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This assignment will focus on introducing you to the question of human dignity and, in particular, the Christian perspective of the intrinsic worth and value of each person. You will have the opportunity to integrate this insight with scientific and philosophical approaches that inform judgements made in health care and contrast it with secular approaches to human value and worth. The logic of human rights will be made explicit as you engage with different concepts of “moral status.”
Based on your reading of the “Case Study: Fetal Abnormality” (attached) and topic Resources, complete the “Moral Status: Case Analysis” (attached) document, in which you will analyze the case study in relation to the following:
- Christian view of the nature of human persons, theory of moral status, intrinsic human value, and dignity
- Theory or theories used by individuals in the case to determine the moral status
- How each theory used determines or influences recommendations for action
- Moral status theory personal response
- Integration of knowledge in health care (theories, multiple ways of knowing, evidence) and knowledge from other disciplines inform and support current or future professional health care practices and judgements
Support your response using only Chapter 2 from the textbook Practicing Dignity: An Introduction to Christian Values and Decision-Making in Health Care and the Topic 2 Resource “The Image of God, Bioethics, and Persons With Profound Intellectual Disabilities.”
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
Moral Status: Case Analysis
Student Name:
After reading of the “Case Study: Fetal Abnormality” and the specific moral status theories in the topic Resources, respond to the following prompts, using only citations from the case and topic Resources:
1. Based on the case and specific moral status theories in the topic Resources, in 450-500 words, what is the Christian view of the nature of human persons, and which theory of moral status is it compatible with? How is this related to the intrinsic human value and dignity?
2. Based on the case, in 200-250 words, which specific moral status theory or theories from the topic Resources are being used by Jessica, Marco, Maria, and Dr. Wilson to determine the moral status of the fetus? What from the case study specifically leads you to believe that they hold the theory or each of the theories you identified?
3. Based on the case and specific moral status theories in the topic Resources, in 200-250 words, how does the theory or each of the theories they used determine or influence each individual’s recommendation for action?
4. Based on the case and specific moral status theory or theories from the topic Resources, in 200-250 words, what theory do you personally agree with and why? How would that theory determine or influence your recommended action in a similar situation?
5. Based on the case and topic Resources, in 200-250 words, how does the integration of knowledge in health care (theories, multiple ways of knowing, evidence) and knowledge from other disciplines inform and support your current or future professional health care practices and judgements regarding moral status issues?
References
© 2024. Grand Canyon University. All Rights Reserved.
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Case Study: Fetal Abnormality
Jessica is a 30-year-old immigrant from Mexico City. She and her husband Marco have been in the United States for the last three years and have finally earned enough money to move out of their Aunt Maria’s home and into an apartment of their own. They are both hard workers. Jessica works 50 hours a week at a local restaurant and Marco has been contracting side jobs in construction. Six months before their move to an apartment, Jessica finds out she is pregnant.
Four months later, Jessica and Marco arrive at the county hospital, a large, public, nonteaching hospital. A preliminary ultrasound indicates a possible abnormality with the fetus. Further scans are conducted, and it is determined that the fetus has a rare condition in which it has not developed any arms and will not likely develop them. There is also a 25% chance that the fetus may have Down syndrome.
Dr. Wilson, the primary attending physician, is seeing Jessica for the first time, since she and Marco did not receive earlier prenatal care over concerns about finances. Marco insists that Dr. Wilson refrain from telling Jessica the scan results, assuring him that he will tell his wife himself when she is emotionally ready for the news. While Marco and Dr. Wilson are talking in another room, Aunt Maria walks into the room with a distressed look on her face. She can tell that something is wrong and inquires of Dr. Wilson. After hearing of the diagnosis, she walks out of the room wailing loudly and praying aloud.
Marco and Dr. Wilson continue their discussion, and Dr. Wilson insists that he has an obligation to Jessica as his patient and that she has a right to know the diagnosis of the fetus. He furthermore is intent on discussing all relevant factors and options regarding the next step, including abortion. Marco insists on taking some time to think of how to break the news to Jessica, but Dr. Wilson, frustrated with the direction of the conversation, informs the husband that such a choice is not his to make. Dr. Wilson proceeds back across the hall, where he walks in on Aunt Maria awkwardly praying with Jessica and phoning the priest. At that point, Dr. Wilson gently but briefly informs Jessica of the diagnosis and lays out the option for abortion as a responsible medical alternative, given the quality of life such a child would have. Jessica looks at him and struggles to hold back her tears.
Jessica is torn between her hopes of a better socioeconomic position and increased independence, along with her conviction that all life is sacred. Marco will support Jessica in whatever decision she makes but is finding it difficult not to view the pregnancy and the prospects of a disabled child as a burden and a barrier to their economic security and plans. Dr. Wilson lays out all of the options but clearly makes his view known that abortion is “scientifically” and medically a wise choice in this situation. Aunt Maria pleads with Jessica to follow through with the pregnancy and allow what “God intends” to take place and urges Jessica to think of her responsibility as a mother.
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2. God, Humanity, and Human Dignity
“Great are you, O Lord, and exceedingly worthy of praise;
your power is immense, and your wisdom beyond
reckoning. And so we humans, who are a due part of
your creation, long to praise you—we who carry our
mortality about with us, carry the evidence of our sin
and with it the proof that you thwart the proud. Yet these
humans, due part of your creation as they are, still do
long to praise you. You stir us so that praising you may
bring us joy, because you have made us and drawn us to
yourself, and our heart is unquiet until it rests in you.”
(St. Augustine of Hippo, ca. 397/2012)
By Nathan H. White and Valerie De La Torre
Essential Questions
What does it mean to be a human being?
Why does a human being have value?
What is meant by the concept of personhood?
What are the practical implications for the value of human beings within
a health care context?
Introduction
Humankind’s restless heart is an invitation to be involved with the human endeavor
and particularly with those who are sick and dying. In caring for other human beings
while loving God, human hearts may feel flooded with the fulfilling praises of God.
Those called as nurses can praise God through their hands, bodies, minds, hearts,
and spirit and will make decisions that may decide life and death. They may even
help others find salvation. St. Augustine writes, “My heart is listening, Lord; open the
ears of my heart and say to my soul, I am your salvation” (St. Augustine of Hippo, ca.
397/2012). This chapter will address why nurses carry this care to others based upon
the Christian belief that every human being is made in the image of God.
One of the main hallmarks of the medical profession is its interpersonal nature.
Medicine is, if nothing else, a very human profession. A nurse gives medicine, offers
comfort to a dying patient, educates patients about their diseases, and walks with
patients through their medical treatment. Interpersonal caring defines the
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experience of the profession. Throughout history, health care professionals have
acknowledged and celebrated the compassionate nature of nursing as its motivation
and foundation.
Although the vocation of nursing centers around caring for other human beings,
medical professionals often do not stop to ask why they are doing what they are
doing or what it is about another human being that warrants the kind of involved and
often difficult care that nurses provide day in and day out. In seeking answers to
these questions, the inherent value of human beings becomes apparent. Nurses
frequently empathize with others and want to do the best for them, and this is to be
applauded. Yet, primarily, the Christian belief that human beings are created in the
image of God, or imago Dei, undergirds the value and dignity of every human being
simply because of his or her existence. This belief suggests certain practical
implications in a range of contemporary health care issues, such as abortion, in vitro
fertilization, the definition of death, and euthanasia. This chapter will begin to
address many of these topics by looking at ways that science, philosophy, and
theology have attempted to answer them.
What Does It Mean to Be a Person?
While the question “What does it mean to be a person?” may, at first, seem to be a
straightforward question, scientists, philosophers, and theologians still debate the
answer. Some perceive a person to be only a physical body with a brain dependent
on the body. This is called naturalism. Others suggest that each person has a body
and a soul. This is termed dualism. Some have more complicated understandings of
the human person that identify the significance of characteristics, such as reason and
the search for meaning, that separate human persons from other living organisms.
Each of these descriptions of a person understands a human being in a different way.
In the field of health care, how health care professionals approach what it means to
be a person uniquely informs treatment options.
For example, if a physician perceives a human as having an eternal soul, practitioners
will craft treatment that involves this spiritual reality. If a person is understood as
having only a physical body, treatment will focus entirely on these options. Every
nurse already approaches a patient with an idea of what a person is, and the goal of
this chapter is to raise awareness of the reality of the personhood that lies within
every patient.
At its most basic level, being a person means that an individual has inherent worth.
The person possesses moral, ethical, and legal rights that a nonperson does not
have. Generally, in the Christian tradition, personhood has been understood as a
substantive nature that all human beings possess. A person may also possess certain
traits, such as faith, reason, moral capacity, and consciousness, that enable deep
mutual relationality with other persons, including God. In the Christian
understanding, personhood is inherent to human beings and is not merely based
upon recognition of certain capacities, such as reason, moral capacity, and
consciousness.
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Worldview and the Question of Personhood
Worldview significantly impacts the understanding of what it is to be human and to
be an individual person. Some believe that God or a transcendent source gives
human beings value. Alternatively, another may understand humankind as simply
being at the top of the food chain, within the closed system of natural selection. Yet
an individual who believes in the existence of God would find God’s nature to be of
primary importance for understanding what it means to be human. On the other
hand, an individual who subscribes to the worldview described as scientism would
assume that science can completely answer the question of what it means to be
human. In each of these cases, the question of personhood is not primarily a
scientific one but, rather, a philosophical one.
Additionally, an individual’s worldview about personhood directly influences
decisions regarding the care and treatment of patients. Nurses and other health care
professionals may think that beliefs and actions separate easily into different boxes
without mutual interaction. In reality, beliefs and assumptions about the world
significantly shape interactions with the world. This is easily seen in health care
situations. If belief in God shapes understanding of personhood, a nurse may display
his or her faith determining the care that is needed based on personal and
professional perception as well as listening attentively to the patient. If a practitioner
perceives a person as being only a physical body, personal interaction with patients
and health care considerations may remain at the level of basic physical care.
For example, in the context of palliative care, what constitutes a human person may
help decide when to withhold or withdraw treatment from a patient. If quality of life
is assumed to be the only consideration for care, treatment could be withdrawn too
early before other methods of comfort care are considered. Alternatively, the
Christian worldview makes it clear that every human being is approached as being
made in the image of God and worthy not only of quality care for physical ailments
but also of complete care for both body and soul.
The Metaphysical Question: What Kind of Thing Is a Human
Person?
The Bible describes the need to reverently consider the mystery of the human
person. Some 3,000 years ago, the writer of the Psalms, prayerfully reflecting on the
finitude of humanity and the mystery of God’s relation to human beings, wrote,
“what is man that you are mindful of him, and the son of man that you care for him?”
(Psalm 8:4 English Standard Version). Yet the psalmist does not specifically relate
what is so special about human beings or what about human nature separates
them from other creatures.
In the postmodern health care situation, nurses will find many understandings of the
human person suggested by other professionals and patients. For example, some
philosophers, such as Hume, have hypothesized that human beings are only a
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collection of perceptions. Some, such as Searle, say humans are the creators of their
own reality, while others, such as Wittgenstein, say that human beings might not
exist at all. All these viewpoints may exist in the health care setting. Yet within the
Christian religious tradition, human beings themselves are inherently deserving of
dignity and respect.
Because, in creation, God made human beings in his image, personhood has a
transcendent origin; therefore, human dignity should be recognized and valued in
all human beings. Practically, the truth of human dignity calls forth respectful
treatment from others. For instance, people who consider themselves as having
dignity would not let others treat them in a demeaning or degrading manner but,
rather, would consider themselves as being worth more than such treatment would
suggest. Thus, individuals would look at themselves as being inherently valuable and
deserving of proper treatment.
Dignity logically relates to the concept of human rights. People rightly view abuses
against human rights, such as genocide, as being among the worst kind of offenses.
But the exact nature of these human rights is not clear. The U.S. Declaration of
Independence suggests that human rights refer to the right to “Life, Liberty, and the
pursuit of Happiness,” but others may consider human rights as being more or less
than this. For instance, some consider the right to life as the most primary of human
rights, while others recently have included access to high-speed internet as a human
right (Human Rights Council, 2016). The range of viewpoints is quite staggering.
Unless practitioners can determine the source of these rights, whether from God or
elsewhere, then there is little reason to ascribe rights to human beings any more
than to any other entity.
A medical professional’s beliefs about what constitutes a human being significantly
impact actions when caring for a sick or dying patient. A person of the Christian faith
sees the human being as a creation of God. In the Bible, the psalmist wrote as a
prayer to God, “I praise you, for I am fearfully and wonderfully made. Wonderful are
your works; my soul knows it very well” (Psalm 139:14a). In the psalmist’s view,
human beings have a special relationship to their Creator who made them in such an
extraordinary way. The relationship of human beings to God and to other creatures
is, then, of utmost importance.
Scientific Classification: Human Persons in Relation to Other
Species
The scientific classification system, based on the ancient Greek philosopher
Aristotle’s thought, divides up entities into various categories based upon observed
traits. The basic differentiation is between the nonliving or the living, with further
differentiation into categories such as animal or plant, vertebrate or invertebrate. In
regard to human beings, the species labelled Homo sapiens, such classification labels
describe shared characteristics between human beings and other animals. This is
helpful to describe what a human being is like, but this does not, in the end, provide
an answer regarding what kind of thing a human being is. For instance, it cannot
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explain why human beings have particular characteristics, such as reason, emotion,
or spirituality.
In his On The Origin of Species (1872/2009), Charles Darwin, the originator of the
naturalistic theory of evolution, attempted to explain human existence without
reference to a divine being. Naturalistic evolution has roots in this system of
taxonomy and views the law of survival as the driving force behind the onward
movement of life itself. Naturalistic evolution, though, fails to answer some questions
fully, such as why human beings exist or how nonphysical phenomena, such as
consciousness, arose from purely physical origins.
Darwin’s Thesis
Published in 1859, the full title of Darwin’s book is quite telling as to its thesis:
On the Origin of Species by Means of Natural Selection, or the Preservation of
Favoured Races in the Struggle for Life.
Human beings, in this understanding, are the most advanced form of life on Earth
but are not the ultimate end to evolutionary progress. One implication of this
viewpoint is that continued human enhancement is not only acceptable but is almost
mandated in the onward march of progress. Another implication follows from this:
human beings are merely one stop in nature’s continuing development in the
evolution of living things. Yet if human beings are not different kinds of things than a
beetle, then there is little ethical reason that they should not both be treated in a
similar manner. If it is ethically justified to kill a beetle, naturalistic evolution provides
little justification for not treating other organisms, including human beings, likewise.
In their assessment of justified ethical treatment for animals, some secular ethicists,
such as Peter Singer (1975), argue animals should receive just as much consideration
as humans.
Theistic Evolution
Some individuals ascribe to belief in theistic evolution, wherein God is
understood to have created all that exists but chose to use the process of
evolution to develop the world to what it is today. This approach resolves some
fundamental difficulties with a naturalistic account of evolution, but it also may
raise other difficulties.
In naturalistic evolution, the existence of phenomena such as the soul, ideas,
conscience, and love are either created by physical factors, such as brain chemistry,
that assist to aid survival or do not exist at all. For example, philosopher Richard
Rorty (1982) wrote,
There is nothing deep down inside us except what we have put there
ourselves, no criterion that we have not created in the course of creating a
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practice, no standard of rationality that is not an appeal to such a criterion, no
rigorous argumentation that is not obedience to our own conventions. (p. xlii)
Thinking, emotions, faith, and self-awareness, then, come merely as a means of
aiding physical survival.
This is a form of reductionism called naturalism in which human persons are treated
as nothing but physical material. This reductionism is an implication of scientism, and
it has negative effects in health care because it reduces human beings to merely a
system of physical phenomena rather than multifaceted beings who should be cared
for holistically. In contrast to reductionism, dualism is a viewpoint that sees human
beings as complex entities consisting of multiple levels; therefore, dualism offers a
foundation for understanding human thinking, emotional awareness, and spiritual
reality.
Dualism
The characteristics that differentiate human beings from other living species are
nonphysical realities, such as mind, soul, or spirit. Dualism views the human person
as being made of both the physical body and nonphysical realities, such as the soul.
The soul is intricately connected with the body but is not identical to the body and
continues after the physical death of the body. In the history of Christian thought,
some thinkers also regard the human person as being comprised of body, soul, and
spirit. Theologians and philosophers debate exactly what constitutes the nonphysical
reality of human beings, with much debate even about the existence of the human
mind. The contents of belief regarding nonphysical phenomena may differ, but that
such a reality exists is affirmed by many.
In recent years, empirical research has supported the reality of human transcendent
phenomena. Modern research has shown the efficacy of nonphysical, even spiritual,
elements in creating beneficial medical outcomes (Koenig, King, & Carson, 2012).
Many medical studies have demonstrated that spiritual and religious activities, such
as prayer, religious service attendance, and meditation, have positive health
outcomes. Alternatively, spiritual maladies, such as unforgiveness and anger, have
corresponding negative physical health outcomes. Additionally, other nonphysical
phenomena that are not specifically related to spirituality, such as expectation,
reappraisal, and worldview, have been shown to have significant effects upon
physical outcomes, including the experience of pain (Tracey, 2010; Wiech, Farias,
Kahane, Shackel, Tiede, & Tracey, 2008).
Many Christians and other religions believe that a spiritual reality exists beyond the
physical; this spiritual reality interfaces with the physical realm, but it is also separate
from it. In this understanding, the human being is more than a body, and some part
of the human being can survive physical death. As an example, in this view, the
human mind is separate from the human brain, though the mind interfaces with and
is in some way dependent on the brain; therefore, damage to the human brain can
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influence expression of the human mind, but it does not eradicate or permanently
damage the mind, the soul, or the human being.
The Question of Value
Many medical professionals perceive human beings as being inherently valuable and
see belief in God as being foundational to their work. They want to ensure the care of
other human beings because each person would want to receive such care. This
attitude has been summed up in the Golden Rule: “The second is this: ‘You shall love
your neighbor as yourself.’ There is no other commandment greater than these”
(Mark 12:31).
Human beings seem to implicitly recognize some aspects of right and wrong,
including the inherent value and worth of human beings. For instance, C. S. Lewis, in
The Abolition of Man (Lewis, 1944/2001), identifies the reality of consistent moral
standards across diverse cultures around the world. Murder, rape, and kidnapping
are almost universally regarded as wrong.
Value and ethical judgments such as these seem to indicate that human beings have
a different status from other creatures. This suggests that human beings should not
be treated in degrading ways. A significant 20th-century example lies in the war
crimes the Nazis perpetrated against millions of Jews, Romani, and others they
deemed undesirable. In the Nuremberg Doctor’s Trial following World War II, Nazi
doctors were charged with crimes against humanity for the genocide and medical
experiments they conducted on innocent victims. Significantly, the Nuremberg Code
that came out of this tribunal set the basic standards for ethical treatment of human
beings in medical and research practice. Standard medical concepts, such as
informed consent, have their origin in this document. Additionally, in the aftermath
of World War II, the United Nations (1948) made a landmark declaration in the history
of humanity regarding “recognition of the inherent dignity and of the equal and
inalienable rights of all members of the human family” (para. 1).
Holocaust
Viktor Frankl (1973), a Jewish psychiatrist who survived the Holocaust, later
wrote:
The gas chambers of Auschwitz were the ultimate consequence of the
theory that man is nothing but the product of heredity and environment
—or, as the Nazis liked to say, “of blood and soil.” I am absolutely
convinced that the gas chambers of Auschwitz, Treblinka, and Maidanek
were ultimately prepared not in some ministry or other in Berlin, but
rather at the desks and in lecture halls of nihilistic scientists and
philosophers. (p. xii)
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If human beings are worthy of any dignity and respect, then reasons for arriving at
this conclusion must exist. In general, there are two ways of reasoning why human
beings have value: a functional view of value and an essentialist view of value.
Functional View of Value
According to the functional view of human value, a person’s abilities determine the
value of that person. For example, a person who has highly developed rational
thinking abilities may be seen as valuable and important to society. Or a nurse’s
ability to educate patients about diabetes or to comfort dying patients will be
understood rightly as making a beneficial contribution.
The problem with functionalism lies in the very logic it uses. By making human worth
contingent upon function, it becomes arbitrary. A person with deficits in rational
thinking abilities may be thought of as less valuable than the person with these
abilities; a person without emotional and social awareness may be perceived as less
than other people. Philosophers call this understanding of a person an extrinsic or
instrumental perspective because it relies on external criteria for determining a
person’s worth. For instance, society could decide the value of a person depending
on his or her actions, abilities, and contributions, though the assessment of these
valuations may change. Alternatively, an intrinsic view of value views human beings
as inherently having worth regardless of abilities.
In Nazi Germany, for instance, a functional view of the value of persons led to the
extermination of the disabled and handicapped. Yet even insulting and degrading
those one disagrees with can also be a subtle form of dehumanization. Others may
be seen as impersonal adversaries rather than human beings with feelings, families,
and inherent worth. Even considering a patient as a number or a symptom rather
than holistically as a human being is itself a type of dehumanization.
Sadly, this extrinsic perspective can be applied to patients without their awareness of
this judgment. For example, if a patient goes through an unsuccessful medical
procedure that leads to extensive brain damage, his or her family must decide about
whether to continue treatment or let their loved one die without intervention.
According to the functional understanding, because the patient’s brain functioning is
now diminished, it would follow that the patient’s value is also diminished.
In another example, when a fetus appears to have few functional abilities, the value
of this fetus may be diminished in the view of the family. This process of perceiving
people at any stage of life as valuable based on their level of functionality can lead to
dehumanization, in which others see the nonfunctioning person as a thing to be
manipulated and even destroyed.
Essentialist View of Value
An essentialist view of human value regards humans as themselves being
intrinsically worthy of value. In contrast to an extrinsic view, an intrinsic viewpoint
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regards human beings as having inherent value apart from any external benefits or
valuations.
The essentialist viewpoint is compatible with Christian belief and undergirds most
approaches to Christian ethics. This is why many Christians believe that abortion,
euthanasia, and genocide are morally wrong because they all are instances of killing
a human being who has inherent value simply by virtue of being human. The kind of
care consistent with the essentialist view of persons is seen in medical professionals
providing hospice care for the dying. In this view, patients’ dignity and worth are
recognized throughout as they near the end of their earthly lives.
Another example of the practical implications of an essentialist view of human value
is the care given to individuals with mental handicaps. Christians believe that people
with severe mental deficits still deserve moral and ethical treatment as fellow human
beings. Yet in a functionalist view of human value, the affording of equal value to
disabled persons makes little sense because these individuals do not have the same
level of functioning as other human beings. The essentialist view of human value, by
regarding human beings as of worth beyond the functions that they are able to
perform, has significant practical implications in medical practice.
Respect for Persons
This brief survey of thought about human beings has argued that persons have
special worth that is bestowed by God. This value is part of the substance of what it
means to be a human being. This is how, in essence, a person is quite different from
a thing. A thing can be used and manipulated; however, personhood suggests that
people ought to relate mutually with one another in an ethical, moral, and respectful
manner. To be a person, then, in part, is to have the ability to be in relationship with
God and others. Human beings have the grace-filled gift of relating to God and to
others, which is a part of personhood.
Those who are deemed to be a person are afforded certain rights and privileges in
accordance with this status. Significantly, many of the standards of care within
modern nursing came about because of human rights abuses in the past. For
example, the actions of Nazi doctors in unethical research led to the drafting of the
Nuremberg Code in which current ideas about autonomy and informed consent
were formed. Later, the National Commission for the Protection of Human Subjects
of Biomedical and Behavioral Research (1978) wrote the Belmont Report that
adopted principles of respect for persons, beneficence, and justice. This report was,
in part, a response to another human rights violation in the Tuskegee syphilis study,
during which the test subjects were not informed of the negative impact participation
in the study would have upon their health. In each case, external oversight boards
felt it necessary to define and delimit the proper treatment of human subjects within
the realm of medicine.
The effects of these guidelines are still evident today when institutional review
boards apply these criteria for the proper treatment of human beings as subjects of
research and medical care. In each case, respect for persons is at the heart of these
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considerations. This means, at a minimum, that practitioners must respect the
autonomy of patients, provide them with informed consent, be truthful, and afford
them courtesy and respect.
Practitioners should see these actions as being fundamental to medical care not just
because these documents say so, but also because it is an inherent duty given the
nature of human beings as persons. In other words, these documents identify what is
already objectively true of human persons—that they have inherent worth and ought
to be treated in an ethical manner. If persons ought to be respected, then
practitioners must have a way to determine who qualifies as the proper recipient of
such respect. Ethicists have utilized the term moral status to identify those to whom
respect and ethical treatment is due. The next section, then, will deal with various
ways that practitioners may make determinations regarding moral status.
Moral Status
Within the medical community, moral status commonly refers to a judgment given
about an individual’s value and rights to be treated according to moral and ethical
standards. For some ethicists, moral status may apply to human beings as well as to
animals and objects in the natural world. If practitioners deem an individual to have
moral status, then there is a moral imperative to treat that person in accordance with
ethical standards. But the most important consideration is how to determine
whether an individual has moral status. This has very practical implications in health
care settings. For instance, when a nurse gives quality and attentive care to a patient,
the nurse is implicitly bestowing moral status upon that patient by recognizing
something in him or her that is deserving of such treatment.
The distinction between functional and essentialist views of human value is a helpful
starting point for determining moral status, but further clarity is needed. Particular
theories of moral status more specifically identify the reasoning behind why a
practitioner believes an individual has moral status. Each of these theories is a
different way of reasoning that an individual possesses moral status and, therefore,
deserves moral and ethical treatment. There are five primary theories of moral
status: the theory based on human properties, the theory based on cognitive
properties, the theory based on moral agency, the theory based on sentience,
and the theory based on relationships.
In the field of nursing, the care that patients receive may change with the moral
status theory subscribed to by the health care professional. For instance, a nurse
may consider whether a brain-damaged patient has the same moral status as a
patient who is not brain damaged. In this case, the medical care that a severely brain-
damaged patient receives could be dependent on how and why the health care
professionals caring for him or her determine whether he or she has moral status.
The Theory Based on Human Properties
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The moral status theory based on human properties has many similarities to an
essentialist view of human value. Both consider human beings as having value
because of fundamental realities that pertain only to human beings. Using the theory
based on human properties, a practitioner would deem an individual as having moral
status simply if that individual is human. In this way of reasoning, a practitioner
would consider unborn children, the elderly, and all human beings as having moral
status because each is human; therefore, a practitioner who uses this theory would
oppose abortion, euthanasia, and destructive medical testing, for instance.
The Theory Based on Cognitive Properties
Alternatively, the theory based on cognitive properties views an individual as
possessing moral status if he or she has certain basic cognitive functions that are
foundational to high-level functioning. An individual may regard the ability to reason
and to communicate as basic cognitive functions that are necessary prerequisites for
moral status. Thus, a person using this theory of moral status may suggest that a tree
does not have moral status because it does not have any cognitive properties, but
neither would a fetus or a brain-dead human being because cognitive functionality is
severely impaired or nonexistent.
The Theory Based on Moral Agency
An individual who subscribes to a moral status theory based on moral agency would
suggest that an individual has moral status only if he or she is a moral agent. That is
to say, the individual must have the ability to make morally significant decisions and
be held accountable to a moral standard. If the individual does not have the capacity
to discern relevant moral information, his or her moral agency is impaired. In one
sense, courtroom discussions regarding an insanity defense are truly about whether
a person who committed a crime can be held responsible as a moral agent. Thus, if
one is not capable of making moral decisions, one does not have full moral status.
The Theory Based on Sentience
Further, other individuals ascribe moral status to an individual based upon whether
that individual is regarded as possessing sentience. A sentient being may also be
described as a being who possesses consciousness in terms of the ability to feel pain
and pleasure and to react appropriately to these stimuli. From this perspective, the
experience of pain is considered evil, while the experience of pleasure is considered
good (Beauchamp & Childress, 2013). Thus, in this viewpoint, a practitioner may
consider a viable fetus, as well as many animals, as having moral status because of
the ability to feel pain. However, if one lacks the ability to feel pain or pleasure, it
follows that they also lack moral status.
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The Theory Based on Relationships
Finally, some would consider an individual as having moral status based primarily on
relationships. This viewpoint suggests that relationality is the fundamental
consideration regarding any individual. This may be understood either in terms of
being the object of relationship or as being the subject of relationship. If an individual
is the object of relationship, this means that other persons relate to this individual as
a fellow bearer of moral status. Alternatively, if an individual is observed as the
subject of relationship, then some would suggest that this individual is deserving of
moral status.
Each of the theories above have the following logical structure: X has full moral status
if, and only if, it exhibits Y. X is the human being in question (i.e., embryo, fetus, 12-
month-old baby), and Y is the property that confers moral status upon that entity
(i.e., human properties, cognitive properties, moral agency, sentience, or a
relationship in which someone else values X). Different worldviews would apply these
theories differently depending on how they think about the nature of human
persons. It may be that thinking about the value of human beings according to such
theories is not compatible with a particular worldview.
Notice carefully that every theory of moral status presented, with perhaps the
exception of the theory based upon human properties, is a functional means of
assessing the value of human persons. Because of this, they stand in contrast to the
Christian view of human beings—an essentialist view of human value—that regards
each human person as having inherent value because humans were made in the
image of God. This judgment is based upon the inherent worth of a human being
rather than on any property that a human being is observed to have.
The Bible on the Nature of Humanity: Divine Image
Bearers
For Christians, the foundation of personhood comes from the view that persons are
created in the image of God. This doctrine of the imago Dei means that God created
human beings to have a likeness to his character not a likeness to his literal physical
appearance. This belief provides the basis for human dignity and worth.
The Image of God
In the account of the creation of the world found in the biblical book of Genesis, the
culmination of the world’s creation is the creation of human beings:
Then God said, “Let us make man [humankind] in our image, after our
likeness. And let them have dominion over the fish of the sea and over the
birds of the heavens and over the livestock and over all the earth and over
every creeping thing that creeps on the earth. So God created man
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[humankind] in his own image, in the image of God he created him; male and
female he created them. (Genesis 1:26–27)
The Genesis creation account views human beings as God’s crowning achievement in
all of creation and as those possessing a special relationship to God. Fundamental to
both Jewish and Christian belief, human beings are described as being made in God’s
image. Theologians and philosophers throughout the ages have proposed various
ideas for what the image of God in humankind is, ranging from the capacity to reason
and think to the ability to act as moral agents, being in possession of a spiritual
nature, and more. One thing is clear: the image of God does not refer primarily to the
physical characteristics of human beings resembling the physical characteristics of
God. Theologians have always upheld the view that God is a spiritual being and
cannot be described in terms of physical characteristics.
Second, the image of God has some relation to the task that God gave to humankind:
to care for the rest of creation. Because all people are made in the image of God,
human beings have been given the authority and ability to do good. Notice how, as
God’s final creation, it is designated for persons to care for and seek the flourishing
of the rest of creation. There is something innate within human nature, then, that
includes a capacity to do good and to help others. Because all persons are made in
the imago Dei, they have personal autonomy and moral agency.
This text from Genesis also provides a relational mandate. God created the world
and then gave humankind the opportunity to partner with God in maintaining and
caring for creation; therefore, the imago Dei also enables a relationship with God who
relates to human beings as fellow persons and, in this capacity, partners with them in
a common task of seeking the flourishing of the world. Thus, being made in the
image of God also means that personhood is derived from God, who first identified
human beings as persons capable of relationship, primarily with God, and
secondarily, with one another. In a very real sense, then, human beings are relational
persons because they are made in God’s image, who is also an inherently relational
being. Relationality is reflective of divine image in human beings, and, in a large
sense, to be human is to be a social creature.
The imago Dei also displays that the foundation of human worth is the grace of God.
In this view, human beings are creatures created by God, not existing of their own
accord or because of random acts of chance. God created human beings because of
God’s grace. Existence, then, is a gift, and even the continuing of human life is
because of God’s sustaining grace. Human hearts continue to beat and lungs
continue to breathe, even during sleep, because of God’s gracious creation and
continued power to sustain human beings in existence. Each human person has a
significant part in cooperatively using the gift of life, but possessing this gift in the
first place is not the result of human effort.
As human beings created in the image of God, human persons are to be treated with
respect and dignity. Sin has marred, but not destroyed, the image of God in
humanity. Because each patient a nurse encounters is created in the image of God,
all patients are to be treated with respect and dignity. Patients are more than their
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diseases or ailments; the patients that nurses care for each day have inherent dignity
because they were created in the image of God. Within the context of medical
practice, nurses should see the imago Dei as being of vital importance because of the
intrinsic value and equal worth that are a result of this view of human beings. For
nurses, discussion about patients should involve words and ideas that maintain the
dignity of the patient. Even in private discussions and meetings among the health
care team, all language should reflect this same respect and dignity.
Body and Soul
A clear implication of the imago Dei is that human beings are more than simply
physical bodies. Because “God is spirit” (John 4:24), being made in the image of God
implies that human beings also possess a nonphysical reality, sometimes described
as a spirit or soul. The Christian understanding of human beings is not an either/or
situation but, rather, that human beings are both physical and spiritual.
Against this understanding, various movements throughout history have tended to
err toward one extreme or the other. Those who emphasize that human beings are
only physical beings, a viewpoint often termed naturalism, deny any nonphysical or
spiritual reality in human persons. Alternatively, others have denied the physical
reality of human beings. These individuals, often called Gnostics, dismiss the
physical world as being inherently and completely evil.
A dualist view of human persons, however, enables an understanding of the
continuity of personal identity. Here, personal identity does not refer to one’s
deepest desires (i.e., to be a mother) or career (i.e., to be a doctor), but rather, it
philosophically refers to what makes an individual the exact person he or she is and
not someone or something else. Consider that various things about a person can
change, such as location, job, health, and desires; however, even with such changes,
people retain their personal identity such that they continue to exist as themselves
because those attributes about them that changed were not essential to them.
Some particularly important attributes about a person might not be essential.
Imagine patients who suffer the loss of limbs because of amputation. While such a
loss would be tragic and painful, these patients do not cease to exist as themselves
after this loss. From a reductionist naturalist viewpoint, the continuity of personal
identity can be difficult to maintain because personal identity is equated, in some
sense, with bodily continuity.
If this is true, then any change to one’s body could mean that one ceases to exist,
which seems incredibly strange. But if human beings are more than a body, just as
the body grows and changes, so, too, do the immaterial aspects of the human person
grow and change throughout one’s lifetime. Nevertheless, throughout all this change,
a human being is the same person. Though a person may gain new experiences and
knowledge, or even gain or lose important body parts through transplantation or
amputation, that person’s essence remains the same. In the Christian view of the
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human being, even after death and the loss of one’s physical body, one’s identity
remains because of the continuance of the soul.
Because human beings have bodies and souls, care of humans must be holistic. In
fact, human well-being has both physical and spiritual facets; therefore, care for the
entire well-being of human beings will involve physical and spiritual components. The
fact of the imago Dei means that, in the Christian vision of humanity, each hum
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an being has intrinsic worth and is to be valued because each one is human without consideration for level of
functionality or benefit provided to others.
Intrinsic Value
The starting point of Christian understanding of human beings is God and what God says about humanity, not what
human beings perceive in themselves or other members of the human race. According to the Christian worldview,
human perception of the world is tainted and imperfect because of the effects of sin and a limited finite viewpoint:
human beliefs regarding the value of a particular individual are not the last word. For Christians, God as the Creator has
the last word regarding the worth of each human being, and God has already spoken regarding each one, making clear
that each has intrinsic worth because each is created by God and bears God’s image. As caretakers of the world, they all
share in God’s creative vision of the world. Thus, human beings are to honor and respect all aspects of creation.
Equal Worth
Because all human beings are made in the image of God, all human beings have equal worth, regardless of physical or
mental ability, status of development, race, sex, educational level, or any other differentiation. In the Christian vision of
the world, the image of God is the basis for equal worth of human beings as well as for human rights. Though
common in Western society today, the idea of inherent human rights that assumes equal worth and inherent dignity
has not been the norm throughout history. One only has to look at the way many Romans treated women and slaves in
the first century or any number of caste systems throughout history to realize that human beings are more prone to
exclude and divide than unite.
This was a significant part of the appeal and growth of the Christian faith in the early centuries. If all human beings have
inherent worth and are of equal value, then they should all be treated the same—with dignity and respect. This is why,
in contrast to the norms of Roman society, early Christians took in and adopted babies who were left to die exposed on
the rocks. It is why women and slaves were given equal status within the early church. It is why early Christians were at
the forefront of medical care as those who created hospitals and pioneered medical care for those without money or
means of payment. In this, they were imitating Jesus’s parable of the Good Samaritan (Luke 15). If the equal worth of
human beings extends to all members of the human race, how much more should equal worth be given to all who have
been unified by faith in Christ? The Apostle Paul put it this way: “There is neither Jew nor Greek, there is neither slave
nor free, there is no male and female, for you are all one in Christ Jesus” (Galatians 3:28).
Moral Status According to The Bible
According to a Christian view of human beings, moral status is afforded to all human beings, regardless of any other
criteria. This dignity is reminiscent of the psalmist’s declaration, “I praise you, for I am fearfully and wonderfully made”
(Psalm 139:14a). The Christian viewpoint is most in accordance with the moral status theory based on human
properties, which likewise recognizes inherent worth in every member of the human race. Similarly, in a Christian
understanding, moral status is a gracious gift extended to every member of the human family because of his or her
existence as a unique creation of God.
Jesus Christ and Human Worth
For Christians, an additional consideration beyond the imago Dei leads them to consider human beings as being worthy
of value: the incarnation of Jesus Christ. Christians believe that God became human in Jesus Christ, who is both fully
divine and fully human. Theologians have termed this mystery the hypostatic union. By becoming human and dying for
the sins of fallen humanity, Jesus demonstrated that humankind is of supreme value—valuable enough for God to
become human and die for their sake.
Because of the fall of humanity, the image of God within humankind had been marred and damaged. Jesus Christ came
to save and heal humanity from their sin and restore what had been broken. Jesus is the “new Adam” (Romans 5:17–18)
who was faithful, whereas the first Adam—from the biblical account in the book of Genesis—had failed. Now, as Paul
says, a Christian is God’s adopted child as he or she “becomes one spirit with him” (1 Corinthians 6:17), transformed
into his image. According to Paul, “For all who are led by the Spirit of God are sons [this infers daughters as well] of
God” (Romans 8:14). The Spirit himself bears witness with Christians’ spirits that they are children of God (Romans
8:16). For Christians, Jesus Christ is the ultimate and essential definition of personhood, or as theologian Dietrich
Bonhoeffer (2005) put it, “To be conformed to the one who has become human, that is what being human really
means” (p. 94).
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This also has implications for nursing care. Many nurses enter this profession knowing that their labors influence not
only the patient they are caring for, but in serving, they also minister to the Son of Man, Jesus Christ. Jesus taught that,
in a mysterious way, by caring for those who are most in need, his followers are caring for Jesus:
Then the King will say to those on his right, “Come, you who are blessed by my Father, inherit the kingdom
prepared for you from the foundation of the world. For I was hungry and you gave me food, I was thirsty and you
gave me drink, I was a stranger and you welcomed me, I was naked and you clothed me, I was sick and you
visited me, I was in prison and you came to me.” Then the righteous will answer him, saying, “Lord, when did we
see you hungry and feed you, or thirsty and give you drink? And when did we see you a stranger and welcome
you, or naked and clothe you? And when did we see you sick or in prison and visit you?” And the King will answer
them, “Truly, I say to you, as you did it to one of the least of these my brothers, you did it to me.” (Matthew 25:34–
40)
Many nurses are enacting this Scripture in the most literal and caring way, “I was sick and you visited me” (Matthew
25:34). When they minister to the least of these, they minister to Jesus Christ.
Christian Reflections
The Christian vision of humanity has significant implications for how human beings are to be treated, including within
the realm of medicine. These implications are wide ranging, extending from how health professionals ought to
approach the task of medicine itself, including approaches to patient care that see the patient as a person possessing
inherent worth and value rather than simply a number or a body, to suggesting ways to view important, current-day
medical issues.
Disability
Contemporary society seems to prize individuals based upon their abilities. Those who are stronger, faster, smarter, or
better at accomplishing certain tasks, such as shooting a ball through a hoop or singing, are assumed to have more
worth than others. In recent years, some opposition to these assessments has begun, with many prizing the underdog,
the powerless, and those with less ability. This has, at times, included championing those with physical, psychological,
and emotional disabilities; however, a potential problem arises in both of these approaches because they both use the
same logic for determining the worth of a human being: both rely on extrinsic means of valuation.
The point is that, for both approaches, the value of persons remains dependent upon ability, whether desirable or not.
Any view that assigns human values based on functional ability rejects a genuine equality of worth among persons;
there will always be someone faster, stronger, smarter, or richer. For example, take the implicit reasoning behind fetal
testing for birth defects, as well as the movement toward so-called designer babies. This testing is not necessarily in
itself a problem, but the implicit values behind it can be. If the reasoning for doing this testing is that a child with what
some may perceive as defects is neither worthy of celebration nor perhaps even life, then from a Christian worldview,
this is not to be accepted (Rae, 2018, p. 205).
In opposition to the tendency to judge the worth of human beings by their level of ability, whether considered positively
or negatively, Christianity affirms the value and dignity of all human beings, regardless of perceived ability or defect.
This is why Christians ought to be at the forefront of celebrating and caring for all people and especially for those who
are disabled. Indeed, this has been the case throughout history.
Care for the Disabled
In the modern era, care for significantly disabled individuals has moved out of the context of the family to
institutional care, and a number of individuals began to see the need for specialized care that embraced those
with disabilities as valuable members of the human race. One such individual was Henri Nouwen, who left a
position teaching theology at Harvard Divinity School to live in a community where he cared for significantly
disabled persons (O’Laughlin, 2005).
Another example is Jean Vanier, who founded the community of L’Arche to embrace and honor the dignity of
those with disabilities (Vanier, 1995). Each saw something inherently valuable in persons with disabilities—a
value that was not being recognized in modern Western culture but from which they learned much about what it
means to be human. These considerations are especially important because a growing concern for many is
caring for individuals with neurodegenerative diseases such as dementia.
John Swinton is a psychiatric nurse and theologian who has reflected extensively on the need to see the image of
God in these individuals who suffer from such terrible diseases. He contends that we can learn much about
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what it means to be human and about how to relate to God as human beings from individuals with disabilities
(Swinton, 2012; Swinton, 2016).
Abortion
The Christian Scriptures provide a consistent account of the worth of human beings from conception onward (Rae,
2018). From the very beginning of Christianity, Christians have opposed infanticide and the killing of unwanted children.
In Roman society, it was common to expose unwanted children to the elements, leaving them in the open countryside
to die. Many of these children were female and undesired because of their gender. Early Christians would often search
for these children, adopt, and raise them as their own (Rae, 2018). The beliefs of the Christians regarding the sanctity of
human life led to practical and costly actions.
Similarly, in the modern era, Christians have often been those individuals most opposed to abortion, which they view
as the killing of unborn children. This is based upon the core Christian belief that all human beings have innate worth
because each is made in the image of God. Thus, all human beings, no matter the stage of development—be they
young or old—are to be treated with respect and their lives valued rather than discarded.
Abortion is a divisive and complex issue. There are many issues at stake, including the autonomy of the mother and the
father—whose rights are often not considered—medical outcomes pertaining to the mother’s health, and more. When
framing the discussion regarding abortion in view of the fetus being a human being with inherent worth and rights,
additional considerations come to light that are often not addressed in similar discussions.
First, by nearly any standard of judgment a practitioner decides to use, the fetus should be recognized as a unique
human entity, not merely as a part of the mother’s body. A standard means of determining what is or is not a part of
someone’s body is the possession of the same DNA and being derivative of the same source. In both cases, the fetus is
clearly a separate entity, possessing different DNA and deriving from an altogether different source than the rest of the
woman’s body.
The Christian worldview consistently emphasizes respect for the powerless and mistreated. This is true in the case of
the disabled, for the unborn, minorities—whether racial, ethnic, gender, or religious—who have been unjustly treated
as well as for the poor. Certainly, Christians, being imperfect people, have not always lived up to this standard, but the
consistent witness of Christians throughout history has been one of loving the least of these and caring for those that
others would exploit.
Mother Teresa
The woman known as Mother Teresa is an example of how powerful an idea the imago Dei is when its
implications are lived fully. Born in 1910 in modern day Macedonia, Mother Theresa devoted her life to service
to God as a nun. She saw the incredible needs of those around her in the Indian city of Kolkata, especially those
living in abject poverty. Recognizing the image of God in those destitute and dying, she began to care for them,
providing medical and palliative care to those on the streets of this city in India that suffers from poverty
exacerbated by dense population. She viewed herself as serving Jesus himself in each patient. After dying in
1997, she was canonized by the Roman Catholic Church, and her legacy lives on in the order of nuns she
founded who continue to do the work of caring for the least of these.
Embryos
The creation of human embryos outside of the confines of the human reproductive system is controversial. This
technological development has been possible only in recent years, and researchers have only begun to consider the
ethical implications of this advance. Questions regarding whether an embryo is a human person have now taken on
added significance given technological advances; however, this is primarily a philosophical question rather than a
scientific one (Rae, 2018).
Given the increasing use of assisted reproductive technologies that create embryos outside of the womb, many are
asking whether these embryos are to be considered human persons. Some would suggest that embryos may gain
moral status at some point within gestation in the womb, such as at implantation. But there is no clear point at which
to make this determination.
Others would point to fetal viability as the point at which a fetus gains moral status, but advances in neonatal
technology mean that fetal viability is moving earlier and earlier in gestation. In fact, it would seem that, starting from
conception, embryonic life needs only shelter and sustenance to continue to grow and develop (Rae, 2018). This alone
is a strong argument, from an essentialist view of human value, for embryos to be considered human persons.
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One major area in which the use of human embryos is involved is in relation to stem cells. The use of stem cells to
treat various diseases, and even to grow human tissue, is one of the fastest expanding and most promising areas of
medical research. Yet it is also an area that is fraught with potential ethical problems. Adult stem cells may be derived
from mature cells via bone marrow, but embryonic stem cells are derived from human embryos and most often
destroy the embryo in the process, creating the potential problem of assessing whether human life had to be destroyed
in order to provide for or sustain another’s viability.
For some who do not recognize the human nature of embryos created uniquely in the imago Dei, such ethical
considerations are not challenging. But for those who acknowledge embryos as having innate worth, this approach to
medical research can be problematic. Now that stem cells may be derived from sources other than human embryos,
the ethical problems as well as possibilities of stem cell research are greatly changing (Regalado, 2019). The use of
human embryonic stem cells to assist in reproductive technologies is a growing dilemma within the field of health care
and will only become more difficult as various worldviews clash in making these decisions.
Assisted Reproductive Technologies
An issue intricately connected with the use of human embryos is the question of technological assistance for those
unable to conceive naturally. Infertility has always been a significant challenge for many wishing to produce their own
child. At times, such as in antiquity, infertility was the central issue for those who could not bear children and produce a
secure heir. Consider, for instance, the biblical stories of Abraham, an important leader who had no heir, and Hannah, a
woman who was barren; both were individuals of great faith who were unable to have children, and they wrestled with
God regarding this issue for many years.
For those who struggle with infertility, these issues are as important as they were for these biblical ancestors. This
means that the advent of assisted reproductive technologies is both increasingly welcome and needed; however, the
ethics of the use of these technologies is debated today. Some faith groups do not allow the use of assisted
reproductive technologies at all, others may find only some procedures acceptable, and still others may not be
opposed to any.
At the heart of many of these concerns is a consideration of the difference between procreation and reproduction (Rae,
2018). Traditionally, procreation was seen as a human task that was ultimately directed by God. Reproduction, on the
other hand, is increasingly seen as a specifically human task, achieving humanly desired results. These distinct
viewpoints on the nature of human reproduction are at the basis of differing attitudes toward assisted reproductive
technologies.
Some assisted reproductive technologies concern aiding the physical functionalities of sexual reproduction. This is the
case with treatments that alter the biological workings of the human reproductive system as well as with procedures
such as intrauterine insemination, in which human reproductive organs are aided in their functionalities to ensure
greater likelihood of fertilization.
Other assisted reproductive technologies take a more invasive approach to addressing more significant reproductive
issues by directing and overseeing the reproductive process itself. This is the case with in vitro fertilization (IVF) in
which eggs are stimulated and harvested, fertilized in a laboratory setting, and transplanted into a maternal uterus.
This infertility treatment and others, such as zygote intrafallopian transfer (ZIFT), gamete intrafallopian transfer
(GIFT), and intracytoplasmic sperm injection (ICSI), involve significant medical intervention to aid human
reproduction.
With the exception of GIFT, these procedures include the fertilization of an egg and creation of an embryo outside of
the human reproductive system. One potentially problematic issue concerns what is done with the other embryos
created as a part of this process but, ultimately, were not implanted. Some of these embryos are destroyed, others are
kept in seemingly permanent storage, while others are donated to science for use in research in which they will
effectively be destroyed.
Indeed, the use of stem cells in assisted reproductive technologies has been in process for some time but has only
become viable quite recently (Foht, 2019). Some researchers see the creation of embryonic stem cells as merely a step
in the trajectory toward producing designer babies (Regalado, 2019; Rae, 2018). If so, a future that includes this
prospect may not be as far away as some might think. This technology could give rise to the possibility of eugenics—the
coordinated effort to purify the genetic makeup of a population, such as the Nazis undertook—in levels of specificity
scarcely dreamed of before. With these technological developments, practitioners and ethicists must judge these
advances and their consequences.
Case Study: Maternal and Fetal Viability
A young married couple, Tina and Jeff, recently moved into their first house. Starting his career in the financial
services industry, Jeff has been doing well in this job. Tina enjoys her job at a Christian school as an elementary
school teacher. In her twentieth week of pregnancy, Tina now prepares for a leave of absence.
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On Tina’s drive home from school one day, she pulls out of the school parking lot when another driver,
distracted by his phone, collides with her car. Despite nearly being in a head-on collision, both Tina and the fetus
are alive. Tina has sustained severe head trauma and is unconscious when paramedics arrive at the scene.
Jeff rushes to the hospital, and doctors tell him that his wife has sustained significant injuries to her brain and
may never fully recover. Medical personnel intubate and closely monitor Tina. The fetus appears to have been
spared major injuries, but doctors cannot assess the full extent of injuries at this time. Physicians are concerned
the fetus may have sustained internal injuries that could cause significant disabilities or other health issues.
Further, they are concerned for Tina’s health and recovery, which is complicated by her pregnancy.
Reflective Questions
1. Should Tina’s pregnancy continue, or should Jeff consider abortion as an option, both for the sake of
Tina’s health and out of concern for the viability of the fetus?
2. Does the fetus have moral status and deserve continued medical treatment, or is the viability of the
fetus questionable enough to merit Jeff focusing primarily upon restoring the health of Tina?
3. What is the Christian view of the worth of human persons?
4. How might different moral status theories lead Jeff to make different decisions?
Conclusion
In modern Western society, the worth of human persons is often taken for granted, especially by those in helping
professions such as nursing. Yet the presumption of human worth is not something that practitioners or ethicists
should take for granted. In this age of relativism, medical practitioners cannot assume that all people grant others
moral status based on intrinsic human properties or the image of God in humanity. Many medical professionals make
moral decisions based on consequentialism’s idea of quality of life in which ethical decisions are made by evaluating
the perceived consequences upon human well-being. Understanding the reasons for these developments, as well as
the reasoning that undergirds them, can enable health practitioners to be more aware of their own thoughts regarding
human worth and can strengthen their resolve to continue to care well for their patients because of their innate worth.
If modern history teaches anything about human tendencies, it is that human beings can easily push aside
considerations of human worth in favor of expediency or the pursuit of personal goals. The Holocaust, the Tuskegee
experiment, and, arguably, the prevalence of legalized abortion displays the human capacity for evil and the
dehumanization of other persons. Yet, in the face of these evils, Christians have often stood up for the value of human
life, even sacrificing their own time, energy, and selves in support of others’ lives. This witness is far from perfect, but its
presence, today as well as in history, displays a counternarrative to dehumanization.
In the medical field, this witness is prominent through individuals such as Florence Nightingale, the mother of modern
nursing, whose faith was the impetus for and the sustainer of her care for the sick. The question to medical
practitioners in the future will be whether the value of human life will remain a preeminent value in society, supporting
the central purpose of medicine in life-saving and healing. Other considerations may significantly crowd out this
fundamental concern, but the decisions made by medical practitioners and researchers today will have drastic effects
upon generations to come for both those who receive health care and for those who provide it. What will be the legacy
that they leave behind?
Additional Resources
Banner, M. (2014). The ethics of everyday life: Moral theology, social anthropology, and the imagination of the human .
Oxford University Press.
Beckwith, F. J. (2007). Defending life: A moral and legal case against abortion choice. Cambridge University Press.
Best, M. (2012). Fearfully and wonderfully made: Ethics and the beginning of life. Matthias Media.
Cherry, M. J. (2017). Created in the image of God: Bioethical implications of the imago Dei. Christian Bioethics: Non-
Ecumenical Studies in Medical Morality, 23(3), 219–233. https://doi.org/10.1093/cb/cbx009
Colson, C. (2009, July 27). Quality control: Imago Dei and health care costs. Christian Headlines.
https://www.christianheadlines.com/news/quality-control-imago-dei-and-health-care-costs-11606587.html
Cortez, M. (2010). Theological anthropology: A guide for the perplexed. T&T Clark.
Frankl, V. E. (1984). Man’s search for meaning. Washington Square Books. (Original work published 1959)
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Hollinger, D. P. (2009). The meaning of sex: Christian ethics and the moral life. Baker Academic.
Kaczor, C. (2015). The ethics of abortion: Women’s rights, human life, and the question of justice (2nd ed.). Routledge.
Kilner, J. F. (2015). Dignity and destiny: Humanity in the image of God. Eerdmans.
Kilner, J. F. (Ed.). (2017). Why people matter: A Christian engagement with rival views of human significance. Baker
Academic.
Lee, P., & George, R. P. (2009). Body-self dualism in contemporary ethics and politics. Cambridge University Press.
Meilaender, G. (2013). Bioethics: A primer for Christians (3rd ed.). Eerdmans.
Pellegrino, E. D., Schulman, A., & Merrill, T. W. (2009). Notre Dame studies in medical ethics: Human dignity and
bioethics. University of Notre Dame Press.
President’s Council on Bioethics. (2008). Human dignity and bioethics: Essays commissioned by the President’s Council
on Bioethics.
https://repository.library.georgetown.edu/bitstream/handle/10822/559351/human_dignity_and_bioethics
Shelly, J. A., & Miller, A. B. (2006). Called to care: A Christian worldview for nursing (2nd ed.). InterVarsity Press.
Stahl, D., & Kilner, J. F. (2017). The image of God, bioethics, and persons with profound intellectual disabilities. The
Journal of the Christian Institute on Disability, 6(1–2), 19–40. https://store.joniandfriends.org/product/image-
god/
Swinton, J. (2012). Dementia: Living in the memories of God. Eerdmans.
Swinton, J. (2016). Studies in religion, theology, and disability series: Becoming friends of time: Disability, timefullness,
and gentle discipleship. Baylor University Press.
van Inwagen, P., & Zimmerman, D. (2007). Persons: Human and divine. Oxford University Press.
Wolterstorff, N. (2010). Justice: Rights and wrongs. Princeton University Press.
Key Terms
Abortion: In this context, understood as the elective act of killing a human fetus while still in its mother’s womb.
Abortion may take place surgically or chemically, such as through the use of RU-486. Technically illegal for most of U.S.
history, abortion was legalized within the United States in the monumental Roe v. Wade Supreme Court verdict in 1973.
Roe v. Wade was subsequently overturned in 2022. The legality of abortion is currently a matter of local and state
legislation.
Assisted Reproductive Technologies: Aids to human reproduction created by scientific advances. These may range
from chemical interventions within the human body to producing human reproductive functions completely apart from
the human reproductive system. Some faith traditions do not believe that the use of such technologies is ethical, while
others consider many of these technologies to be allowable.
Belmont Report: A document written by the National Commission for the Protection of Human Subjects of Biomedical
and Behavioral Research in 1978. It provides an overview of fundamental ethical principles for conducting research
involving human subjects and suggests that the three essential principles in this work are respect for persons,
beneficence, and justice. This document remains foundational for the United States Department of Health and Human
Services as well as for institutional review boards.
Continuity of Personal Identity: The unity of a person’s individual identity across his or her lifespan and even beyond
death. This means that, although persons grow and change throughout their life, they also remain the same. The
continuity of personal identity is crucial for the concept of personhood and is intricately tied to an immaterial soul.
Disability: A deficiency in full human functioning. This may be a physical deficiency, such as an inability to walk, or a
cognitive-behavioral deficiency, such as dementia. For adherents of a functional view of human value, a disability would
result in lessened human worth. But for those who subscribe to an essentialist view of human value, a disability does
not decrease human value.
Dualism: A metaphysical point of view concerning human beings that understands humans to be made of nonphysical
attributes, such as a soul, in addition to physical attributes. In opposition to the viewpoint of naturalism, dualism sees
nonphysical human attributes as being just as integral to human beings as physical attributes.
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Embryo: An early stage of development of an unborn offspring. An embryo develops from a zygote (i.e., fertilized egg).
In an essentialist view of human value, an embryo is considered a human person because it possesses all the potential
to become a mature human being. Recent developments in assisted reproductive technology have enabled the creation
of embryos outside of the human reproductive system. Embryonic stem cells may also be derived from embryos, but
the embryo is destroyed in this process.
Essentialist View of Human Value: A view that understands human beings as being inherently valuable because of
their status as human beings. Such a view, similar to an intrinsic valuation of human worth, finds value in the essential
nature of human beings rather than in the functions that humans may provide. Thus, a human being’s essence is
something deeper than his or her functions or abilities. From a Christian point of view, the imago Dei present in all
human beings is the basis for an essentialist view of human value that recognizes humans as being unique in this
valuation among all creatures.
Extrinsic Value: (Also instrumental value) The use of external criteria for determining the worth of an entity. If an entity
has extrinsic value, it is valuable only to the extent that it provides some benefit or may be used to accomplish a
desired end. Extrinsic valuation fundamentally differs from intrinsic valuation.
Fertilization: The process of a human sperm entering a human egg and the creation of a zygote. Many believe this to
be the beginning of a new human life. Fertilization may occur as a result of natural human reproduction, but more
recently, technological advances have enabled fertilization to occur outside of the human reproductive system in
laboratory conditions, enabling a range of assisted reproductive procedures.
Functional View of Human Value: A view that appraises the worth of human beings based primarily upon the
function that an individual may provide. Akin to an extrinsic (instrumental) valuation of human beings, such a view sees
uniquely human functions such as the ability to reason, make independent decisions, act as a moral agent, and be
creative as being the aspects of human beings that make them valuable. In this view, the loss of these functions, as in
the case of an individual with a severe disability, consequently, reduces the value of that human being.
Gamete Intrafallopian Transfer (GIFT): An assisted reproductive procedure in which sperm and eggs (i.e., gametes)
are surgically transferred to the fallopian tube.
Gestation: The time that an implanted embryo grows and develops within the womb. Gestation can also be
understood as the time between conception and birth.
Gnosticism: An early pseudo-Christian sect that denied the Incarnation and essential physical nature of Jesus Christ
and, instead, prized the spiritual over the physical, which they believed to be wholly evil; therefore, those who were
enlightened sought to divest themselves of their physical human trappings by either fully embracing or alternatively
denying their carnal passions because they deemed only the spiritual to be of value. Many derivative philosophies exist
and are often termed pseudo-Gnosticism or nontraditional Gnosticism.
Human Dignity: The belief that human beings are the proper objects of respectful treatment. Dignity is especially
important for medical professionals because it is the motivation for proper care. Dignity itself refers to rendering due
esteem proper to the status of an entity. Beyond innate worth, the concept of dignity suggests an attitude of respectful
reverence that is based upon an acknowledgement of the mysterious nature of human existence. Rather than being
automatically given, dignity is based upon the inherent worth of human beings but requires a choice on the part of
others to recognize. Dignity is closely related to a mandate to care.
Human Nature: The conglomeration of characteristics that, together, form what it means to be a human being. The
term may be used to identify innate tendencies, abilities, or faculties common to all human beings but should not be
confused with the theological term sin nature that identifies humans as having an inherent bent toward sin.
Human Rights: Those freedoms understood to be inherently deserved by all human beings. Theologians often identify
these rights as being bestowed by God. Identification of the existence of human rights largely took place in the modern
West, particularly because of its Judeo-Christian heritage, and was further cemented through events such as the
Nuremberg Trials following Nazi persecution of Jews in World War II. Although the existence of human rights is now
often taken for granted, the particular identity of these rights is not agreed upon.
Image of God: (Latin, imago Dei) The Christian doctrine explaining that all human beings, regardless of age, race,
gender, religion, or any other qualifier, were created in God’s image and, therefore, possess inherent worth. This
understanding is grounded in the biblical creation account in the book of Genesis that describes Adam and Eve, the first
human beings, as created “in the image of God” (Genesis 1:27). Theologians have understood the imago Dei to be
related to a variety of human attributes including rationality, sociality, moral agency, and spirituality; however, the
significance of the imago Dei lies not in these properties but, rather, in the inherent value of human beings.
Implantation: The conjoining of an embryo into the uterine wall of a female human being.
In Vitro Fertilization (IVF): An assisted reproductive procedure in which an egg is stimulated, retrieved, fertilized with
sperm outside of human reproductive systems, and transferred to a maternal uterus. The first successful IVF procedure
occurred in the late 1970s.
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Intracytoplasmic Sperm Injection (ICSI): A treatment for male infertility in which a single sperm is injected into the
cytoplasm of an egg. After fertilization, embryos may be transferred to a maternal uterus. ICSI differs from in vitro
fertilization (IVF) in that sperm naturally penetrate the egg in IVF treatment.
Intrauterine Insemination: An assisted reproductive procedure in which sperm are placed in a woman’s uterus to aid
fertilization by decreasing the sperm’s travel time to the egg and increasing the number of sperm that reach the
fallopian tubes.
Intrinsic Value: A means of assessing the worth of an entity based solely upon the inherent worth of the entity and
valued independently from any benefit or detriment that the entity may provide. Intrinsic value is contrasted with
extrinsic, or instrumental, value. If an entity has intrinsic value, it has worth inherently and for its own sake.
Moral Agency: The ability to make morally significant decisions. This includes, but is not equated to, autonomy
because, in addition to being able to make a decision, the agent must also be able to weigh the moral ramifications of
decisions.
Moral Status Theory Based on Cognitive Properties: A manner of reasoning that utilizes the presence or absence of
cognitive abilities as the basis for determining moral status. From this viewpoint, if an entity possesses key cognitive
properties, such as consciousness and the ability to reason or to communicate, a practitioner may reasonably
determine that the entity has moral status.
Moral Status Theory Based on Human Properties: A method of determining whether an entity has moral status
based upon whether that entity possesses human properties. These properties may be physical in nature (e.g., DNA),
relational in nature (e.g., parentage of the entity), or nonphysical (e.g., possession of reason, consciousness, or moral
agency). This moral status theory is generally considered to be the most compatible with Christian belief.
Moral Status Theory Based on Moral Agency: A means of identifying moral status that recognizes the ability of an
entity to act as a moral agent as the key determining factor in assigning moral status.
Moral Status Theory Based on Relationships: A theory that perceives the fact of and/or the ability to be in
relationship with others as the most important factor in determining moral status. In this way of thinking, the
relationship that one has with an entity gives significance and worth, understood in terms of moral status, to that
entity. In turn, the reciprocal relationship of that entity to other beings who possess moral status is an exceedingly
important consideration.
Moral Status Theory Based on Sentience: A theory in which the sentience of a being is the most significant factor for
determining whether an entity has moral status. Some ethicists view human beings as the only entities capable of
sentience, while others also identify some animals as sentient beings.
Moral Status: A determination regarding an entity in which certain ethical obligations are due to it because of its status
as a moral being. Some philosophers argue that moral status may apply to animals and other members of the natural
world in addition to human beings. Practitioners may use various methods of reasoning to arrive at a conclusion about
whether an entity does or does not have moral status.
Naturalism: A metaphysical viewpoint that understands the world, including human beings, as consisting of only
physical matter. This view excludes the possibility of nonphysical elements such as soul, god, or a spiritual realm. Any
seeming occurrence of nonphysical phenomena would be considered merely an illusion rather than a substantive
reality. In this view, the physical world is the only source of reliable knowledge or truth.
Person: A designation that recognizes an individual as being intrinsically worthy of dignity and respect. Historically,
philosophers have used Boethius’s (ca. 524/2007) definition of a person as “an individual substance of a rational
creature” (Chapter III, para. 1) as a starting point for defining personhood. This suggests that person is a designation
that is inherent and is not merely based upon recognition of certain capacities, such as reason, moral capacity, and
consciousness; however, personhood is a prerequisite for an awareness of others as the potential recipients of mutual
relational interchange. The term may be applied to human beings or to other sentient beings, such as God, and carries
with it certain religious or spiritual, moral, ethical, and legal responsibilities.
Personal Identity: The substance of an individual as being distinct from any other person. Such identity is both static—
meaning that a person at age 2 is also the same person at age 64—and dynamic—meaning that a person at age 64 has
changed drastically from the person he or she was at age 2. For the Christian, personal identity is understood to be
maintained even beyond death because of the continuance of the soul. It also can have a spiritual origin because
personal identity can be given by God (see Revelation 2:17).
Respect for Persons: An integral part of proper understanding of personhood. Identification of an entity as a person
necessarily also requires treatment of this person with dignity and respect. In part, this is because of the relational
nature of personhood in which identification of an entity as a person is also identification of that person as the proper
object of relationship. In part, respect for persons means that practitioners ought to honor their patients’ autonomy,
provide them with informed consent, be truthful, and afford them courtesy.
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Secular: A term often used as the opposite of sacred to mean something that is not based upon religious beliefs or
tenets. A secular understanding of the world, for instance, would view the world without regard to God, religious
considerations, or the obligations that these beliefs would entail. The secular and sacred are not necessarily at odds
with one another and can denote general areas of responsibility.
Sentience: The ability to perceive pain and pleasure and to react appropriately to these stimuli. From this perspective,
the experience of pain is evil, while the experience of pleasure is good. Thus,
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19
The Image of God, Bioethics,
and Persons with Profound
Intellectual Disabilities
D e v a n S t a h l
Michigan State University
J o h n F . K i l n e r
Trinity International University
Abstract
All people are created in the image of God, which gives every human being a
dignity that can never be lost or diminished. This article develops a biblically
sound understanding of what it means to be in God’s image. Next, it explores
how important such an understanding is for people with disabilities. Finally,
it traces out a number of implications of that understanding for people with
profound intellectual disability.
Keywords: agency, destiny, dignity, image of God, intellectual disability,
justice, relationality
Devan Stahl, Ph.D. (St. Louis University), M.Div. (Vanderbilt Divinity School) is Assistant Professor of
Clinical Ethics at the Center for Ethics and Humanities in the Life Sciences, Michigan State University.
She chairs the Bioethics and Christian Theology Affinity Group of the American Society for Bioethics
and Humanities and has published on genetics and disability. stahldev@msu.edu
John F. Kilner, Ph.D. and A.M. (Harvard University), M.Div. (Gordon-Conwell Theological Semi-
nary) is the Forman Chair of Theology and Ethics, Professor of Bioethics & Contemporary Culture, and
Director of Bioethics Programs at Trinity International University. His 20+ books include the recent
award-winning Dignity and Destiny: Humanity in the Image of God (Eerdmans, 2015).
19
© 2017 Joni and Friends, Agoura Hills, CA. Used with permission.
All rights reserved. Additional reproduction is prohibited.
20
© 2017 Joni and Friends, Agoura Hills, CA. Used with permission.
All rights reserved. Additional reproduction is prohibited.
The Image of God, Bioethics, and Persons with Profound Intellectual Disabilities
From The Journal of the Christian Institute on Disability (JCID) Vol. 6.1-6.2 – Spring/Summer & Fall/Winter 2017
The biblical affirmation that all people are created in God’s image has long
been a liberating force in the world, as documented in Dignity and Destiny
and Why People Matter (Kilner 2015, 2017).1 It has inspired people to respect
and protect the dignity of every human being. The creation of humanity in
God’s image, rightly understood, makes a huge difference for people with
profound intellectual disabilities (PID)2 in particular. It endows them with a
dignity that demands humanity’s attention and best efforts in support. It re-
quires of others—who are also created in God’s image—that they reflect such
divine attributes as love and justice in their individual and societal response
to the needs of those with such disabilities. If this is the case regarding the
most readily-disparaged people with profound disabilities, then people with
disabilities of all sorts stand to benefit as well. The problem is that misun-
derstandings related to the image of God have too frequently neutralized
its liberating power and even fostered oppression. Identifying and guarding
against such misunderstandings must first take place if humanity’s creation
in God’s image is to foster humanity’s flourishing, to God’s glory.
The common, basic misconception here is that being in God’s image
is about how people are (actually) “like God” and “unlike animals.” This
view understands being in God’s image in terms of attributes that people
have now, most commonly people’s ability to reason, rule over (manage)
creation, be righteous, or be in relationship. In this view, sin can damage
such attributes and thus damage God’s image. Accordingly, people vary in
the extent to which they have these attributes—and are in God’s image. For
many, that means how much people warrant respect and protection as those
in God’s image varies from person to person. The door to devastation is open
as soon as people begin to define being in God’s image in terms of currently
having God’s attributes. People who are lowest on the reason, righteousness,
1. The present essay draws upon some of the material presented in Kilner 2017, which is a chap-
ter-length summary of parts of the fuller account in Kilner 2015—the fuller account providing
substantially more documentation and illustration than space here permits. Material from Kilner
2017 used by permission of Baker Academic, a division of Baker Publishing Group.
2. The Diagnostic and Statistical Manual on Mental Disorders (DSM-5) and the American Associa-
tion on Intellectual and Developmental Disabilities (AAIDD) agree that “[i]ntellectual disability is
a disability characterized by significant limitations both in intellectual functioning (reasoning,
learning, problem solving) and in adaptive behavior, which covers a range of everyday social and
practical skills” (AAIDD 2017). DSM-5 classifies the severity levels of intellectual disability, also
known as intellectual developmental disorder, as mild, moderate, severe and profound, based on
adaptive functioning conceptual, social and practical domains (APA 2013, 318.2 F73). Generally,
persons with profound intellectual disabilities have an IQ score of 20 or below as well as poor
adaptive functioning, such as extreme difficulty with language development, social skills and
performing daily tasks.
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© 2017 Joni and Friends, Agoura Hills, CA. Used with permission.
All rights reserved. Additional reproduction is prohibited.
The Image of God, Bioethics, and Persons with Profound Intellectual Disabilities
From The Journal of the Christian Institute on Disability (JCID) Vol. 6.1-6.2 – Spring/Summer & Fall/Winter 2017
rulership, relationship, or similar scale are deemed least like God and least
worthy of respect and protection. This way of thinking has put people with
disabilities in great jeopardy, particularly people with PID.
The problem here is not that a biblical idea has proven to be destructive,
but that an unbiblical idea masquerading as a biblical idea has proven to
be destructive. This unbiblical idea is at odds with what the Bible’s authors
mean by being created in God’s image and how they employ this concept in
life situations. Accordingly, this article will first develop a biblically sound
understanding of what it means to be in God’s image. Next, it will explore
how important such an understanding is for people with PID. Finally, it will
trace out a number of implications of that understanding for people with
such disabilities.
What It Means to Be in God’s Image
When the Bible talks about something being an “image,” that means it has a
connection with something else in a way that may also involve a reflection
of it. Being the image “of God,” in particular, means having a special con-
nection with God as well as being a substantial reflection of God. Having a
special connection is significant, because mistreating the image means one
is mistreating the original. Being a substantial reflection is significant, since
that means the image displays attributes (capacities, traits, abilities, etc.) of
the original to the extent that it is able. The idea that being an image sig-
nifies having a special connection is evident, for example, in Daniel 3:1-7,
which reports the Babylonian King Nebuchadnezzar erecting a large image
in the province of Babylonia. Kings in the ancient Near East would periodi-
cally erect an image to establish their presence as rulers where they were not
physically present (Clines 1968; Middleton 2005, 104-7).
The other element often present in an image is the way that it provides
a reflection of certain attributes of the original. In Old Testament times,
images often displayed something about a king. In Daniel 3, the great height
and gold surface of the image reflected the king’s grandeur and wealth. When
the New Testament refers to Christ as God’s image, both connection and
reflection are in view. In Colossians 1:15, for instance, Paul straightforwardly
affirms that Christ “is the image of the invisible God.”3 Christ’s special con-
nection with God is so close here as to constitute oneness. Moreover, Jesus is
a substantial reflection of God—someone who can be seen, in contrast with
3. Unless indicated otherwise, all quotations of the Bible are from the New Revised Standard Version.
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The Image of God, Bioethics, and Persons with Profound Intellectual Disabilities
From The Journal of the Christian Institute on Disability (JCID) Vol. 6.1-6.2 – Spring/Summer & Fall/Winter 2017
the “invisible God” (Kelsey 2009, 966). The text surrounding 2 Corinthians
4:4 similarly communicates that Christ’s image-of-God status involves con-
nection with, and reflection of, God.
Being vs. Being in God’s Image
Whereas Christ “is” God’s image, the Bible states people are “in” or “accord-
ing to” God’s image. The insertion of a preposition indicates people stand in
some relationship with God’s image. The image-related passages in Genesis
(1:26; 1:27; 5:1; 9:6) consistently insert a preposition between people and the
image. Image-related passages in the New Testament directly or indirectly
referring to Genesis (e.g., James 3:9; Col. 3:10) also insert a preposition.
It’s not plausible that in each of these passages the author is simply
saying that people are God’s image, as if there were no prepositions there,
and no need to add them.4 In fact, prepositions such as “in” or “according
to” make quite a difference. Saying that someone is in the water is quite dif-
ferent from saying that someone is the water. Saying that a violin is according
to a paper blueprint is quite different from saying that the violin is a paper
blueprint.
The Bible’s authors use prepositions to distinguish the rest of humanity
from Christ. With Christ not overtly in view as a reference point in the Old
Testament, the recognition there would simply have been that people are not
yet God’s image but are created “according to” 5 the standard of who God is
(in order to reflect God’s attributes to God’s glory).6 In the New Testament
it becomes clearer that Christ as God’s image is the standard to which people
need to conform. James 3:9 is particularly significant on this point since it
conveys a New Testament author’s summary of how the Genesis idea should
be understood.7
The Impact of Sin
Failing to take seriously the distinction between Christ being God’s image
and humanity being in God’s image has contributed to overlooking a second
important distinction—that sin has damaged people, not damaged God’s
image. If people were God’s image, then by damaging people, sin would
4. For further explanation, see Hughes (1989, 21).
5. The standard Hebrew and Aramaic Lexicon of the Old Testament by Ludwig Koehler and Walter
Baumgartner (2001, 104) specifies that “according to” is the best rendering of both prepositions,
be and ke, in image-of-God passages in Genesis 1 and 5.
6. On the importance of this distinction see McDonough (2009, 91).
7. On the harmony of 1 Cor. 11:7 with this understanding, see Kilner (2015, ch. 3) and Hughes (1989, 22).
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© 2017 Joni and Friends, Agoura Hills, CA. Used with permission.
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The Image of God, Bioethics, and Persons with Profound Intellectual Disabilities
From The Journal of the Christian Institute on Disability (JCID) Vol. 6.1-6.2 – Spring/Summer & Fall/Winter 2017
plausibly damage God’s image. However, if people are created in (i.e., accord-
ing to the standard of) God’s image, there is no damage done to the standard
just because people are later damaged.
There is ample discussion and documentation in the Bible regarding
the destructive impact of sin on people. Yet, at the same time, there is every
indication people remain “in God’s image”—that no harm has been done
to this status or to the image on which it is based (see Gen. 5:1; 9:6). People
retain a special connection with God (though their relationship with God
is badly damaged), and God still intends for people to reflect likenesses to
God (though in actuality they largely fail to do so). The image of God is the
standard of who people are created to be—embodied in the person of Christ—
and that standard is not diminished in any way because of sin. Similarly, in
sanctification it is people who are being renewed. God’s unchanging image
is the standard for that renewal (see Rom. 8:29; 2 Cor. 3:18: Col. 3:10).
What Exactly Is in God’s Image?
People, then, are created in (according to) God’s image, in a way unaffected
by their fallenness. “People” (the “adam” of Genesis 1:27) refers not only to
a single man named Adam but also to humanity as a whole. Contemporary
readers can easily miss this point if they are located in societies like the
United States that emphasize individuals, personal freedom, and autonomy.
Connecting God’s image both to humankind as a whole and to each of the
humans who constitute that “kind” of creation guards against a destructive
over-emphasis on individuals or collectives.
Equally important, being in God’s image has to do with people as entire
beings (whether humanity as a whole or its component members are in view).
There is no suggestion that being in God’s image is constituted by particular
“attributes” people have or once had (i.e., abilities, traits, capacities, or other
things that people are, do, etc.). Select attributes (even if God-like) are not
what are in God’s image—persons as a whole are.
As we will see in the following sections, people with disabilities are espe-
cially at risk of being demeaned and oppressed when particular attributes
rather than persons are considered to be in God’s image. The (generally
unspoken) logic is that since attributes like reason, sensory abilities, and
strength are what make people in the likeness of God and worthy of protec-
tion, those deficient in such attributes are not as valuable as others. A similar
logic is at work concerning one’s degree of wealth, skin color, etc.8 Biblical
8. Regarding this logic, see Cortez (2010, 282-83).
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© 2017 Joni and Friends, Agoura Hills, CA. Used with permission.
All rights reserved. Additional reproduction is prohibited.
The Image of God, Bioethics, and Persons with Profound Intellectual Disabilities
From The Journal of the Christian Institute on Disability (JCID) Vol. 6.1-6.2 – Spring/Summer & Fall/Winter 2017
affirmations that all people are created in the image of God provide a ringing
denunciation of basing people’s significance on their particular attributes.
As Martin Luther King, Jr. (2000, 88) has observed, “there are no gradations
in the image of God.”
Image and Likeness
Being “in God’s image” is actually an abbreviated way of referring to the
biblical idea of being “in God’s image and likeness.” Because two terms are
involved here, some people have mistakenly thought they refer to two differ-
ent ideas. However, there is ample biblical and external evidence to confirm
there is a single idea here that falls within the range of meaning of each term.
Either term alone is sufficient to refer to this idea.9 Nevertheless, that idea
does have two aspects, related to connection and reflection.
First, some sort of special connection between God and people is in view
here, as previously explained. However, an image may or may not have any-
thing to do with being like (i.e., sharing the traits or other attributes of) the
original. Including “likeness” with “image” communicates the kind of im-
age in view here somehow has to do with likeness to the original. It ensures
reflection as well as connection are a part of the concept. The reflection
cannot be referring to people’s actual reflection of God’s attributes today,
however, because that is damaged by sin and varies in degree from person to
person. Rather, the focus here is on God’s intention—who God wanted people
to be at creation and still wants them to be today. Being created in the image
and likeness of God—or in the image of God, for short—is thus about special
connection and intended reflection. People have a special connection with
God and God intends them to reflect God’s own attributes to the extent that
they are able. The tremendous significance of human beings is completely
secure, rooted in God’s unwavering intentions rather than in variable current
human capacities.
Being in God’s image is not unrelated to the actual capacities, relation-
ships, and functions that people have—but having those things is what nor-
mally flows from being in God’s image, it is not what defines it. People who
lack those things are not any less “in God’s image” than anyone else, because
of what it means to be “in” (i.e., “according to”) God’s image. It means that
God’s image (revealed to be Christ in the New Testament) provides the stan-
dard for their existence and their growth. To whatever extent they fall short
9. See Kilner (2015, 124-28).
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The Image of God, Bioethics, and Persons with Profound Intellectual Disabilities
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of fulfilling that standard, God intends more for them and offers them the
means now and eternally to become more.
Why Being in God’s Image Matters
The implications this understanding of God’s image has for how best to
view and treat people are extensive. Every person matters precisely because
each has a special significance that comes from being in God’s image. This
is not the dignity that varies according to circumstances, but the dignity
that necessarily accompanies being human. Since God’s image has a cor-
porate dimension to it and is not just something true of particular people
by themselves, humanity’s existence in God’s image entails that everyone
has this special significance. There is a basic equality among members of
the human community. This does not mean that people should consider
everyone to be equal or identical in every respect; rather, it suggests “that
they deal with each person as uniquely sacred and ignore all claims to special
sanctity” (Niebuhr 1996, 155). As ethicist Hans Reinders observes, human-
ity’s creation in God’s image signifies “in the loving eyes of God… there are
no marginal cases of being ‘human’” (Reinders 2006, 124). People who are
socially marginalized need not define themselves by their circumstances or
the demeaning viewpoint of those who would oppress them.
Such dignity is the foundation for the often-misunderstood concept
of human rights. Tying rights closely to a clear sense of the dignity of all
people is important. Otherwise, rights claims can degenerate into mere as-
sertion of self with no regard for others. Human rights are really God’s
rights over humanity more than one person’s rights over another. God is
every person’s creator, so God is the one to direct how people treat one
another. People have rights; but contrary to much secular thinking, they
do not have a right to those rights. Those rights flow from the God-given
dignity rooted in creation in God’s image. Moreover, just as humanity is not
merely a collection of separate people but is also an interrelated whole, so
humanity’s status as created in God’s image has implications for the whole
of humanity. God intends justice to be a hallmark of human society, as it is
of God’s own character. How the weakest people in a community are treated
is an indicator of the extent to which a community is living out its status
as created in God’s image.
People never warrant less than what justice requires, but they frequently
warrant more—they warrant love. Love is essential to who God is, and is
God’s ultimate intention for relationships of people with one another and
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with the natural world as well. Love involves giving more than the minimum
required and requires more than utilitarian maximizing of social benefit. It
generates true solidarity and communion. Such social blessings are as much
human rights as are personal protections and provisions. Not only do all
warrant receiving love because they are in God’s image—they also must love
others for the same reason. People can empower others to love themselves—
and their neighbors as themselves—by helping them to recognize everyone
as created in God’s image.
Implications for Persons with PID
Persons with PID are among those created in God’s image and, as a result,
warrant special care and welcome. They have an image-based dignity that
does not waver, regardless of their ability or potential ability (Yong 2007, 173;
Rodriguez 2008, 50). Persons with disabilities have a special connection with
God, and God intends them to become a reflection of God as well. For per-
sons with disabilities, as for others, God’s intention must await resurrection
after death before it can be completely fulfilled. Humanity’s creation in the
image of God can make one of its most powerful differences in this world
long before then, however, as people live out their image-related status by
caring for those with PID.
Apart from the biblical affirmation that all are created in God’s image,
the rights of all individuals are not secured and our duties toward other
persons remain unclear. If people do not believe human worth is externally
conferred, then they must look to internal characteristics to establish what
about human beings makes them unique and, therefore, worthy of respect.
For centuries, philosophers and theologians have tried to discover which
human characteristics set “persons” apart from “non-persons” and give the
former a unique dignity. Unfortunately, regardless of the characteristics se-
lected, some humans are necessarily left out of the “personhood” category
as a result. They are thereby considered devoid of human dignity and so not
due the respect and protections that such dignity requires.
Past Mistreatment
Where people have understood being in God’s image (and thus human worth)
in terms of the rational capacities that humans possess, persons with PID are
often deemed less worthy of respect and protection (Hall 1986, 108-9; Brink
2001, 93). Some Christian leaders in the history of the church, such as Thom-
as Aquinas, have considered the image of God in mentally-compromised
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people to be “practically nonexistent” (1947, I.93.8).10 The result has been a
degrading of all people with intellectual disabilities—a denial of their dignity
(Primavesi 2003, 187; Hilkert 2002, 78). This has led to their exclusion from
activities and communities in which they ought to be able to participate
(Moore 2003, 106). They have been viewed at best as “marred images,” re-
sulting in “perilous” outcomes (Reynolds 2008, 177).
Given this background, it is not surprising that when disabled people
gathered at a symposium in Sheffield, England to compare their experienc-
es, they repeatedly reported not being viewed or treated as “made in God’s
image” the way that other people are.11 As one participant painfully tried
to understand the source of the discrimination that she regularly experi-
ences: “I became disabled—so was I once in God’s image, but am no lon-
ger?” (Davies-John 2003, 124). Her experience participates in a long history
in which some Christian leaders such as Emil Brunner have denied that
normal protections apply to people with profound disabilities (e.g., those
who are “grossly retarded”) because of the compromise to God’s image that
they consider to have occurred.12 Apparently Martin Luther even advocated
drowning a “feebleminded” 12-year-old child because his severely limited
mental capacities appeared to evidence corruption of his reason and soul.13
Such treatment of people with disabilities was characteristic of the culture
in which the early church developed,14 and has offered an influential pattern
for the church’s treatment of people with disabilities whenever Christians
have reduced being in God’s image to particular attributes.
The Nazi holocaust is another powerful historical illustration of how
the idea of humanity in God’s image invites destructive misuse when people
understand it to be referring to current human attributes. Adolf Hitler, as
part of developing his approach to the weaker members of society in his 1927
book Mein Kampf, identifies the stronger members of society as “images of
the Lord.” In contrast, the weaker members for Hitler are mere “deformities”
10. See discussion in Hoekema (1994, 37).
11. This symposium, a fruit of a World Council of Churches initiative, is discussed in Mayland (2003, 211).
12. For Brunner (1952, 57), the protection of being in the image of God “ceases where true hu-
man living ceases—on the borderline of imbecility or madness.” Wennberg (1985, 131), reflecting
on whether all people are fully in God’s image and so have full moral standing, concludes: “the
grossly retarded… need not be assumed to possess a moral standing as full as that of a normal
human adult.”
13. Luther (1952, 387) reports this in a write-up of one of his famous “Table Talks.” See discussions in
Kanner (1964, 7); Towns & Groff (1972, 38-39).
14. As Seneca (1995, 32) affirmed in the first century: “We destroy abnormal offspring at birth; chil-
dren, too, if they are born weak or deformed, we drown.” Cf. discussion in Ferngren (2009, 101).
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From The Journal of the Christian Institute on Disability (JCID) Vol. 6.1-6.2 – Spring/Summer & Fall/Winter 2017
of that image to be “cleansed” from society (Hitler 1939, 606). What resulted
in Nazi Germany were categories of people who were untermenschen (subhu-
man), those in whom the attributes that constituted God’s image were most
deformed, marred, distorted, etc. They became the targets of Nazi efforts to
eliminate people with disabilities or other frailties through neglect, forced
sterilization, or killing.15
Dietrich von Hildebrand was one of a relative few in Germany at the time
who recognized that it was precisely the biblical teaching that all of humani-
ty continues in the undeformed image of God that offered the greatest defense
against Hitler’s destructive initiatives. As he wrote, soon after being forced to
flee Nazi Germany in 1933: “All of Western Christian civilization stands and
falls with the words of Genesis, ‘God made man in His image.’”16 Hildebrand
was exceptional among Christians in his recognition of the importance of
understanding God’s image in a way that excluded the possibility of it being
diminished. Sad, laments ethicist Lisa Cahill (2006, 58), has been “the dev-
astating refusal by Christian theology to attribute the fullness of the imago
Dei” to groups such as the millions exterminated in Nazi Germany.
The Current Challenge
Today, Christians must be cautious in assuming biology alone informs the
abilities, capacities, and potentialities of groups of people. What is deemed
“natural,” “normal,” and deserving of moral attention may be dictated by
persons in power whose interests are self-serving. The dignity of persons with
PID remains precarious. Within the arena of bioethics, which is a field that
helps to shape medical responses to persons with disabilities, debates con-
tinue over the need for prenatal screenings to detect and potentially abort
fetuses with genetic disabilities (Buchanan et al. 2000). Similar debates ad-
dress the ethical rights of parents to euthanize newborns with disabilities
that are expected to be profound (Giubilini and Minerva 2013). Naturally,
secular bioethicists do not appeal to the image of God when determining
whether disabled newborns lack personhood, but the logic is analogous.
Much like those who claim the image of God is damaged in some persons,
15. Many influences helped to shape Hitler’s thinking, including the government-run program
of forced sterilizations of intellectually disabled people in the United States. During the Nurem-
burg Trials, that program was a primary precedent to which those defending the actions of Hitler
and his followers appealed. See http:/buckvbell.com and Lombardo (2008). Others have noted the
very same idea so captivating to Hitler—that God’s image can be damaged—has continued to be
influential up to the present, to the detriment of the weakest people in society (Yong 2007, 173)
16. As translated in Crosby (2006, 9).
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philosophers and bioethicists debate the qualities and characteristics that
comprise “personhood.” According to many philosophers (see McMahan
2003), one can be a human (a member of the species), but not a person (a
being worthy of moral status). Non-persons, the thinking goes, should not
be granted the same moral and legal status as persons. Without the belief
that all humans have inherent dignity, people who do not measure up to
some people’s definitions of personhood are vulnerable to social neglect
and violence.
Without the presumption that all persons, regardless of their capabili-
ties, warrant protections, some bioethicists have felt free to argue, based on
quality of life standards, that some lives should be ended or at least prevent-
ed (Singer 1993). Moreover, many bioethicists and medical professionals
drastically underestimate the quality of life experienced by persons with dis-
abilities and many discount the direct testimony of people with disabilities
who describe the quality of their lives (Goering 2008). There is a continuing
presumption in much of bioethics that self-determination is so bound up
with well-being that persons who are unable to make autonomous choices
will remain “unfulfilled” human beings (Ho 2008). For some bioethicists,
dignity is a useless term, because respect for dignity is really just respect for
autonomy (Macklin 2003). The trouble is that persons who cannot exercise
autonomy are not afforded the same dignity as those who can. The ability of
persons with PID to flourish or live the good life, therefore, seems severely
limited if not impossible, given the psychological abilities that are commonly
valued in contemporary culture.
The contention that persons with disabilities should not be abandoned,
should not be killed, and should be recognized as a marginalized group de-
serving of basic human and civil rights is not universally recognized. Some
bioethicists argue persons with severe impairments should not be consid-
ered persons with moral status, while others work to discredit the disability
rights movement. For example, in their book From Chance to Choice: Genetics
and Justice, four leading bioethicists claim the disability rights movement
should not be considered a civil rights movement because impairments (un-
like gender or race) are innately disadvantageous (Buchanan et al. 2000).
For the authors, creating a just community does not require adjusting so-
cial frameworks to include people with “major impairments,” because the
changes required for accommodation would upset our economic system
and disadvantage able-bodied people (see also Amundson & Tresky 2007).
The logic goes that for the able-bodied to flourish, the rights of persons
with disabilities must be denied. Lacking a common understanding of the
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universal dignity of all persons, a corresponding ethic that requires all per-
sons be accommodated so they can have the means and space to flourish is
not advocated.
Without a God who grants dignity as a gift to all people, it is difficult to
find a purely rational basis for why anyone should treat all persons justly or
why anyone would believe that people simply have dignity rather than believe
people must earn, express, or be given dignity by others (Kilner 2017). To say
that all people have an essential dignity turns out to be a belief statement.
When Christians ask what makes them human, or what unites all persons as
human beings, they must respond that it is God who makes people human
and, therefore, God who confers dignity. Unless Christians insist all people
are fully in God’s image, they ultimately cannot take it for granted that each
and every person, regardless of her capabilities, capacities, or potentialities,
is worthy of dignity and care.
Justice and Destiny
Once Christians have established that all people have dignity as a result
of being made in God’s image, the real work of discovering what it means
to honor that dignity can begin. As previously stated, humans’ dignity is
bound up with their destiny, and so honoring one another’s dignity also
requires working together toward a shared destiny. For Christians, destiny
involves the Kingdom of God. In the Kingdom of God people will live as
God intended them to live, in just and loving relationship with one another
in the likeness of God. The Kingdom is a state of being where persons as
individuals and as a community are conformed to Christ. The already-but-
not-yet nature of the Kingdom is analogous to human creation in the image
and likeness of God. Just as being in God’s image is simultaneously about
who human beings presently are and who they are destined to be, so too is
the Kingdom of God part of both the present and the future. Although it
is God who brings about the Kingdom and not human beings, humans can
represent the Kingdom communally by living in just relationship with one
another and with all of creation.
Unfortunately, the idea of the Kingdom of God has sometimes been
used as a way to further marginalize persons who do not fit into the domi-
nant structures of society. As noted previously, many communities that fail
to recognize all people as being in the image of God have become commu-
nities that reject certain people. They have even attempted to eliminate the
people they believe prevent the community from flourishing. This was not
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only true of the Nazi regime, but it has been true of American Christians
who believed certain people could prevent the Kingdom of God from ar-
riving. In the 1920s, many Christians who supported the Social Gospel
movement found themselves to be natural allies of the American eugenics
movement. One of the most prominent ministers of the early 20th century,
Rev. Harry Emerson Fosdick, praised eugenics’ “humanitarian desire to take
advantage of the scientific control of life so as to change social conditions
that mankind may be relieved from the crushing handicaps which now
press it” (1922, 87). For Fosdick and others, impairments or “handicaps”
were seen as impediments to the Kingdom of God. Accordingly, persons
with certain impairments needed to be sterilized so they could no longer
hinder the flourishing of the community. Rather than working to build
communities in which all people could participate, many Christians have
historically attempted to remove the individuals they believed prevented
the rest of the community from flourishing. If, however, the way in which
Christians treat the least powerful among them is a reflection of how they
honor God, then exclusion or elimination is an inadequate response to
God’s creation. Any theological ethic that excludes certain people based on
their inabilities or inherent limitations fails to appreciate God’s intention
for humanity in creation.
All human beings are in some sense limited, because they are not yet
who they are destined to be in God’s Kingdom. The resurrection promises to
transform individuals. Within the biblical narrative the exact nature of this
transformation is unclear. What Christians do know is that they shall be like
Christ (1 John 3:1-3). Theologians from Tertullian to Augustine to Aquinas
have speculated about how our future eschatological bodies will look and
function, and many have assumed the resurrected body will be free of what
humans consider to be frailties (Yong 2007, 266). The danger of seeing the
resurrected body as perfectly “able-bodied” is that doing so hinders people
from seeing everyone now as fully in the image of God and appreciating the
goodness of embodiment as humans currently experience it. For persons
with disabilities, the promise of a future ‘cure’ or ‘fix’ to their bodies or
minds only serves to reinforce the understanding that they are defective and
more in need of transformation than their able-bodied counterparts.
When considering persons with Down syndrome, theologian Amos
Yong provocatively suggests the perfected body promised in resurrection
might retain the marks of disability or even their phenotypic traits and
that persons with disabilities will be recognized for their proper role in
God’s natural order and within the communion of saints (Yong 2007, 282).
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“The norm will be the resurrected Christ,” Yong contends, “not our con-
ventions of able-bodiedness (2007, 274).” Too often, Christians confuse
the eschatological body with the young, powerful, and beautiful bodies
that Western culture prizes. Yong’s ontological understanding of the res-
urrected body is debated,17 but his aim is to press what it means to be in
the image of God as a person with a disability and how our eschatologi-
cal imagination shapes the ways we interact with and make room for all
people (2012).
We do not know how our future bodies will appear, but Christ’s
wounded body testifies to the fact that the resurrected body will be both
identifiable and surprising, continuous and discontinuous with our cur-
rent selves. If Christ’s own resurrected body continued to bear his wounds,
then there is no reason to believe that our own resurrected bodies will
not continue to bear the marks of our own embodied experiences. Jesus’
resurrected body was not exactly disabled—he did after all walk through
walls and conquer death. And for people, bearing the image of God in
Christ will ultimately include reflecting such intended attributes as trans-
formed “spiritual” bodies and imperishability (1 Cor. 42-49).18 Yet, Jesus’
wounds bear testimony to God’s love and vulnerability (Swinton 2011,
284). Somehow in Christ’s body, woundedness and wholeness are compati-
ble, undermining the idea the resurrected body will conform to our current
understanding of able-bodied normativity (Yong 2007, 274).
Agency and Relationality in Human Destiny
If, as people in God’s image, Christians are charged with working toward
their own flourishing as well as the flourishing of others, how can persons
with PID participate in this flourishing? Although there is a tendency in
disability theology to prize relationality over rationality, not all persons are
capable of mutual relationship in the ways most people commonly under-
stand it. Protestants in particular are often keen to assume being created
in the image of God is about relationship, because the triune God created
while the three persons of God were in mutual relationship (Westermann
17. In opposition to Yong’s vision of the resurrected body, certain theologians contend dis-
ability is not ontologically essential to a person’s identity, and, therefore, can be eliminated in the
resurrection without doing violence to a person’s identity (Mullins 2011). Yong counters that
the accidental features of our lives “shape our identities in indelible ways,” and to separate our
embodiment from our identity is “Platonism (at best) or Gnosticism (at worst)” (2012, 8).
18. See Kilner (2015, 299-310).
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1994). But just as being in the image of God cannot be reduced to ra-
tionality, it also cannot be reduced to relationality. Relationships come
from, rather than constitute, being in God’s image (Kilner 2015, 217).
The problem with prizing relationship as the key identifier of creation
in God’s image is that relationship often implies the intellectual capacity
to understand one’s self as separate from others and to act intentionally
with others (Haslam 2012). Not all persons are capable of such self-aware-
ness and agency.
In attempting to describe what makes persons in the image of God,
some theologians have specified that all persons have the capacity for
rationality and relationality, even if they have not actualized those capac-
ities. The trouble with this line of reasoning is twofold. First, it assumes
that being in the image of God requires actually having a set of identi-
fiable capacities (rationality, relationality, and so on). Second, it implies
persons who lack such capacities are ontologically defective. The first
problem has already been addressed throughout this article. As for the
second problem, if being in the image of God is about the origin and telos
of human life, then those who cannot participate in their telos will be seen
as deficient. In discussing Kelly, a young girl he met with microcephaly,
Hans Reinders (2008, 92) explains,
Even when questions regarding the protection of human beings
like Kelly can be effectively answered on the grounds that she is
of human descent, this does not answer the question of what it
means for Kelly to lead a human life. . . . We do not only need to
identify her origin as a human being; we also need to ask how she
participates in our final end as a human being.
If Christians cannot meaningfully explain how Kelly participates in her fi-
nal destiny, then they must believe she, and those like her, are fundamen-
tally defective and must await a radical transformation in the resurrection.
We would do better to recognize that because all persons are created
in the image of God, there is a way to understand persons with PID as
participating in their own destiny. If, on the grounds of our shared status
as created in God’s image, Christians believe no person is fundamentally
defective, then they must acknowledge it is possible for people with PID
to participate in that destiny now. This acknowledgment has two impli-
cations. First, Christians must develop a theological anthropology that
does not preclude persons with PID from being understood as human
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The Image of God, Bioethics, and Persons with Profound Intellectual Disabilities
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in the fullest sense. Second, Christians must work to create communities in
which all persons are able to participate in their flourishing.19
Working to ensure that all people have the opportunity to participate
in their image-related destiny will require careful attunement to the needs
of a diverse group of people. All persons are limited in ways that prevent
them from being fully conformed to Christ (Creamer 2009). There will not
be a one-size-fits-all method for accomplishing this work. It will require:
(1) seeking out persons who are particularly marginalized and giving their
needs ethical priority; (2) getting to know people and their particular needs;
(3) removing the barriers that prevent people from fully participating in
society; and (4) entering into loving friendship with persons with PID.
First, as previously mentioned, justice requires both understanding the
social context in which people live and giving priority to the weakest people
in the community. Justice does not require treating all people equally; it may
require giving preferential treatment to those who are least advantaged in
society. There are clear indicators that our society disadvantages persons
with disabilities, particularly persons with intellectual disabilities. Rather
than looking to how individual impairments limit persons, we may instead
consider how impairments lead to persons being disabled in society. Even in
developed nations, persons with intellectual disabilities have suffered health
inequalities as well as higher rates of mortality and morbidity, in part be-
cause of barriers they experience in accessing health care (Ouelette-Kuntz
2005; Sutherland, Couch, and Iacono 2002; Krahn, Hammond, and Turner
2006). Persons with intellectual disabilities are more likely to experience
socioeconomic disadvantage and social exclusion (Leonard and Wen 2002;
Emerson 2004; Fujiura and Yamaki 2000). Due to the general lack of social,
political, and educational support that persons with intellectual disabilities
and their families experience—as well as the devastating effect this can have
on their health, economic status, and general well-being—the vulnerability
of this group demands special attention by the Christian community.
Of course, neither “disabled people” nor “people with profound intel-
lectual disabilities” are a monolithic group. The needs of individuals with
disabilities are always unique. This uniqueness demands people actually get
to know people with PID and their caregivers, to learn what they in fact do
need rather than assuming what they need. As disability scholars point out,
most people have very little empirical or phenomenological knowledge of
19. For examples of theological anthropologies that provide grounding for these implications,
see Reinders (2008) and Haslam (2012).
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what it is like to live with or experience disability (Scully 2008, 21). Evidence
shows able-bodied people are not very good at imagining what it is like to
have a disability (Scully 2008, 54; Ubel et al. 2005). The moral imagination,
in reality, is limited. It is difficult to use our minds to understand what it
must be like to have a very different kind of mind.20 Meeting people with PID
takes effort, since persons with such disabilities are often precluded from
participating in the dominant structures of society. IQ alone (which is one
way medicine delineates mild, moderate, severe, and profound intellectual
disability) is a poor indicator of what an individual might need from others
(CDDH Fact Sheet [n.d.]). Abilities, capacities, sources of joy, and struggles
will be different for different people.
Once Christians have come to know people with PID and their care-
givers, they will be in a better position to discover what justice entails. If
communities of people created in God’s image must create conditions in
which all people can flourish, then it will be essential to try to remove the
barriers that prevent certain people from being included and thriving in our
communities. Removing barriers might mean access to medical resources,
but it might also mean removing the social barriers that prevent flourish-
ing, including attitudinal barriers. If, as discussed earlier, Christians are not
convinced that the Kingdom of God is a place where everyone gets “normal-
ized,” then our communities should not demand this either. Medical cures
will bring some persons into community and allow them to flourish. Such
cures, however, will not be available to all. Christians should not demand
all people become “normal”; rather, they must desire that all become like
Christ in ways that are both common to humanity and uniquely tailored
to each person. As theologian Stanley Hauerwas (2004, 40) contends, “[t]he
demand to be normal can be tyrannical unless we understand that the nor-
mal condition of our being together is that we are all different.” Christians
must work to form communities that are open to all people, in all of their
states of embodiment, and in all of their uniqueness.
In addition to requiring Christians to create just communities, their
creation in God’s image demands Christians love one another. Our standard
and model is Jesus Christ. Christians love others, not because people always
have qualities Christians admire or enjoy, but because God made each person
worthy of love by loving all persons first. Reinders (2008, 27) reminds his
readers that what persons with PID often need more than anything else is
friendship. Rights are good to have, he adds, but rights do not make friends
20. Disability bioethicist Jackie Scully (2008) and others have called this the “disability paradox.”
36
© 2017 Joni and Friends, Agoura Hills, CA. Used with permission.
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The Image of God, Bioethics, and Persons with Profound Intellectual Disabilities
From The Journal of the Christian Institute on Disability (JCID) Vol. 6.1-6.2 – Spring/Summer & Fall/Winter 2017
(2008, 42-43). By befriending others, even others who may not be able to
reciprocate that friendship, Christians begin to enact a Kingdom ethic where
all persons can participate in what is good. How people with PID participate
in the love and friendship others share with them might remain mysterious,
because we cannot always know how they receive that love or friendship. At
the same time, participation in the life of God will ultimately be a gift from
God and not an achievement born of human capacity. If no human being
will be excluded from his or her destiny because of a biological impairment
or a limited capacity for rationality, then Christians must love people with
PID indiscriminately.
Conclusion
For better or for worse, the influence of the image-of-God concept is not
likely to disappear soon, since its potential to inspire continues to shape
the guiding documents of a wide range of Christian traditions and denom-
inations, including Protestant, Orthodox, and Catholic.21 Nevertheless, the
doctrine of the image of God is always in danger of losing its constructive
influence when people alter what it means, either consciously or uncon-
sciously, to benefit themselves and to put down others.22 Persons with dis-
abilities, particularly those with PID, are prime targets for denigration and
neglect when their status as created in God’s image is denied. As this article
has shown, the Bible teaches that all people are created in the image of God,
which means that all people have a great God-given dignity and that all
can participate in a glorious God-intended destiny. The real work of the
Christian life, therefore, will not be to determine who counts as a person,
but figuring out how to be in just and loving relationship with one another
in communities that promote the flourishing of all. The Christian commu-
nity must ensure persons with disabilities flourish, first by recognizing the
ways in which social structures, including churches, marginalize persons
and then working to bring them into loving and just relationship with the
community. How best to accommodate, include, and befriend persons with
disabilities will not be obvious or easy, but it is what justice demands if we
believe all people truly are made in the image of God.
21. Protestant: Moltmann (1984, 12); Orthodox: Habib (1998, 36-37); Catholic: Ruston (2004, 270).
22. See Kilner (2015, ch. 1) for many further illustrations of the devastation caused by altering the
biblical meaning of the idea of creation in God’s image.
37
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From The Journal of the Christian Institute on Disability (JCID) Vol. 6.1-6.2 – Spring/Summer & Fall/Winter 2017
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