), is currently enrolled at the University of Michigan School of Dentistry. Used with permission.

[48] Arthur F. Holmes, Shaping Character: Moral Education in the Christian College (Grand Rapids, MI: Eerdmans, 1991), 55-56.

[49] Stanley Hauerwas, God, Medicine, and Suffering (Grand Rapids, MI: Eerdmans, 1990).

[50] Meilaender, Bioethics, 2.

[51] Hershberger, “Recognizing Ethical Issues,” 23.