Finishing Well: Short Outline on End of Life Issues [SK]

Your grandfather is dying of cancer. He’s requested no extraordinary measures to keep him alive a few weeks longer. His physical pain is controlled with morphine, which leaves him minimally conscious. The morphine may even hasten death. Even his feeding tube is a burden to him and only prolongs his suffering.

Suppose you have legal authority to make decisions for your grandfather. Should you honor his wish and withhold or withdraw treatment? Is it wrong for his doctor to intentionally help him die to relieve suffering?

Let’s begin by defining two key terms. Euthanasia means the physician directly kills the patient, usually with a lethal injection. Physician-assisted suicide means the doctor gives the patient a prescription for lethal drugs, which the patient then takes on his own.

Key point (thesis):

It is one thing to withhold treatment that no longer benefits a dying patient; it is quite another to intentionally kill an innocent human being via euthanasia or physician-assisted suicide. A review of theology, ethics, and pastoral care explains why.

Help from theology

1. The biblical case against euthanasia and physician assisted suicide is rooted in the Imago Dei. Humans bear the image of God and thus have value (Gen. 1:26-27). Because humans bear the image of God, the shedding of innocent blood—that is, the intentional killing of innocent human beings—is strictly forbidden (Ex.  23:7; Prov. 6:16-19; Matt. 5:21). Euthanasia and physician assisted suicide shed innocent blood—that is, intentionally kill innocent human beings. Therefore, euthanasia and physician-assisted suicide are wrong.

2. How and when a person dies is up to God (Eccl. 3:1-12; Heb. 9:27). Death was not part of God’s design but is here due to sin (Rom. 5:12). It is now a normal and natural part of the human race. For the Christian, death is indeed an enemy, but it’s a conquered enemy. The resurrection of Jesus Christ secures a resurrected and perfected body for every believer (1 Cor. 15).

3. Because death is a conquered enemy, we must not always resist it. In cases where further treatment is futile or burdensome to the dying patient, death can be welcomed as the doorway to eternity. Earthly life, while good, is not our ultimate good. Eternal fellowship with God is. Allowing natural death to run its course does not violate the sanctity of human life. However, we must never forget that terminally ill patients—like all humans—bear God’s image. Thus, we are never to intentionally kill them via euthanasia or doctor-assisted suicide. We are obligated to always care and never harm.

Help from ethics

1. What do we intend? When treating a dying patient, we must always examine our intent. Are we withdrawing treatment because we intend to kill the patient or because it no longer benefits him? Agneta Sutton makes a great point: A truly medical (as opposed to quality of life) decision to withdraw treatment is based on the belief that the treatment is valueless (futile), not that the patient is so. So, while doctors are indeed qualified to determine if a treatment is futile, they are no more qualified than anyone else to determine that an individual life is futile. In your grandfather’s case, food and water should only be withdrawn in the final stages when they no longer benefit him and will only cause additional suffering. On this understanding, the withdrawing of treatment is not intended to kill, only to avoid prolonged and excessive agony for the patient. True, death will come, but it comes as the result of the illness not my direct action.

2. Are we caring or comparing? Gilbert Meilaender puts it well: “The fact that we ought not aim at death for ourselves for another does not mean that we must always do everything possible to oppose it.” Thus, rejecting a treatment that is burdensome is not a refusal of life. But here the physician must be both careful and honest. Instead of asking, “Is the patient’s life a benefit to him?” the physician should inquire “What, if anything, can we do that will benefit the life that he has? Our task, writes Meilaender, “is not to judge the worth of this person’s life relative to other possible or actual lives. Our task is to care for the life he has as best we can.”

3. Do we intend death or merely foresee it? Regarding morphine, we must again draw careful distinctions, this time between euthanasia and sufficient pain relief to dying patients. Put differently, Meilaender says we must distinguish between an act’s aim (intent) and its foreseen results. A patient in the final stages of terminal cancer may request increasingly large doses of morphine to control pain even though the increase might (though not necessarily) hasten death. In this particular case, the intent of the physician is to relieve pain and provide the best care possible given the circumstances. True, he can foresee a possible result—death may come slightly sooner—but he does not intend that. He simply intends to relieve pain and make the patient as comfortable as possible. Thus, instead of intentionally killing the patient with a heavy overdose, he provides a carefully calibrated increase in morphine aimed at controlling pain, not bringing about a quicker death. As Rae points out, “it’s acceptable for dying patients to sleep before they die.” Though death is foreseen, it is not intended. In the end, the patient dies from his underlying illness, not because the doctor intentionally kills him.

To sum up, treatment can be removed when:

• competent patient requests removal
• futile
• burden outweighs benefit

Help from pastoral care

Instead of intentionally killing dying patients, Christians should help them bring closure. They need a “heads-up” that it’s time to say what needs to be said to wrap up. Four key things dying patients need to hear and say frequently:

• I love you.
• Thank you.
• Forgive me.
• I forgive you.

Suggested Reading:

1. Scott Rae, Moral Choices: An Introduction to Ethics (Grand Rapids: Zondervan, 2009)

2. Agneta Sutton, Christian Bioethics: A Guide for the Perplexed (London: T&T Clark, 2008)

3. Gilbert Meilaender, Bioethics: A Primer for Christians(Grand Rapids: Eerdmans, 2005)

4. Leon Kass, Life, Liberty, and the Defense of Dignity (San Francisco: Encounter Books, 2002)

5. John Kilner, ed., Why the Church Needs Bioethics (Grand Rapids: Zondervan, 2011)

6. Christopher Kaczor, A Defense of Dignity: Creating Life, Destroying Life, and Protecting the rights of Conscience (Notre Dame: Notre Dame University Press, 2013)

Deal Breaker [James Jenkins]

For years we have been hearing variations of “Planned Parenthood performs good services” in response to criticisms the organization traffics in fetal remains, exploits young girls, and skirts the law.Recently, Donald Trump praised Planned Parenthood while claiming the pro-life credentials. But can a true pro-lifer give Planned Parenthood a pass?

Trump's praise of PP is deeply flawed. Imagine a young man bringing his fiancé home to meet his parents for the very first time. He is very proud and tells his parents all of the wonderful things about her. She volunteers for two charitable organizations, is a great cook, plays the piano at church, has her degree in nursing and she is just an all - around great catch! But there's one small problem:  For 11 days each year (only 3% yearly!), she insists on going to Las Vegas for sexual liaisons with strange men. She has no intention of curtailing these liasons while married.  The parents are astonished, not only at the young woman's demands, but their son's defense of her behavior. “BUT SHE DOES SO MANY OTHER WONDERFUL THINGS!"

What we have here is a deal killer. No one in his right mind would marry under these terms. Why, then, would anyone with true pro-life credentials tout Planned Parenthood's good deeds when it's bad ones are legion? Providing a free breast exams does not make up for ripping faces off unborn human beings. Good deeds do not atone for bad ones.

Trump is ignoring the severity of abortion. Abortion is wrong because it intentionally destroys an innocent human being in the most inhumane way imaginable. Planned Parenthood performs over 300,000 abortions every year. Of course, PP claims only 3% of its activity is abortion-related. Fine. Then stop the 3% and the controversy ends! Planned Parenthood can enjoy near-unlimited funding from Congress. Of course, Planned Parenthood has zero interest in stopping abortion. For Donald Trump to highlight PP's alleged virtues while ignoring its known evil  is tantamount to justifying spousal infidelity because you still have a majority interest in your adulterous wife's activity calendar!

In short, only by assuming that the unborn are not human can a person justify Planned Parenthood's alleged virtues. Would Trump or anyone else defend an organization which killed 2-year-olds but provided free pap smears to their mothers? Never in a million years--unless, of course, they assume toddlers aren't human!

Trump wants it both ways. He wants the pro-life vote, but he wants Planned Parenthood's services. God help us. A nation willing to live with that tension has aborted its conscience as well as its children.

Untrapped (The California Story) Part 3 [Serge]

In part one of this series, we challenged the idea that so-called TRAP laws are predominantly responsible for the decrease in abortion providers as argued by this John Oliver video and the upcoming documentary Trapped. I used the state of Iowa as an example of a state without any TRAP laws that have lost a number of abortion clinics. One may argue that Iowa is a small state and could very well be an outlier, so today I turn my attention to the largest state and the one that performs the most abortions - California.

California is possibly the most abortion friendly state in our nation. They not enacted any TRAP laws, and they have specifically passed a law that ensures that surgical abortion clinics would not be held to any building standard that primary care facilities are not held to. In other words, if a building is appropriate for a doctor to check your child for strep throat, it is fine to be used to perform abortions. Basically, it is an anti-TRAP law.

Also, California has specifically attempted to increase access to abortion by allowing nurses and PA's to perform abortions. This was branded at the time as a game changer. In fact, this is how these two laws were described:

But California is going in the opposite direction, with two bills that could lead to the one of the biggest expansions of access to abortion in the United States since the FDA approved mifepristone, aka the abortion pill, in 2000.(emphasis mine)

Here we have the state that performs the greatest number of abortions, specifically enacting laws designed to increase abortion access - even to the point of not requiring a doctor perform surgical abortions. Even our opponents expected the biggest expansion of abortion availability to occur after these change. So what exactly did happen? Has California bucked the trend of abortion facilities closing?

The answer is no. According to Bloomberg, over a dozen clinics have closed in California since 2011. If the goal of these laws was increased access to abortion, they have been an abject failure. If one believes that eliminating all TRAP laws will result in an increase in abortion access, all evidence shows that they are simply wrong.

I'm not the only one who has seen this trend. Both The Guardian and the Washington Post among others have reported that the decrease in abortion clinics has also occurred in liberal states as well as conservative ones. Yet this evidence is completely ignored by Oliver's video and most likely will be ignored by the Trapped documentary. If you believe decreased access to abortion is a horrible tragedy, it's easy to attempt to lay the blame on callous pro-life legislation. It's much more difficult to acknowledge that this "problem" is occurring in states that have the most liberal abortion laws. Putting teary eyed abortion workers on camera doesn't change this fact.

Untrapped Part 2 [Serge]

I wish to respond to some of the more specific points in John Oliver's video, but before I tackle that I wish to make a general point about abortion access in general. There is a general implication that unless there is easy and close access to abortion, then the right to have an abortion itself is threatened. Obviously I deny that this right should exist, but this argument itself is fallacious and it is easy to demonstrate why.

Allow me an example. I have a desire to see the documentary that Oliver references in his video. Unfortunately, the closest screening to me is about 300 miles away. It would be prohibitively costly both in terms of time and finances for me to view this documentary that I really want to, and in fact have a right to see.

Furthermore, what if I contacted my local theatre and asked them to host a screening? They then check into the possibility both report back to me that it would be prohibitively expensive for them to host. They would love to, but the money that they would have to invest in order to show that documentary is not worth it.

Would any of these facts change the "right" that I have to see a movie of my choosing? Am I being denied my constitutional rights because someone in Chicago has access to this movie and I do not? How close does the viewing need to be to me before my rights are considered protected?

Likewise, even if abortion is not locally available or convenient does not indicate that one's constitutional rights are being fringed upon. Roe v Wade did not guarantee abortion to be a locally available procedure.

This is not to argue that all of the so-called TRAP laws are wise in this fight, but the mere fact that abortion may be more difficult to obtain does not an infringement of any supposed rights.

Untrapped Part 1 [Serge]

I've got to admit that I love John Oliver's stuff. His video on voter ID laws made me reconsider my position on that issue. So when he took on abortion laws in a recent video, I paid very close attention. He used footage from an upcoming documentary "Trapped" to show that efforts from pro-lifers to legislate abortion clinics have made abortion unattainable in many parts of the country. Because of his popularity, I believe it is important to take his argument seriously, and respond to it appropriately. Is the legislative efforts of pro-lifers solely responsible for the significant decrease of abortion doctors and clinics willing to perform this procedure?

First, I do believe that I am in a unique position to respond to this argument. In many ways, I share some interesting parallels to an abortion provider. As a board certified oral and maxillofacial surgeon, I own and run an office that routinely provides outpatient surgical procedures under anesthesia. I have full hospital admitting privileges and understand the steps necessary for running a practice based on outpatient surgery.

There are many specific claims in Oliver's video that I could respond to, but I wish to start with his general point: that abortion laws have been predominantly responsible for the decrease in providers and clinics that perform abortions. He states that 70 clinics have closed because of TRAP (targeted regulation of abortion providers) laws in 11 states. Just to be clear, I am not in favor of every single TRAP law - in fact I think there have been some significant overreach in many of these laws. However, is it true that this legislation is primarily responsible for the closures of these clinics? There is an easy way to find out.

Let's take a look at a specific state: Iowa. Iowa is unique for a number of different reasons. First, according to Guttmacher, there are no TRAP laws that have been passed in Iowa. Second, in order to increase access to abortion, Iowa is the center of a program to provide telemed medical abortions throughout the state. This ability was challenged by the Iowa Board of Medicine, but last summer this decision was overturned by the Iowa Supreme Court. In other words, a woman can get a medical abortion through Skype throughout the state since 2008 without an actual physical exam. Third, every abortion clinic in Iowa is run by Planned Parenthood, the largest abortion provider and advocate for increased access to abortion. It seems that Iowa would basically be the shining star of abortion access and a model for other states to follow.

Running an abortion clinic would be so much easier in a state like Iowa with no restrictions and access to additional means of income by providing telemed abortions to rural areas. They are run by the largest advocate of abortion access. So how many new abortion clinics have popped up in Iowa since 2011?

Actually, 14 clinics that performed abortion have closed in that time. No TRAP laws. Increased access to medical abortions. Yet 14 clinics closed.

Putting that into perspective, Texas has over eight times the population than Iowa. If abortion clinics closed in Texas at the same rate as Iowa, 112 would have been closed in Texas during the same time period. Clearly there is something else besides TRAP laws that have caused the closing of so many abortion clinics. The "decreased access to abortion care" cannot be blamed on TRAP laws alone, and in the case of Iowa, cannot be blamed on them at all.

I may go into detail in a future post, but there are many reasons why abortion clinics are closing. All of medicine is being effected by increased consolidation. There appears to be less demand for abortion services. For a variety of reasons there are less doctors willing to perform abortions. All of these are factors that effect the ability for women to obtain an abortion, and not one was mentioned in Oliver's video.

Lastly, one of the more powerful portions of the video showed a clinic worker describing the plight of a poor woman unable to obtain an abortion without traveling a significant distance. Since she could not find an abortion provider in her town, she was asking how she could perform her abortion at home. The camera showed a teary eyed clinic worker recounting this story. The implication is that TRAP laws placed this poor woman in this precarious position.

However, here's a story about the latest abortion clinic to close in Dubuque, Iowa. This clinic offered both surgical and medical abortions, and is now being closed. Women who were served by this clinic will now have to drive 70 miles to Cedar Rapids for abortion services. According to a past board member:

They would have to travel,” Straley said. “For some people, that’s a deal-breaker … Often the people who need that service the most are people who do not have money for transportation for someplace that is 70 or 100 miles away.”

In other words, a state with zero TRAP laws, regulations specifically designed to increase abortion access, and an abortion industry fully controlled by the tax payer funded Planned Parenthood also has the problem of providing abortion care to poor women who "need" it. Repealing every single TRAP law will do nothing to help this woman's story if she were in Iowa. Blaming this situation fully on legislation brought about by pro-lifers is disingenuous and simplistic. There is far more going on here.