IIIM Magazine Online, Volume 1, Number 20, July 12 to July 18, 1999

THE MEDICAL MODEL REVISITED:
Moral Responsibility and Physical Disability

by John M. Frame

I. Some Questions

This paper will explore the Bible's teaching concerning human moral responsibility in relation to various physical conditions: genetic and birth defects, illnesses, injuries. Do such conditions ever influence our moral responsibility? And if so, in what ways?

Dr. Jay Adams, father of the nouthetic counseling movement and grandfather (can we say Godfather, without being misunderstood?) to the recent movement toward biblical ethics in medicine, began our recent discussion in his groundbreaking Competent to Counsel¹ by a biblically based² attack on the concept of "mental illness." There are, Adams, argues, genuine physical illnesses and other disabilities which affect behavior adversely. These may, depending on the state of medical technology, be amenable to medical treatment in some degree. There are also, he says, spiritual problems which may produce morally wrong actions. These, he maintains, are not the province of medical science but of counseling based on the word of God. There is, however, no third category, no category of "mental" or "psychiatric" illness distinct from the first two. Says Adams, "Psychiatry has no exclusive province that it may call its own."³

According to Adams, the tendency of modern secular thinking is to treat moral-spiritual problems as if they were physical illnesses. Hence the "medical models" of alcoholism, homosexuality,⁴ various phobias, compulsions, emotional instabilities and the like. Thus nouthetic counselors tend to reject such medical models and to look for sinful roots to such behavior, roots which can be dealt with through scriptural teaching.

Adams does recognize that there are cases in which it is difficult to tell "whether a problem stems basically from organic or non-organic sources,"⁵ and he gives schizophrenia as an example. He also recognizes that there are physical conditions that "may affect the brain directly,"⁶ such as "brain damage, toxic problems, hardening of the arteries, and insanity by gene transmission."⁷

This last category, however, deserves more attention.⁸ For one thing, if as some believe there is some sort of genetic component to alcoholism, the rapidly developing science of genetics may uncover genetic links to other conditions we are inclined to want to treat as "spiritual." Further, the examples Adams gives raise questions. If someone's behavior is affected by brain damage, does the biblical counselor simply refer that person to his physicians and have no more to do with the case? Or are there overlaps, crisscrossing areas of mutual influence between the physical and spiritual realms? Is it not possible that some problematic behavior has a plurality of causes, some physical, some spiritual, which interact in complex ways so that it becomes difficult to say, in Adams' terms, "whether a problem stems basically from organic or non-organic sources." Is it possible to engage in counseling without knowledge of what factor is "basic?" Must treatment, in some situations, be a team effort between physicians and biblical counselors?

Behind these questions lies a deeper one, a question about the very nature of human responsibility. To what extent do people remain responsible for their actions even when those actions are to some extent the result of physical causes or disabilities?


II. Human Responsibility and Other Modals

"Responsibility" is what philosophers call a "modal" term, as we can tell from its "-ibility" ending. Modal nouns refer, not to empirical objects like tables, chairs, trees, animals or persons, but to the capacities, abilities or possibilities of those objects. To say that a watch is immersible is not to say that it has been immersed or ever will be immersed, but rather to say that it can be, it is able to be, immersed without damage.

Capacities, abilities, possibilities are mysterious things.⁹ They cannot be seen or heard. They may depend upon physical properties (as in the example of immersibility), but they are not synonymous with any physical property or properties. They are often problematic in theology. Examples: (1) How does one define divine omnipotence, the proposition that God "can" do everything? Does that entail that God can make square circles? If there are logical limits on God's omnipotence, may there not be other kinds of limits as well? (2) What is meant by the "impeccability" of Christ? How does his human nature differ from that of pre-fall Adam, who was perfect, but "able to sin?" (3) How can we be "responsible for" the sin of Adam? (4) What is meant by the "total inability" of man without grace? (5) If believers continue to sin in thought, word and deed, what ability do they gain that the unbeliever does not have? What is the nature of that ability? (6) What is meant by the "impossibility" of having saving faith without works? Does that mean that works are as "necessary" (another type of modal term!) to salvation as faith is? (7) "Can" one be saved if he/she does not believe X, understand Y, do Z?

Complicating the picture is the fact that there are many different kinds of abilities, capacities, possibilities. Logical possibility is a different sort of thing from physical possibility, and those two are both different from economic possibility.¹⁰ For an average man to jump fifty feet into the air is a physical impossibility, but it is not logically impossible. Thus, "can" is often ambiguous. Apart from grace, one might say, human beings are morally unable to do anything good. But this inability does not necessarily extend to the logical, physical, intellectual or economic spheres. Indeed, in the latter senses they may very well be "able" to do good.¹¹

Talk about possibility often presupposes the existence or non-existence of certain barriers. We may say "Bill can't jump six feet" without thinking twice; but in saying that we assume certain conditions: Bill is not jumping from a trampoline or in a space shuttle. There are, therefore, specific barriers that prevent Bill from jumping six feet: his physiology, the stability of the ground from which he jumps (as opposed to a trampoline), the force of earth gravity. "Bill can't jump six feet" presupposes those barriers or others. Similarly, "Bill can jump six feet" assumes the absence of barriers sufficient to prevent such an accomplishment on the occasion in view.¹²

Now "responsibility" is a kind of passive modal, referring not so much to what we can do as to what can be done to us by someone else. To be morally responsible is to be liable to moral judgment, to moral curse or blessing. In a biblical morality, the agent of such judgment is God. Human "responsibility," therefore, refers to what God can do with us; it refers to the divine omnipotence.¹³ What can God do with us by way of judgment? Well, one biblical answer is, simply, "anything he likes!" The figure of the potter and the clay stresses God's right to do whatever he wishes with his own creation. See especially Romans 9:14-24 and Matthew 20:15 in context. This is an important biblical "perspective." When we are talking about human responsibility, we are all too eager to talk about our rights, what we deserve, what God owes to us. It is important to recognize that at the most fundamental level God owes us nothing. And as a potter may make a vessel for "ignoble use" and smash it after that use is complete, so God has the right to do with his creations. Ignoble vessels, in a sense, deserve to be destroyed, even when they have not done anything to make themselves ignoble.

But that is certainly not the whole story. For human beings are not only dust, clay in the potter's hands. They are also the potter's image. And thus God does not treat us merely as pots. God is omnipotent, but he exercises his omnipotence in accord with his character. Therefore, his omnipotence will never act in contradiction to his wisdom, his righteousness, his faithfulness, or his love. Because he is wise, he treats his creations according to what they really are. Because he is righteous, he deals with them according to his revealed law. Because he is faithful, he deals with them according to his promises. Because he is love, he works through all circumstances to bring blessing to his people.¹⁴ Thus, to expand our perspective is not at all to abandon the model of the potter and the clay. It is, after all, God who works out everything in conformity with the purpose of his will (Eph. 1:11). The sin of man itself is not outside the eternal plan of God (Gen. 50:20; Luke 22:22; Acts 2:23; 4:27ff.). God treats us "as we are" because he has ordained us to be what we are. To say this is not at all to excuse the wickedness of those who commit sin. Notice the references to human wickedness in the passages cited in the last parenthesis. Note also the apostle Peter as an example of one who took full responsibility for his sin (denying Christ!) even though that sin was predicted beforehand (see Luke 22:31-34,54-62).

Now, to get a full picture of human responsibility, of what God "can" do with us, we need to consider his wisdom, his faithfulness, his righteousness, his love, indeed all his attributes (such as omnipotence, which is prominent in the potter/clay model). Particularly, we must never forget that as believers we are objects of God's grace in Christ, and that God deals with us in and through him. But in the space remaining, I wish to focus on God's righteousness, the attribute which is usually prominent in discussions of specifically moral responsibility.

God's righteous demands of us are particularly revealed in his law, in the commands of Scripture.¹⁵ The doctrine of the sufficiency of Scripture teaches that in one sense, all of our obligations to God are exhaustively set forth in Scripture. Thus in one sense we all have the same responsibilities, summarized in the Ten Commandments. Paul is therefore able to say that the temptations each of us experiences are "common to man" (1 Cor. 10:13). As a man, Jesus also had the same responsibilities we all have, and because of that universal human commonness, the Letter to the Hebrews states that Jesus was "tempted in every way, just as we are, yet was without sin" (Heb. 4:15).

On the other hand, there is also a sense in which we differ in our responsibilities. For the commandments do not apply to each of us in the same way. That is to say, for those of you who are familiar with my other writings, that there is a situational perspective as well as a normative. We must know the situation in order to understand what precisely the norm requires of us. I have the obligation to read this paper to you today, because I previously promised to do so and the ninth commandment therefore requires me to do so. But most of you have not made such promises; so the ninth commandment does not apply to you in the same way. The fifth commandment requires me to honor in a special way Mrs. Violet M. Frame of Pittsburgh, PA. None of you has precisely the same obligation, unless unbeknownst to me one of my siblings has entered the room.

We also differ somewhat in the kinds of temptations we face. Our temptations are the same in that all of us are tempted to break the Ten Commandments or, even more concisely, in that all of us are tempted to renounce our covenant loyalty to our Lord. But some people are more strongly tempted, say, to abuse alcohol, than other people are. That difference is also a difference in "situation." One person's heredity, environment, training may be such that the use of alcohol is not a problem for him; with someone else, the case may be far otherwise.

In general, our obligations, our moral responsibilities, differ according to our gifts, our callings, our opportunities. One who has the gifts and calling to be an architect, and the opportunity to get the training and credentials necessary for that profession, has an obligation to give more attention to architecture than most of us would dream of giving. Similarly, we can say that obligations also change with maturity (both physical and spiritual). When Paul writes to Corinth asking the people to set aside some contributions for the poor saints in Jerusalem, common sense would lead us to believe that he is not addressing children of six months and under. Those who are ordained to the eldership have a responsibilities for the welfare of the church body that "babes in Christ" do not have as yet. Scripture teaches us, "From everyone who has been given much, much will be demanded; and from the one who has been entrusted with much, much more will be asked" (Luke 12:48). Thus Jesus is far more critical of the Jewish leaders, who have been entrusted with much knowledge, than he is of the ordinary Jews and Gentiles who are relatively ignorant of God's word.

No one, of course, escapes from God's obligations entirely. Little children have the obligation of hearing and obeying their parents in the Lord. And ignorance, while a mitigating circumstance as we have seen, is not an excuse. The principle is: "That servant who knows his master's will and does not get ready or does not do what his master wants will be beaten with many blows. But the one who does not know and does things deserving punishment will be beaten with few blows" (Luke 12:47ff.; cf. Lev. 5:17; Num. 15:27-29; Rom. 2:12). That is to say, no one is completely devoid of those divine gifts and opportunities requisite for obedience. Sometimes ignorance itself is culpable, since the person has the means to overcome his ignorance and should have used them. The deepest desire of the servant should be to know his master's will so that he may do it.

To what extent, then, are we as Christians able to accept the principle that moral responsibility is a function of freedom? That principle is commonly asserted in the ethics literature. The basic point is that if someone is not free to perform or not to perform an action, if he "could not have done otherwise," as it is often put, he cannot be blamed for that action. To use the most extreme example: if someone is in a coma, but his body is manipulated by machinery so that he takes money illegally from a bank, he certainly is not responsible for that theft. He could not have done otherwise.

The basic point represents a scriptural principle, but we must recognize the qualifications which Scripture places upon it. For one thing, there are outright exceptions. I am not and never have been free to reverse Adam's decision to eat the forbidden fruit. Yet God sees me, in solidarity with Adam, as guilty of that sin. Similarly, I did not freely choose that Jesus would live a perfect life and atone for my sins. Yet God sees me, in solidarity with Jesus, as a doer of Jesus' righteousness. The principle of free choice must be qualified by the principle of federal headship.

Further, we must clarify the concept of "freedom" as employed in the principle under discussion. Some philosophical libertarians and theological Arminians often claim that no action is free unless it is "causeless." On this view, free actions may not be caused, not by anything outside the moral agent, not even by his/her own motives. But to insist on such freedom is to see moral choices as sheer accidents, events which spring up by pure chance. Indeed, since these "choices" are not at all under the control of the moral agent himself, they cannot meaningfully be described as his. And if one is controlled by such freakish events springing up within himself, it makes more sense to speak of such a condition as bondage rather than freedom.

Other libertarians and Arminians are willing to concede at least that moral choices have causes within the moral agent, whether motives or something else. But either these causes are themselves causeless (in which case again is raised the spectre of freakish internal accidents), or they are themselves linked with the chain of causes God has created into the natural world, in which case we may no longer equate freedom at all with causelessness.

The fact is that nobody ever uses "causelessness" as a criterion of moral responsibility. Certainly civil courts do not presume to determine if an action is causeless before passing sentence. They are not competent to do that, for the negative proposition "there was no cause" is virtually impossible to prove. (If a court were truly convinced that, say, a murderer's behavior was truly causeless, it would doubtless conclude that he was not guilty by reason of insanity.) Nor do ordinary people feel obligated to make such causal judgments before "accusing or excusing one another." Certainly there is no trace of any such doctrine in Scripture; on the contrary, Scripture teaches that human sin is within the plan of God, as I indicated earlier.

Then what is freedom? Freedom is, like responsibility, a modal concept. It asserts, in various contexts, certain abilities and denies certain barriers to the fulfillment of those abilities. Bill is free to jump five feet if he has the ability to do that by his own choice and no barrier prevents him from putting his choice into effect. (The causality behind that choice is irrelevant.) He is free not to jump five feet if there is nothing forcing him to do so against his will. There are as many kinds of freedom as there are kinds of ability; in fact, "freedom" and "ability" are nearly synonymous.

We have already seen that in Scripture moral responsibility is limited by ability. In that sense, then, and only in that sense (I would say), moral responsibility is limited by freedom. Moral responsibility is limited by those abilities which are coordinate with the gifts, opportunities, callings, training, physical and spiritual maturity, noted earlier.

Not every ability is equally relevant to moral responsibility. Significantly, I should point out that moral ability itself (those character traits which permit the doing of good) is not relevant to moral responsibility. One can never excuse sin, or even mitigate his responsibility for sin, simply by denying that he has good character. Imagine someone telling a civil judge, "I couldn't help it, your honor; I could not do otherwise, because I'm such a rotten person." The judge would not be moved by such a plea; nor is God. Thus no one can use the doctrine of total inability to excuse, or even to mitigate blame for, his sins.


III. The Role of Physical Disability

But we can see how physical infirmities can and do bear upon assessments of moral responsibility. One who is unable to get out of bed simply does not have the ability to help his team win a relay race, even though he might be otherwise committed to doing so. He does not have the requisite ability to bear that particular moral responsibility.

While maintaining this basic point, we should be aware that the overall relation between the physical and moral realms is more complicated. For one thing, not only does physical disability affect moral responsibility, but our moral choices also may have physical consequences as in the case of sexually transmitted disease. A physical disability, therefore, may not be so much a divinely granted exemption from moral struggle as a challenge to repent from grave sin. On the other hand, the Book of Job teaches us that physical disability is not always a sign of moral guilt.

Indeed, sin may masquerade as illness; hence Adams' examples of people who act in bizarre ways to avoid being confronted with their sin. Hence our cultural tendency to misuse the "medical model." Relations between disease and sin can cause confusion in doctors, counselors and patients alike. Very often we must deal with both disease and sin, and it is hard to separate the two.

Even when it is not the result of moral choice, physical disability does not take us out of the moral struggle. Rather, it creates a new kind of moral struggle, a new situation to deal with according to God's word. It is not only healthy people, after all, who are called to make moral choices. Those who are sick have an obligation to deal with that sickness in a way that brings glory to God. They are faced with temptations somewhat different from those faced by healthy people — perhaps especially the temptation to self-pity and the temptation to avoid responsibility by exaggerating one's disability.

The same must be said about genetic and other congenital conditions which in some way predispose a person to commit certain sins. These may be seen as extraordinary sources of temptation, and these people are faced with the peculiar moral challenge of facing and overcoming these temptations. Such conditions do not excuse the sins in question, but they certainly do make the overcoming of those sins more difficult. They also stand as a rebuke to the moral pride of others. Most of us would be less harsh, impatient and unforgiving toward others if we understood the extent to which they may have a harder moral struggle than we. We must keep this difference in mind, especially when we seek to offer biblical counseling to such people.

"Disability," of course, is a relative term. Compared to Einstein, most of us are mentally disabled, at least in the fields of mathematics and physics. Compared to Mikhail Baryshnikoff, most of us are physically clumsy. We all, therefore, have "disabilities" to deal with; accepting our finitude for what it is will always be part of the moral battle. Learning how to contribute to God's world despite our disabilities will always be part of our mandate. The physically disabled, therefore, are not morally different from the rest of us except in degree, except in the situational specifics. They also, indeed, have strengths, abilities, as we do; and the abilities as well as the disabilities present temptations as well as opportunities for moral growth. Keeping in mind the similarities as well as the differences will encourage in us a proper loving empathy.


IV. The Medical Model Again

The above discussion should help us to clarify the issues surrounding the "medical model." Nothing in Scripture rules out the possibility that some physical disability might predispose people to alcoholism, homosexuality, violent behavior (the extra y chromosome?) or other sins. Those physical disabilities, when treatable, can only be treated medically. There is no reason why we should not give names to those conditions, such as "pre-alcoholism syndrome." It would, however, be confusing if we used a term like "alcoholism" for such a syndrome; for commonly "alcoholism" refers not to such a syndrome, but to the behavior to which such a condition predisposes a person.

So even if there is such a condition predisposing one to alcoholism, it would be wrong to call such a person an alcoholic (a predisposition to behavior is not the behavior itself, nor a deterministic cause of the behavior), and it would be wrong to call alcoholism a disease. The same is true for other predispositions to sin. Although the relation between sin and disease is complex, the two are not the same thing, and no good can come of confusing them.

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1.Nutley (N.J.: Presbyterian and Reformed Publ. Co., 1970), pp. 26-40.

2.Others, of course, had also attacked this notion, but without Adams' biblical basis for doing so. Adams himself cites Thomas Szasz, The Myth of Mental Illness (N. Y.: Dell, 1960).

3.Op. cit., 36.

4.Granted, the medical model for homosexuality is already out of date. The present consensus is rather to treat homosexuality as a legitimate alternative lifestyle. Thus the secular mind moves, in my estimation, even further from the scriptural norm. One wonders to what extent the present medical models will, in the future, change into descriptions of legitimate alternative lifestyles.

5.Op. cit., 37.

6.Ibid., 40.

7.He lists these as exceptions to his general exclusion of the "mental illness" category, thus apparently permitting the use of the phrase "mental illness" to describe such conditions. Such "mental illness," however, is clearly within the "physical" category; so Adams does not here compromise the exhaustiveness of his twofold distinction.

8.I don't find that attention given in Competent to Counsel, but I would certainly not wish to claim dogmatically that Adams has never discussed this matter anywhere in his large printed output. It is very possible that I have missed something by him or by his disciples.

9.The tendency in recent philosophy to analyze possibility in terms of "possible worlds" is useful in some ways, but it does not dissolve the mystery. It only pushes that mystery back a step: If a watch's "immersibility" means that there is a possible world in which that watch is immersed without damage, what is it that makes that world a possible world?

10.Doubtless, one could find a different kind of possibility (or something like possibility) in each of Herman Dooyeweerd's "modal spheres:" numerical, kinetic, physico-chemical, biotic, emotional, logico-analytical, historical, linguistic, social, economic, aesthetic, legal, ethical, pistical. See his A New Critique of Theoretical Thought (Philadelphia: Presbyterian and Reformed Publ. Co., 1969), 4 vols. There are other kinds as well. For example, I would define "metaphysical" possibility as follows: an event is metaphysically possible if and only if God has ordained it to take place. Or meta-metaphysical possibility: an event is meta-metaphysically possible only if God, consistently with his own character, might have brought it to pass. (I realize that I have here defined one modal by another one, what "can" happen by what God "can" do.

11.The distinction between moral and physical inability is often made by Reformed theologians; yet many would-be evangelists in the Reformed camp confuse their unbelieving hearers by telling them purely and simply that they "cannot" believe, an evangelistic approach not sanctioned by Scripture and which is easily misunderstood as an encouragement to passivity. It may sound Arminian, but it is fully Calvinistic to tell unbelievers that in some important senses they can believe in Christ and therefore are responsible to do precisely that.

12.Even in logic, possibility and impossibility often, at least, presuppose specific conditions. Two propositions are logically inconsistent, and therefore impossible to assert together, only when one claims they are true "at the same time and in the same respect." Change a time or a respect, and the impossible may become possible.

13.Ultimately, all modals refer to God's omnipotence. As Van Til says, God is the source and criterion of possibility and impossibility.

14.As to why God's love does not save all human beings I have no very good answer. Evidently such a universal saving purpose would conflict with his wisdom in ways beyond what I can discern. Scripture doesn't give us the answer, and I do not see how we can answer it apart from such revelation. I do think, however, that the non-elect also are objects of God's love insofar as they are cabable of receiving it; see Matt. 5:43-48; Acts 14:17ff.

15.I won't discuss here the important hermeneutical questions about the relation of Mosaic law to the New Testament believer, etc. There are enough commands given in the New Testament itself to underscore the fact that we are responsible to obey our Lord. I am interested simply in the nature of obedience to divine commands as such.