MARTIN E. MARTY
RELIGION, THEOLOGY, CHURCH, AND BIOETHICS
ABSTRACT. Modem medical ethics developed in America after mid-century chiefly at theological schools, but discourse on bioethics soon moved to the pluralist-secular settings of the academy and the clinic, where it acquired a philosophical and intentionally non-religious cast. An effort was made, on the grounds of liberal culture' and late Enlightenment rationality' to find a framework for inquiry which aspired to the universal. Today, while that language persists, it coexists with, challenges, and is challenged by forms of ethical analysis and advocacy which take into consideration the 'thickness' of complicating narrative and reasoning based in the many religious traditions. It has become incumbent upon advocates of those traditions to propose 'publicly accessible' argument. Key Words: bioethics, church, religion, theology THE PREVALENCE OF ACADEMIC PHILOSOPHY IN BIOETHICS
To frame the present inquiry, it is necessary to state what is unnecessary to document elaborately, that academic philosophers have prevailed over their contemporaries and colleagues, the theologians, in the development of bioethics. This is abundantly evident to anyone who compares the number of clinical, academic, and governmental agencies, departments, or impetuses dealing with medicine and ethics which either ignore or exclude formal religion, theology, or the concerns of the church, with those which include them. The reasons for the hegemony of non-religious and sometimes anti-theological language in bioethics are also evident. The most obvious element in the context is the pluralistic character of American society. The first question that has to be asked when theologians speak is particular which believing community among many produced the language they represent? There are too many communities and thus too many universes of discourse to be Martin E. Marty, Ph.D., The Divinity School, Sxvift Hall, University of Chicago, Chicago, IL 60637, USA. The Journal of Medicine and Philosophy 17:273-289,1992. © 1992 Kluiver Academic Publishers. Printed in the Netherlands.
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reckoned with or to be accepted as authoritative. So it is efficient and perhaps prudent to ignore them all. To this pluralism one must add the reality of secularization, however defined. The society, for instance by legally 'separating church and state' and through many other conscious and unconscious decisions, has made clear to itself that no particular religion, or even religion itself, is to be established or given privilege in any legal sense. Since so many universities and clinics, to say nothing of the obvious case of the government, are taxsupported and include people of no faith and many faiths as constituents, the introduction of religious issues, theological interests, and church concerns to bioethics apparently would complicate all endeavors. A third reason has to do with the practitioners of bioethics. Whether they were brought up religiously or not; whether or not they find theological language congenial in their personal and private lives; whether they do or do not find church existence congenial, they tend to adopt the Western academic ethos. In that ethos, one leaves theology behind or repudiates it; God has not had it easy among the philosophers in the last two centuries. Godtalk is relegated to one part of life, one which, in the differentiation that characterizes modernity, is much narrower than the protean 'bio-realm.' A ROLE FOR THEOLOGY AND COMMUNITY
The late philosopher and novelist Arthur A. Cohen summarized the result of the pluralist, secular, and modernizing development in a passage which combines reference to the segregation of theology, the limitless scope of its subject, and, in its second paragraph, the 'scandal' which results when people set out to address it: Theology need not be a pretentious discipline; it need not usurp the sciences, dismiss natural philosophy, nor overturn logic. It is a modest discipline founded, to be sure, upon an immodest history. Once theologians ruled the sciences and held court in universities, whereas presently they are hidden away in drafty seminaries and muster disciples from the thin readership of lugubrious journals. The unhappy condition of theology has undoubtedly made theologians snappish and defensive, but we can ill afford to forget that whereas theologians are human their object of concern remains God. Theology is not concerned with any God. This is only to say that there is no
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general theology (leaving aside, for purposes of this discussion, the special history of natural theology or theology founded upon the decretals of unaided religion). There is only a theology which works upon the materials of faith. Again, not any and all faiths; but rather one's own true and chosen faith. There is Moslem theology and Christian theology; there is Jewish theology (Cohen, 1962, p. 301).
"Their object of concern remains God": with those words Cohen set out to legitimate the theologians' universe of discourse. "There is only a theology which works upon the materials of ... one's own true and chosen faith": with that phrase he further shows determination to do justice to the integrity of theological language within specific believing communities and to show the difficulty of employing such language across the boundaries of such communities. Cohen would no doubt call 'natural theology or theology founded upon the decretals of unaided reason' something such as 'philosophy of religion' and not real theology. Why? Because for him as for most theologians, there is nothing to talk about in dealing with theos unless there is a believing community which witnesses to certain experiences, derives from specific revelations and texts, and prescribes or encourages coherent practices. CBelieving community7 in the title of this article is code-named 'church', but it includes the worlds of mosque, synagogue, and other religions. Theologically, 'church' is a Christian term; sociologically and politically it applies genetically to all believing communities, as in the phrase 'separation of church and state', which is by no means a Christian preserve.) Karl Rahner, in the encyclopedia entry on Theology7, used the term in this present scandalous, offensive, particularizing sense: Theology is an ecclesiastical science of faith. Since human intersubjectivity is at its peak in faith, while faith, the hearing of the revelation directed to the people of God, is the faith of the Church and faith within the Church, theology is necessarily ecclesiastical. Otherwise it ceases to be itself and becomes the prey of the wayward subjective spirituality of the individual, which is today less fitted than ever to be the cohesive force of a community. Since the faith of the Church [="believing community", which can be Moslem or Jewish or whatever] is necessarily linked to the historical word of divine revelation, Church theology is necessarily dependent on Scripture and tradition.... (Rahner, 1970, pp. 235-236).
Rahner reinforces Cohen's notion of the concrete communal base of theology as opposed to the more abstract philosophy of religion.
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Meanwhile, Fred S. Carney in The Enq/clopedia of Bioethics,
contrasts "theological ethics" with "everyday religious moralities of one sort or another". The former are to the latter, by analogy, what "medical scientists" are to "the set of persons who engage in health-enhancing actions". While he gives much room to ethics located in the philosophy of religion, he also points to the concreteness and particularity of theological language in communities of faith. "Most (but not all) theological ethicists are participants in one or another religious community, adhering to many (if not all) of its tenets on morality". On the other hand, he adds, "the overwhelming majority of participants in religious moralities are not also involved in theological ethics, properly speaking". Carney takes some pains to distinguish between kinds of "religious communities", in ways that are again relevant to the present discussion. He writes for an encyclopedia whose readers are primarily North American and, in a more inclusive universe, Western. The term "theological ethics" (or "moral theology") embraces, he says, at least in principle, analysis of the moralities of Christianity, Islam, Buddhism, Hinduism, Judaism, and other religions, including what are sometimes called 'primitive religions.' In its restricted sense, however, theological ethics refers to discourse about a particular theistic morality embraced by the writer or by a significant part of the society to which the writer belongs. Thus in EuropeanAmerican society the most common expressions of theological ethics are Christian and/or Jewish.... This understanding of theological ethics may be employed even when the meaning of religion is extended to include such belief systems as Marxism and secular humanism, as has recently become fashionable in some circles. If such belief systems are to be considered 'theologies' by virtue of their exhibiting the phenomena of faith (that is, trust and commitment) in valued objects or states of affairs (that is, 'gods'), then theological ethics may also take the form either of examining the general bearing of such faiths on morality or of analyzing the particular relation of, for example, secular humanism to morality. Nevertheless, such an extension of the meaning of religion is both problematic and marginal to the enterprise of theological ethics as ordinarily conducted (Carney, 1978, p. 429).
THE INCREASE OF PLURALISM
Well aware of the morass or chaos that can surround any pushing of 'theology7 into the sphere of such "belief systems as Marxism
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and secular humanism, as has recently become fashionable in some circles", Carney perhaps wisely chose to drop the subject. In the little more than a decade after he wrote, however, that choice has become harder to justify, for at least two reasons. The first is the great growth in awareness of the vital pluralism of American communities, as the Muslim, Mormon, 'New Religion', Asian, and other non-'Christian and/or Jewish' cultures have enlarged and become more vocal. They make up constituencies of universities and find themselves in the classrooms of academic philosophers and theologians alike. They are parts of both the clienteles and staffs of medical institutions, and will be heard. A series of books issued by the Park Ridge Center for the Study of Health, Faith and Ethics for a North American audience had to move beyond dealing with titles like Health and Medicine in the Jewish Tradition and Health and Medicine in the Catholic Tradition, to others such as Health and Medicine in the Hindu Tradition, Health and Medicine in the Islamic Tradition, the Native American, the
Mormon, and more (Feldman, 1986; McCormick, 1984; Desai, 1989; Rahman, 1987; volumes on Native American and Mormon or Latter-day Saints, among others, are forthcoming). Latter-day Saints derive from and relate to 'Christian and/or Jewish' sources and communities, but also are quite properly seen, as Jan Shipps speaks of their emergence, as making up a new "separate religious tradition ... that must be understood and respected on its own terms" (Shipps, 1985, p. x). Not to deal with such faith traditions would represent a failure of service to the political and medical communities and a disservice to the unrepresented other-believers who are as legitimately North American as are those in 'Christian and/or Jewish' traditions. Still, as Carney did, we shall concentrate on the overwhelmingly preponderant tradition. THEOLOGICAL CRITIQUES
The other reason for at least taking note of the religious or quasireligious character of secular humanism has to do with critiques made by theologians and informed or aroused traditional believers against the hegemony of such humanistic voices in the academy, clinic, and government. Increasingly, critics and theologians in the conservative, especially neoconservative, and liberal religious communities - as well as numbers of not formally committed members of the academy -
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have questioned the monopoly or at least the legally privileged hegemony given 'academic philosophy7 which brings, or can bring with it, quasi-religious commitments (Berman, 1974; Bellah, 1970, p. 237-257). The code name for this construct is 'the Enlightenment Project7, because of its roots in the eighteenth century Enlightenment, which undergirds so much of the academic, medical, and governmental ethos in North America. While not always ruling out from bioethics the possibility of academic or clinical discourse that might be 'purely secular7 in its intention, the realization of the Enlightenment Project often carries with it sets of unquestioned assumptions that are unquestionably metaphysical and often implicitly religious. Or, when the intention is successfully carried out on chastely 'secular rationalist7 grounds, it is frequently argued, as we shall see, that such a program cannot do justice to all the dimensions of an issue or the interests of the whole political community. (See the discussion of Greenawalt, below.) THE SITUATION OF RELIGION, THEOLOGY, CHURCH
Of less interest here than the reasons for the hegemony of secular rationalist bioethics in the academy, the clinic, and the government, or for criticisms of it, is the assigned focus: what has gone on, should be expected of, and is occurring in the spheres of 'religion, theology, and church' in respect to bioethics? If modern North American medical ethics was born as much in the seminary as in the university, and was initiated by theologians as much as by philosophers, the university and the philosophers must have won their place in part because they met needs or found a voice in the face of weakened, recessive, or poorly positioned religionists and theologians. Such, it turns out, is the case. To address the issue of the religious community's poise and interest we must point first to the power of religious institutions and the prevalence of religious sentiment and then to the recognition that there are long and deep churchly and theological concerns with the 'bio-realm'. Institutional religion: beleaguered, beset, defensive, and flawed as it may be in a culture that calls itself 'secular7 or in which many advocate a private, non-institutional and even non-communal religion, organized religion thrives. A recent survey based on a half century of polling, limited as such an instrument may be,
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provides some glimpse of religious power near the century's end. The most visible indicator of participation is membership. America's is the highest in the industrialized West. The effects of anti-institutionalism or indifference to organized religion were apparent in the realization that there had been some recent decline: "The percentage of Americans who identified themselves as members of a church or synagogue in 1988 ... was the lowest since the Gallup Poll began tracking such figures in 1937", thanks chiefly to Catholic membership decrease. Yet an astonishing 65% of the public identified themselves as members. (As recently as 1985, 71 percent claimed membership.) Losses were highest among young and college-educated cohorts. As for the second indicator, attendance: it has remained stable for a generation, with 42% claiming to have attended in a typical week (back to where it was in 1937, down from a high of 49% in 1955 and 1958, and approximately where it has been each year since 1967). A third and (even) more subjective indicator is the degree of importance Americans attach to religion; this was another stable area. In 1987, 54% of Americans said religion was "very important" in their lives and 32% said it was "fairly important", while only 14% said it was "not very important". What about belief in God as the content or object of religion? Some Unitarian Universalists, Ethical Culturists, Taoists, many kinds of Buddhists, 'New Age' religionists, and other small minorities in the whole population are religious but non-theistic. (They do have theologians, however, whose subject matter was implied in Fred S. Carney's second and larger definition of theology.) When asked whether they believe in God (the theos of theology), as if reflexively, year in and year out, well over 90% (in 1988, 94%) of the citizens answer affirmatively. For contrast, the figures for 'Catholic7 Spain and Italy are 51% and 43% while Protestant Norway and Denmark draw only 36% and 21% affirmative responses. What is more, 88% say they believe God loves them, and only 3% declare that this is not the case. The Americans have to be and are tolerant of pluralism; in 1985 a survey found that 62% of Americans agreed that "God reveals himself through a variety of religious beliefs and traditions". More than three-fourths claimed that religious involvement has been a positive experience in their lives, and 78% say they have given "a lot" or "a fair amount" of thought to their relationship to God through the past two years.
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The surveys have been curiously uncurious about the public's connectings between religion or theology and issues of health, medicine, care, and justice in respect to their delivery. Insofar as these are or become political matters, the polled public is divided: 56% say "churches should keep out of politics", while 37% disagree; however, only 45% of church attenders wanted them to stay out, while 50% disagreed with the notion of their being aloof. Again, insofar as health care relates to governmental expenditure, there was considerable support among the practicing religious. As far as support for "increased government spending for health care" was concerned, 67% of white Protestants, 70% of white Catholics, and 74% of Jews said they asked for it. On the most controverted issue in the 'bio-realm' there were wide disparities between major communities. Asked whether the church should politically support the antiabortion cause, 45% of the evangelicals said "yes", as did 39% of the Catholics; but only 21% of the "white non-evangelicals", 31% of the black Protestants, and 18% of the Jews affirmed the involvement. They were not asked how many were for alternatives to "antiabortion" (Gallup, 1989, pp. 232, 202, 216-18). This brief survey of involvements and beliefs as discerned by pollsters has had a singular purpose: to press the point that not only 'religion' and 'theology' but 'church' is at issue. That is, the concrete reality of the believing community has a stake in public issues, in the polis. To dissolve the question of theology into the more ethereal spheres of religious philosophy might give this inquiry an apparently more appealing philosophical cast. But we are to explore issues of power, public preference, and the believing community as the source of the language for theologians, 'the scientists of faith' and of their particular faiths. RELIGION AND THE BIO-REALM
Alongside that preoccupation with the relative power assigned religion and religious organizations, comes the recognition that church and synagogue and their cognates have always found good reason to be preoccupied with the Ino-realm'. It is hardly necessary to remind readers that Judaism, Christianity, to many extents Islam, and most world religions began and developed as healing cults, where there was little conception of excluding the realm of the bios or physical existence and the psyche, the spirit,
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from the scope of religious experience and practice. The prophets healed; Jesus healed; they mandated mercy and justice in respect to bodily needs and the evils associated with madness, the demonic, depression, or deviance from presumed norms of health and well-being. Similar root terms in the sacred texts apply to both healing and 'salvation'. For centuries, religious agencies were the main providers of health care. Much of the nursing profession grew up in religious orders or pietist communities. Physicians were to pursue their callings coram deo, in the sight of God. Hospitals, such as they were, ordinarily emerged under religious auspices and were stewarded and staffed by people of religious motivation. Much of the ethos and practice of almsgiving through the centuries was directed to health care. The confessional, counselling, and pastoral care were under clerical or rabbinic direction. Religion and religious organizations remain deeply involved in health care and in providing understandings of disease and wholeness. Over six hundred hospitals in America remain connected somehow with the Catholic church, and thousands of hospitals, clinics, substance abuse treatment centers, homes for aged, and other kinds of institutions of mercy, as they once were called, are affiliated with religious organizations and supported in part by people motivated by their faith. They may have suffered as a result of the lack of financial resources and for other causes which we shall shortly enumerate. But as governmental subsidy decreases relatively, many religious institutions are reentering the field with imagination and vigor. Yet medical research, provision of care, interpretations of 'bio-realms', and ethics relating to all of the above, in any case progressively passed from the hands of the theologians and clergy, and they have been on the defensive for some time. THE EXILING OF THEOLOGY
What happened? One needs a very broad brush to portray even in outline some of the occurrences. We can point to a few. First was the specialization that goes with modernization: differentiation is one of the key features of such a trend. The church, in this division of labor, was to take care of the eternal and other agencies of the temporal. Religion was to deal with the spiritual realm and science and politics were to treat the bio-realm. Medical professionals treated the body and religious professionals treated the
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soul, in this easily caricatured situation. Theologians were first cowed and then awed by scientists, and many retreated from realms where, at least in the mythology of medievalism, they had once sat in the chair of the 'queen of sciences'. At this point we are not interested in the scientists' or academic philosophers' reach for hegemony or monopoly so much as in the occasions for retreat and the development of a vacuum in the communities of faith. Easily documented is the preemption of some specifically religious space and understanding by government. Sociologist Robert Wuthnow even argues that "engagement by religious movements in the political sphere, perhaps ironically, has often resulted in an expansion rather than a contraction in the power of the state". Thus by supporting a larger governmental involvement in health care, the churches cornered themselves or withdrew, choosing to use their own dwindling resources elsewhere. Wuthnow cites H. Paul Douglass, a sociologist who wrote presciently in the Great Depression: "much of the work of the private institutions now in the hands of the church shall in the future pass over to the state". That has occurred, just as much funding and support have come from private and secular foundations, people of wealth, 'community and united funds', and the like - all of them instances where religious motivation was secondary, invisible, or suppressed (Wuthnow, 1988, pp. 317, 6; Douglass and deBrunner, 1935, p. 200). Within the religious communities, the status of the theologian had long been ambiguous. In recent decades, for a variety of reasons, there has been a brain drain of religious thinkers from seminaries, where specific faith communities are vivid, to more secular, more pluralist, often tax-supported colleges and universities. With that move, the voice of theology has become more diffused, less representative of the language of particular believing communities, more generalized in 'religious studies', and thus less interesting for those dealing with clinical or other medical and 'bio-realmed' concerns. In a story too complex for anything more than mention here, there has also been a loss of confidence among the theologians: 'God-talk7 came to be problematic in new ways, especially during the period in which Anglo-American language philosophies, antimetaphysical as they were, discouraged such talk. The shift in religious power from the kind of mainstream and liberal Protestant and Catholic orbits, where the first words of modern North
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American bioethics were spoken, to religious movements that were more suspicious of science, politics, and the secular, further led to the decline of influence on the part of theologians in the bioethical sphere. Theologian and ethical thinker James M. Gustafson summarized the trend: "Among the moral philosophers whose works have been taken seriously in the past decades, there are none who would base their ethics on theological principles, whether derived from 'natural reason' or from a historical religious tradition". He went on to say that "given the basic assumptions of the philosophical enterprise in the modern Western world, this is as it should be". Even when theology was more vital, the theologians dependent upon revelation had always found it necessary and valuable to link with prevailing philosophies such as Stoicism, Neoplatonism, Aristotelianism, Kantianism, or whatever. Gustafson did note, however, that the trend created problems during "the more radical secularization of Western culture in recent centuries". This resulted from the fact that while there has been "growing knowledge of cultural pluralism and various vital religious traditions, it has not been unreasonable to seek a basis for morality that transcends religious beliefs, one that can be held to by persons holding different religious beliefs and that would appeal to all 'rational' and 'autonomous' agents" (Gustafson, 1981, p. 76). A somewhat unnatural and unrepresentative situation developed, however. There was an ever widening gap between the zones of discourse in which 'academic philosophers' and clinical ethicists debated bioethics and medical ethics on one hand, and those in which the vast majority of the patients and public lived. Gustafson himself noted further that universalizing ethical thinkers were themselves in a way sectarian - my word, not his because they had not come close to arriving at a "moral theory that would be persuasive to all rational agents". Therefore he urged paying more attention "to the historical traditions out of which have come a great deal of the motives and goals for action among humankind" (Gustafson, 1981, pp. 81-82). Many vivid bioethical issues have explicit religious dimensions, as the classic cases in the United States of Karen Quinlan, Baby Fae, Barney Clark, or the Twitchells - with their Catholic, Adventist, Mormon, and Christian Science ties - make clear. Less clearly defined religious communities than the four mentioned there also in-
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fluence ethical decisions and interpretations of illness and health, pain and recovery, but they also are not reckoned with in the conventional academic philosophy and ethical schools. One clinical ethicist in conversation put it this way: When a patient's family is deciding whether to let the D.N.R. sign appear, or, in the crude language, to 'pull the plug on grandpa', they are not likely to invite in the academic philosopher to discourse on beneficence or nonmaleficence in Aristotle or Mill. They are more inclined to ask, 'What does my physician say? What does my minister think? What does my family want?' And these questions are rooted in the historical traditions, often in communities of faith, which have often been muffled, excluded, or self-exiled. AN ALTERNATIVE TO AND A REFUGE FROM LIBERAL CULTURE
Religion has come back, and, to some extent, so has theology, into the fields of medical and health concerns and bioethics. The return will always be limited by boundaries and restraints occasioned by the vast majority of the religious public's adaptation to secularity, its at-homeness in pluralism, and its acceptance of a liberal culture. In other words, few seek a theocracy, hierocracy, clerisy, or even mild religious establishment, and most do not desire all the consequences of giving legal privilege to a particular religion. Political scientist Robert Booth Fowler has given a credible accounting of the public's ease within liberal culture and of the roles citizens assign religion. He defines the liberal culture as including three elements: (1)
(2)
(3)
a commitment to skeptical reason, an affirmation of pragmatic intelligence, and an uneasiness about both abstract philosophical thinking and nonrational modes of knowledge; enthusiasm in principle (and increasingly in practice) for tolerance not only in political terms but much more obviously in terms of lifestyle and social norms; affirmation of the central importance of the individual and individual freedom.
Meanwhile, Fowler continues: religion in America has been, and continues to be, an alternative to the liberal order, a refuge from our society and its pervasive values. Yet, by providing that space from our liberal order, it unintentionally helps that liberal world (Fowler, 1989:4).
Religion, Theology, Church, and Bioethics That is, typical citizens practically favor the liberal culture but find it spiritually unsatisfying. They will ordinarily resort to its modes when allocating resources, supporting research, going about scientific inquiries, or debating medical ethics in the abstract. But they need an alternative to the dominance of those modes. Religion is a refuge not in the sense of an opiate, a permanent hiding place; instead, they use it as armies use retreats, to regather force for new involvements. They will therefore draw upon their faith and community understandings in concrete situations, to provide special motivations, or to establish particular institutions. Yet - and here the academic philosophers and secular humanists can relax - the religious 'help' the liberal culture along because they return to it, having changed it somewhat and themselves more. But the spiritual concerns they bring from their retreats more and more are coming back into the language of bioethics and medical ethics. THE SEARCH FOR PUBLICLY ACCESSIBLE ARGUMENT
Such concerns and language are not reliant on the claims that those in other religious communities or outside the sphere of religion entirely must accept these communities' understandings of a supernatural revelation or what they draw from the magisterium of a particular church, such as the Roman Catholic. Some within the communities may be thus reliant, but they soon falter in frustration because they get no hearing abroad in public and little at home, in their own communities. Pentecostal 'faith-healers' and Christian Science practitioners may be effective, or Jehovah's Witnesses in their opposition to blood transfusions may be convincing, but only to their fellow believers. They are not likely to get public funds for the administration of care based on particular revelations of God, or public support for the arcane (to others) positions they hold. How, then, do serious religious thinkers, theological ethicists, and representatives of professions or the broad membership of faith communities begin to find a hearing on the scene where one kind of academic philosopher or clinical ethicist had dominated and controlled the discourse? Space permits but one illustration, which I shall develop by analogy from political into medical and ethical spheres from the work of Kent Greenawalt. He begins a summary paragraph with the word 'legislation", but here anal-
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ogy comes into play and we can enlarge it to all political, ethical, and medical decision. Legislation, and by extension these other decisions must be justified in terms of secular objectives, but when people reasonably think that shared premises of justice and criteria for determining truth cannot resolve critical questions of fact, fundamental questions of value, or the weighing of competing benefits and harms, they do appropriately rely on religious convictions that help them answer these questions.
Greenawalt notes that the usual mode of referring to the background of argument in a liberal society is to its 'rational' or its 'secularly rational' character. He cites David Lyons, Louis Henkin, Glanville Williams, John Rawls, and Bruce Ackerman as eloquent and effective articulators of such a universe. Thus Ackerman said that "nobody has the right to vindicate political authority by asserting a privileged insight into the moral universe which is denied to the rest of us". Public discourse then has to be nonreligious and rational, for the liberal state is "deprived of divine revelation". Greenawalt agrees. But having argued for the legitimacy of religious discourse in the public sphere, he must then make the case by doing more than simply arguing that secular rationality must have no monopoly. He does this by referring to what he calls "publicly accessible reasons and shared premises", reckoning that these do not all come from the grounding in one particular (postEnlightenment?) brand of secular rationality. In highly qualified ways, Greenawalt contends, appeals to personal intuition, feeling, commitment, tradition and authority, suspect as these are to conventional rationalists, are capable of being addressed in "publicly accessible" ways - and they may do more justice to many ethical situations than does mere secular rationality unnuanced by these other appeals. He chooses animal rights, environmental policy, and abortion as three typical cases in which not all parties in their original position are capable of standing on the premises of such rationality. They need advocates, who may well draw on the other modes of appeal as well (Greenawalt, 1988, pp. 12, 54-55, 24, and passim). Such condensed and cryptic references to Greenawalt may be frustrating to those who look for a complete argument. His work here is used illustratively, not forensically, to show how
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arguments for "publicly accessible" religious claims and contentions are being legitimated. While Greenawalf s approach may seem to be threatening and encroaching to oldline rationalists, some theological critics have come at him from the opposite side, arguing that he need not yield rationality to the secular camp, leaving only intuition, feeling, commitment, tradition, and authority (and one might add community, and more) to religion and theology. Franklin I. Gamwell has both appreciated Greenawalt in general and criticized him on this particular. Audaciously Gamwell attempts what theologians in their prime era were expected to do: to argue theologically and to use reason - also in defense of reason (Gamwell, 1990). Gamwell begins: "However diverse its formulations or radical its disagreements, modern moral philosophy has widely agreed that its task is systematically to articulate a nonreligious basis for the moral enterprise", until in our century "the independence of morality from religion has been largely taken for granted" (Gamwell, 1990, p. xii). He goes on to argue that this dominant consensus is mistaken. His thesis is "that the validity of moral claims presupposes the existence of God". With that challenge to the ethicists' communities, Gamwell also challenges the theists. He contends "that one cannot affirm or deny any moral claim without at least implicitly affirming a divine reality" (Gamwell, 1990, p. xiii). There is here little reference to revelation, to Ackerman's disdained notion of "some conversation with the spirit world" which leaves out those who are "deprived of divine revelation" (Ackerman, x, pp. 127,103). Gamwell will be unsatisfying to those who believe that religious language should be non- or ir- or antirational and wholly derived from divine revelation in some pure 'bolt out of the blue' and hermetically sealed sense. But he does revisit the traditions of reason which were very much a part of theologians' preoccupations in the past and are selectively so in contemporary times. As an historian who no doubt brought trouble among philosophers by adducing Greenawalf s "publicly accessible" notion of religious language, I am aware that I am compounding things by introducing - without his detail - Gamwell's thesis about "the validity of moral claims presupposling] the existence of God". Both cases are cited here in the historians' manner, that is, to point to trends.
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The overall trend has been toward at least some modest recovery of religion in the 'bio-realm'; some reassertion of theology in bioethics; some resolution that churches have a part to play in providing health care; and, more, in interpreting illness and wellness or advocating and embodying measures of justice in delivery of care. For reasons suggested above by Robert Booth Fowler, it is likely that, though these religious, theological, and churchly voices might speak for the citizen majorities found by Dr. Gallup, their own attraction to the rewards of a liberal culture, their own secularity and welcoming of pluralism, the diffidence of their theologians or the atrophy of their skill in using theological language, will determine limits for their involvement. In the mean time, for the many, they will continue, as Fowler noted, to provide alternatives to the Enlightenment mode of understanding and refuge from the colder claims of secular rationality in isolation, even while they continue to provide help for that liberal culture of which they are such familiar and integral parts. REFERENCES Ackennan, Bruce: 1980, Social Justice in the Liberal State, Yale University Press, New Haven, CT. Bellah, Robert N.: 1980, 'Between religion and social science', in Beyond Belief: Essays on Religion in a Post-Traditional World, Harper and Row, New York, pp. 237-257. Berman, Harold: 1974, The Interaction of Law and Religion, Abingdon, Nashville, TN. Carney, Fred S.: 1978, Theological ethics', in Warren Reich, ed., The Encyclopedia of Bioethics, Maanillan, New York, I, pp. 429-437. Cohen, Arthur A.: 1962, The Natural and the Supernatural Jew, Pantheon, New York. Desai, Prakash N.: 1989, Health and Medicine in the Hindu Tradition, Crossroad, New York. Douglass, H. Paul and DeBrunner, Edmund deS.: 1935, The Protestant Church as a Social Institution, Russell and Russell, New York. Feldman, David M.: 1986, Health and Medicine in the Jewish Tradition, Crossroad, New York. Fowler, Robert Booth: 1989, Unconventional Partners: Religion and Liberal Culture in the United States, Wm. B. Eerdmans, Grand Rapids, MI. Gallup, George, Jr. and Castelli, Jim: 1989, The People's Religion: American Faith in the 90's, Macmillan, New York. Gamwell, Franklin I., 1990: The Divine Good: Modern Moral Theory and the Necessity of God, Harper/Collins, San Francisco.
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Creenawalt, Kent: 1988, Religious Convictions and Political Choice, Oxford University Press, New York. Gustafson, James M.: 1981, Ethics from a Theocentric Perspective I: Theology and Ethics, University of Chicago Press, Chicago. McCormick, Richard: 1984, Health and Medicine in the Catholic Tradition, Crossroad, New York. Rahman, Fazlur: 1987, Health and Medicine in the Islamic Tradition, Crossroad, New York. Rahner, Karl: 1970, Theology', in Karl Rahner, ed., Sacramentum Mundi: An Encyclopedia of Theology, Herder and Herder, New York, pp. 233-246. Shipps, Jan: 1985, Mormonism, The Story of a New Religious Tradition, University of Illinois Press, Urbana, IL. Wuthnow, Robert, 1988, The Restructuring of American Religion: Society and Faith Since World War II, Princeton University Press, Princeton, New Jersey.
RELIGION, THEOLOGY, CHURCH, AND BIOETHICS
ABSTRACT. Modem medical ethics developed in America after mid-century chiefly at theological schools, but discourse on bioethics soon moved to the pluralist-secular settings of the academy and the clinic, where it acquired a philosophical and intentionally non-religious cast. An effort was made, on the grounds of liberal culture' and late Enlightenment rationality' to find a framework for inquiry which aspired to the universal. Today, while that language persists, it coexists with, challenges, and is challenged by forms of ethical analysis and advocacy which take into consideration the 'thickness' of complicating narrative and reasoning based in the many religious traditions. It has become incumbent upon advocates of those traditions to propose 'publicly accessible' argument. Key Words: bioethics, church, religion, theology THE PREVALENCE OF ACADEMIC PHILOSOPHY IN BIOETHICS
To frame the present inquiry, it is necessary to state what is unnecessary to document elaborately, that academic philosophers have prevailed over their contemporaries and colleagues, the theologians, in the development of bioethics. This is abundantly evident to anyone who compares the number of clinical, academic, and governmental agencies, departments, or impetuses dealing with medicine and ethics which either ignore or exclude formal religion, theology, or the concerns of the church, with those which include them. The reasons for the hegemony of non-religious and sometimes anti-theological language in bioethics are also evident. The most obvious element in the context is the pluralistic character of American society. The first question that has to be asked when theologians speak is particular which believing community among many produced the language they represent? There are too many communities and thus too many universes of discourse to be Martin E. Marty, Ph.D., The Divinity School, Sxvift Hall, University of Chicago, Chicago, IL 60637, USA. The Journal of Medicine and Philosophy 17:273-289,1992. © 1992 Kluiver Academic Publishers. Printed in the Netherlands.
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reckoned with or to be accepted as authoritative. So it is efficient and perhaps prudent to ignore them all. To this pluralism one must add the reality of secularization, however defined. The society, for instance by legally 'separating church and state' and through many other conscious and unconscious decisions, has made clear to itself that no particular religion, or even religion itself, is to be established or given privilege in any legal sense. Since so many universities and clinics, to say nothing of the obvious case of the government, are taxsupported and include people of no faith and many faiths as constituents, the introduction of religious issues, theological interests, and church concerns to bioethics apparently would complicate all endeavors. A third reason has to do with the practitioners of bioethics. Whether they were brought up religiously or not; whether or not they find theological language congenial in their personal and private lives; whether they do or do not find church existence congenial, they tend to adopt the Western academic ethos. In that ethos, one leaves theology behind or repudiates it; God has not had it easy among the philosophers in the last two centuries. Godtalk is relegated to one part of life, one which, in the differentiation that characterizes modernity, is much narrower than the protean 'bio-realm.' A ROLE FOR THEOLOGY AND COMMUNITY
The late philosopher and novelist Arthur A. Cohen summarized the result of the pluralist, secular, and modernizing development in a passage which combines reference to the segregation of theology, the limitless scope of its subject, and, in its second paragraph, the 'scandal' which results when people set out to address it: Theology need not be a pretentious discipline; it need not usurp the sciences, dismiss natural philosophy, nor overturn logic. It is a modest discipline founded, to be sure, upon an immodest history. Once theologians ruled the sciences and held court in universities, whereas presently they are hidden away in drafty seminaries and muster disciples from the thin readership of lugubrious journals. The unhappy condition of theology has undoubtedly made theologians snappish and defensive, but we can ill afford to forget that whereas theologians are human their object of concern remains God. Theology is not concerned with any God. This is only to say that there is no
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general theology (leaving aside, for purposes of this discussion, the special history of natural theology or theology founded upon the decretals of unaided religion). There is only a theology which works upon the materials of faith. Again, not any and all faiths; but rather one's own true and chosen faith. There is Moslem theology and Christian theology; there is Jewish theology (Cohen, 1962, p. 301).
"Their object of concern remains God": with those words Cohen set out to legitimate the theologians' universe of discourse. "There is only a theology which works upon the materials of ... one's own true and chosen faith": with that phrase he further shows determination to do justice to the integrity of theological language within specific believing communities and to show the difficulty of employing such language across the boundaries of such communities. Cohen would no doubt call 'natural theology or theology founded upon the decretals of unaided reason' something such as 'philosophy of religion' and not real theology. Why? Because for him as for most theologians, there is nothing to talk about in dealing with theos unless there is a believing community which witnesses to certain experiences, derives from specific revelations and texts, and prescribes or encourages coherent practices. CBelieving community7 in the title of this article is code-named 'church', but it includes the worlds of mosque, synagogue, and other religions. Theologically, 'church' is a Christian term; sociologically and politically it applies genetically to all believing communities, as in the phrase 'separation of church and state', which is by no means a Christian preserve.) Karl Rahner, in the encyclopedia entry on Theology7, used the term in this present scandalous, offensive, particularizing sense: Theology is an ecclesiastical science of faith. Since human intersubjectivity is at its peak in faith, while faith, the hearing of the revelation directed to the people of God, is the faith of the Church and faith within the Church, theology is necessarily ecclesiastical. Otherwise it ceases to be itself and becomes the prey of the wayward subjective spirituality of the individual, which is today less fitted than ever to be the cohesive force of a community. Since the faith of the Church [="believing community", which can be Moslem or Jewish or whatever] is necessarily linked to the historical word of divine revelation, Church theology is necessarily dependent on Scripture and tradition.... (Rahner, 1970, pp. 235-236).
Rahner reinforces Cohen's notion of the concrete communal base of theology as opposed to the more abstract philosophy of religion.
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Meanwhile, Fred S. Carney in The Enq/clopedia of Bioethics,
contrasts "theological ethics" with "everyday religious moralities of one sort or another". The former are to the latter, by analogy, what "medical scientists" are to "the set of persons who engage in health-enhancing actions". While he gives much room to ethics located in the philosophy of religion, he also points to the concreteness and particularity of theological language in communities of faith. "Most (but not all) theological ethicists are participants in one or another religious community, adhering to many (if not all) of its tenets on morality". On the other hand, he adds, "the overwhelming majority of participants in religious moralities are not also involved in theological ethics, properly speaking". Carney takes some pains to distinguish between kinds of "religious communities", in ways that are again relevant to the present discussion. He writes for an encyclopedia whose readers are primarily North American and, in a more inclusive universe, Western. The term "theological ethics" (or "moral theology") embraces, he says, at least in principle, analysis of the moralities of Christianity, Islam, Buddhism, Hinduism, Judaism, and other religions, including what are sometimes called 'primitive religions.' In its restricted sense, however, theological ethics refers to discourse about a particular theistic morality embraced by the writer or by a significant part of the society to which the writer belongs. Thus in EuropeanAmerican society the most common expressions of theological ethics are Christian and/or Jewish.... This understanding of theological ethics may be employed even when the meaning of religion is extended to include such belief systems as Marxism and secular humanism, as has recently become fashionable in some circles. If such belief systems are to be considered 'theologies' by virtue of their exhibiting the phenomena of faith (that is, trust and commitment) in valued objects or states of affairs (that is, 'gods'), then theological ethics may also take the form either of examining the general bearing of such faiths on morality or of analyzing the particular relation of, for example, secular humanism to morality. Nevertheless, such an extension of the meaning of religion is both problematic and marginal to the enterprise of theological ethics as ordinarily conducted (Carney, 1978, p. 429).
THE INCREASE OF PLURALISM
Well aware of the morass or chaos that can surround any pushing of 'theology7 into the sphere of such "belief systems as Marxism
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and secular humanism, as has recently become fashionable in some circles", Carney perhaps wisely chose to drop the subject. In the little more than a decade after he wrote, however, that choice has become harder to justify, for at least two reasons. The first is the great growth in awareness of the vital pluralism of American communities, as the Muslim, Mormon, 'New Religion', Asian, and other non-'Christian and/or Jewish' cultures have enlarged and become more vocal. They make up constituencies of universities and find themselves in the classrooms of academic philosophers and theologians alike. They are parts of both the clienteles and staffs of medical institutions, and will be heard. A series of books issued by the Park Ridge Center for the Study of Health, Faith and Ethics for a North American audience had to move beyond dealing with titles like Health and Medicine in the Jewish Tradition and Health and Medicine in the Catholic Tradition, to others such as Health and Medicine in the Hindu Tradition, Health and Medicine in the Islamic Tradition, the Native American, the
Mormon, and more (Feldman, 1986; McCormick, 1984; Desai, 1989; Rahman, 1987; volumes on Native American and Mormon or Latter-day Saints, among others, are forthcoming). Latter-day Saints derive from and relate to 'Christian and/or Jewish' sources and communities, but also are quite properly seen, as Jan Shipps speaks of their emergence, as making up a new "separate religious tradition ... that must be understood and respected on its own terms" (Shipps, 1985, p. x). Not to deal with such faith traditions would represent a failure of service to the political and medical communities and a disservice to the unrepresented other-believers who are as legitimately North American as are those in 'Christian and/or Jewish' traditions. Still, as Carney did, we shall concentrate on the overwhelmingly preponderant tradition. THEOLOGICAL CRITIQUES
The other reason for at least taking note of the religious or quasireligious character of secular humanism has to do with critiques made by theologians and informed or aroused traditional believers against the hegemony of such humanistic voices in the academy, clinic, and government. Increasingly, critics and theologians in the conservative, especially neoconservative, and liberal religious communities - as well as numbers of not formally committed members of the academy -
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have questioned the monopoly or at least the legally privileged hegemony given 'academic philosophy7 which brings, or can bring with it, quasi-religious commitments (Berman, 1974; Bellah, 1970, p. 237-257). The code name for this construct is 'the Enlightenment Project7, because of its roots in the eighteenth century Enlightenment, which undergirds so much of the academic, medical, and governmental ethos in North America. While not always ruling out from bioethics the possibility of academic or clinical discourse that might be 'purely secular7 in its intention, the realization of the Enlightenment Project often carries with it sets of unquestioned assumptions that are unquestionably metaphysical and often implicitly religious. Or, when the intention is successfully carried out on chastely 'secular rationalist7 grounds, it is frequently argued, as we shall see, that such a program cannot do justice to all the dimensions of an issue or the interests of the whole political community. (See the discussion of Greenawalt, below.) THE SITUATION OF RELIGION, THEOLOGY, CHURCH
Of less interest here than the reasons for the hegemony of secular rationalist bioethics in the academy, the clinic, and the government, or for criticisms of it, is the assigned focus: what has gone on, should be expected of, and is occurring in the spheres of 'religion, theology, and church' in respect to bioethics? If modern North American medical ethics was born as much in the seminary as in the university, and was initiated by theologians as much as by philosophers, the university and the philosophers must have won their place in part because they met needs or found a voice in the face of weakened, recessive, or poorly positioned religionists and theologians. Such, it turns out, is the case. To address the issue of the religious community's poise and interest we must point first to the power of religious institutions and the prevalence of religious sentiment and then to the recognition that there are long and deep churchly and theological concerns with the 'bio-realm'. Institutional religion: beleaguered, beset, defensive, and flawed as it may be in a culture that calls itself 'secular7 or in which many advocate a private, non-institutional and even non-communal religion, organized religion thrives. A recent survey based on a half century of polling, limited as such an instrument may be,
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provides some glimpse of religious power near the century's end. The most visible indicator of participation is membership. America's is the highest in the industrialized West. The effects of anti-institutionalism or indifference to organized religion were apparent in the realization that there had been some recent decline: "The percentage of Americans who identified themselves as members of a church or synagogue in 1988 ... was the lowest since the Gallup Poll began tracking such figures in 1937", thanks chiefly to Catholic membership decrease. Yet an astonishing 65% of the public identified themselves as members. (As recently as 1985, 71 percent claimed membership.) Losses were highest among young and college-educated cohorts. As for the second indicator, attendance: it has remained stable for a generation, with 42% claiming to have attended in a typical week (back to where it was in 1937, down from a high of 49% in 1955 and 1958, and approximately where it has been each year since 1967). A third and (even) more subjective indicator is the degree of importance Americans attach to religion; this was another stable area. In 1987, 54% of Americans said religion was "very important" in their lives and 32% said it was "fairly important", while only 14% said it was "not very important". What about belief in God as the content or object of religion? Some Unitarian Universalists, Ethical Culturists, Taoists, many kinds of Buddhists, 'New Age' religionists, and other small minorities in the whole population are religious but non-theistic. (They do have theologians, however, whose subject matter was implied in Fred S. Carney's second and larger definition of theology.) When asked whether they believe in God (the theos of theology), as if reflexively, year in and year out, well over 90% (in 1988, 94%) of the citizens answer affirmatively. For contrast, the figures for 'Catholic7 Spain and Italy are 51% and 43% while Protestant Norway and Denmark draw only 36% and 21% affirmative responses. What is more, 88% say they believe God loves them, and only 3% declare that this is not the case. The Americans have to be and are tolerant of pluralism; in 1985 a survey found that 62% of Americans agreed that "God reveals himself through a variety of religious beliefs and traditions". More than three-fourths claimed that religious involvement has been a positive experience in their lives, and 78% say they have given "a lot" or "a fair amount" of thought to their relationship to God through the past two years.
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The surveys have been curiously uncurious about the public's connectings between religion or theology and issues of health, medicine, care, and justice in respect to their delivery. Insofar as these are or become political matters, the polled public is divided: 56% say "churches should keep out of politics", while 37% disagree; however, only 45% of church attenders wanted them to stay out, while 50% disagreed with the notion of their being aloof. Again, insofar as health care relates to governmental expenditure, there was considerable support among the practicing religious. As far as support for "increased government spending for health care" was concerned, 67% of white Protestants, 70% of white Catholics, and 74% of Jews said they asked for it. On the most controverted issue in the 'bio-realm' there were wide disparities between major communities. Asked whether the church should politically support the antiabortion cause, 45% of the evangelicals said "yes", as did 39% of the Catholics; but only 21% of the "white non-evangelicals", 31% of the black Protestants, and 18% of the Jews affirmed the involvement. They were not asked how many were for alternatives to "antiabortion" (Gallup, 1989, pp. 232, 202, 216-18). This brief survey of involvements and beliefs as discerned by pollsters has had a singular purpose: to press the point that not only 'religion' and 'theology' but 'church' is at issue. That is, the concrete reality of the believing community has a stake in public issues, in the polis. To dissolve the question of theology into the more ethereal spheres of religious philosophy might give this inquiry an apparently more appealing philosophical cast. But we are to explore issues of power, public preference, and the believing community as the source of the language for theologians, 'the scientists of faith' and of their particular faiths. RELIGION AND THE BIO-REALM
Alongside that preoccupation with the relative power assigned religion and religious organizations, comes the recognition that church and synagogue and their cognates have always found good reason to be preoccupied with the Ino-realm'. It is hardly necessary to remind readers that Judaism, Christianity, to many extents Islam, and most world religions began and developed as healing cults, where there was little conception of excluding the realm of the bios or physical existence and the psyche, the spirit,
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from the scope of religious experience and practice. The prophets healed; Jesus healed; they mandated mercy and justice in respect to bodily needs and the evils associated with madness, the demonic, depression, or deviance from presumed norms of health and well-being. Similar root terms in the sacred texts apply to both healing and 'salvation'. For centuries, religious agencies were the main providers of health care. Much of the nursing profession grew up in religious orders or pietist communities. Physicians were to pursue their callings coram deo, in the sight of God. Hospitals, such as they were, ordinarily emerged under religious auspices and were stewarded and staffed by people of religious motivation. Much of the ethos and practice of almsgiving through the centuries was directed to health care. The confessional, counselling, and pastoral care were under clerical or rabbinic direction. Religion and religious organizations remain deeply involved in health care and in providing understandings of disease and wholeness. Over six hundred hospitals in America remain connected somehow with the Catholic church, and thousands of hospitals, clinics, substance abuse treatment centers, homes for aged, and other kinds of institutions of mercy, as they once were called, are affiliated with religious organizations and supported in part by people motivated by their faith. They may have suffered as a result of the lack of financial resources and for other causes which we shall shortly enumerate. But as governmental subsidy decreases relatively, many religious institutions are reentering the field with imagination and vigor. Yet medical research, provision of care, interpretations of 'bio-realms', and ethics relating to all of the above, in any case progressively passed from the hands of the theologians and clergy, and they have been on the defensive for some time. THE EXILING OF THEOLOGY
What happened? One needs a very broad brush to portray even in outline some of the occurrences. We can point to a few. First was the specialization that goes with modernization: differentiation is one of the key features of such a trend. The church, in this division of labor, was to take care of the eternal and other agencies of the temporal. Religion was to deal with the spiritual realm and science and politics were to treat the bio-realm. Medical professionals treated the body and religious professionals treated the
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soul, in this easily caricatured situation. Theologians were first cowed and then awed by scientists, and many retreated from realms where, at least in the mythology of medievalism, they had once sat in the chair of the 'queen of sciences'. At this point we are not interested in the scientists' or academic philosophers' reach for hegemony or monopoly so much as in the occasions for retreat and the development of a vacuum in the communities of faith. Easily documented is the preemption of some specifically religious space and understanding by government. Sociologist Robert Wuthnow even argues that "engagement by religious movements in the political sphere, perhaps ironically, has often resulted in an expansion rather than a contraction in the power of the state". Thus by supporting a larger governmental involvement in health care, the churches cornered themselves or withdrew, choosing to use their own dwindling resources elsewhere. Wuthnow cites H. Paul Douglass, a sociologist who wrote presciently in the Great Depression: "much of the work of the private institutions now in the hands of the church shall in the future pass over to the state". That has occurred, just as much funding and support have come from private and secular foundations, people of wealth, 'community and united funds', and the like - all of them instances where religious motivation was secondary, invisible, or suppressed (Wuthnow, 1988, pp. 317, 6; Douglass and deBrunner, 1935, p. 200). Within the religious communities, the status of the theologian had long been ambiguous. In recent decades, for a variety of reasons, there has been a brain drain of religious thinkers from seminaries, where specific faith communities are vivid, to more secular, more pluralist, often tax-supported colleges and universities. With that move, the voice of theology has become more diffused, less representative of the language of particular believing communities, more generalized in 'religious studies', and thus less interesting for those dealing with clinical or other medical and 'bio-realmed' concerns. In a story too complex for anything more than mention here, there has also been a loss of confidence among the theologians: 'God-talk7 came to be problematic in new ways, especially during the period in which Anglo-American language philosophies, antimetaphysical as they were, discouraged such talk. The shift in religious power from the kind of mainstream and liberal Protestant and Catholic orbits, where the first words of modern North
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American bioethics were spoken, to religious movements that were more suspicious of science, politics, and the secular, further led to the decline of influence on the part of theologians in the bioethical sphere. Theologian and ethical thinker James M. Gustafson summarized the trend: "Among the moral philosophers whose works have been taken seriously in the past decades, there are none who would base their ethics on theological principles, whether derived from 'natural reason' or from a historical religious tradition". He went on to say that "given the basic assumptions of the philosophical enterprise in the modern Western world, this is as it should be". Even when theology was more vital, the theologians dependent upon revelation had always found it necessary and valuable to link with prevailing philosophies such as Stoicism, Neoplatonism, Aristotelianism, Kantianism, or whatever. Gustafson did note, however, that the trend created problems during "the more radical secularization of Western culture in recent centuries". This resulted from the fact that while there has been "growing knowledge of cultural pluralism and various vital religious traditions, it has not been unreasonable to seek a basis for morality that transcends religious beliefs, one that can be held to by persons holding different religious beliefs and that would appeal to all 'rational' and 'autonomous' agents" (Gustafson, 1981, p. 76). A somewhat unnatural and unrepresentative situation developed, however. There was an ever widening gap between the zones of discourse in which 'academic philosophers' and clinical ethicists debated bioethics and medical ethics on one hand, and those in which the vast majority of the patients and public lived. Gustafson himself noted further that universalizing ethical thinkers were themselves in a way sectarian - my word, not his because they had not come close to arriving at a "moral theory that would be persuasive to all rational agents". Therefore he urged paying more attention "to the historical traditions out of which have come a great deal of the motives and goals for action among humankind" (Gustafson, 1981, pp. 81-82). Many vivid bioethical issues have explicit religious dimensions, as the classic cases in the United States of Karen Quinlan, Baby Fae, Barney Clark, or the Twitchells - with their Catholic, Adventist, Mormon, and Christian Science ties - make clear. Less clearly defined religious communities than the four mentioned there also in-
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fluence ethical decisions and interpretations of illness and health, pain and recovery, but they also are not reckoned with in the conventional academic philosophy and ethical schools. One clinical ethicist in conversation put it this way: When a patient's family is deciding whether to let the D.N.R. sign appear, or, in the crude language, to 'pull the plug on grandpa', they are not likely to invite in the academic philosopher to discourse on beneficence or nonmaleficence in Aristotle or Mill. They are more inclined to ask, 'What does my physician say? What does my minister think? What does my family want?' And these questions are rooted in the historical traditions, often in communities of faith, which have often been muffled, excluded, or self-exiled. AN ALTERNATIVE TO AND A REFUGE FROM LIBERAL CULTURE
Religion has come back, and, to some extent, so has theology, into the fields of medical and health concerns and bioethics. The return will always be limited by boundaries and restraints occasioned by the vast majority of the religious public's adaptation to secularity, its at-homeness in pluralism, and its acceptance of a liberal culture. In other words, few seek a theocracy, hierocracy, clerisy, or even mild religious establishment, and most do not desire all the consequences of giving legal privilege to a particular religion. Political scientist Robert Booth Fowler has given a credible accounting of the public's ease within liberal culture and of the roles citizens assign religion. He defines the liberal culture as including three elements: (1)
(2)
(3)
a commitment to skeptical reason, an affirmation of pragmatic intelligence, and an uneasiness about both abstract philosophical thinking and nonrational modes of knowledge; enthusiasm in principle (and increasingly in practice) for tolerance not only in political terms but much more obviously in terms of lifestyle and social norms; affirmation of the central importance of the individual and individual freedom.
Meanwhile, Fowler continues: religion in America has been, and continues to be, an alternative to the liberal order, a refuge from our society and its pervasive values. Yet, by providing that space from our liberal order, it unintentionally helps that liberal world (Fowler, 1989:4).
Religion, Theology, Church, and Bioethics That is, typical citizens practically favor the liberal culture but find it spiritually unsatisfying. They will ordinarily resort to its modes when allocating resources, supporting research, going about scientific inquiries, or debating medical ethics in the abstract. But they need an alternative to the dominance of those modes. Religion is a refuge not in the sense of an opiate, a permanent hiding place; instead, they use it as armies use retreats, to regather force for new involvements. They will therefore draw upon their faith and community understandings in concrete situations, to provide special motivations, or to establish particular institutions. Yet - and here the academic philosophers and secular humanists can relax - the religious 'help' the liberal culture along because they return to it, having changed it somewhat and themselves more. But the spiritual concerns they bring from their retreats more and more are coming back into the language of bioethics and medical ethics. THE SEARCH FOR PUBLICLY ACCESSIBLE ARGUMENT
Such concerns and language are not reliant on the claims that those in other religious communities or outside the sphere of religion entirely must accept these communities' understandings of a supernatural revelation or what they draw from the magisterium of a particular church, such as the Roman Catholic. Some within the communities may be thus reliant, but they soon falter in frustration because they get no hearing abroad in public and little at home, in their own communities. Pentecostal 'faith-healers' and Christian Science practitioners may be effective, or Jehovah's Witnesses in their opposition to blood transfusions may be convincing, but only to their fellow believers. They are not likely to get public funds for the administration of care based on particular revelations of God, or public support for the arcane (to others) positions they hold. How, then, do serious religious thinkers, theological ethicists, and representatives of professions or the broad membership of faith communities begin to find a hearing on the scene where one kind of academic philosopher or clinical ethicist had dominated and controlled the discourse? Space permits but one illustration, which I shall develop by analogy from political into medical and ethical spheres from the work of Kent Greenawalt. He begins a summary paragraph with the word 'legislation", but here anal-
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ogy comes into play and we can enlarge it to all political, ethical, and medical decision. Legislation, and by extension these other decisions must be justified in terms of secular objectives, but when people reasonably think that shared premises of justice and criteria for determining truth cannot resolve critical questions of fact, fundamental questions of value, or the weighing of competing benefits and harms, they do appropriately rely on religious convictions that help them answer these questions.
Greenawalt notes that the usual mode of referring to the background of argument in a liberal society is to its 'rational' or its 'secularly rational' character. He cites David Lyons, Louis Henkin, Glanville Williams, John Rawls, and Bruce Ackerman as eloquent and effective articulators of such a universe. Thus Ackerman said that "nobody has the right to vindicate political authority by asserting a privileged insight into the moral universe which is denied to the rest of us". Public discourse then has to be nonreligious and rational, for the liberal state is "deprived of divine revelation". Greenawalt agrees. But having argued for the legitimacy of religious discourse in the public sphere, he must then make the case by doing more than simply arguing that secular rationality must have no monopoly. He does this by referring to what he calls "publicly accessible reasons and shared premises", reckoning that these do not all come from the grounding in one particular (postEnlightenment?) brand of secular rationality. In highly qualified ways, Greenawalt contends, appeals to personal intuition, feeling, commitment, tradition and authority, suspect as these are to conventional rationalists, are capable of being addressed in "publicly accessible" ways - and they may do more justice to many ethical situations than does mere secular rationality unnuanced by these other appeals. He chooses animal rights, environmental policy, and abortion as three typical cases in which not all parties in their original position are capable of standing on the premises of such rationality. They need advocates, who may well draw on the other modes of appeal as well (Greenawalt, 1988, pp. 12, 54-55, 24, and passim). Such condensed and cryptic references to Greenawalt may be frustrating to those who look for a complete argument. His work here is used illustratively, not forensically, to show how
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arguments for "publicly accessible" religious claims and contentions are being legitimated. While Greenawalf s approach may seem to be threatening and encroaching to oldline rationalists, some theological critics have come at him from the opposite side, arguing that he need not yield rationality to the secular camp, leaving only intuition, feeling, commitment, tradition, and authority (and one might add community, and more) to religion and theology. Franklin I. Gamwell has both appreciated Greenawalt in general and criticized him on this particular. Audaciously Gamwell attempts what theologians in their prime era were expected to do: to argue theologically and to use reason - also in defense of reason (Gamwell, 1990). Gamwell begins: "However diverse its formulations or radical its disagreements, modern moral philosophy has widely agreed that its task is systematically to articulate a nonreligious basis for the moral enterprise", until in our century "the independence of morality from religion has been largely taken for granted" (Gamwell, 1990, p. xii). He goes on to argue that this dominant consensus is mistaken. His thesis is "that the validity of moral claims presupposes the existence of God". With that challenge to the ethicists' communities, Gamwell also challenges the theists. He contends "that one cannot affirm or deny any moral claim without at least implicitly affirming a divine reality" (Gamwell, 1990, p. xiii). There is here little reference to revelation, to Ackerman's disdained notion of "some conversation with the spirit world" which leaves out those who are "deprived of divine revelation" (Ackerman, x, pp. 127,103). Gamwell will be unsatisfying to those who believe that religious language should be non- or ir- or antirational and wholly derived from divine revelation in some pure 'bolt out of the blue' and hermetically sealed sense. But he does revisit the traditions of reason which were very much a part of theologians' preoccupations in the past and are selectively so in contemporary times. As an historian who no doubt brought trouble among philosophers by adducing Greenawalf s "publicly accessible" notion of religious language, I am aware that I am compounding things by introducing - without his detail - Gamwell's thesis about "the validity of moral claims presupposling] the existence of God". Both cases are cited here in the historians' manner, that is, to point to trends.
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The overall trend has been toward at least some modest recovery of religion in the 'bio-realm'; some reassertion of theology in bioethics; some resolution that churches have a part to play in providing health care; and, more, in interpreting illness and wellness or advocating and embodying measures of justice in delivery of care. For reasons suggested above by Robert Booth Fowler, it is likely that, though these religious, theological, and churchly voices might speak for the citizen majorities found by Dr. Gallup, their own attraction to the rewards of a liberal culture, their own secularity and welcoming of pluralism, the diffidence of their theologians or the atrophy of their skill in using theological language, will determine limits for their involvement. In the mean time, for the many, they will continue, as Fowler noted, to provide alternatives to the Enlightenment mode of understanding and refuge from the colder claims of secular rationality in isolation, even while they continue to provide help for that liberal culture of which they are such familiar and integral parts. REFERENCES Ackennan, Bruce: 1980, Social Justice in the Liberal State, Yale University Press, New Haven, CT. Bellah, Robert N.: 1980, 'Between religion and social science', in Beyond Belief: Essays on Religion in a Post-Traditional World, Harper and Row, New York, pp. 237-257. Berman, Harold: 1974, The Interaction of Law and Religion, Abingdon, Nashville, TN. Carney, Fred S.: 1978, Theological ethics', in Warren Reich, ed., The Encyclopedia of Bioethics, Maanillan, New York, I, pp. 429-437. Cohen, Arthur A.: 1962, The Natural and the Supernatural Jew, Pantheon, New York. Desai, Prakash N.: 1989, Health and Medicine in the Hindu Tradition, Crossroad, New York. Douglass, H. Paul and DeBrunner, Edmund deS.: 1935, The Protestant Church as a Social Institution, Russell and Russell, New York. Feldman, David M.: 1986, Health and Medicine in the Jewish Tradition, Crossroad, New York. Fowler, Robert Booth: 1989, Unconventional Partners: Religion and Liberal Culture in the United States, Wm. B. Eerdmans, Grand Rapids, MI. Gallup, George, Jr. and Castelli, Jim: 1989, The People's Religion: American Faith in the 90's, Macmillan, New York. Gamwell, Franklin I., 1990: The Divine Good: Modern Moral Theory and the Necessity of God, Harper/Collins, San Francisco.
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Creenawalt, Kent: 1988, Religious Convictions and Political Choice, Oxford University Press, New York. Gustafson, James M.: 1981, Ethics from a Theocentric Perspective I: Theology and Ethics, University of Chicago Press, Chicago. McCormick, Richard: 1984, Health and Medicine in the Catholic Tradition, Crossroad, New York. Rahman, Fazlur: 1987, Health and Medicine in the Islamic Tradition, Crossroad, New York. Rahner, Karl: 1970, Theology', in Karl Rahner, ed., Sacramentum Mundi: An Encyclopedia of Theology, Herder and Herder, New York, pp. 233-246. Shipps, Jan: 1985, Mormonism, The Story of a New Religious Tradition, University of Illinois Press, Urbana, IL. Wuthnow, Robert, 1988, The Restructuring of American Religion: Society and Faith Since World War II, Princeton University Press, Princeton, New Jersey.
