Christian Morality and Ministry in the Culture Death (Part 2)
IS REFUSAL OF TREATMENT TANTAMOUNT TO ACTIVE EUTHANASIA?
While the Christian is not to seek assisted-suicide, there still remains the need to address the issue of whether the refusal of treatment (whether that be through withholding or withdrawing) is ever consistent with a Christian worldview. It is important to clearl y distinguish between the idea of actively killing and letting die. The reason being is that the latter can, and has been traditionally seen as “good medicine”[1] There does come a time when the Christian must accept the inevitability of death and allow the disease or underlying injury to take its course. John Frame, in consideration of the biblical material regarding this point, states,
Death is, of course, the last enemy (1 Cor 15:26), but it is not on that account always to be resisted. God’s people can accept death because they look forward to the certainty of immediate fellowship with God and the future resurrection of the body. They are not suicidal, but when it is evident that their life is at an end, they do not desperately, against all natural probability, seek its prolongation.[2]
Along these same lines, Farley remarks, “Every person is utterly valuable, and each one’s life is utterly valuable, yet things other than life are sometimes more valuable. Human life deserves respect; it even has sanctity; but death may sometimes be welcomed.”[3] A Christian sense of destiny involves “hope” in eternal life, or resurrection. The believer’s resurrection is vouchsafed on the basis of Christ’s resurrection[4] But seeking death is not the same as accepting it. “Scripture always presents mercy killing negatively,” asserts Frame.[5] He demonstrates how people who sought to kill themselves or have others kill them are “always seen as disobedient.” Suicide—self killing—is a contradiction of the legitimate self-love Scripture “assumes and commands.” Suffering does not render a life meaningless or valueless (just as important for the sufferer to know this as for those who care for them), and since our lives are not our own, they are not at our disposal.[6] just as we do not have the prerogative to kill another , we do not have the prerogative to kill ourselves. As stated above, God alone has this prerogative Frame concludes, “so ‘letting die’ is sometimes justified, though ‘killing’ never is.[7]
Yet advocates of active euthanasia actually refer to the more “passive” forms of letting people die to justify PAS They do this by claiming that an impertinent distinction has been drawn between the two. An article written by James Rachels in The New England Journal of Medicine in 1975 was the first major challenge to the traditional view.[8] He defended euthanasia as being just as humane and thus morally acceptable as using passive means to kill. For him, there is no moral distinction between the two. More recently, the arguments propounded by the 2nd and 9thCircuit Courts of Appeal (in New York and Washington respectively), have also tried to argue that the constitutionally protected right that patients have to refuse life-sustaining treatment should be extended to the right to PAS, because both decisions are highly personal and should not be forbidden by law.[9] “The heart of the complaint is that the traditional view arbitrarily rules out all cases of intentionally acting to terminate life, but permits what is, in fact the moral equivalent, letting people die.”[10] Such a comparison is quite problematic for the following reasons.
It must be conceded to Rachels that the withholding or withdrawing of medical treatment may be motivated by the desire to bring about the death of a person,[11] one must insist that it is not always the case. Rachels does not allow for this, he does not allow that the motive for omission may be other than causing death, while the motive for active euthanasia can be nothing but death. Writing in direct response to Rachels, Thomas Sullivan puts this in clear perspective.
The traditional view is that the intentional termination of human life is impermissible, irrespective of whether this goal is brought about by action or inaction. Is the action or refraining aimed at producing a death? Is the termination of life sought, chosen or planned? Is the intention deadly? If so, the act or omission is wrong. But we all know it is entirely possible that the unwillingness of a physician to use extra-ordinary means for preserving life may be prompted not by a determination to bring about death, but by other motives.[12]
Sullivan then gives examples. “[the physician] may realize that further treatment may offer little hope of reversing the dying process and/or be excruciating . . . but it certainly does not follow from the fact that he intends to bring about death.”[13] Sullivan presents the analogy that it is quite possible to omit an action knowing that such may bring about certain consequences, but not necessarily desire those consequences. For example, Americans constantly choose not to eat healthily or exercise, knowing that such omissions may result in disease and early death, but this does not mean these consequences were desired when the omissions were chosen. “It is not the case,” he writes, “that all the foreseeable consequences and side effects of our conduct are necessarily intended.”[14]
Thomas Beauchamp, also in direct response to Rachels, likewise concedes that passive omissions may be motivated by the desire to cause death, but Rachels and his ilk must admit that this is not necessarily the case. For example, Beauchamp refers to the case of Karen Ann Quinlan, whose father stated in an interview that he was not trying to cause his daughter’s death, but rather wanted to “remove her from the machines in order to see whether she would live or die a natural death.”[15] He states that although there are difficult situations in which treatment is removed yet “we do not know that recovery is empirically impossible, even if good evidence is available. [16] He concludes, “Active termination of life removes all possibility of life from the patient, while passively ceasing extraordinary means may not.”[17]
So from both a medical and ethical standpoint, the active/passive distinction, or better the killing/letting die distinction, must be maintained. While it is possible for omission of treatment to be motivated by the desire for death to result, it does not prevent possible recovery, killing a patient actively, on the other hand, absolutely precludes the possibility of recovery, and the result of such is invariably to make the patient dead.
CHAPTER 3
IS TERMINAL SEDATION EQUIVALENT TO ACTIVE EUTHANASIA?
Another important issue to broach in the discussion is whether or not the administration of a dose of medication strong enough to kill pain, but may also inadvertently kill the patient, is tantamount to active euthanasia. The debate concerning “terminal sedation” is still in its early stages, but there is no doubt a fine line to be drawn here. It is perhaps the most controversial level of palliative care. “ Dr. Robert J. Kingsbury, sees this level of care as being consistent with biblical principles, because the physician who applies the medication is doing so to fulfill the physicians mandate of benefiting the patient and doing no harm.[18] He writes,
Terminal sedation is a recent addition to the lexicon of palliative care . . . a survey of 61 selected palliative care experts, arrived at the following definition; ‘terminal sedation is deliberately inducing and maintaining deep sleep but not deliberately causing death in very specific circumstances.’ The ‘specific circumstances ‘ were defined as intractable symptoms at eh end of life . . . for which standard palliative care intervention had failed to provide adequate relief.[19]
While it might be questioned as to whether the sedation itself hasten death, Kingsbury cites a study which “showed no statistically significant difference in survival from date of admission between sedated and non-sedated patients,” concluding that the “the need for
sedation is an indicator of impending death and not a cause of premature death.”[20] Kingsbury observes,
“Patients who spend their last hours or days sedated are very sick. Even before they are sedated, these patients are eating and drinking substandard amounts, and artificial hydration and nutrition is usually contraindicated because it would increase the risk of pulmonary edema and other adverse effects.[21]
Kingsbury answers those who criticize this methodology for managing severe pain as a form of euthanasia, called by some ‘slow euthanasia.’ The objection is that intent is difficult to measure, and all that matters is outcome, which is, namely, death. Kingsbury, however, counters this and insists that physician intent, although unknown for the most part, can be objectively measured to a certain extent by asserting that
analgesics or sedatives are administered only for pain relief or distress if they are titrated to achieve specific end points(such as the absence of grimacing or moaning in patients unable to report pain) and not beyond. In contrast, the rapid administration of medication with no effort to titrateindicates that hastening of death was the first intent.
Kingsbury has pointed out not only an important distinction, but also provided an objective standard for determining intent to some degree. He then conscientiously explains how such intervention is consistent with a biblical perspective by first affirming his belief in the sanctity of human life as created in the imago Dei and the consequent responsibility that physicians have not only to their patients, but to God who is the giver all life. He defends this practice as suffering with (true compassion) patients. In his practice he assures patients that the hospice is a ‘euthanasia-free zone’ and that they may be sedated if they choose, and they will sleep until they die.
It seems that the Scriptures support the principle of palliative care, and by implication, terminal sedation. In Proverbs 31:6-7 we find the following instruction to a king.
Give strong drink to him who is perishing, and wine to those who are bitter of heart.
Let him drink and forget his poverty, and remember his misery no more.
The instruction is that kings are not to be drinkers of wine or strong drink since it distorts moral judgment, and thus issues in the perversion of social justice. Nevertheless, this same kind of drink is legitimate for one who is dying, so that individual can forget his impoverished and miserable condition. It would seem possible that the narcotics used in terminal sedation are consistent with this biblical idea. Those who are suffering in their dying are to be given some kind of substance to help them “forget,” their impoverished and miserable condition, and, by implication, to die in as little suffering as possible. Implicit also is the idea that actively killing a person in such a state is forbidden. There is no suggestion to suicide or assisted suicide in this text, but it would seem quite appropriate to the context if such was given divine sanction.
The discussion about terminal sedation is, as already indicated, in its earliest stages. It is practiced by Christian physicians who are seeking to relieve the suffering of the dying without deliberately killing them or stepping over into euthanasia. Yet the reader should know that this practice is still under the scrutiny of Christians in the medical community who equate it with active euthanasia, or at least see a slippery slope leading to it.[22]
[1] Koop and Johnson, 48. Koop relates a case in which he withdrew treatments from a three-year-old girl who was dying of an abdominal tumor. To continue treatments would have given her three more months, but this time would be very painful, while withdrawing treatments would mean that the cancer would cause death in about six weeks, but relatively little pain and suffering would be experienced. Koop opines, “I don’t think that’s euthanasia; I think it’s good medicine. I think its good medicine for the child, for the family and for all of us.”
[2] John M. Frame, Medical Ethics; Principles, Persons and Problems (Phillipsburg, NJ: Presbyterian and Reformed Publishing Co.), 63.
[3] Farley, 195. For biblical resources concerning the welcoming of death see Psalm 116:15, Ecclesiastes 3:2, 2 Corinthians 5:8, Philippians 1:20-21, and 1 Thessalonians 4:14-17.
[4] See John 14:19, 1 Corinthians 15:17-22, 2 Corinthians 4:14, and 1 and 1Thessalonians 4:14.
[5] Frame, 69.
[6] Ibid.
[7] Ibid.
[8] James Rachels, “Active and Passive Euthanasia,” inMorality and Moral Controversies, 6th ed., Ed. John Arthur (Upper Saddle river, NJ: Prentice Hall, 2002), 249-252. Due to the significance of Rachel’s essay, the reader will find it in most ethics textbooks dealing with the issues of death, dying and euthanasia.
[9] See Arthur J Dyck, When Killing is Wrong; Physician assisted Suicide and the Courts (Cleveland: Pilgrim Press, 2001), for analysis and critique of the circuit courts attempt to justify PAS.
[10] Thomas D. Sullivan, “Active and Passive Euthanasia: An Impertinent Distinction?” in Social and Personal Ethics, 3rded., Ed.. William H. Shaw (Belmont, CA: Wadsworth, 1999), 108.
[11] See Wesley J. Smith Culture of Death; The Assault on Medical Ethics in America (San Francisco: Encounter Books), for clear examples where the withholding and withdrawal of treatment were intended to cause death, and could be considered euthanasia.
[12] Sullivan, 109 (emphases are Sullivan’s).
[13] Sullivan, 109-110.
[14] Sullivan, 110.
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[15] Thomas L. Beauchamp “A Reply to Rachels on Active and Passive Euthanasia,” in Contemporary Moral Problems, 4th ed., Ed. James E. White (Minneapolis/St. Paul: West Publishing Co., 1999). 165.
[16] Ibid.
[17] Ibid.
[18] Kingsbury and Ducharme, available on line.
[19] Ibid.
[20] Ibid.
[21] Ibid.
[22] The reader is referred to the same article in which Dr. Howard M. Ducharme provides counter arguments to Kingsbury. The excessive citation of Kingsbury in the present essay is not an advocacy of his position, it is just to show that there seems to be an apparent distinction between active euthanasia and terminal sedation, thus no basis for euthanasia advocates to justify PAS. This writer is still quite apprehensive about the practice, yet thinks that Kingsbury has made some cogent points.
