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)