Ethics at the End of Life
Sunday, July 28, 2002
Today we are talking about a very serious subject. We are beginning a series about end-of-life issues. What is ethical at the end of life? People have struggled with this question and sought God’s guidance. This is a serious issue because we are talking about life and death and probably the last decision you will ever make and the last act you will ever perform in this life before you go before the throne of God. With what posture do you want to enter into his throne room–having been faithful to God the whole way, or having fumbled the ball on the last yardline, not taking it all the way into the end zone?
All of us want to be able to say what Paul did in II Timothy 4: 6-7: “I have fought the good fight, I have finished the race, I have kept the faith.”
When it comes to end-of-life decisions, how do we keep the faith, even to the very end? What is God’s guidance concerning the issue of “pulling the plug.” Is there a time to “pull the plug” or should hope burn eternal? Is “pulling the plug” murder, or is it allowing death to come naturally?
How about the withholding of treatment–is that ethical? Can I refuse treatment? How about living wills and advanced directives and the powers-of-attorney for medical purposes? What do I say, what do I fill in, and what do I tell my attorney concerning these issues? Perhaps some of these questions are facing you right now or perhaps you have already faced them.
As Americans we have the right to life, liberty and the pursuit of happiness. As part of that understanding, do we also have the right to die or not? As Christians, do we have the right to die? What if, during natural death, I experience intractable pain or face the possibility of losing my dignity–is that a concern? Or is that something that’s more of a secular thought? Is this really not my main concern as a Christian? Is my own personal dignity a real priority in my life?
We are going to address these issues today as well as in the month of August. Again, this is serious because the discussion involves eternal issues as well as the welfare of our loved ones. It involves our own welfare, as well. We want the best for our loved ones and we want the best for ourselves as well. Some of you have had profound life-shaking experiences that are incredibly personal that have already formed your thoughts and the basis for how you make a decision. They are so potent and so vibrant that it is hard to listen to anything else.
I experienced the death of my grandparents and watched highly competent people become woefully incompetent. I looked into the face of my grandfather and didn’t recognize him anymore. How do we deal with that?
Two movies affected me as a young person. One in 1973 was called “Soylent Green” starring Charlton Heston. This depicted how horrible life would be in the future. The other movie was “Rollerball” in which a person dies and is in a vegetative state. As a young person, I imagined what it would be like to be a vegetable. I remember lying in my bed, trying not to breathe, and trying to imagine what that life experience must be like.
There were dozens of times when I was given the privilege to escort people from this life into the next. I was a chaplain on an oncology ward and I saw the process of dying over and over again. It is a profound and intense experience. If you have gone through that, you know exactly what I am talking about.
Our call is to take all the information we have and all our pre-judgments and set them aside for a little while and seek God’s wisdom, hear what God has to say to us, allow God to touch our lives on this very critical issue. Does his word give us light? Yes, it does.
This is an issue we must face and there are decisions we must make because they are forced upon us in our modern day. Wouldn’t it be nice to go back to the good old days when a person’s heart stopped and they stopped breathing, there was nothing that could be done. They were simply given into the hands of God. In this modern day, we have the ability to keep a person alive almost indefinitely. As a result of that, we have been forced to make some very critical decisions. Just because we can do it, should we do it? What is humane, what is merciful, and what is suicide? What is keeping the faith on these issues?
Probably the best text is M. Scott Peck’s The Denial of the Soul. This really captures every issue surrounding this question. It is written by a person who spent his entire life dealing with people who are facing life’s end, both as a psychologist and as a hospital worker.
Today, we are simply going to define terms. What do the terms mean that we are going to face.
First, what is euthanasia? It goes by other euphemisms such as death with dignity, mercy killing, initiative 119, the right to die, exiting peacefully, taking control of one’s life, etc. The word itself comes from the Green word “eu” and “thenos” and means “good death.” It came to mean dying pain-free. The definition accepted today comes from the 1938 Euthanasia Society which defines a good death in this way: “The termination of human life by painless means for the purpose of ending someone’s suffering.”
Now, that’s a good goal and one that we can embrace as Christians. It is not bad to help people not suffer. But what does it mean to terminate life and how do we do that? That term has come to mean four different things.
One it has come to literally mean to die pain-free. This would include things like giving oxygen to a patient who is in respiratory distress, or a moderate dose of painkillers to keep a person comfortable. This would include IV antibiotics for a patient who is dying but has developed an infection like pneumonia, or it could include a feeding tube to keep a patient from starving to death.
It has also come to mean enabling a person to die by permitting them to do so by means of withholding treatment that most people would consider the prolongation of the dying process. An example would be withholding a blood transfusion from a person dying of stomach cancer who is hemorrhaging, the fore-going of the fourth or fifth round of chemotherapy when it is having no effect, or withholding further treatment from a child who is suffering from neuroblastoma.. I will let you decide which is more ethical. The history of this disease is that the child will live six weeks with treatment. However, they will experience intense, relentless pain and will go blind and deaf in the last three weeks. Without treat-ment, the child will die in three weeks. However, they will avoid all three of these side-effects. Again, what is ethical, what is Christian, and what is humane?
The third definition for the termination of life could mean to enable a person to die through a medical act, the intention of which is to alleviate the pain of another with the secondary effect of causing premature death. An example of this would be a very high dosage of morphine to a cancer patient with the intent to alleviate pain but in the process the patient may die.
The fourth definition is the deliberate act to end the life of another to avoid suffering. This would include things like intentionally giving a person a very high dose of morphine in order to take away their life rather than to alleviate their pain. This would include strapping a person to a machine like that of Dr. Kevorkian. It would include mercy killing such as death by gunshot or by carbon monoxide poisoning.
Of these, the first three definitions are also called “passive euthanasia” or “indirect euthanasia.” The fourth definition is called “direct or active euthanasia.” Which of these are consistent with the Christian faith? Throughout the ages, which of these has the Church agreed are natural deaths? The first three have always been considered by the church, theologians and scripture to be consistent with natural death. Whether you read literature from the first century, the fourth century, the sixteenth century or the modern century, the record of interpretation on this issue is very consistent. The first three are considered natural deaths.
We see this with Jesus himself as he is going through the process of dying on the cross. They offer him a sponge of wine mixed with a certain group of herbs that would cause a loss of consciousness, thereby being a painkiller. Jesus refused this initially because he wanted to remain conscious. In John 19, we also find that he took it near the end of his life. In his day, both for Jewish and Christian believers, this was considered to be absolutely ethical. It was an act of kindness to the dying.
Only the fourth has been considered outside of the faith, suicide or homicide. You will not find a single verse of scripture that permits or advocates taking the life of another or a person’s own life. There are many verses on the giving of life but not the taking of your own life or the life of another.
Genesis 1-2 tells us that we were created in God’s image. It was God who gave to us the breath of life. If God owned the gift of life, who but God can take it away? If a person belonged to God and realized that God gave them the gift of life, it was consistent to realize that only God could take it away. It is this understanding that undergirds Job 1:21, “Naked I came from my mother’s womb, and naked I will depart. The Lord gave, and the Lord has taken away. May the name of the Lord be praised!” Job is simply saying that he recognizes that he belongs to God. Everything he had belonged to God, and God can do whatever he wants to do with what belongs to him. Our lives belong to God, and he can do whatever he desires with our lives.
This is the same faith reflected by Jesus on the cross when he said, “Father, into your hands I commend my spirit.” Jesus relinquished himself to God. Notice the wonderful thing that God does here. How long did Jesus suffer on the cross, especially after that statement? Not long. God graciously and mercifully took him.
Contrast this with many doctors who have allowed their patients to suffer very cruel and inhumane deaths, all because they feared that the painkillers would mask certain diseases or would cause addiction. The absurdity is worrying about causing addiction in the dying. They won’t be alive long enough to become addicted.
Deuteronomy 32:39 says, “It is I who bring death and life, says the Lord.” Colossians 3:23 says, “Whatever you do in word or deed, do it all as unto the Lord and not unto men.” This not only includes our lives–everything we do is given to God. This also includes our dying. Can we give God our dying? Can we die as unto the Lord? Can we trust the promise of Psalm 23:4, “Though I walk through the valley of the shadow of death, I will fear no evil for Thou art with me.” Can we trust God to hold true to his promises?
I’d like to read you a tremendous story of God’s view for those who are dying. This comes from Presbyterian Today, April 2000:
“I’ve never seen an angel. The closest I’ve come is the time when someone cleaned two feet of snow from my driveway. But I do know someone who has actually seen an angel–four angels to be exact. I take him at his word. Let me tell you about my son.
“Several years ago, three weeks after Bram’s sixth birthday, I started his bedtime breathing treatments, a routine part of the daily battle with asthma. About one minute into the treatment, Bram had a clear choking noise and called out, Mommy!” My mouth was open to yell at him to quit screwing around and be quiet and go to sleep. With a deeper wisdom, I knew something was terribly wrong, and my feet were running even as I gathered breath to scold. I scooped him up in my arms and ran into the family room. My husband looked at me with a smile on his face. I said, “He’s in respiratory failure. We’ve got to go now.” Ken’s feet too were moving before the expression on his face caught up. By some grace bigger than comprehension, the car was parked facing out at the end of the driveway. Ken somehow kept the wheel. We made it up the unplowed road to the hospital, and I ran in, paper work mailed in before, dangling bare feet. He was hooked up to monitors within seconds, and all of them were flashing and beeping. His oxygen level was 28. The doctors pulled us aside and began the speech, “We are going to do everything we can for him, blah, blah...Just step out into the waiting room for a few minutes while we...”
“Ken and I sat beside each other staring straight ahead. The helicopters were grounded due to the blizzard. Because of the snow, the chief anesthesiologist was still at the hospital. An ambulance crew was hanging out in the break room. The roads were officially impassable, and the crew volunteered to enter into the jaws of hell and drive him to the children’s hospital in Pittsburgh. Even though he was currently stable, the great fear was that once the steroids wore off, the rebound paroxysmal spasms might carry him away. They sedated him to keep him one level above death, and the anesthesiologist volunteered to ride in the ambulance to guard the precarious balance. This meant there was no room for either Ken nor I.
“Ken and I drove home wordless. I tried to say something in the car. I remembered the old spiritual, “When I get to Heaven, I’m going to put on my shoes...” and I thought, “Oh my God, I forgot his shoes.” Normally, it is a one-and-one-half-hour trip to children’s hospital. This time it took three hours. When we got there, Ken dropped me at the door and went to park. I did not run in like some frantic, crazy mother. I plodded in. It was the longest distance I’d ever walked. A technician looked at my slab of a face and walked with me to the Emergency Room and there was my son, jabbering away, elated that he had pulled his first all-nighter. He was glad to see me, but he really wanted to see his dad. He needed to pee. They were going to make him go in a bottle and all the nurses were female, and that mortified him. Bram and I held hands and watched the sun rise.
“I finally said, “Bram, I have never been so scared in my entire life. What was it like for you?” He said, “You know, every night my daddy prays that there be four angels with flaming swords around the four corners of my bed and the four corners of the house to keep me safe. The first time my daddy prayed last night, it didn’t work. So when they pulled me onto the bed in the ambulance, I prayed it again. I prayed it all by myself for the first time. I closed my eyes and kind of fell asleep, and then I opened them and they were there. One of them held the bed, one of them held the IV bottle so it wouldn’t bang from side to side, one of them held my head on her lap, and she sang a story. The biggest one took his flaming sword and cut a pathway down my airpipe so I could breathe. I saw them Mom. They were there.”
Do we ever doubt God’s promise to be there for us?
The fourth option, taking one’s life directly, is not a good option for several reasons. One is because it treats death as a friend, and in scripture death is always understood an an enemy. I Corinthians 15:25, “The last enemy to be destroyed is death.” Death is something that we naturally run away from, and we should continue to do so. It also makes life’s value based upon its usefulness to us or to others.
Pope John Paul wrote an encyclic called the “Gospel of Life.” He states, “When the prevailing tendency is to value life only to the extent that it brings pleasure and well-being, suffering seems like an unbearable set-back, something from which one must be freed at all costs. Death is considered senseless if it suddenly interrupts a life still open to a future of new and interesting experiences, but it becomes a rightful liberation once life is held to be no longer meaningful but is filled with pain and inexorable doom to even greater suffering. Furthermore, when one denies or neglects his fundamental relationship to God, man thinks he is his own rule and measure with the right to demand that society should guarantee him the ways and means for deciding what to do with his life in full and complete autonomy.”
Scripture puts the basis for a person’s life, not upon one’s experiences in life, but upon the fact that God created us in his image and that God gave his life for us. We have intrinsic value regardless of our experiences.
The third contradiction has to do with the assumption that “It’s my life” which is reflected in what Pope John Paul said, and as a result if it’s my life, then it’s also my death. I will die the way that I want to. For the secular person, this is true because they are outside of God’s will and God’s word. But for the Christian, the model for us is I Corinthians 6:20: “You were bought at a price. Therefore, honor God with your body.” Romans 12:1 tells us that our bodies are living sacrifices to be given to him in sacrificial service.
This is the Biblical basis for the reason that the Church decided that everything except for the taking of your life intentionally is proper and appropriate for end-of-life issues.
When we are writing a living will or advanced directives, we will encounter certain terminology. One is “ordinary” versus “extraordinary means.” One problem with these terms is that they are slippery. What was considered extra-ordinary a few years ago is ordinary today. So, what is extraordinary and what is ordinary? C. Everett Koop writes a wonderful book called The Right to Live and The Right to Die, and he picks up on this. Perhaps an example would help to clarify the slipperiness of these definitions:
“If one were struck down by a car and had a serious head injury which rendered him unable to breathe and made him unable to respond, and if his bladder sphincter were in spasm so he could not urinate, he could be placed on a respirator. He could be fed intravenously or by a stomach tube. His urinary obstruction would be taken care of by the proper placement of a catheter. If it were assumed that he would recover in a matter of a few days, all of these things would be considered ordinary care. If, on the basis of superior knowledge of the neurosurgeon attending him at this time, it were known that there was essentially no way that he could be expected to recover, all of these things might be considered extraordinary care since without them his injuries would produce death.
“If one had an acute appendicitis and postoperatively developed a situation where his kidneys did not function, to put him on a dialysis machine would be an extraordinary act and might at times be considered to be extraordinary care. However, in a normal individual with a normal life expectancy of several decades ahead of him, it would not be considered extraordinary. On the other hand, if in a 93-year-old individual the same kidney shut-down took place as the result of a disease process that inevitably would take this person’s life, the institution of dialysis would be extraordinary and would definitely be thought of by any medically competent individual as providing extraordinary care.”
What is ordinary or extraordinary is defined by the moment, by the timing, the context and the history. There are so many factors that it is hard to make the blanket statement that something is ordinary or extraordinary.
The second problem with terminology is that one has to make these decisions near death. That’s the terminology–“near death.” But, who can predict what is “near death”? Medical World News from May 5, 1974, reported the case of a woman with myasthenia gravis who lived artificially for 652 days in intensive care and then made a remarkable recovery. Said the hospital representative at the Harvard General Hospital in Florence, CA, “She made us recognize that there is no such thing as an inordinate effort. She had such a tenacity for life that we felt that everything we did, no matter how extraordinary, was appropriate to this situation, and we could not have predicted that she would have recovered.”
Time and time again you find the same thing. The Karen Anne Quinlan case is the big one. They said she would absolutely die without the life support systems. They took her off, and she lived four more years. They can’t predict.
An Iowa police officer who was on life support for seven years made a full recovery. M. Scott Peck in his book tells us about his 81-year-old grandmother who, the day he was going to sign the paper to end her life, snapped out of it. He was absolutely certain that there was no life left that was useful, and she was soon to die, and he is an expert. She lived after this experience eight more years of wonderful productive life, and she saw six more great-grandchildren born into the family. You just can’t predict these things.
The best we can do is in the moment with much prayer and much discernment, asking God to reveal what to do.
What have we learned. We have learned that terms are slippery and complex. There are not easy answers. We also have discovered that there is a wide range of choices for the Christian as to the issues of termination of one’s life. I will address this again on August 18. We will look at the issue of pain, and on September 1 we will look at the issue of dignity. We fear pain and the loss of our dignity. What does God’s word have to say about this. Does God address these issues?
Is the only choice for me as a Christian a natural death? Is my only choice to suffer intractable illness and to lose my dignity? Is that the only Christian option? Many people after hearing this will say that this seems to be what I am saying, but it’s not. There are other, better solutions than killing onself. There are other, better options.
