Friday, November 4, 2016

Life, Death, & Growing Old (part six): End of Life Issues

* 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?”[1]   --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.”[2]

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.”[3]

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[4]

                                            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.”[5]

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.”[6]

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).”[7]

                                              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.”[8]

                                            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.”[9]

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.”[10]

Good motive: respect for relative.
Bad motive: greed.
Bad motive: hate.
Good intention: love grandmother.
Bad intention: selfishly securing place in will.
Bad intention: selfishly securing place in will.
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.”[11]

                                            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.”[12]

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.”[13]

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.”[14]

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.[15]

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.”[16]

                                              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.”[17]

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.


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:

Joe Carter, “Nine Things You Should Know About Physician-Assisted Suicide” Gospel Coalition Website (June 21, 2016). Online:

Daniel J. Hurst, “Physician-Assisted Suicide and Euthanasia: A Slippery Slope Indeed” Canon & Culture (July 29, 2015).  Online:

Gilbert Meilaender, Bioethics: A Primer for Christians. Grand Rapids, Mich.: Eerdmans, 1996.

J. P. Moreland, “The Euthanasia Debate: Understanding the Issues” Christian Research Journal (Winter, 1992).  Online:

J. P. Moreland, “The Euthanasia Debate: Assessing the Options” Christian Research Journal (Spring, 1993).  Online: 

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)

     [1] Steve Hays, “Assisted Suicide,” Triablogue (November 1, 2016).  Online:
     [2] Daniel J. Hurst, “Physician-Assisted Suicide and Euthanasia: A Slippery Slope Indeed” Canon & Culture (July 29, 2015).  Online:
     [3] Joe Carter, “Nine Things You Should Know About Physician-Assisted Suicide” Gospel Coalition (June 21, 2016). Online:
     [4] J. P. Moreland, “The Euthanasia Debate: Understanding the Issues” Christian Research Journal (Winter, 1992), 6—note: page numbers are to online edition:
     [5] Moreland, “The Euthanasia Debate: Understanding the Issues,” 6.
     [6] Moreland, “The Euthanasia Debate: Understanding the Issues,” 6.
     [7] Moreland, “The Euthanasia Debate: Understanding the Issues,” 6.
     [8] Moreland, “The Euthanasia Debate: Understanding the Issues,” 6.
     [9] Moreland, “The Euthanasia Debate: Understanding the Issues,” 7.
     [10] Moreland, “The Euthanasia Debate: Understanding the Issues,” 8.
     [11] David VanDrunen, Bioethics and the Christian: A Guide to Making Difficult Decisions (Wheaton, Ill.: Crossway, 2009), 210-211—bold-face added.
     [12] Gilbert Meilaender, Bioethics: A Primer for Christians (Grand Rapids, Mich.: Eerdmans, 1996), 70-71.
     [13] Gilbert Meilaender, Bioethics: A Primer for Christians (Grand Rapids, Mich.: Eerdmans, 1996), 71.
     [14] Gilbert Meilaender, Bioethics: A Primer for Christians (Grand Rapids, Mich.: Eerdmans, 1996), 74.
     [15] John Frame, “Between the Apostles and the Parousia: Bearing the Burdens of Change and of Knowledge” (May 16, 2012).  Online:
     [16] Joe Carter, “Nine Things You Should Know About Physician-Assisted Suicide” Gospel Coalition Website (June 21, 2016).  Online:
     [17] J. P. Moreland, “James Rachels and the Active Euthanasia Debate,” JETS 31.1 (1988), 89.