Bioethike

The Imago Dei in Pro-life Orthodox Lutheran Discourse: PVS as a Test Case

Robert C. Baker

For partial credit in:
MHE 605 Section 01 Philosophical Bioethics – Spring II 2010
Creighton University, Omaha, Nebraska

April 25, 2010

Abstract: Technological advancements in medicine have extended lives that would have been lost decades ago. In those cases where a patient’s partial or full recovery has been made possible through such advancements, they have been considered a blessing. However, in cases of severe debilitation such as the persistent vegetative state (PVS), questions arise about whether or not life-extending treatments are appropriate. To advance their argument that life-extending treatments such as artificial nutrition and hydration (ANH) cannot be denied to any patient regardless of debilitation, some contemporary pro-life Lutheran authors have used the concept of imago Dei (the “image of God”). However, the carefully-nuanced orthodox Lutheran understanding of imago Dei lends little support to such an approach. Rather, the imago Dei concept does offer an opportunity to revisit the unique dignity of every human being and, on that basis, developing an ethic of providing the very best care we can offer.

Key words: image of God, persistent vegetative state, end-of-life, Lutheran

Word Count: 2,990

Introduction

Technological advancements in medicine have extended lives that would have been lost decades ago. In those cases where a patient’s partial or full recovery has been made possible through such advancements, they have been a blessing. However, in cases of severe debilitation such as the persistent vegetative state (PVS), questions arise about whether or not life-extending treatments are appropriate. Highly-publicized and emotional PVS cases such as Quinlan (ventilator), Cruzan (ANH), and Schaivo (ANH) have highlighted the thorny ethical issues that not infrequently accompany such cases. Decades ago, patients in similarly debilitated states verylikely would have died within a few days of their initial injuries or onset of conditions. Nevertheless, humankind has been blessed by the development life-extending treatments, ethical challenges notwithstanding.

The Christian community typically responds to ethical quandaries resulting from technological advancements, including those affecting end-of-life care, by applying rules or directives specifically mentioned in the Bible or promulgated by Church authorities. However, many times that community applies abstract biblical or theological principles to concrete cases in order to resolve ethical dilemmas. An example of this is the imago Dei, or the “image of God” concept, which is used by some Christians to affirm the inherent dignity of each human being. Pro-life Lutherans have also used the imago Dei to argue that regardless of debilitation, interventions such as ANH should not be denied to any patient, including PVS patients, unless contraindicated. However, a close inspection of the nuances of the imago Dei from an orthodox Lutheran perspective shows that this concept does not readily lend itself to drawing such a conclusion. That being said, the imago Dei concept does offer an opportunity to revisit the unique dignity of every human being and, on that basis, developing an ethic of providing the very best care we can offer.

What Is the imago Dei?

The imago Dei is first mentioned in Genesis 1:26-27:

Then God said, ‘Let us make man in Our image, in Our likeness. . .’ So God created man in his own image, in the image of God he created him; male and female He created them.1

Although there are other passages of Scripture mentioning God’s image or likeness,2 it is well known that the definition of God’s image in humankind has been imprecise throughout the history of the Church. In his Panarion (ca. A.D. 370-374), Church Father Epiphanius of Salamis affirms the image in every human being while recounting various interpretations of the image.3 In his Lectures on Genesis (1535), Reformer Martin Luther notes the “sea of questions” and asks, “What is that image of God according to which Moses says that man was made?”4(p.60) Lutheran theologian Johann Gerhard, writing in his Loci Theologici (1625), notes the varying definitions of the imago Dei according to the Church Fathers and other teachers: Basil, Ambrose, Augustine, Chrysostom, Bernard, and Peter Lombard, among others. He concludes, “The fathers do not at all agree with each other nor stand with each other on this subject.”5(p.12)

Even among contemporary Lutherans there seems to be some confusion as to what the imago Dei is. Is the image an expression of “humanity’s dignity and God’s majesty”?6 Or is it an indication that humanity is “unlike” other creatures, that humans (at least initially, before the fall into sin), enjoy a “special, unique communion” with God and are “capable of relating to Him and are responsible to Him for what takes place”?7 Does the imago Dei simply mean “to be made like God,”8 since “both body and soul are created in the image of God”?9 Does the “likeness to God” such as “reason, intellect, and the ability to choose” remaining in human beings after humanity’s fall into sin “[engender] inherent value and respect for human life”?10 Except in cases of imminent death, should ANH be administered to all PVS patients because withdrawal would constitute the taking of a human life created in God’s image?11

The Image of God within Orthodox Lutheranism

What is Orthodox Lutheranism?

Lutheran historians have commonly referred to “the time of the Formula of Concord [1577]. . . to the first quarter of the 18th century” as the age of Lutheran orthodoxy.12  Following the Protestant Reformation, there was a great need to systematize Lutheran doctrine, particularly Luther’s insights concerning the Gospel and the doctrine of justification by faith. That initial task fell to Luther’s colleague, Philip Melanchthon, who published his Loci Communes in 1521, which Luther highly praised. Further work in organizing Lutheran doctrine fell to later theologians including Martin Chemnitz (1522-1586), an author of the Formula of Concord, and Johann Gerhard (1582-1637), author of Loci Theologici. Systematizing efforts by these theologians were especially necessary due to the doctrinal formulations of the Roman Catholic Council of Trent (1545-1563) and those of the Reformed churches (Heidelberg Catechism:1563; Belgic Confession: 1566; and the Canons of Dort: 1619).

What Is the Orthodox Lutheran Definition of the imago Dei?

An Accident, Not a Substance

Orthodox Lutherans were familiar with, and put to use in theological discussions, philosophical categories such as substance and accident.13 Abraham Calov (1612-1686) suggests that the image of God is man’s conformity to God, “which, having been impressed upon our first parents in creation, and having been almost entirely lost through transgression, is to be restored by renovation in this life, and, chiefly, in blessed regeneration for the life to come.”14 This conformity is considered to be accidental, not in the sense that someone had an accident and had to go to the hospital, but in the sense that the imago Dei is not an essential part of man’s nature. Here, an example is order. Let’s say that we have a wall that is white. The wall would be the substance. The quality of the wall that we call “white” is an accident. White is not essential, not substantial, to the wall. There are many other colors of walls! The accident of whiteness is not the substance of wallness. Whiteness is just a quality of wallness. Take away the white and what do you have? You still have a wall, right?15

In the same way, the orthodox Lutherans reasoned that while the imago Dei was fully in human nature prior to the fall into sin, and is being renewed in those who are baptized and believe, the image was not human nature itself; it was neither body nor soul.16 The imago Dei, according to them, was accidental to human nature, not substantial to it. They deduced this chiefly from those passages of Scripture speaking to the renewal of the imago Dei in believers.17 All the attributes generally ascribed to the imago Dei—righteousness, holiness, perfect use of the bodily faculties, and so on—are not human nature per se, they reasoned. Echoing Peter Lombard, Luther can pile on high praise for humanity in its pristine, primordial state: “Man alone is God’s image, as appears in the Sentences. In the remaining creatures God is recognized by His footprints; but in the human being, especially in Adam, He is truly recognized, because in him there is such wisdom, justice, and knowledge of all things that he may rightly be called a world in miniature.”4(p.68) Yet, while Luther and the orthodox Lutherans could say that when Adam and Eve sinned they “lost” the image of God, they did not mean that Adam and Eve stopped being human. Neither did they mean that there was an essential change to human nature after the fall.18,19

A State of Integrity of Both Soul and Body

The orthodox Lutherans understood that when Scripture presents the imago Dei, it does so according to two attributes: (1) primarily, the image of God refers to the original righteousness and holiness that Adam and Eve possessed prior to the fall into sin and, now, by God’s grace in Word and Sacrament, is being renewed by the Holy Spirit in all believers; and (2) secondarily, the image of God refers to the perfection of all bodily faculties in concert with such righteousness and holiness. Thus, Luther:

My understanding of the image of God is this: that Adam had it in his being and that he not only knew God and believed that He was good, but that he also lived a life that was wholly godly; that is, he was without the fear of death or of any other danger, and was content with God’s favor.4(p.63)

and Gerhard:

The image of God in the first man was the natural and total perfection of the whole man and the uprightness of all his powers of soul and body, his wholeness, his conformity with God his archetype. . . 5(p.76)

Notice the emphasis on “wholly, “the whole man” and “wholeness.” In short, the imago Dei consists of integrity of both soul and body. With Luther, the orthodox Lutherans confessed that due to sin, humanity completely lost that integrity in the sense of completely losing original righteousness and holiness. Nevertheless, even after the fall, humans remained human, both body and soul, although corrupted. Likewise, Lutheran and his followers confessed that while some aspects (“vestiges” or “tinders,” they are sometimes called) of the image of God remain, these too do not exist in a state of integrity. However, despite the loss of the image, Luther still can say, “there is still great difference between the human being and the rest of the animals.”4(p.67) Here Luther affirms the dignity of the human being in spite of the near-complete loss of the divine image.

What Is PVS?

It is important to keep that thought, the dignity of the human being, in mind when we think about severely debilitated patients such as those in a persistent vegetative state.20 Jennett and Plum are credited with coining that phrase in 1972.21 However, Jennett notes that the condition was first described in the German medical literature in 1899. A German physician named Rosenblath recorded the case of a 15-year-old tightrope walker, who became “strangely awake” after a fall and subsequent coma. While the patient was tube fed, he died after 8 months.22 From that and numerous other recorded accounts in the medical literature, it is reasonable to assume that PVS is not a new condition. Years ago, PVS may have been diagnosed as something else (proper diagnosis is still a problem today) or, most likely, patients simply died before the PVS symptoms were fully expressed and the condition could be analyzed and recorded.

PVS is a brutal debilitation for the patient. It is likewise a cruel disease for the patient’s family, loved ones, and for caregivers. A study released in 1994 revealed the following. PVS patients are completely unaware of themselves and their environment. They experience cycles of sleeping and waking, but do not express any type of meaningful response to external stimuli. Their hypothalamus (which regulates, among other things, hunger and thirst) and brain stem may be either completely or partially functional, but PVS patients exhibit no other higher brain function. They are incontinent. PVS patients are unable understand language or non-lingual forms of communication. They are unable to communicate themselves. If these conditions are present, the diagnosis of PVS is made one month after traumatic or non-traumatic brain injury, or in patients with degenerative of developmental issues effecting the brain. Some PVS patients have recovered. However, PVS patients seldom recover. After twelve months, recovery of PVS patients is unlikely. Most have an extremely shortened lifespan from between two to five years, with a lifespan over 10 years being highly usual.23 Typical care of PVS patients include physical therapy and ANH.

The imago Dei Applied to PVS Patients

Do PVS patients possess the image of God? The question turns on the definition of that image. Insofar as PVS patients today are being renewed in that image through their incorporation into Jesus Christ through Baptism and faith, orthodox Lutherans would answer, “Yes.” However, this limited application of the imago Dei only to Christian PVS patients is obviously problematic in today’s diverse healthcare settings. But what about the second aspect of the image discussed earlier? Do PVS possess the divine image in sense that even apart from faith and spiritual renewal they should be accorded respect because they possess “vestiges” or “remnants” of God’s image? Non-substantial (“accidental”), secondary perfections still residing in a now imperfect human nature seems to be a weak foundation upon which to build an ethical framework for thetreatment of other human beings. In patients with severe cognitive dysfunction, it appears that there is even less of an image of God, at least according to second attribute mentioned above.

But let’s go even further. Perhaps instead of asking, “What evidence do we find in PVS patients that proves they still possess the imago Dei?”, we should ask, “To what extent does PVS and other forms of profound human suffering expose the loss of the imago Dei?” If, as the orthodox Lutherans argued, prior to the fall the image existed in humankind enjoying a state of integration, does not PVS show more clearly a state of disintegration? How would such a view affect our care of others if we recognized such a loss? First, such questions recognize the reality of human suffering as it is: the brokenness, the vulnerability, the sin. Those of us who believe that God created humankind in perfection can readily observe with our own eyes that something has gone terribly wrong. Second, such questions move us away from trying to find the source of human dignity within the (spiritual, physical, mental) abilities of human beings, which seems to be what those who appeal to the imago Dei are trying to do. Third, such questions also uncover the real questions underlying such efforts: How do we ascribe human dignity to each and every human being, regardless of their present state of being? Why do we sense that human beings are unique and deserving of special care?

This is not to suggest that human beings do not possess some dignity apart from the imago Dei, apart from being in a perfect state of integrity. In fact, as a Lutheran Christian I believe that they do. Going back to our analogy of the wall, even if a wall is not white, it still is a wall. It still possesses its wallness. Even if a human being does not possess righteousness and holiness, the first aspect of the imago Dei, that human being is still a human being. And even if that same human being cannot express the use of certain otherattributes, such as “reason, intellect, and the ability to choose,” which PVS patients still possess in their soul but cannot express by their higher brain, that human being still has value and should be accorded respect and the highest level of care. Here, a possible argument could be made that God intends to restore the lost image through His Son, Jesus Christ, and has begun to do so, and will complete this restoration in “the life of the world to come,” as we confess in the Nicene Creed. But that sort human dignity, in view of our teleological future, is extra nos, that is, itcomes from outside ourselves; it comes from God Himself.

Conclusion

We began by briefly noting the varying definitions of the imago Dei in Church history, then by looking how it has been defined by orthodox Lutherans. A key understanding of the imago Dei from an orthodox Lutheran perspective is that it is not part of the substance of human nature, either body or soul. The image is a state of wholeness, a state of integrity of body and soul. Within human beings, the imago Dei is understood to have been present at creation, lost due to sin, is now being restored in believers, and ultimately will be perfected in heaven. In this latter sense, the orthodox Lutheran understanding of the imago Dei is similar to other Christian faith traditions. However, as I have shown, the particular nuances of the imago Dei in the orthodox Lutheran tradition do not readily lend themselves an abstract biblical and theological concept to concrete cases concerning human care, especially PVS. Rather, PVS in a unique way evidences the profound loss of the divine image while highlighting our search to ascribe human dignity to severely-debilitated members of the human family.

Since I began with Scripture, I would like to conclude with Scripture. This passage that was frequently quoted by orthodox Lutherans when discussing the renewal of the imago Dei in human beings:

And we, who with unveiled faces all reflect the Lord’s glory, are being transformed into His likeness with ever-increasing glory, which comes from the
Lord, who is the Spirit (2 Corinthians 3:16-18).

Here St. Paul references the ministry of the Law, particularly Moses’ Ten Commandments, which point out human sin and brokenness. In a sense, as caregivers we witness that “ministry of brokenness” every day as we diagnose, treat, and care for our patients. We know and understand in our hearts and minds that this is not the way that it should be. Children should not get sick. Cancer should not develop in the human body. The brain should recover. People should not die. But here St. Paul also mentions another ministry, the ministry of the Gospel. This more glorious ministry is meant to take away sin, to restore completely that which is broken. This ministry takes away the veil from our eyes so that, as he says, we “with unveiled faces all reflect the Lord’s glory,” as we “are being transformed into His likeness.” Here St. Paul is talking about the imago Dei, the image of God in you, as the Spirit works through you to care for others. I hope that you find that profoundly comforting as I do. The God who creates, redeems, and sanctifies still values His human creation. We know this because He sent His own Son, Jesus Christ, His full and complete image, so that we might be recreated in His image and enjoy life in a sinless and unbroken world forever.

References

1. All Scripture passages are from The Holy Bible, English Standard Version. Wheaton, Illinois: Good News/Crossway; 2001. Available at: http://www.biblegateway.com/passage/?search=gen%201:26-27&version=ESV. Accessed April 15, 2010.

2. For example, see: Genesis 9:6; 1 Corinthians 11:7; Ephesians 4:24; Colossians 1:15; 3:10; James 3:9. In these passages, “image,” “likeness,” “new self,” all refer to the imago Dei, but with certain nuances. While Genesis 1:26-27 speaks about the image in humankind before the fall into sin, Genesis 9:6 refers to the image in humankind after the fall, Ephesians 4:24 and Colossians 3:10 denote the image being renewed only in believers, while Colossians 1:15 refers to the substantial image of God, that is, the fullness of deity, in Christ. Clearly the variety of definitions of the imago Dei in Scripture accounts for some of the theological confusion about this concept.

3. Epiphanius. On the schism of the Audians. Williams F, trans. The Panarion of Epiphanius of Salamis, Books II and III. New York: E.J. Brill, 1994;402-418.

4. Luther M. Lectures on Genesis. Pelikan J, ed. Luther’s Works. Vol. 1. St. Louis: Concordia Publishing House, 1958.

5. Gerhard J. Commonplace VIII: On the image of God in man before the fall, § 44. Dinda R, trans. Loci Communes (1625). St. Louis: Unpublished manuscript owned by Concordia Publishing House.

6. Note on Genesis 9:6. In: The Lutheran Study Bible: English Standard Version. Engelbrecht EA, Deterding PE, Ehlke, RC, eds. St. Louis: Concordia Publishing House, 2009;28.

7. Commission on Theology and Church Relations. The Creator’s Tapestry: Scriptural Perspectives on Man-Woman Relationships in Marriage and the Church. St. Louis: The Lutheran Church—Missouri Synod, 2010;11-12.

8. Jastram N. The spitting image of love. Paper delivered at the “In the Image of God: The Christian Vision for Love and Marriage” conference, Fort Wayne, Indiana, September 18-20, 2006. Available at: http://www.cranach.org/imageofgod/papers.php. Accessed April 15, 2010.

9. Jastram N. Man as male and female: created in the image of God. In: Concordia Theological Quarterly. Fort Wayne, Indiana: Concordia Theological Seminary, 2004;17.

10. Lamb JI. The image of God and the value of human life. In: God’s Word for Life Bible. Orange Park, Florida, and Nevada, Iowa: God’s Word to the Nations and Lutherans for Life, 2005; 2d.
11. Bartlett LD and Rehder K. Ventilators, feeding tubes, and other end-of-life questions. Lutherans for Life Web site. 2005. Available at: http://www.lutheransforlife.org/Life_Issue_Info/End-of-Life/ventilators_-_feeding_tubes.htm. Accessed April 15, 2010.

12. Preus RD. The Theology of Post-Reformation Lutheranism. St. Louis: Concordia Publishing House, 1970;27. Here I will defer to Preus’s judgment, since arguing for what completely defines Lutheran orthodoxy is outside of the scope of this paper.

13. For example, the writers of the Lutheran Confessions were familiar with and used these terms: “But in the schools, among the learned, these words [substantia and accidens] are rightly kept in disputes about original sin. For they are well known and used without any misunderstanding to distinguish exactly between the essence of a thing and what attaches to it in an accidental way.” Epitome of the Formula of Concord. In: Concordia: The Lutheran Confessions. 2nd ed. McCain PT, Engelbrecht EA, Baker RC, eds. St. Louis: Concordia Publishing House, 2006;477.

14. Schmid H. The Doctrinal Theology of the Evangelical Lutheran Church. 3rd ed. Hay CA and Jacobs HE, eds. Minneapolis, Minnesota: Augsburg Publishing House, 1961;222.

15. For a classical treatment of substance and accidents (or qualities), see Aristotle’s Categories. Available at: http://classics.mit.edu/Aristotle/categories.html. Accessed April 15, 2010.

16. This is an important point that will become especially clear as we talk about PVS patients. In his On the Trinity, Augustine uses Ephesians 4:23 and Colossians 3:9 to argue that the renewal of the image of God is chiefly spiritual: “If, then, we are renewed in the spirit of our mind, and he is the new man who is renewed to the knowledge of God after the image of Him that created him; no one can doubt, that man was made after the image of Him that created him, not according to the body, nor indiscriminately according to any part of the mind, but according to the rational mind, wherein the knowledge of God can exist. And it is according to this renewal, also, that we are made sons of God by the baptism of Christ; and putting on the new man, certainly put on Christ through faith.” Book VII, Ch. 7. The Nicene and Post-Nicene Fathers of the Christian Church. Schaff P, ed. Grand Rapids: Eerdmans, 1956;159.

17. Like Augustine before him, Gerhard uses Colossians 3:10, Ephesians 4:23, and 2 Corinthians 3:18 to arrive at this conclusion. Following the interpretive principle of Scripture interpreting Scripture, the orthodox Lutherans also used these passages to deduce that the principle part of the imago Dei in humankind was original righteousness, which through Baptism and faith in Jesus Christ was being restored in believers. Jastram, noted above, induces from numerous Scriptural passages about the image to form the general conclusion that the image simply is “to be like God” in some way. Jastram says that since mountains (Psalm 36:6), cedars (Psalm 80:10), fire (Job 1:16), stars (Isaiah 14:13), and other animate and inanimate objects are like God since they have certain characteristics, they likewise are images of God. Telephone conversation with Dr. Nathan Jastram, April 22, 2010.

18. Gerhard specifically refutes the notion that the image of God is the soul or the body of the human being (Ch. 3, § 94-96, pp. 42-43). He also mentions the errors of the Anthropomorphites, who maintained that “the image of God is expressed in the outline of the human body. These are refuted on the basis of John 4:24 and Luke 24:39.” Along with the Augustine passage above, Gerhard offers further proofs from Augustine and the Christian Socrates (pp. 8-9). He likewise mentions Epiphanius, discussed earlier.

19. In the Panarion, Epiphanius regards as “stubborn” and “ignorant” the opinion of the heretic Audius who, on the basis of Genesis 1:26-27, argues that “the gift of being in his image which God granted Adam applies to his body [emphasis added]. . . If being ‘in the image of God’ applies literally, and not figuratively, to the body, we shall either make God visible and corporeal by saying this, or else make man God’s equal.” Epiphanius. Panarion;404. Audius and his followers induced from Scripture passages analogically referring to God in human terms (God “listens,” “sees,” etc.) that God, who is pure Spirit, had a body.

20. Luther and the orthodox Lutherans would have considered “reason, intellect, and the ability to choose,” as mentioned in paragraph four, as faculties of the soul, that is, part of human nature. That reason, intellect, and the ability to choose are, due to the effects of sin, compromised, is an effect of the loss of original righteousness, a loss of the image of God. That some persons who are not able to use these faculties does not mean, however, that they do not possess them, since they are part and parcel of being human.

21. Jennett B, Plum F. Persistent vegetative state after brain damage: a syndrome in search of a name. Lancet 1972;1:734-737.

22. Jennett B. The Vegetative State: Medical Facts, Ethical and Legal Dilemmas. E-resource. Cambridge University Press, 2004. Available at: http://site.ebrary.com.cuhsl.creighton.edu/lib/creighton/docDetail.action?docID=10062265. Accessed April 10, 2010.

23. Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state (1). N Engl J Med. 1994; 330:1499-1508. Available at: http://content.nejm.org.cuhsl.creighton.edu/cgi/content/full/330/21/1499. Accessed April 10, 2010.