* The following is part of a teaching series done for a Sunday School class.
Life, Death & Growing
Old
·
End of life issues: terminating life support, physician-assisted
suicide, and euthanasia
1.
Biblical Principles on Death: Important points
to remember and factor into our thinking when discussing these topics
a.
Timing and manner of death belong ultimately to
God: Deuteronomy 32.39; Matthew 10.28; Revelation 1.18
§
We are not autonomous! We live under the sovereign lordship of God.
b.
Death was not part of God’s design. It is an alien intruder into God’s good
creation; an enemy: 1 Corinthians 15.26
c.
Death is “normal” now due to the state of
sinfulness in the world—“The way of all the earth” as a metaphor for death:
Joshua 23.14; 1 Kings 2.1
d.
Death is both “normal” and an enemy (b. and c.
above)
e.
Life is to be sought after—all of Scripture
teaches this as its default setting: Proverbs 24.11-12; Galatians 6.10; 1
Thessalonians 5.15
f.
This earthly life is not the highest good:
Romans 14.7-8; 1 Corinthians 10.31; 2 Corinthians 5.9-10
g.
God can and does use human suffering for good: 2
Corinthians 12.7-10; 1 Peter 2.21-24; 4.12-17
2.
Definitions
a.
Termination of life support (TLS)
i. Used
to be called “passive euthanasia”
ii. Nothing
“passive” about it—deliberate act
iii. Usually
withdrawing ventilator support for breathing or withholding CPR for patients whom
it would be futile.
b.
Physician-assisted suicide (PAS)
i. Physician
more actively serves as a causal agent in the patient’s death.
ii. Physician
provides medicine and knowledge of how to use it to bring about death.
iii. Death
is directly caused by medication and not by underlying disease.
c.
Euthanasia (sometimes called “mercy killing”)
·
Note: euthanasia
comes from the Greek word “eu-thanatos” meaning “good death”
·
Sometimes the term “euthanasia” is used broadly
to cover all the categories including TLS and PAS.
i. Refers
to the direct and intentional efforts of a physician or other medical
professional to help a dying patient die.
ii. Usually
accomplished by administering a lethal injection of drugs into the patient.
iii. The
patient is actually killed by the direct action of the physician.
·
Note: The main difference between
physician-assisted suicide and euthanasia is the direct involvement of the
physician in the patient’s death.
·
Distinctions we have been discussing…
·
The “slippery slope” in arguing for
physician-assisted death:
· “Even
if, for the sake of argument, we grant the legitimacy of assisted suicide,
that's only "necessary" in a fraction of cases (i.e. incapacitating
accidents). Yet euthanasia is applied far more broadly. And notice how quickly
it goes from voluntary to involuntary euthanasia.
The real reason is that assisted suicide is a pretext
for government to expand its authority to kill people. It uses the guise of
"compassion" and "death with dignity" and "mercy
killing" as an excuse to assume the role of public executioner, become the
arbiter of life and death. It's really about the absolute power of the state.
And not coincidentally, this dovetails with nationalized healthcare. The
apotheosis of the state. Physicians as public employees who kill at the behest
of the state.
There's also something undeniably diabolical behind it
all. The devil hates humans. The devil is a murderer for the beginning (Jn 8:44). The devil is the unseen architect of genocide. How else
do we account for self-loathing humanism?” --Steve Hays
3.
Important for Christians to think about these
things
a.
“For the church, physician-assisted suicide and
euthanasia is a very pressing issue, and the big debates loom just over the
horizon.
We must affirm to our
churches what it means not only to have a good life but a good death.
A good death is able to minimize
suffering when possible, and it affirms the inherent dignity of the
person.
In a profound, true sense,
one cannot evade all forms of human suffering.
I am not arguing, of course, that people should simply
accept every kind of suffering.
However, the opposite position that one must intervene to alleviate all
suffering, or even intervene before the suffering begins, is an extreme
one.
Suffering was not part of
God’s original design for his creation.
It is the result of the fall, just like death.
However, God can use these to accomplish his greater
purposes in the world.
The notion
of suffering and its ability to produce character and make possible a deeper
experience with God is littered throughout Scripture.
This is a point that opponents to our position will not be
fond of, yet it is one that Christian tradition and Scripture stand upon and
must not forfeit.
The Christian
church would do well to recover a robust
ars
moriendi [art of dying] and stand ready to articulate their position on
assisted dying, lest culture attempt to redefine it for us.”
b.
“Five states—California, Oregon, Washington,
Montana, and Vermont—have legalized physician-assisted suicide in some form.
PAS remains illegal by statute in Montana, but a 2009 Montana Supreme Court
decision shields doctors from prosecution so long as they have the
patient's request in writing. New Mexico's statutes continue to list assisted
suicide as a fourth-degree felony, but the courts briefly made the practice
legal in 2014 before the New Mexico Court of Appeals ruled against it.”
4.
Distinctions: Important for how we reason about
these issues and how to respond to unbiblical views
a.
Withholding vs. Withdrawing Treatment
i. Definitions:
1.
Withholding: treat not started
2.
Withdrawing: stop a treatment already begun
ii. Emotionally:
more difficult to stop a treatment
iii. Ethically:
there is not a relevant difference between the two
iv. “When
one begins a treatment, the implicit promise (and thus, patient expectation)
only involves using that treatment until a point is reached when it becomes
pointless and excessively burdensome.”
b.
Voluntary, Nonvoluntary, and Involuntary
“Voluntary euthanasia occurs whenever a competent, informed
patient autonomously requests it. Nonvoluntary euthanasia occurs whenever a
person is incapable of forming a judgment or expressing a wish in the matter
(e.g., a defective newborn or a comatose adult). Involuntary euthanasia occurs
when the person expresses a wish to live but is nevertheless killed or allowed
to die.”
c.
Ordinary/Extraordinary distinction
i. Ordinary
means: “all medicines, treatments, and operations that offer a reasonable hope
of benefit without placing undue burdens on a patient (e.g., pain or other
serious inconvenience).”
ii. Extraordinary
means: “those that are not ordinary; that is, those that involve excessive burdens
on the patient and that do not offer reasonable hope of benefit.”
iii. Important
qualifications:
1.
Distinction is relative to the changes that
happen in medicine. What was
excessive 50 years ago may be ordinary today.
2.
Distinction should be applied to kinds of
treatments for specific persons in specific situations. Same treatment may more or less
burdensome or painful for differing patients.
3.
“The line between ordinary and extraordinary
treatment is not always easy to draw, and such judgments should be made on a
case by case basis and should involve the patient, the family, and the
attending physician.”
4.
Because of these points the terms more in use
today are obligatory and optional. This takes into account the role that different
circumstances play in determining which treatments are morally required and
which ones are not.
d.
Motives, Intentions, and Means
§
1 Samuel 16.7 “…for God sees not as man sees,
for man looks at the outward appearance, but the Lord looks at the heart.”
§
Hebrews 4.12 “For the word of God is living and
active and sharper than any two-edged sword, and piercing as far as the
division of soul and spirit, of both joints and marrow, and able to judge the thoughts and intentions
of the heart.”
i. Motives:
Why
one acts.
ii. Intentions:
What
one intends on doing.
iii. Means:
How
one acts.
§
Evaluating the morality of an action requires
that we need to determine if an immoral
means was used to accomplish a moral/good
end.
§
“The ends do not justify the means.”
iv. Illustration:
“Suppose that Patty, Sally, and Beth each have a grandmother who will leave
behind a large inheritance.
Each
visits her grandmother on a Saturday afternoon and brings a cherry pie to
her.
Patty, motivated by respect
for a relative, intends to love her grandmother by means of being with her for
the afternoon and by giving her a cherry pie.
Sally, motivated by greed, intends to secure a place in the
will by means of being with her grandmother for the afternoon and by giving her
a cherry pie.
Beth, motivated by
hate for her grandmother, intends to secure a place in the will by means of
giving her grandmother a cherry pie with poison in it.”
|
|
Patty
|
Sally
|
Beth
|
|
Motive
|
Good
motive: respect for relative.
|
Bad
motive: greed.
|
Bad
motive: hate.
|
|
Intention
|
Good
intention: love grandmother.
|
Bad
intention: selfishly securing place in will.
|
Bad
intention: selfishly securing place in will.
|
|
Means
|
Good
means: spend time; give pie.
|
Good
means: spend time; give pie.
|
Bad
means: killing grandmother with poisoned pie.
|
5.
The Distinction between “killing” and “letting
and die”
a.
There are some who say this is a distinction
without a difference.
b.
Important to maintain this distinction
c.
Intentions and results
i. Killing:
aiming at death as the goal
ii. Letting
die: not necessarily (and usually not) aiming at death as the goal
iii. “To
kill—that is, actively to take someone’s life—is by definition to choose death,
whether this be done out of wicked or merciful motives.
To let an ill person die (ourselves or
another), however,
may well be to choose
not death but one form of life over another.
A person’s choice to forgo an additional round of
chemotherapy when her cancer is evidently a terminal case is probably not a
choice to die.
The fact of death
has already been decided, apart from the cancer victim’s will.
Instead, the choice to forgo more
chemotherapy may be a decision to
live a somewhat shorter life than
the chemotherapy might make possible, but a shorter life that is free from the
debilitating burden of chemotherapy and that enables the person to enjoy her remaining
life more—to finish projects, to spend time with loved ones, and to get her
house in order.
It is not necessarily a choice between life
and death, therefore, but a choice between one kind of life and another kind of
life.”
iv. “One
more example is needed to unpack the implications of our distinction between an
act’s aim and its result.
A
patient in the last stages of terminal illness, who is suffering greatly, may
request and receive increasingly large doses of morphine to control his
pain.
We know that increasingly
large doses of narcotic drug may bring death more quickly by suppressing
respiration.
That is one possible
result of this treatment, and of course
one could aim at that result by giving a dosage large enough to cause
death.
But a carefully calibrated
increase in the amount of medication is aimed at controlling pain, not at
bringing a quicker death than would otherwise have happened, though that is
hard to know.
The intent, however,
is to provide the best care possible in these difficult circumstances.
Neither the patient who requests the
morphine nor the doctor who authorizes it is necessarily choosing death in so
doing.”
d.
We do not always need to do everything possible
to avoid death.
“Nevertheless, the fact that we ought not to aim at death for ourself or
another does not mean that we must always do everything possible to oppose
it.
Life is not our god, but a
gift of God; death is a great evil, but not the ultimate evil.
There may come a time, then, when it is
proper to acknowledge death and cease to oppose it.
Our aim in such circumstances is to care for the dying
person as best we can—which now, we judge, means withdrawing rather than
imposing treatment.”
e.
Guidelines used to determine when to refuse
treatment
i. A
treatment can be refused if is useless.
·
Sometimes continued treatments in an attempt to cure a patient only impose needless
difficulty and may well get in the way of the effort to care for the person.
ii. A
treatment can be refused if it excessively burdensome.
·
“Because life is not our god, we need not accept
all burdens—no matter how great—in order to stay alive.
We need to recognize clearly what this
means.
It means that we rightly
refuse even useful treatment that would prolong our life for a significant
period of time if that treatment really does carry with its significant
burdens.”
6.
Difficulties in applying God’s standards to
difficult cases
It is also the case, as we mentioned before, that many issues of the
modern day are not specifically discussed in scripture. If we cannot fax the
apostles to learn their view of baptism, much less can we determine directly
what they would say about nuclear weaponry, the government role in welfare, the
medical use of life-support equipment. Here too, there are biblical principles
which apply; but the argument can be complicated. It is not as if the apostles
were readily available for interviews.
In facing our epistemological disadvantages, the first thing to be said
is that God understands. He is the Lord of history. His providence has planned
and controlled it. It is no accident that we are in the present epistemological
situation. That situation, uncomfortable as it may be at times, suits God’s
purposes perfectly, and we must be thankful for it. We should not murmur or complain,
as Israel in the wilderness. When someone calls and asks me a hard question,
say, about whether they should remove life support systems from a dying
relative, I usually begin by saying that these are, after all, hard questions,
and that God understands how hard they are for us. We cannot fax the apostles,
but He doesn’t expect us to. He has left us with Scripture and the Spirit’s
illumination, and He has determined that that is enough. We may fumble around
in searching for answers. We may make decisions which we regret later on,
because we hadn’t at first considered all the relevant principles and facts.
But God understands that! He doesn’t expect us to be perfect theologians. He is
not waiting up in heaven with a club to hit us over the head when we make an
exegetical mistake.
In such
situations, it is helpful to remember that we are justified by faith, not by
works, nor, therefore, by ethical accuracy. That comfort does not, of course,
excuse us from hard thinking. If God has justified us, we will want to please
him, and we will make intellectual and other efforts to do what he wants. But
the sincerity of such efforts is not measured by the perfection of the results.
We may try very hard to apply biblical principles and come up with an answer
that later proves inadequate. Yet God will still honor the attempt. He knows
the heart, and he takes into consideration the obstacles (including
epistemological) that we must overcome.
7.
What are the primary arguments given in support
of physician-assisted suicide/euthanasia?
How would you respond to each one?
a.
Argument from mercy: merciful to relieve the
suffering of the terminally ill
i. Most
cases of pain can be controlled and managed through medication
· “
A report by the National Institute of Health notes that in published
studies, pain is not a dominant motivating factor in patients seeking PAS. The
reasons for seeking to die are usually depression, hopelessness, issues of
dependency, and loss of control or autonomy.”
ii. Acceptable
for patients to “go to sleep” through medication before they die
iii. Even
if pain relief control slows down heartbeat and breathing this is justified
under “double effect”
§
“Double effect”: an unintended but foreseen
negative consequence of a specific action does not necessarily make that action
immoral
b.
Argument from utility: it’s a “win-win”
situation—benefits the suffering patient, family, high cost of medical care is
avoided, medical staff can get on with helping others.
i. Such
calculations need to include the impact on the public at large over the long
term as well as the short term.
ii. Do
the actions produce a balance of good consequences in society in general,
especially as it relates to future terminally ill patients who might be coerced
into consenting to active euthanasia.
iii. This
utilitarian reasoning assumes the adequacy of utilitarian moral reasoning. There are also deontological arguments
that need to be considered (i.e., the sanctity of life and the prohibition of
killing innocent people.
c.
Argument from autonomy: timing and manner of
one’s death are personal and private decision protected by the right to
privacy.
i. Personal
autonomy is not absolute. Some
things we cannot do with our bodies (i.e., illegal drugs, prostitution).
ii. When
there has been a conflict of personal autonomy and the rights of others, the
rights of others usually takes precedence.
1.
Opening the door to euthanasia threatens the
lives of others at the end of their lives—Dutch experience strongly suggests
that some euthanasia is being administered against people’s will.
iii. If
autonomy is used then autonomy is a “universal right” and thus
physician-assisted suicide cannot be limited to terminal patients. It must be available to all regardless
of age or illness.
iv. Christian
worldview: theologically it is not the case that people have the right to
choose the time of their death.
God is the one to decide when one dies.
d.
Argument that euthanasia is not a violation of
the Hippocratic Oath: (1) HO also outlaws abortion but we allow that today; (2)
HO is less a moral requirement than a quaint piece of history not taken
seriously today; (3) if Hippocrates had known of chronic diseases he would have
understood the need for physician-assisted suicide.
i. If
Hippocrates had known of the pain management medicines he would have been able
to uphold his standard of not taking life.
ii. We
don’t think that abortion should be allowed.
e.
No morally relevant difference between killing
and letting die: uses James Rachels’ argument—nephew in bathtub and uncle who
stands to inherit money if boy dies: (1) active killing by drowning and (2)
allowing a fallen nephew who is passed out under water to die by refusing to
help.
i. Rachels’
analogy is overblown—has a masking or “sledge-hammer effect.” The two cases given by Rachels are both
so morally atrocious that they fail to take into account other features of
their situation (killing versus letting die) that are morally determinative.
ii. Main
problem: inadequate analysis of the human moral act. Merely looks at overt behavior but does not take account of
intentionality.
1.
“A human act, moral or otherwise, is a composite
whole that contains various parts among which are these two: (1) the object,
end, or intention of the act, and (2) the means-to-the-end of the act.”
2.
Rachels leaves out the intentionality of the
agent from his analysis.
3.
If actions and intentions are linked then
Rachels’ argument fails. If
actions and intentions are de-coupled then actions cannot reveal intentions
(which most ethicists deny).
iii. Cause
of death is different in both cases.
In one (letting die) the disease is allowed to take its course. In the other (killing) the physician
administers the lethal action—his or her action is the immediate cause of
death.
Bibliography
Ryan T. Anderson, “Always Care, Never Kill: How
Physician-Assisted Suicide Endangers the Weak, Corrupts Medicine, Compromises
the Family, and Violates Human Dignity and Equality”
Backgrounder (The Heritage Foundation: March 24, 2015). Online:
http://thf_media.s3.amazonaws.com/2015/pdf/BG3004.pdf.
Gilbert Meilaender, Bioethics:
A Primer for Christians. Grand Rapids, Mich.: Eerdmans, 1996.
Scott B. Rae, Moral
Choices: An Introduction to Ethics 3rd ed. Grand Rapids, Mich.:
Zondervan, 2009. Chapter 8—“Physician-Assisted Suicide and Euthanasia”.
David VanDrunen, Bioethics
and the Christian: A Guide to Making Difficult Decisions. Wheaton, Ill.:
Crossway, 2009. Especially chapters 7-9.
State of Arizona Attorney General’s “Life Care Planning”
page:
·
Contains the following:
o Durable
Health Care Power of Attorney
o Durable
Mental Health Care Power of Attorney
o Living
Will (End of Life Care)
o Pre-Hospital
Medical Directive (Do Not Resuscitate)
