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[ JBEM Index / Volume 2 / Number 4 ]

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A Biblical Model for Medical Ethics
4. Treatment Decisions at the End of Life

Dr. Heimburger is Associate Professor of Nutrition Sciences and Medicine in the University of Alabama at Birmingham.

One of the most pressing and common ethical issues in modern medicine concerns the best way to treat patients as they near the ends of their lives. The physician often has at hand a variety of treatments that can prolong a patient's survival just a little bit longer, or get the patient through repeated acute crises along the course of an inexorably advancing condition. Frequently, though, physicians, patients, and families wonder whether giving a particular treatment is really the best idea. When should we forge ahead, and when should we say "enough is enough"?

When presented with these dilemmas, Christians typically focus their attention narrowly on "euthanasia". Our sole concern is most often to be certain that the one suggesting non-treatment (even if it is the patient himself) is not trying to break the Sixth Commandment. We feel uncomfortable carrying the discussion beyond this, so we often don't.

At the other extreme, secularists are sometimes concerned mainly with forging and protecting the patient's "right to die". Having no basis for an absolute prohibition against killing, groups as the Hemlock Society seek to make it not only legal but respectable for persons to commit suicide when for almost any reason - they don't want to go on any longer.

In their polarization, these two groups commit opposite errors related to the three factors to be accounted for in ethical discussions (see article #2 in this series; Volume 1, No. 2, April 1987). In insisting on a "right to die" the secularist ignores normative concerns, while Christians' exclusive interest in the sanctity of life dismisses situational and existential considerations. As we unfold the issue we can see these come into sharp focus.

First, what norms apply? No one can ignore the fact that some norms are being applied whenever decisions are being made. For the Christian, Scripture is the sufficient and final arbiter of truth and the source of norms. What do the Scriptures say about decisions at the end of life?

Second, what is the nature of the situation? Though Christians are uncomfortable analyzing situations because they fear slipping into relativism, ethical decisions - and treatment decisions require an understanding of the situation, including the options available. God doesn't ask us to apply his norms in a vacuum, but sovereignly places us in circumstances where they apply. So we will actually be in sin if we don't analyze the situation carefully.

Third, what is the personal (existential) investment - the needs and motives - of each person involved? God is present with us in every circumstance, and cares for our personal concerns. Further, he weighs motives, not just outward appearances or consequences, in judging the rightness of our choices. These must be examined as well. For an action to be right, all three factors must line up: we must employ the right normative standard, chart a course that is appropriate to the situation, and use the right motives.

Normative Considerations

Of the Scriptural norms that apply directly to the questions at hand, the preeminent is the right to life. This right is fundamental - it is derived from God, defined in Scripture, and protected by the Law of God. Because we are made in the image of God and declared unique (Gen. 1:26-27), God says the one who wrongfully takes a life must be punished (Gen. 9:6, Ex. 20:13; 21: 12,14). We are God's sacred temple, and if anyone destroys God's temple, God will destroy him (1 Cor. 3:16,17). So, in all our decisions we must respect the life that only God can give. We must never slip into the attitude that a person's worth is based on his form or function; it is a gift of God that no one can take away (Ps. 139:13-16).

At the other extreme, Scripture does not define a right to die. Rather, since we are all under sentence of death, we don't have a right not to die. How odd that persons condemned to death should be demanding a right to die! The issue of the "right to die", and the focus of our discussion, might therefore be restated:

Under what circumstances and in what ways can an individual righteously exercise prerogative in the timing and/or mode of his or her death?

It is obvious that we should never do something to a patient, even when death is very near, in which the intention is to kill. But this simple proscription does not account for many real-life medical situations. What if we need to use large doses of narcotics to treat pain from advanced cancer but know they might hasten the patient's death? Though a mechanical ventilator can be used to relieve the fright of dyspnea in a patient with amyotrophic lateral sclerosis, in the end it may simply prolong his dying. If one elects not to use mechanical ventilation, is one cruelly killing the patient or mercifully allowing him to die? If the patient refuses the ventilator, is he trying to commit suicide? These situations produce an uncertainty about the real meaning of respect for life that only submitting the situation and the motives to Biblical analysis can ease.

But first, it helps to note that the Scriptural norm of respect for life is not the only standard we are uphold as the end of life approaches. There are some things it does not entail. For one thing, although the right to life is fundamental, the fact that the murderer forfeits it means that it is not absolute (Ex. 21:23,24). For another, we are not directed always to extend life as long as possible. Which leads to the second Biblical norm: Christians need not be enslaved by fear of death, but can approach it positively as a reunion with Christ. By his death Christ "destroyed him who holds the power of death that is, the devil - and freed those who all their lives were held in slavery by their fear of death" (Heb. 2:14,15). Knowing what lies on the other side should reassure us that we can let go of life rather than hang frantically on as it ebbs away.

The final norm we'll mention is that in all issues of life and death, we are not our own, but belong to God. "For none of us lives to himself alone and none of us dies to himself alone. If we live, we live to the Lord; and if we die, we die to the Lord. So, whether we live or die, we belong to the Lord" (Rom. 14:7,8). Paul's wish was that Christ be exalted in our bodies, whether by life or by death (Phil. 1:20-26). We must never forget that God is the giver of life, and it is his prerogative and his alone to take it away. Of course, he does whatever he sovereignty determines to do, but he has made us responsible for consciously yielding our decisions at the end of life into his hand. This means that we must not fight him by taking steps either to end life intentionally or to prolong it unduly.

Situational and Existential Considerations

By now it is obvious that even though we may agree on the norms, it is not always clear how they are to be applied. To determine this, we must consider situational and existential factors. This doesn't mean Scripture lacks relevance to modern situations. It just means that we need to explore the relationship that has always existed between God's norms and the situations he places us in, to see how this influences medical ethics. Does the Bible designate any situations, goals, and motives in which a choice leading to death can be proper and righteous?

Though it doesn't mention mechanical ventilators or feeding tubes, the Bible says a great deal about end-of-life situations. It describes a number of people who wanted to die, and some who proceeded deliberately to do so. Some of them did it righteously and others wrongly, with the deciding factors being the particular circumstances, the goals pursued, and the motives expressed. The Bible clearly presents two extremes with very different moral implications - suicide and self-sacrifice - and alludes to or allows for some intermediate graduations, each of which will be discussed separately. They are listed below, along with their attendant motives and Biblical verdicts.

 
Suicide Selfish Culpable
Accidental death Unintended Unavoidable 
Foregoing therapy Acquiescent Permissible
Self-sacrifice Selfless Commendable

Suicide - Culpable Self-Centeredness

There are several instances of suicide in the Bible, the most familiar being those of Saul and Judas. Saul killed himself after Israel was routed by the Philistines (1 Chron. 10:4,13, 14). His goal was to avoid humiliation and torture at the hands of the Philistines, and his motive was selfish pride and despair. We are told that

"Saul died because he was unfaithful to the Lord," and that "the Lord put him to death," an affirmation of God's sovereignty over death, even suicide. Judas committed suicide after the crucifixion of Jesus, in order as well to eliminate suffering, in this case spiritual torment over the sin he had committed (Matt. 27:3-5). His motive, like Saul's, was unrepentant selfishness.

Ahithophel hanged himself when he saw that Absalom followed Hushai's advice on how to overthrow David, and not his own advice (2 Sam. 17:23). He was undoubtedly in despair, perhaps in fear of his own life; he certainly wasn't thinking of others! Zimri, a murderous man who ruled Israel for seven days, burned the palace around him when he was overthrown by the army of Israel. "He died because of the sins he had committed" (1 Kings 16:18-19).

Job and Jonah are slightly different. Both experienced points of despair in which they wished they were dead or never born - so it might be said that they contemplated suicide. At the height of his personal suffering job described himself as "longing for death that does not come" (Job 3:11,2023; 7:15,16). Jonah was so angry and bitter over God's compassion toward the Ninevites that he said twice, "it would better for me to die than to live" (Jonah 3:104:11). The thoughts of both were centered on themselves and on obtaining relief for their suffering. Both were bitter toward God, but not enough to consummate their wishes.

The features of suicide are obvious from these examples. It is not sufficient to say that these people had a hand in their own deaths, or longed for death. Suicide is impelled by a desire to eliminate or avoid personal suffering. It displays only concern for one's own interests, and no regard for others'. It is culpable, intentional selfdestruction for improper motives. To be sure, none of these individuals had a "right to die."

To apply this to the matter at hand we can ask, Does the Bible condone treatment choices leading to death when the incentive is primarily to relieve suffering? This is usually the reason behind the expressions, "I hate the quality of my life," "I want my rights," or "whose life is it anyway?" It is clear that the elimination of suffering is not presented in Scripture as an end for which a death choice is the appropriate means. The more a lethal course of non-treatment requested by a patient, whether "active" or "passive", is spurred by the desire to relieve suffering, the more it tends toward suicide; and the more it tends toward suicide, the more it receives Biblical reproach.

Accidental Death - Unintended Side Effects

On more occasions than we would like to admit, physicians have a hand in the deaths of their patients. Because we wish to help and not to harm, we feel a great sense of responsibility and even guilt when an appropriate use of narcotics or anesthesia, much less a diagnostic test, proves fatal. However, when we guilelessly cause a death by accident, God does not blame us because our intention was not to kill (Ex. 21:13,28-30). This has been called the "law of double effect": a therapeutic effect is intended but a lethal one supervenes. The determinative factor, as long as one is acting competently, is the motive.

Foregoing Therapy - Permissable Acquiescence

Since little effective medical therapy was available in Biblical times (in fact, until the 20th century), there are no Biblical examples of foregoing life-prolonging therapy. But the Bible does contain instructive examples of a righteous acquiescence to death. Jacob and Joseph, aware that their deaths were approaching, gave burial instructions to their families and died (Gen. 49:29,33; 50:24-26). The Biblical account is sketchy, but it implies that they were satisfied with the courses of their lives and were ready to be with the Lord.

Simeon, the "righteous and devout man" to whom "it had been revealed that he would not die before he had seen the Lord's Christ," was actually joyous when the sign that his life was over - Jesus - appeared (Lk. 2:25-32).

He saw his imminent death as his reward, and thanked the Lord for holding it off no longer. His goal was apparently the glory of God and the advancement of his kingdom, and he was motivated by joy in seeing God's promises fulfilled.

How would these men have responded if they had been offered life-prolonging therapy? Of course, we have no idea whether their final illnesses would have been curable if they had lived in the 20th century. But if not, they probably would have considered it pointless, much as some dying believers do in modern times. When such a person, who has walked with God, is faced with an incurable illness and a marginally effective treatment, it can be entirely reasonable for him to say, "why put off my reunion with Christ?"

Far from forbidding it, the Scriptures permit the refusal of medical therapy out of righteous anticipation of and readiness for the inevitable, given the right circumstances and the proper motives. Before proceeding, one must carefully and prayerfully analyze the situation (what is the prognosis without treatment? What treatment is available, and what and how likely are its benefits and risks?, etc.) and the desires and motives of all involved. But as long as one honors the Scriptural norms regarding man as the image-bearer of God, and of life and death belonging to him, medical therapy can righteously, even laudably, be suspended in the face of terminal illness.

This blending of circumstances and motives is all-important, and gives substance to the popular distinction between "prolonging life" and "prolonging dying". If a patient is convinced, no matter how humbly, that he should die in order to be with the Lord, but has an easily manageable illness, the circumstances are not right. Take, for example, a 35-year-old husband and father with new-onset insulin-dependent diabetes or acute pneumococcal pneumonia. For him to refuse insulin or penicillin because of a feeling that "the Lord is calling me home" is unconscionable and points either to confused theology or hidden motives such as depression. On the other hand, if a patient has an incurable illness but his goal in refusing therapy is self-centered, such as only to relieve suffering, then the motives are not right. We should be very cautious, and counsel the patient candidly.

Self-Sacrifice - Commendable Selflessness

The other end of the spectrum from suicide, self-sacrifice represents a setting aside of one's own wishes, even assenting to death, for others. Of the several examples of this in Scripture, the one that most closely parallels modern medical dilemmas comes from the book of Jonah. At a point prior to the one discussed above, Jonah was fleeing from God, and from preaching to the Ninevites. In chapter 1, the familiar scene of the storm at sea is described. After the lot had fallen on Jonah, and his shipmates had interrogated him, he confessed that he was to blame for their peril because he was running away from the Lord. In telling them they had to cast him overboard to calm the sea, he apparently placed their survival over his own (there must not have been any Ninevites on board!). It appears that he was motivated by unselfish concern for others, and was willing to give his life.

His shipmates' response is also important: at first they refused his offer of self-sacrifice and tried to row back to land, in order to save all lives if possible. As far as we can tell, his companions were motivated by regard for his life as much as for theirs. Finally, though, they had no alternative but to sacrifice the assenting Jonah in order to avoid bringing death to all. As they did it, they were remorseful and distraught out of fear of Jonah's God.

To some extent this scene corresponds to treatment decisions when life is at stake. If one imagines Jonah as the patient and his companions the health care team and family, one sees the latter trying to save the patient's life but finally being unable to, and then giving up the effort with the consent of the patient. One can even envision the patient foregoing a marginally beneficial treatment, because it is somehow in the bests interest of others to do so. The Bible does not forbid this, and even commends it, provided the situation and motives are appropriate.

Jonah's case also parallels the fortunately rare situation where a pregnancy truly threatens the life of the mother. Out of a commitment to giving the baby the best chance for survival, the pregnancy is maintained as long as possible. But when there is not a shadow of doubt left that the mother, and therefore the baby, will die if it is continued, the baby is delivered prematurely to save the mother. Attempts are made to keep the baby alive, even though it may be obvious that they will be futile. The intent throughout is to save both lives, but it is not always possible to do so.

Jonah's experience, therefore, illustrates a few general lessons. First, situations exist in which it may be righteous to choose a course of action leading to death. All reasonable alternatives should be tried, but when only death and another undesirable option are left, the motives of all involved are pivotal in determining whether death can be righteously chosen. The distinction we have forged between suicide and self-sacrifice turns on the use of the right motives in the right situation.

Second, there is broader significance to our situations than we may realize. The things that happen to us are often inscrutably related to spiritual warfare. And third, the preservation of the earthly lives of our patients is not the final and only goal to be pursued.

There are other examples of self-sacrifice in Scripture, the supreme one, of course, being Jesus. Romans 5:6-8 tells us that "very rarely will anyone die for a righteous man, though for a good man one might possibly dare to die," and contrasts it with what Jesus did: "while we were still sinners, Christ died for us." The question here is not one of permission to die for someone else, but of daring to do so! To follow Jesus' example, we must have as our goal the glory of God, and our motive a love for other that puts their lives above ours. John 15:13 goes further, using superlative terms: "greater love has no one than this, that one lay down his life for his friends."

As mentioned earlier, Paul struggled with his conflicting desires to minister to God's people and to be with God himself. Though he would have preferred death, he chose life, because of what others needed (Phil. 1:20-26), acknowledging that whether we live or die, we belong to the Lord.

Both Christ and Paul struggled with suffering. Christ knew that he would suffer on the cross, and chose a course leading to death, for us. Paul knew that he would gain if he died and joined Christ, but chose to remain in spite of the suffering involved, for the welfare of the disciples and the advancement of the gospel. Both of them looked beyond their personal suffering to the broader purposes of God, left the matter of their lives and deaths in the hands of God, and made choices that would advance the kingdom of God and benefit others.

In addition to the Biblical examples, there are numerous historical cases of self-sacrifice for the benefit of others. Far from being an exception, the present day actually contains some new situations in which such a choice may be appropriate. For instance, provided the right situation and pure motives, could it not be permissible for a dying person voluntarily to forego a prohibitively expensive therapy for the benefit of his family's overall, even economic, welfare?

Summary

Oftentimes discussions of the withdrawal of treatment at the end of life rely heavily on the distinction between killing and allowing to die, with the former being unethical but the latter allowable. However, the distinction is usually precarious because it focuses on contrasts among the means used to end life, such as "active" vs. "passive" euthanasia or "ordinary" vs. "extraordinary" treatment. These differences are tenuous because one can very "passively" commit murder, and today's extraordinary treatments become tomorrow's ordinary ones. As unfolded in the Bible, on the other hand, the distinction between killing and allowing to die turns both upon circumstances and upon one's goals and attitudes.

Real-life situations are rarely cut-and-dried, and motives are never completely pure. But if we examine them openly we will attain a measure of clarity in the application of Biblical norms to our treatment choices. This is, of course, much more straightforward when the patient can participate in the decision than when he or she is incompetent. Careful safeguards must be used in the latter cases, but we need not feel obligated to continue death-postponing therapy just because the patient cannot dialogue about it.

A Biblical approach to treatment decisions at the end of life, as to any ethical dilemma, requires that we honor all clear Biblical norms and pursue a contextually appropriate course of action with the proper motives. Patients with terminal illnesses, and their families, frequently request non-treatment, knowing that death will come sooner. When they appear motivated mainly by self-concern and avoidance of suffering, these desires tend to resemble suicide and should elicit caution. But the less self-centered the focus and the more humbly and expectantly the patient and family are resigned to the inevitable, the more a request for non-treatment represents a relinquishing of life into the hand of God, and the more we should be willing to grant it. Further, situations may occur in which patients desire to forego treatment in order to benefit others. Those cases representing selfless sacrifice are commendable, and can even exert a more powerful witness to the Truth in death than many wield in a lifetime.

[ JBEM Index / Volume 2 / Number 4 ]

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