Review of Gilbert Meilaender's Bioethics: A Primer for Christians
 When they enter the field of bioethics, too many theological ethicists check their theological credentials at the door. Thus, they lose theological eloquence, as they learn medical-ese. Not so with Valparaiso University's Gilbert Meilaender: he never loses fluency in that first language of faith. Not every Christian will agree with his conclusions on abortion or stem cell research, but those who differ find their arguments sharpened by wrestling with a most worthy opponent.
 A little less than ten years ago, Meilaender published the first edition of Bioethics - to critical acclaim. At the time, World magazine ranked it one of the top 100 books in the twentieth century. This year Eerdmans published a second edition of basically the same book. Meilaender identifies four substantive changes; (1) data updates; (2) a hardening in the stand against abortion, for both "empirical and 'metaphysical'" reasons; (3) revision of the chapter on organ donation; and (4) attention to the issue of research on embryos, a clear nod to the controversy on stem cell research. Quick comparison with the first edition reveals these changes to be relatively minor, testimony to the book's durable insights, the ongoing witness of the Christian faith -- and the continuing neuralgia of certain issues in bioethics.
 Beginning- and end-of-life issues, medical decision-making, organ donation, and human experimentation continue to vex us. The medicine may change, but the moral issues remain. Ought we do everything we can do for a terminally ill patient? When does medical technology allow us to prolong life - or merely prolong the process of dying? How much truth does a patient need or want or deserve? Who decides the medical fate of children, the embryo fertilized for IVF or already implanted in a woman who seeks an abortion, those who are mentally unable to state their wishes? Finally, how are we as Christians to respond?
 In analyzing Meilaender's responses to these enduring questions, I want briefly to comment on his method, both what he says he is doing - and what he actually does. Then I want to reframe an issue that is at the heart of my disagreement with Meilaender on reproductive health issues, shifting his "focus on the family" from the biological family to the family of the baptized. Finally, I raise two issues in twenty-first century medicine that Christians should be worried about. My critical remarks must be seen against the background of admiration for Meilaender's broad medical knowledge and keen theological insight.
 First, in terms of moral method, bioethics has pursued two paths, both of which Meilaender rightly rejects, one explicitly - the other implicitly. Meilaender moves away from an approach to bioethics that emphasizes "rights." Acknowledging that such language has an important place in emphasizing the just claims of often-ignored others, he nonetheless finds rights-language a "thin" expression of rich Christian convictions: it feeds an illusion of autonomy. Instead, Meilaender describes the "mutual burdening and unburdening" that marks Christian community. Exploring the rationale for advance directives, he considers an often-cited advantage: advance directives relieve loved ones of the "burden" of decision-making. Meilaender demurs: "to burden one another is, in large measure, what it means to belong to a family - and to the new family into which we are brought in baptism" (82). The mutuality of those who bear one another's burdens far exceeds the stiff reciprocity articulated by a language of rights and responsibilities - and rights-language never spelled out as clearly attendant responsibilities on caregivers and health professionals. Refusing the well-traveled path of patients-rights, Meilaender directs his readers to a richer, more nuanced vision of Christian community.
 I want to underscore another methodological move that Meilaender makes - but only implicitly. He says he works within a deontological ethic, i.e., an ethic offering rules and principles that limit the goals that might otherwise drive medical research and care (5). In their classic Principles of Biomedical Ethics, Beauchamp and Childress propose a deontological corrective to the utilitarian calculus that has governed much of health care (Tom L. Beauchamp and James F. Childress (eds), Principles of Biomedical Ethics, 5th Ed., New York: Oxford University Press, 2001). Principles like respect for autonomy, nonmaleficence, beneficence, and justice orient their approach to bioethics, an approach Meilaender says he favors.
 But is this what the book does? I find Meilaender's project less organized by rules and principles than character and questions about "what sort of people we wish to be and ought to be" (23). Accordingly, Meilaender emphasizes throughout the qualities or virtues that describe Christian communities: gratitude (15), truthfulness (72 ), humility (45), hospitality (81), interdependence (80), hope (123). He names the corresponding vices: independence, self-sufficiency, deception, idolatry, possessiveness or greed, etc. Meilaender sketches all of these character traits against the background of a "Christian vision of life" which believes that death is not the last word.
 Certainly the deontology and virtue ethics are not agonistic approaches in ethics. Even later editions of Beachamp and Childress's classic text identify virtues corresponding to their organizing principles: e.g., respectfulness as the virtue corresponding to the principle of respect for autonomy, nonmalevolence as the virtue for nonmaleficence, benevolence as the virtue for beneficence, etc. (Cf. Rosalind Hursthouse, On Virtue Ethics, New York: Oxford University Press, 1999, p. 41ff.). Character or virtue ethics gives the richer account of the Christian life that Meilaender seeks, because it attends to questions of formation and discernment. Rules and principles alert us to what is morally salient in any given situation, but we consider context and we respect persons in applying them. Meilaender himself recognizes this, valuing someone who struggles to be "in the truth," as he puts it (74) over someone who rigidly resolves to tell the "truth, the whole truth, and nothing but the truth." From William F. May, he borrows a telling illustration: a man who knew he had terminal cancer wanted his son, an acknowledged expert on death and dying, to "go easy" on him. He did not want the "whole truth and nothing but the truth" about his condition; he wanted an appropriate truth - and he wanted it delivered with love. I hope there is a third edition of this fine book - and I wish it would embrace boldly the character ethics at its heart, for I think Meilaender adds an important complement to a principalism that dominates bioethics at the moment.
 Second, I want to reframe an issue that is the heart of my disagreement with Meilaender on reproductive health, in specific, abortion, adoption, and IVF. With Meilaender I agree that Christians should focus on the family - the question is which family? Without wishing to diminish its importance, I would hold the family of brothers and sisters in Christ more dear than the biological created by marriage and childbearing. Baptism inducts children into this new family, and the name given there overrides ties of blood, paternity, or maternity. "Child of God" signals a new belonging in a new community. Christians have yet to take their child-rearing responsibilities in this arena as seriously as they should - or as seriously as their first and second century forefathers and foremothers did. Then, becoming a Christian cut people off from their biological families. As they embraced the Christianity, people were disowned and disinherited by their families of origin, and so they turned to their new family of brothers and sisters in Christ for spiritual, but also physical support.
 In his chapters on medical decision-making and end-of-life issues and in his illuminating discussions of "mutual burdening and unburdening," Meilaender focuses on the family of the baptized as the primary family unit for Christians. Yet, when he turns to issues of reproductive health, Meilaender accords primacy to the biological family, the sacrality of the mother-child bond, and the image of the Trinity reflected in the nuclear family. Abortion registers as a violation on all counts: it rips apart families, destroys the mother-child bond, and shatters the imago trinitatis embedded in the foundational family unit. Meilaender's stand against abortion has only hardened since the first edition. Yet, if he were to retain the primacy of the family of the baptized in his chapters of reproductive health, Meilaender might come to a different stand on abortion. Judgment would shift from the women seeking abortion to a society that undervalues and financially burdens its weakest members. Censure would fall on a church that too often shuns out-of-wedlock mothers, treats shabbily the children in its midst, and fails to offer material support to the family of brothers and sisters in Christ.
 I have often argued that the proper Christian "focus on the family" should be on the family of the baptized. Christians should shun the practice of abortion, adopting all "unwanted" children as their own. Until our churches can practice that kind of hospitality, abortion exists as a judgment upon us: we are not the kind of people we are called to be. Until the church can truly be the family of the baptized, welcoming strangers into its midst, abortion should be "safe, legal - and rare."
 Meilaender carries this focus on the biological family into his discussion of adoption. While acknowledging the spirit of generosity in the act of adoption, he raises questions. Adoption blurs lines of biological kinship and results in a child "who cannot (biologically) embody the union of his adoptive parents" (16). Meilaender finally finds adoption "an emergency measure, aimed chiefly at caring for children whose biological parents have not, cannot, or will not care for them" (18). Someone with a focus on the baptized, rather than the biological family might judge adoption differently. If the apostle Paul is right that we all "wait for adoption" (Rom. 8:23) as children of God, then Christians should love with abandon even and especially children who do not bear our DNA. We should manifest that love spiritually, but also materially, opening our homes to those in need.
 The primacy of the biological family over the baptized family leads to a certain ambivalence on the very knotty areas of IVF and stem cell research. Part of the dis-ease surrounding stem cell research it that utilizes frozen but fertilized embryos "left over" from IVF. Lots of ethicists focus on the question of whether to use for research purposes fertilized embryos with the potential to develop into human beings. We have paid less attention to the procedures that gave us these fertilized embryos in the first place. IVF produces more fertilized embryos than needed, creating the "left over" embryos in demand by stem cell researchers. Moreover, IVF implants more of these embryos in the mother's womb, eliminating those that are not "needed." These aspects of IVF seem clearly abortifacient, yet they never seem to register as such with "pro-life" moralists. Again, Meilaender places constraints on IVF and assisted reproduction. But the primacy of the biological family combines with a warning against adoption to create a questionable openness to reproductive technologies that assist parents in having their own genetically marked children.
 Finally - and all too briefly, twenty-first century Christians should be talking about two issues that surface only briefly in this book: health care costs and health care access. The kind of moral decision-making Meilaender envisions presumes insurance plans and employers who support them, both of which are vanishing breeds among today's workforce. Too many people have health care decisions made for them, by virtue of carrying no health insurance or having inadequate coverage from the insurance they do carry. IVF is a moral dilemma only for those wealthy enough to afford the costly procedures of harvesting, fertilizing, and storing eggs. And the fruits of stem cell research (at this point highly overpromised) will be available only for those with the money to purchase them. Meilaender's evocative section on "Who Decides?" could have been complemented by an equally haunting chapter entitled "What Decides?" For better and for worse, money will resolve too many of the dilemmas, and it probably won't be worried about the ethics involved.
 I urge Christians of all stripes to read and wrestle with this honest and insightful book. I encourage them to respond with the theological integrity Meilaender presents, especially where they disagree. Such a conversation would lead to the very best kind of theological health.
© November 2005
Journal of Lutheran Ethics
Volume 5, Issue 11