This essay forms part of an ongoing series in philosophical theology produced through the Department of Philosophical Theology at Christ School of Theology. The series explores questions of intelligibility, reality, theological language, and the philosophical conditions for Christian belief.
Abstract
The doctrine of informed consent represents one of the great moral achievements of modern medicine, correcting paternalistic practices and recognizing the patient as a responsible moral agent rather than a passive object of clinical expertise. This essay argues, however, that contemporary bioethics has too often elevated consent from an indispensable procedural safeguard into the governing principle of a medical ethics that tacitly reduces the patient to a preference-bearing will. When autonomy becomes the primary category through which patients are understood, medicine risks losing sight of the deeper realities that constitute personal identity, vulnerability, embodiment, and vocation.
Drawing upon philosophical theology, contemporary metaphysics, and Lutheran anthropology, the essay contends that patients are not simply autonomous choosers but persons whose identities are irreducible to acts of consent. Clinical judgment therefore cannot be exhausted by procedural respect for autonomous preference. Medicine is fundamentally ordered toward the good of embodied persons whose dignity is grounded in realities that precede and exceed autonomous choice.
Rather than rejecting informed consent, the essay relocates it within a richer account of the human person and the vocation of medicine. Physicians are called not merely to secure the patient's consent but to serve the flourishing of persons created in the image of God, whose lives possess objective meaning and worth independent of their present capacities for autonomous decision. In this way, informed consent is preserved as an essential ethical practice while recovering the broader ontological and theological framework within which it has its proper place and force.
Key Words: informed consent; patient autonomy; principlist bioethics; Beauchamp and Childress; H. Tristram Engelhardt; Edmund Pellegrino; Alasdair MacIntyre; ontology of the patient; personal identity; extrinsic individuation; medical vocation; imago Dei; coram Deo; Lutheran anthropology; life ethics
I. Introduction: A Moral Achievement and Its Inflation
The modern doctrine of informed consent represents a genuine moral achievement. Its emergence in the mid-twentieth century marked a decisive break with a paternalism so habitual in clinical medicine that it had ceased to recognize itself as such. Patients had been subjected to experimental procedures without disclosure — at Tuskegee, at Willowbrook, and in the Nazi medical programs that prompted the Nuremberg Code — to surgical interventions decided by physicians who considered their own clinical judgment sufficient warrant for action, and to a systematic reduction of the embodied person to an object of professional expertise. The correction demanded by the consent doctrine was not a refinement of existing medical ethics; it was a moral challenge to its foundations. The physician's expertise, it declared, does not confer authority to determine the course of another person's life. The patient is an agent, not a substrate. Information must be disclosed, comprehension secured, and the patient's free authorization obtained before anything is done.
This correction was right, and nothing argued in what follows proposes to reverse it. The patient's voice must be heard; her preferences must be taken seriously; coercion and manipulation in the clinical setting are genuine wrongs. These are not abstract principles; they were purchased at the cost of real suffering, and the history of bioethics has given us abundant reasons to maintain vigilance on precisely these points.
What requires urgent criticism, however, is something different: the inflation of consent from a necessary condition of ethical medical practice into the governing principle of a medical ethics that tacitly reduces the patient to a preference-bearing will. This is not a small or merely technical dispute. It concerns what medicine is for, who the patient is, and what a physician owes to both. When autonomy is elevated from a necessary safeguard into the controlling principle of medical morality, the patient is tacitly reconceived as a preference-bearing will, medicine becomes a technical service industry, and the physician's vocation is reduced to competent compliance. Each of these consequences is a distortion — not merely of Christian medical ethics, but of medicine and of the human person as such.
This essay argues that the autonomy model in its dominant contemporary form presupposes an ontology of the patient that it cannot itself supply. The patient precedes the patient's choices and retains moral significance even when the capacities for deliberation, memory, communication, or consent are diminished or absent. To explain why this is so — and to do more than merely assert it — requires recovering a richer account both of the person and of medicine. In prior contributions to this journal, I have argued that all intrinsic accounts of personal identity ultimately fail, that what individuates persons is finally the intentional love of God, and that human life is constituted by divine address prior to and independent of any social mediation or functional capacity.¹ I have also argued that the concept of vocation names not primarily what one does but what one is: a creature called into being, relation, and responsibility.² These arguments bear directly on the crisis of bioethics, and the present essay draws out their implications for the clinical setting.
The argument proceeds in seven stages. It first reconstructs the principlist consensus and traces the philosophical pedigree of autonomy's rise to primacy. It then identifies three philosophical failures of the autonomy-as-master-principle model and examines what that model presupposes but cannot supply: an ontology of the patient adequate to the problem of personal identity. The essay next develops a Christian account of the patient as embodied creature, relationally constituted person, and divinely addressed self; retrieves the concept of medical vocation and its implications for the physician's moral agency; and concludes by offering a constructive account of a richer medical ethics that situates rather than supplants consent.
II. The Principlist Consensus and the Ascendancy of Autonomy
Any serious engagement with the autonomy model must begin by understanding its intellectual architecture. The regnant framework in anglophone bioethics did not emerge arbitrarily; it drew on deep resources in modern moral philosophy and was institutionalized through a rigorous and widely influential body of work. To criticize it responsibly requires first reconstructing it fairly.
Beauchamp and Childress and the Four Principles
The dominant framework in anglophone bioethics for the past half century is the principlist architecture associated with Tom Beauchamp and James Childress, most fully developed in their Principles of Biomedical Ethics, now in its eighth edition.³ On this account, medical ethics is organized around four prima facie principles: respect for autonomy, beneficence, non-maleficence, and justice. These principles are presented as mid-level norms derived from the overlapping consensus of common moral experience and a range of ethical theories. They require specification and balancing in particular cases, and no single principle enjoys automatic priority over the others.
In formal terms, this is a balanced framework. In practice, however, autonomy has emerged as first among equals. Beauchamp and Childress themselves acknowledge the special weight the respect-for-autonomy principle carries in contemporary clinical ethics, particularly in contexts of patient refusal. When a competent patient refuses a recommended intervention — even one the physician judges urgently necessary — the refusal is generally understood to be binding. The language of "patient-centered care" and "shared decision-making" that now pervades clinical culture expresses this priority. So does the proliferation of advance directive legislation, surrogate decision-making frameworks, and the legal doctrine of informed consent itself, which in most jurisdictions permits liability not only for failures of disclosure but for interventions undertaken without adequate authorization, whatever their medical outcome.
The Philosophical Pedigree
This priority has a serious philosophical pedigree. The roots run to Kant's account of rational autonomy as the ground of moral worth, to Mill's harm principle as the limiting condition on legitimate interference with individual choice, and through both to a broadly liberal tradition that treats rational self-governance as definitive of what distinguishes persons from things. On the Kantian inheritance in particular, the capacity for autonomous rational agency is not merely one valuable property among others that persons happen to possess; it is constitutive of personhood itself. To override a competent agent's considered choice is therefore not merely to act against that person's interest — it is to treat her as less than a person, to substitute one's own will for hers and thereby deny the very capacity that makes her a moral subject rather than a mere object. This is why, on Kantian grounds, even a beneficent override of autonomous choice carries a moral cost that no good outcome can fully cancel: it is a wrong to the person as person, not merely a miscalculation about welfare.
Engelhardt and the Secular Bridge
H. Tristram Engelhardt Jr. drew the inference with unusual clarity and unflinching consistency. In a secular, pluralist society, he argued, there is no morally authoritative account of the good life available to all parties through reason alone. Moral strangers — persons who do not share a thick ethical framework — can nonetheless interact peacefully and cooperate in institutions like medicine, but only if they observe the procedural principle of mutual respect for autonomy. Beneficence has no agreed-upon content in a morally plural world; autonomy at least gives us a procedure.⁴ On this view, the physician's proper role is to provide accurate information, ensure comprehension, and then stand aside. The patient's authorization is what makes a medical intervention legitimate; without it, even a beneficial act is a trespass.
Autonomy as Master Principle in Practice
The result, as Leon Kass has noted, is a medicine increasingly understood as a service industry whose product is the satisfaction of patient preferences.⁵ The physician is the expert; the patient is the consumer. The encounter is transactional rather than relational, and its moral content is exhausted by the terms of the transaction. This picture has achieved sufficient cultural penetration that it is now largely invisible — experienced not as one possible account of medicine but as the natural and obvious one.
This is the adversary worth engaging. Its philosophical foundations are serious; its humanitarian motivations are genuine; and its critique of paternalism was historically warranted. But the account is nonetheless deeply mistaken, and the mistakes run all the way down to the question of who the patient is.
III. Three Philosophical Failures of the Autonomy-as-Master-Principle Model
The principlist consensus reconstructed in the preceding section is philosophically serious and historically understandable. What follows is not a dismissal of it but a diagnosis. The autonomy-as-master-principle model fails, and fails at the level of its foundations, on three distinct fronts: ontological, normative, and vocational. Each failure is independent; together they are decisive.
The Ontological Problem: The Patient Who Precedes Her Choices
The first and most fundamental failure of the autonomy model is ontological. Autonomy is a predicate that requires a subject, and the model has no adequate account of that subject. The preference-bearing will that appears at the clinical encounter — expressing values, issuing authorizations, declining interventions — is presupposed by the framework but never adequately analyzed within it. The patient is identified with her choices, but this identification is unstable.
The instability becomes visible at the margins of the framework: at the bedside of the patient in the terminal stages of dementia, who can no longer express coherent preferences; in the neonatal intensive care unit; in the care of the patient with acute psychotic crisis. The standard response is to invoke advance directives, surrogate decision-making, and best-interest standards — mechanisms that attempt to honor autonomy where its direct exercise is impossible. But this is a repair operation performed on a framework whose foundations have quietly shifted. The patient in these cases is acknowledged to have moral status that precedes and exceeds her current capacity for self-determination. The question the framework cannot answer from its own resources is the one that matters most: what grounds that status?
If personal moral status is grounded in the capacity for autonomous rational agency — as the Kantian inheritance suggests — then those who lack that capacity have diminished or no status. This conclusion is not merely monstrous; it is embraced with logical consistency by some bioethicists who follow the Kantian premises wherever they lead.⁶ The standard principlist response is to insist that the four principles must be balanced, and that the interests of those who cannot exercise autonomy fall under the beneficence and non-maleficence principles. But this response defers rather than resolves the problem. What is the ground of the beneficence owed to the demented patient? If it is not their capacity for autonomous choice, what is it?
The autonomy model has no satisfying answer, because the moral significance of the patient who cannot consent is not derivable from a framework whose master principle is consent.
The Normative Gap: Consent Authorizes but Does Not Justify
The second failure is normative. Consent authorizes; it does not justify. A patient's informed and voluntary agreement to a procedure establishes a necessary condition for the physician's performing it, but necessary conditions are not sufficient ones. There is a gap between what the patient wants and what is medically good for the patient, and the autonomy model systematically collapses this gap.
Consider the physician confronted with a patient who requests an intervention the physician judges to offer no medical benefit, or affirmative harm, or that belongs to a category of acts the physician regards as incompatible with medicine's internal goods. The autonomy model, taken to its logical conclusion, generates an obligation for the physician to comply or at minimum to facilitate access. The physician's clinical and moral judgment becomes, in this picture, an obstacle to be managed rather than a contribution to be integrated. The physician is re-described as someone who offers services; the patient is re-described as someone who orders them.
But this conception of medicine is not self-evidently correct; it is a substantive and contestable view that has achieved the status of common sense by winning an argument it was never required to make explicit. Edmund Pellegrino, perhaps the most philosophically rigorous defender of a different view, argued throughout his career that medicine possesses internal goods — truthful diagnosis, healing where possible, palliation where cure is impossible, relief of suffering, faithful accompaniment of the ill — that are not derived from patient preference but constitute the telos of the practice.⁷ The patient's authorization is morally necessary because the patient is a person whose body is at stake; but the authorization does not create the good toward which medicine is ordered. Consent is morally indispensable within medicine; it is not the foundation of medical morality.
The Vocational Problem: The Physician Reduced to Competent Compliance
The third failure concerns the physician. The reduction of medical ethics to the authorization of patient preferences has consequences for the physician's moral agency that are rarely discussed with the seriousness they deserve. On the autonomy-as-master-principle model, the physician's personal moral convictions are a liability to be disclosed and then set aside. The widespread use of the language of "conscientious objection" to describe physician reluctance to participate in certain procedures — abortion, assisted suicide, certain reproductive technologies — reveals the underlying assumption: the physician's conscience is an exception to a default of compliance, not the center of a vocation.
But this inverts the proper order. The physician is not someone who happens to possess technical skills and rents them to whichever preferences present themselves in the consultation room. The physician is someone who has entered a practice constituted by goods — health, healing, truthful accompaniment of the suffering — and whose integrity consists precisely in orienting her skills toward those goods. The "conscientious objector" framing presupposes that the physician's primary obligation is compliance, with conscience as a permitted deviation from that default. The vocational understanding inverts this: conscience is the center, and what requires justification is any demand that the physician act against it.
When we reduce the physician to competent compliance, we do not merely restrict her moral agency. We deprive her of the vocational structure within which medicine's own goods become intelligible.
IV. The Ontology the Autonomy Model Cannot Supply
The three failures just identified share a common root. The autonomy model does not merely make errors at the level of application; it operates with an impoverished account of the person that it never subjects to critical scrutiny. This section excavates that account, shows why it collapses under philosophical pressure, and identifies what a more adequate account of the patient must supply.
The Thin Self and Its Failures at the Margins
These problems converge on a single underlying difficulty: the autonomy model operates with a thin, functionally defined account of the self, and that account cannot bear the normative weight placed upon it. To see this clearly, it is worth attending carefully to what the model implicitly assumes.
The model assumes that patients have preferences — that is, that they have psychological states with intentional content, organized into something like a set of values or a life plan. It assumes that these preferences can be elicited and expressed under conditions of adequate information and freedom from coercion. And it assumes that respecting these preferences is the primary form that respect for the patient-as-person takes.
What the model does not do is provide any account of why the preference-bearing subject deserves moral respect in the first place, or of what makes that subject the particular individual she is. These are not idle metaphysical questions; they have direct clinical and ethical consequences. If what grounds moral status is the capacity for rational preference-formation, then the capacity matters more than the individual who possesses or lacks it. And if what identifies the patient as this particular patient is her psychological continuity — her memories, personality, beliefs, and values — then radical disruption of psychological continuity raises the question of whether the person who consented is the same person who is being treated.
The Personal Identity Problem and Its Bioethical Consequences
I have argued at length elsewhere in this journal that all intrinsic accounts of personal identity ultimately fail.⁸ Neither bodily continuity, nor psychological continuity, nor the appeal to an immaterial soul individuated by its own haecceity, can accomplish what personal identity requires — namely, the re-identification of this individual across possible situations, including the possible situation of radical psychological disruption or bodily transformation.
The case of the Alzheimer's patient makes this vivid. Consider a patient who has, over years of progressive dementia, lost her memories, her characteristic personality, her capacity for deliberation, and her ability to recognize her own family. A psychological criterion of personal identity — the view, associated with Locke and his successors, that personal identity consists in continuity of consciousness and memory — implies that the woman currently in the bed is not, or perhaps not entirely, the same person as the woman who signed an advance directive five years earlier.⁹ The bodily criterion fares no better in the long run: for if we cannot conceive that the same person might have a different body (as it seems we can), then bodily continuity does not suffice to identify the person. And the appeal to an immaterial soul runs into the problem of what individuates souls — a problem that dissolves into either the claim that all souls share the same properties (which leads to the conclusion that there is only one soul) or the postulation of a bare haecceity that explains individuality by positing what cannot be specified.¹⁰
The conclusion is not that persons do not exist — it is that their existence cannot be grounded in any intrinsic property or set of properties they happen to possess. There is nothing in Bob, on any account, that fully explains why Bob is Bob and not someone else, and why Bob remains Bob through radical psychological or physical change.
What Must Be True of the Patient
This conclusion has a direct implication for medical ethics. The autonomy model implicitly relies upon a psychological criterion of the patient's identity: it is the patient's values, preferences, and life-narrative that make her the particular individual whose consent is sought. But if psychological continuity cannot fully individuate the person, then the moment the patient's psychological continuity is disrupted — by dementia, coma, psychiatric crisis, or even the radical transformation that serious illness brings — the framework loses its footing.
At the same time, our moral intuitions — confirmed by clinical practice at its best — insist that the patient in the advanced stages of dementia remains a person who commands care, whose suffering must be relieved, whose dignity must be honored. These intuitions are right. But they cannot be derived from the framework that makes autonomous preference the ground of moral status. They require a different account of who the patient is.
What must be true of the patient if her moral significance is to survive the loss of those capacities the autonomy model relies upon? The patient must have significance prior to her preferences — significance that does not depend on her ability to form or express them. And this significance cannot rest on any property she intrinsically possesses, since all such accounts fail. It must be grounded in something extrinsic to the patient — in a relation in which the patient stands independently of her capacities, and which is not dissolved by the loss of those capacities.
V. A Christian Account of the Patient
The preceding analysis established what the autonomy model cannot supply: an account of the patient whose moral significance survives the loss of the functional capacities on which the model relies. The present section offers that account. It is explicitly theological, and it makes no apology for being so. The argument is not that Christian theology provides one supplementary perspective among others, but that it articulates what the philosophical critique already requires — an ontology of the person that precedes and exceeds any capacity the person happens to possess at a given moment.
The Patient as Embodied Creature: Life Received, Not Self-Created
Christian theology identifies the patient, in the first instance, as an embodied creature. This is not a trivially pious claim; it has specific philosophical content. To be a creature is to exist as the recipient of a gift one did not produce and cannot fully secure. Life is not an achievement but a receiving; it precedes any activity of the self and cannot be fully grasped from within the framework of self-authorship.
Gilbert Meilaender has noted, in these pages, that a living human being is not just a thing, not an inanimate object: "We do not exist the way a rock does, 'simply and fixedly what it is, identical with itself over time, and with no need to maintain that identity by anything else it does.'"¹¹ We are organisms that must work to sustain our life through the metabolic processes of embodied creaturely existence. But we are also more than organisms: our being is, as Meilaender puts it, ecstatic — we have a kind of inner freedom from our own substance, a capacity to reach out toward something that transcends our present condition. The patient is neither pure will, as the autonomy model implies, nor pure biology, as reductive naturalism implies. She is an embodied creature whose very existence participates in a drama of creation, fall, and redemption that she did not author.
This creaturely character of human life is directly relevant to the medical encounter. The patient who arrives in the clinic is not a sovereign self who happens to need technical services. She arrives carrying a body she received, sustained by relations she did not choose, embedded in a history she did not write. The finitude, fragility, and dependence she presents at the clinical encounter are not aberrations from her normal condition; they are revelations of what she always was. Medicine's response to her condition is not simply the fulfillment of a contract; it is an act of attending to the creature in her creatureliness.
The Patient as Relationally Constituted: Extrinsic Individuation and Divine Love
Second, the patient is a relationally constituted self whose identity is sustained through relations that exceed subjective consciousness. I have argued in this journal that the problem of personal identity is genuinely intractable on any account that attempts to ground it in intrinsic properties of the person — whether bodily, psychological, or spiritual.¹² The argument, briefly reconstructed: neither bodily continuity, nor psychological continuity, nor an immaterial soul with a bare haecceity, can accomplish the individuation of persons across possible situations and times. All intrinsic accounts founder on the same problem: there is nothing in the person that uniquely identifies her, that necessarily distinguishes her from every other possible person, and that remains constant through radical physical or psychological change.
The only available solution is extrinsic individuation: the person is the particular individual she is not because of any property she intrinsically possesses, but because of the relation in which she stands to one who individuates her through his love. "Peter is Peter because God regards Peter so. God thus functions as a type of ideal agent that grants personhood — they are the person that they are because God has loved them into a self-same one."¹³ God's love for Peter in an appropriately Peter-directed way discriminates Peter from all others whom God loves in their own particular ways.
This is not a merely consoling thought; it is a metaphysical claim with direct ethical consequences. If what makes the patient this patient — what individuates her as the particular person she is — is divine love and intentionality rather than any capacity or property she intrinsically possesses, then her moral significance is not exhausted by, and does not depend upon, her present functional capacities. The patient with advanced Alzheimer's disease retains her personhood not because she retains a sufficient degree of psychological continuity, but because God has not ceased to love her into the particular self she is. Her identity is held in existence by a love that does not diminish when memory fades or preference becomes inexpressible.
This account also illuminates the imago Dei in a way that avoids the standard difficulty of identifying the image with some specific intrinsic property — reason, will, moral capacity — that is diminished or absent in conditions of cognitive impairment. The image of God is not a property the patient possesses; it is a relation in which she stands. She is made in the image of God not because she can do what God can do, in some analogous sense, but because God has addressed her and continues to address her as a particular, beloved creature. The image is not an achievement but a gift — and like all gifts from God, it cannot be revoked by the limitations of finite creaturely existence.¹⁴
The Patient as Divinely Addressed: Dignity Coram Deo
Third, and most fundamentally, the patient is a creature who stands before God — coram Deo — independently of any social recognition, clinical evaluation, or capacity for self-expression. I have argued, drawing on the Lutheran theological tradition, that human life is constituted by address: "life is given before it is chosen and answerable before it is fully understood."¹⁵ To be human is to stand coram Deo before one can stand within any social order — before one can exercise autonomy, form preferences, or participate in the procedures through which principlist bioethics adjudicates moral status.
The coram Deo dimension of human existence names the givenness of life. Prior to social mediation — prior to participation in the structures of medicine, law, family, or economy — life stands before God. Its worth is not conferred by system, negotiated through procedure, or bestowed by successful recognition. It is given. Address precedes action; grace precedes achievement. This is precisely the ontological claim that the autonomy model cannot supply. The dignity of the patient does not derive from her capacity to consent. It precedes her capacity to consent, and it remains even when that capacity is gone.
This coram Deo structure has a correlate in the coram hominibus dimension: life before God does not terminate in private religious consolation. It issues in answerability to the neighbor. The patient who stands before God as addressed and loved is also the neighbor who stands before the physician as one to whom something is owed — not merely technical competence, not merely respect for expressed preferences, but faithful attention to the whole person in her creaturely condition. The physician-patient relationship is structured by this dual relatedness, and neither the physician nor the patient can be adequately understood without it.
VI. Medicine as Vocation: The Goods Internal to Practice
The account of the patient developed above has direct implications for how medicine itself must be understood. If the patient is not a preference-bearing will but an embodied creature addressed by God and individuated by divine love, then the practice ordered toward her cannot be adequately conceived as a technical service industry. This section retrieves an understanding of medicine as a vocation constituted by internal goods — an understanding that the autonomy model systematically obscures.
Pellegrino and the Internal Goods of Medicine
The autonomy model's reduction of the physician to competent compliance requires, as its correlate, a conception of medicine as a service industry — a body of technical expertise rented to whatever preferences present themselves for fulfillment. This conception is not merely philosophically inadequate; it is unfaithful to the actual character of medicine as a practice with its own internal goods.
Edmund Pellegrino, in a body of work spanning more than four decades, argued persistently against this reduction. Medicine has an end (a telos), he maintained, that is internal to the practice itself and that cannot be reduced to the satisfaction of patient preferences: the right and good healing action in this particular patient at this particular time.¹⁶ This end encompasses truthful diagnosis, healing where possible, palliation where cure is impossible, the relief of suffering, the protection of bodily integrity, and faithful accompaniment in illness and dying. These are not externally imposed goals; they are what medicine is for. A physician who disregards them in the name of patient preference has not respected the patient's autonomy; she has abandoned her vocation.
Pellegrino's account draws on a broadly Aristotelian framework, retrieving the notion that practices are constituted by the goods they characteristically pursue and that the virtues are precisely those dispositions that enable practitioners to pursue those goods reliably and well.¹⁷ The good physician is not merely a skilled technician who happens to possess certain values; she is someone whose character has been formed by the goods of medicine in such a way that she can be trusted to pursue them even when doing so is inconvenient, unprofitable, or contrary to patient demand.
MacIntyre in the Background: Practices, Virtues, and the Telos of Healing
Alasdair MacIntyre's analysis of practices and their internal goods provides the broader philosophical framework within which Pellegrino's account of medicine operates.¹⁸ For MacIntyre, a practice is a coherent, complex form of socially established cooperative activity through which goods internal to that activity are realized in the course of trying to achieve those standards of excellence appropriate to it. The internal goods of a practice cannot be identified or pursued apart from participation in the practice itself; they are not reducible to external goods like income, prestige, or patient satisfaction.
Medicine, on this account, is a practice in the fullest sense: it has internal standards of excellence (diagnostic accuracy, therapeutic efficacy, appropriate palliation), internal goods (the patient's genuine health, the relief of genuine suffering), and a tradition of reflection on those goods that extends from Hippocrates through the long history of medical ethics. The autonomy model, by subordinating all of this to the patient's expressed preferences, effectively collapses the distinction between internal and external goods — treating the patient's satisfaction as the only relevant measure of medical success. This is not an enrichment of medical ethics but an impoverishment of it.
Vocation as Ontological Address: The Physician Before God
The Christian tradition adds a further dimension that the MacIntyrean framework does not supply. The physician's calling is not merely the result of having entered a practice with internal goods; it is a vocation in the theological sense — a calling that comes from outside the self and that is answerable to something more than the internal logic of medical practice.
I have argued, in dialogue with the Lutheran tradition, that vocation does not name first what one does but what one is: a creature called into being, relation, and responsibility.¹⁹ In its fundamental sense, vocation names the creaturely condition as such: life received from God and given for the neighbor within concrete forms of creaturely existence. The physician's vocation is a specification of this fundamental creaturely calling. She is summoned to care for the neighbor in the particular vulnerability of illness, to attend to the creature in her creatureliness, and to serve the goods of healing, truth, and compassionate accompaniment — not because she has contracted to do so, but because she stands coram Deo as one to whom this service has been given.
This vocational understanding of medicine has two important implications. First, it means that the physician's conscience is not an exception to her professional role but its center. She is not a technician with incidentally held values; she is a person whose integrity consists in the faithful ordering of her skills toward goods she has received and is accountable for. When demands are made of the physician that conflict with the internal goods of medicine or with her own moral convictions, the language of "conscientious objection" is precisely backwards: it is the demand for compliance, not the exercise of conscience, that requires justification.
Second, and equally importantly, the vocational understanding of medicine situates the physician coram Deo in her relation to the patient. The patient before the physician is not merely a preference-bearer with whom a transactional agreement is negotiated. She is a creature whom God has loved into existence, whom God continues to address and sustain, and who stands before both physician and God in the vulnerability of her creaturely condition. The physician who attends to her does so as one who is herself coram Deo — answerable for what she does and does not do with the gifts of knowledge and skill she has received. Medical care is not merely a technical transaction; it is an exercise of creaturely responsibility before God.
VII. Toward a Richer Doctrine of Informed Consent
The argument developed in the preceding sections is critical in its diagnosis but constructive in its intention. Having shown that the autonomy model presupposes an ontology of the patient it cannot supply, and having offered a Christian account of the patient and of medicine adequate to what the critique requires, it remains to show what a richer doctrine of informed consent looks like in practice — and what it is capable of protecting that the autonomy model is not.
Consent Situated Within, Not as the Governing Principle
Nothing argued in the preceding sections implies that consent is dispensable, that the patient's voice should be overridden, or that paternalism in its historical forms was anything other than a moral failure. The argument is not that autonomy does not matter but that autonomy cannot bear the full normative weight assigned to it.
A richer medical ethics situates consent within a broader framework constituted by medicine's internal goods, the physician's vocation, and an adequate account of the patient as a person whose dignity is not generated by her preferences. Within this framework, consent retains its indispensable function: it protects the patient from coercion, manipulation, and the reduction of her embodied person to an object of professional decision. It ensures that the physician's clinical judgment is not exercised unilaterally, but in partnership with the patient whose life and body are at stake. It honors the patient as an active participant in her own care rather than a passive recipient of expert decisions.
But consent now has a different status. It is not the ground of medical morality; it is a necessary expression of a medical morality already constituted by deeper goods. The physician seeks the patient's consent because the patient is a person whose creaturely dignity demands it — not because consent is what makes the intervention legitimate in the abstract, but because this particular creature has been addressed by God as the one whose participation in her own healing is owed to her as a matter of her God-given dignity.
What a Thicker Medical Ethics Protects
A medical ethics that situates consent within a richer framework is capable of protecting things the autonomy model cannot protect. It can account for the moral significance of the patient who cannot consent — the demented, the unconscious, the neonate — without the strained mechanisms of advance directives and best-interest standards that the autonomy model requires. The demented patient commands care not because her earlier expressed preferences survive or because her interests can be inferred from her former values, but because she stands before God as an addressed and loved creature whose significance is not a function of her current capacities.
It can also protect the physician's moral agency in ways the autonomy model suppresses. If the physician's conscience is the center rather than the margin of her professional identity, then demands for her participation in acts she regards as incompatible with medicine's internal goods cannot simply override that conscience in the name of patient preference. The physician is not a neutral tool; she is a person with a vocation, answerable for what she does and does not do.
And it can sustain the goods of truthfulness, faithful accompaniment, and compassionate presence that the service-industry model of medicine systematically erodes. Paul Ramsey observed long ago that the patient is not merely a biological problem to be solved but a person to be accompanied.²⁰ Accompanying a person through illness and dying is not reducible to respecting her preferences; it requires forms of presence, truthfulness, and care that go beyond the fulfillment of any contract. Medicine practiced as vocation is medicine oriented toward these forms of presence as constitutive of the practice itself.
The Distinction between Necessary and Sufficient
The fundamental distinction at stake can be stated simply: consent is necessary because the patient is a person; it is insufficient because the patient is more than a will.
The patient is a person: she possesses dignity that demands she be treated as an agent, not merely as a substrate for intervention. Her preferences must be taken seriously; her authorization must be sought; her right to refuse must be honored. The consent doctrine expresses something real about what she is.
But she is more than a will: she is an embodied creature whose life is received rather than self-created, a relationally constituted self whose identity is held in existence by divine love, and a creature who stands before God independently of her capacities for choice. These dimensions of her existence are morally relevant — indeed, they are morally primary — and they cannot be captured by a framework that treats autonomous preference as the master principle of medical morality. It is to the conclusion that these distinctions finally point.
VIII. Conclusion: The Vocation of Medicine and the Dignity of the Patient
Modern bioethics was built, in part, on a justified protest against the reduction of the patient to an object of professional expertise. The protest was right. The correction — the insistence that patients are persons whose voices must be heard and whose authorizations must be sought — was morally necessary and remains practically indispensable.
But the protest has generated a framework that cannot sustain its own deepest commitments. The dignity of the patient who cannot consent, the moral seriousness of the physician's vocation, the goods internal to the practice of medicine — none of these can be adequately grounded in a framework whose governing principle is the satisfaction of patient preferences. The autonomy model gives us an indispensable safeguard and mistakes it for a foundation.
The recovery of a richer medical ethics requires attending to what the autonomy model presupposes but cannot supply: an account of the patient as more than a preference-bearing will. That account is available, though not without theological commitment. The patient is an embodied creature whose life is received from God and whose significance does not depend on her present capacity for self-determination. She is a relationally constituted self whose identity is held in existence by divine love that does not diminish when memory fades or preference becomes inexpressible. And she is a creature who stands coram Deo — before the God who has addressed and loved her into the particular person she is — independently of any social recognition or functional capacity.
Medicine practiced as vocation — ordered toward the genuine goods of healing, truth, relief of suffering, and faithful accompaniment — is medicine adequate to this patient. Consent belongs within such a medicine, and it belongs there necessarily. But it cannot constitute such a medicine, because the patient who arrives in the clinic is not first and finally a will. She is a creature — addressed, loved, and called — whose dignity the physician is summoned to serve.
Notes
1. Dennis Bielfeldt, "Personal Identity, Divine Love, and Extrinsic Individuation," Verba Vitae 1, nos. 3–4 (Autumn/Winter 2024): 21–44; Dennis Bielfeldt, "Gaining Clarity on the That and What of Life," Verba Vitae 1, nos. 1–2 (Spring/Summer 2024): 39–52.
2. Dennis Bielfeldt, "Alienation, Vocation, and the Ontology of Life," Verba Vitae 3, no. 1 (Spring 2026): 39–58.
3. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York: Oxford University Press, 2019). The first edition appeared in 1979; the work has shaped anglophone bioethics across eight editions.
4. H. Tristram Engelhardt Jr., The Foundations of Bioethics, 2nd ed. (New York: Oxford University Press, 1996), 67–114. Engelhardt's position grew more explicitly theological in his later work; see The Foundations of Christian Bioethics (Lisse: Swets and Zeitlinger, 2000), where he largely abandons the secular project.
5. Leon R. Kass, Life, Liberty, and the Defense of Dignity: The Challenge for Bioethics (San Francisco: Encounter Books, 2002), 1–40. Kass's critique of the service model of medicine runs throughout his bioethical writing.
6. The most consistent defenders of this view are Peter Singer and Michael Tooley. See Peter Singer, Practical Ethics, 3rd ed. (Cambridge: Cambridge University Press, 2011), 73–105; Michael Tooley, "Abortion and Infanticide," Philosophy and Public Affairs 2, no. 1 (1972): 37–65. For a careful response, see Robert P. George and Christopher Tollefsen, Embryo: A Defense of Human Life (New York: Doubleday, 2008).
7. Edmund D. Pellegrino and David C. Thomasma, For the Patient's Good: The Restoration of Beneficence in Health Care (New York: Oxford University Press, 1988). See also Edmund D. Pellegrino, "Toward a Virtue-Based Normative Ethics for the Health Professions," Kennedy Institute of Ethics Journal 5, no. 3 (1995): 253–77; and Edmund D. Pellegrino, The Philosophy of Medicine Reborn: A Pellegrino Reader, ed. H. Tristram Engelhardt Jr. and Fabrice Jotterand (Notre Dame, IN: University of Notre Dame Press, 2008).
8. Bielfeldt, "Personal Identity, Divine Love, and Extrinsic Individuation," 26–36.
9. The locus classicus for the psychological criterion is John Locke, An Essay Concerning Human Understanding, ed. Peter H. Nidditch (Oxford: Clarendon Press, 1975), bk. 2, chap. 27. Its most influential contemporary defender is Derek Parfit; see Reasons and Persons (Oxford: Clarendon Press, 1984), 199–347. For the bioethical application of Parfitian considerations, see Jeff McMahan, The Ethics of Killing: Problems at the Margins of Life (New York: Oxford University Press, 2002).
10. Bielfeldt, "Personal Identity, Divine Love, and Extrinsic Individuation," 28–32. The argument draws on the analysis developed there, which engages Jacob Berger's critique of soul theories of personal identity and Jaegwon Kim's "pairing problem" for dualist accounts.
11. Gilbert Meilaender, "Death in the History of Redemption," Verba Vitae 1, nos. 1–2 (Spring/Summer 2024): 19. The passage Meilaender quotes is from Hans Jonas, The Phenomenon of Life: Toward a Philosophical Biology (New York: Harper and Row, 1966), 80.
12. Bielfeldt, "Personal Identity, Divine Love, and Extrinsic Individuation," 26–36; Dennis Bielfeldt, "Gaining Clarity on the That and What of Life," Verba Vitae 1, nos. 1–2 (Spring/Summer 2024): 44–52. The latter article develops the metaphysical distinction between the that (existence) and the what (essence) of a thing, arguing that existence is irreducible to essence — an insight directly relevant to the recognition that the patient's moral significance cannot be read off from her present properties or capacities.
13. Bielfeldt, "Personal Identity, Divine Love, and Extrinsic Individuation," 33. The argument draws on Robert C. Koons, "Divine Persons as Relational Qua-objects," Religious Studies 35, no. 4 (1999): 383–401, extending Koons's account of intra-Trinitarian individuation through divine love to the individuation of created persons.
14. The argument is developed in relation to the imago Dei in Bielfeldt, "Personal Identity, Divine Love, and Extrinsic Individuation," 38–43. See also Dan Lioy, "The Imago Dei: Biblical Foundations, Theological Implications, and Enduring Significance," Verba Vitae 1, nos. 3–4 (Autumn/Winter 2024): 45–72, for a complementary biblical-theological account.
15. Bielfeldt, "Alienation, Vocation, and the Ontology of Life," 40. The formulation draws on Luther's account of the Christian's standing coram Deo as developed in The Freedom of a Christian (1520); see Martin Luther, "The Freedom of a Christian," in Luther's Works, American Edition, vol. 31, ed. Harold J. Grimm (Philadelphia: Muhlenberg Press, 1957), 327–77.
16. Pellegrino and Thomasma, For the Patient's Good, 147–70. See also Edmund D. Pellegrino and David C. Thomasma, A Philosophical Basis of Medical Practice: Toward a Philosophy and Ethic of the Healing Professions (New York: Oxford University Press, 1981), 192–220.
17. Pellegrino, "Toward a Virtue-Based Normative Ethics," 260–63. The connection between internal goods and the virtues required to pursue them is central to Pellegrino's appropriation of Aristotelian ethics for medicine.
18. Alasdair MacIntyre, After Virtue: A Study in Moral Theory, 3rd ed. (Notre Dame, IN: University of Notre Dame Press, 2007), 187–203. MacIntyre himself does not directly apply his framework to medicine in After Virtue, but the application has been developed extensively by others; see Warren Thomas Reich, ed., Encyclopedia of Bioethics, rev. ed. (New York: MacMillan, 1995), and the essays collected in Daniel Sulmasy, The Healer's Calling: A Spirituality for Physicians and Other Health Care Professionals (New York: Paulist Press, 1997).
19. Bielfeldt, "Alienation, Vocation, and the Ontology of Life," 45–47. The Lutheran theological background is Luther's own account in "The Freedom of a Christian" and in his treatment of the Three Estates; see also Robert Kolb, "Martin Luther's Definition of the Human Creature," Verba Vitae 2, no. 2 (Summer 2025): 41–62.
20. Paul Ramsey, The Patient as Person: Explorations in Medical Ethics (New Haven: Yale University Press, 1970), xi–xviii. Ramsey's insistence that the patient is a person — a fellow human being — rather than a case or a problem remains one of the most important formulations in twentieth-century medical ethics, and his work anticipates much of what both Pellegrino and the present essay argue.
Bibliography
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