Mr. W is 82 years old and has many serious medical problems, including ischemic heart disease, hypertension and diabetes mellitus. He has had a series of debilitating strokes that have left him severely disabled and unable to communicate his wishes. His health care providers feel that he would not benefit from resuscitation attempts if he were to suffer a cardiac arrest and suggest to his family that a do-not-resuscitate (DNR) order be placed on his chart. The devoutly Baptist family are quite upset and reject this suggestion. They believe that God could still heal their husband and father, and they accuse the health care providers of trying to “play God.”

Mr. G is 65 years old and has a history of ischemic heart disease and arthritis. He presents to the emergency department complaining of weakness, frequent episodes of angina and black tarry stools. His hemoglobin concentration is 62 g/L, and an urgent endoscopy shows a duodenal ulcer. The attending physician recommends a blood transfusion, but Mr. G is hesitant, stating that he is a Jehovah's Witness. After discussing the matter with his family and members of his church, Mr. G tells his physician that he does not want a blood transfusion under any circumstances. His physician is concerned that Mr. G does not fully appreciate the potential risks of his decisions and that he is being coerced by his family and friends.

When Martin Luther first challenged the teachings of the Christian church in the early 16th century, few could have predicted the tumultuous consequences. The Reformation was founded on the idea that salvation could not be earned through human effort or bought through indulgences, concepts that were prevalent in the church at the time. The reformers preached that it is by God's grace alone that people are saved. They challenged the authority of the Pope and encouraged their followers to read and interpret the scriptures for themselves.

A wide variety of denominations have grown from these common roots,¹ and Protestant churches have been established throughout the world. The first Canadian Protestant congregations were founded in the mid-eighteenth century by Anglicans and other Protestants immigrating from England, Ireland and Scotland. Lutheran and German Protestants arrived from Germany and Switzerland shortly thereafter, followed by American Protestants from New England. By 1850 over a million Protestants were living in Canada, accounting for more than half of the country's Christian population.² The four largest denominations were Methodist, Presbyterian, Anglican and Baptist, but many other Protestant groups also established a presence in Canada. In 1925 the Methodists, Congregationalists, Unionists and majority of Presbyterians combined to form the United Church of Canada, which has been the largest Canadian Protestant denomination since. The Anglican Church is the second largest Protestant denomination in Canada. Lutheran, Presbyterian, Baptist and Pentecostal churches are also present in significant numbers throughout the country.³

Describing a distinct “Protestant bioethic” is difficult, for a number of reasons. Much of the contribution that Protestant thinkers have made to modern bioethics has occurred subtly, over hundreds of years, as part of the larger Protestant influence on Western culture. The value of autonomy is a good example of this. Protestants have played an important historical role in articulating and promoting this concept, but it is now so widely accepted that it would not be considered a unique feature of a Protestant bioethic.

A second important factor is the secularization of Protestant thought and behaviour.⁴ Mainstream Canadian values and institutions reflect the culture-building role of Protestant churches. Most Protestants would see mainstream bioethics as compatible with their personal values and beliefs.

At the same time, there is tremendous diversity within Protestant thought and theology. The United Church is the most theologically liberal of the denominations, as evidenced by their ordination of women and their acceptance of homosexual clergy. The Baptist and Pentecostal Churches are on the conservative end of the spectrum. Many conservative denominations are fundamentalist, believing the Bible to be literally true. Some Anglican churches are very close theologically to the Catholic Church, while others have adopted different positions on a variety of issues. Many smaller Protestant denominations are notable because of their contributions to Canadian society (the Salvation Army) or their unique culture (the Mennonites).

Sectarian Protestantism describes groups with Protestant origins that have developed distinct theology or practices.⁵ Some have grown to be so different from other Protestant groups that they may question or even reject the label of Protestant. Examples include Jehovah's Witnesses, the Church of Jesus Christ of Latter-day Saints, Seventh-Day Adventists, and the Church of Christ, Scientist. Many of these groups have specific doctrines or beliefs related to illness and medical care. Probably the best known of these is Jehovah's Witnesses' scriptural understanding that believers should not receive blood or blood products. Christian Scientists may reject conventional medical treatments because of their unique beliefs regarding disease and death.

Because it is so difficult to define a “typical” Protestant approach to bioethics, we will instead identify common Protestant beliefs and highlight concepts that have emerged from the Protestant tradition that are particularly relevant to bioethics.

Protestants particularly emphasize that it is through grace that believers are reconciled with God. It is not something they deserve or earn. This does not mean that they do not concern themselves with good deeds or acts of charity. One of the key assertions made by the early Protestant reformers was that all believers are to be ministers or servants to one another and that their beliefs should find an outward expression. A true faith in Christ will give rise to virtues such as love, joy, peace and patience in the lives of believers.⁶

Protestants have traditionally viewed the Bible as their primary source of direction and guidance.⁷ New Testament writings are particularly emphasized, and Jesus Christ is considered the ultimate role model. Biblical principles are understood and applied to daily living through prayer and through discussion with fellow believers.

A second Protestant theme is the value of individual freedom. One of the foundational ideas of the Reformation was that earthly authorities are fallible and that believers should read and understand the scriptures themselves. This historical Protestant emphasis on personal freedom has contributed to the establishment of respect for persons or autonomy as a foundational concept in modern bioethics.¹¹ However, significant differences exist between secular and Protestant conceptions of autonomy. Many secular formulations emphasize personal freedom and argue that autonomy is best served by minimizing restrictions on individual choice. Protestants would argue that autonomy can be fully expressed only in the context of a relationship with God and that individuals must account for their personal relationships and their responsibilities to the larger community.¹²

Protestant ideas about work and vocation have important implications for how the physician–patient relationship is viewed. In rejecting the traditional church structure, early Protestants asserted that all believers should be “ministers” to one another. God's love and compassion is revealed in many different jobs, not just the work of the priest. Medicine is seen as a calling, and the language of covenant is used to describe the relationship between doctor and patient.¹³ Physicians are to be more than “hired guns” or technical experts. They are called to empathize with their patient's suffering and to establish relationships of care and respect that allow them to enter into their patient's world.¹⁴

Many religious traditions rely on historical precedence or guidelines to encourage uniformity of belief and practice. In the Jewish tradition, it is the Torah, Talmud, codes and responsa. Casuistry helps serve this purpose in the Catholic Church. These practices shape the way followers of these religions approach bioethical concerns and dilemmas. In contrast to these highly articulated procedures, one finds a diversity of methods used in Protestant churches.

Thirty-six percent of Canadians identify themselves as Protestant,³ so Canadian physicians will probably encounter Protestant patients on a daily basis. Many physicians and other health care workers also have Protestant beliefs that influence their medical decision-making and their interactions with patients and colleagues.¹⁵

Protestant denominations have built and supported many hospitals and other medical institutions in Canada. Until recently, the Salvation Army administered the “Grace” hospitals in many Canadian cities. The presence of religious organizations in hospital administration and in the provision of acute care is declining across Canada; however, Protestant denominations remain active in other areas of health care, particularly long-term and institutional care.

The more conservative or fundamentalist beliefs of some Protestant denominations differentiate them from other religious (or nonreligious) groups, but these beliefs represent an approach that is distinct from mainstream bioethics and are not representative of the views of all Protestants. Physicians should be sensitive to the fact that the treatment wishes of patients belonging to these groups may differ greatly from those of the majority of their patients. Routine practices and standard treatments may need to be modified to account for these beliefs. Many institutions have special policies for these situations, such as a modified consent process or consent form for patients who do not want blood products under any circumstances.

The influence of Protestant scholars on modern bioethical thought is pervasive. Twentieth century ethicists Paul Ramsey, Joseph Fletcher and James Gustafson have been particularly influential.¹⁶ Ramsey¹⁷ described a deontological approach to bioethics in which he articulated “unexceptionable moral principles.” He wrote on a variety of topics, and his ideas on the value of the individual and the “canon of loyalty” that exists between physician and patient have had a significant impact on subsequent work in the field. Fletcher¹⁸ advocated a situation ethic that closely resembles act-utilitarianism (i.e., the consequences of an action are used to assess whether the action is right or wrong). Fletcher was an Episcopalian who emphasized the need to understand moral issues from the patient's perspective and felt that human freedom and choice were of the utmost importance.¹⁹ Ramsey and Fletcher represented the opposite ends of the polarities of principles versus situation, deontological versus consequentialist and norms versus context. Gustafson²⁰ helped to move the debate forward. He focused on the agent and emphasized the web of human relationships in which the actors are situated. The starting place for his ethical reflections is ordinary human existence rather than church doctrines or scriptural passages. After describing a situation in terms that do not presuppose distinctive religious teachings or authority, Gustafson then asks how religious beliefs and presumptions might influence how the situation is being described, and what weight should be assigned to different values and consequences.²¹ Gustafson provides useful guidance for understanding the thought patterns of many Protestants in the clinical setting.

Patients want their physicians to respect their spiritual beliefs, and they feel better cared for when this important part of their life is recognized.^22,23,24 Including a spiritual history is particularly important when assessing a serious or terminal illness or when making significant treatment decisions.

Because of the influence that Protestant thought has had on Western culture, and the secularization of Protestantism, most Canadian physicians (religious or not) will find that they share many values and beliefs with the majority of their Protestant patients. Examples include the importance of respecting patient's wishes and the value of a caring, empathic relationship between physician and patient.

Physicians should be particularly sensitive to their Protestant patients' beliefs when dealing with end-of-life issues, concerns about consent and refusal of care, and beginning-of-life issues such as abortion, genetic testing and the use of assisted reproductive technologies. Physicians should also recognize that certain Protestant groups and denominations, particularly those with conservative beliefs, may have different approaches to making decisions and unique treatment wishes. Understanding how to elicit these wishes and respond appropriately will enhance patient care and minimize conflict. In these cases the physician should enquire about the patient's personal beliefs and their relationship to their faith community. This discussion will help physicians identify the particular needs or desires of the patient that the physician may not have anticipated. Examples include the avoidance of blood products for Jehovah's Witnesses or a patient's wish to have time to pray with her family before an operation. It also will identify areas of potential conflict that physicians can address before they arise. A withdrawal of treatment may be more easily negotiated if a family's views are understood beforehand. Great care must be taken not to stereotype or generalize. There is a great diversity of Protestant beliefs and a variety of expression of these beliefs. A chaplain from the same denomination as the patient may be an invaluable resource.

End-of-life care Most Protestants are comfortable with a wide variety of life-sustaining treatments and will want them when indicated. Faced with little hope of recovery, most Protestant patients and families understand why health care providers suggest a withdrawal of aggressive interventions and often are in agreement. Many Protestants draw strength from their belief that their loved one will go to Heaven when he or she dies. At the same time, Protestant beliefs have played a role in cases in which families have been reluctant to withhold or withdraw treatment.^25,26 The families in these situations argued that health care providers should not be “playing God.” In one case, the family was hoping that a miracle might occur and that their loved one would be healed.²⁵ Although the reluctance to withhold or withdraw treatment may be the exception rather than the rule, physicians should listen carefully to the family's wishes and proceed cautiously.²⁷ In cases that have gone before the courts, judgements have consistently stated that the wishes of the substitute decision-maker be respected.

Consent and refusal of care When faced with important decisions, many devout Protestants seek to determine God's “will” for their lives through prayer, reading the Bible and consulting with other believers. Health care providers who do not understand this decision-making process may question their patient's capacity to make decisions or feel that their patients are being coerced by friends or church leaders.

Physicians should not assume, however, that such a process is invalid or inappropriate when it leads to what they see as negative consequences. An often cited case in this regard is Malette v. Shulman.²⁸ An Ontario physician caring for a woman severely injured in a motor vehicle collision felt that she required a blood transfusion to save her life. He knew she had a signed card asking that no blood products be given because of her religious beliefs but chose to give the blood anyway. He was sued for battery, and the judge found in the plaintiff's favour.

Although physicians must respect a competent adult's informed decision, this is not the case with dependent minors. An important rationale for respecting adult's religious beliefs is that they may be carefully considered and deeply held. Young children are not seen as capable of this same kind of careful consideration and should not suffer harmful consequences as a result of their parent's beliefs. Canadian courts have affirmed this in many cases, supporting physicians who wanted to give a life-saving blood transfusion to the baby of a Jehovah's Witness despite parental objections²⁹ and agreeing with the Saskatchewan oncologists who wanted to treat Tyrell Dueck's cancer despite the boy's and his parents' refusal.³⁰ In cases involving older children and teenagers, courts may decide that they are mature enough to make their own decisions and allow them to reject care on the basis of their own beliefs.³¹

Abortion, genetic testing and new reproductive technologies Protestant views and practice are particularly diverse when it comes to the issue of abortion. Conservative groups are among the most active in the pro-life movement, as many believe that life begins at conception. Some liberal denominations are pro-choice: they believe that principles such as the right to life and the freedom to choose must be applied and weighed by taking into account the particular circumstances and that, during the first trimester, the decision to have an abortion should be between a woman and her doctor.

Protestant attitudes toward post-conception genetic testing are similarly diverse and often linked to the individual's views on abortion. If there is no situation in which a person would consider an abortion, they may refuse this type of testing. Although some Protestants may object to in-vitro fertilization because of the potential for embryo wastage, many would consider this an option if they were infertile.

This case is similar to a 1998 court case in Manitoba.²⁶ An elderly man with many medical problems was transferred to a rehabilitation hospital. His physicians placed a DNR order on his chart. The man's wife objected to the DNR order, citing religious and personal reasons. She sought a court injunction to remove the order from his chart, which was granted.