Framing the Issues Biblically:
The Value of Life
All human life is a gift from God and ought to be cherished for that reason alone.
That all human life has value can be seen not only in the doctrine of the image of God (Ge. 1 & 2), but also in the biblical picture of a God who cares for the weakest among us. These truths ought to guide our treatment of the sick, the disabled, the very young, and the very old.
The Problem of Sin and the Inevitability of Death
End of life care is an issue precisely because of the events that took place in Genesis 3. When the Lord placed Adam in the Garden of Eden, he told him that he was free to eat from any tree save one: the tree of the knowledge of good and evil. Unfortunately, Adam and Eve succumbed to the temptation of the Serpent and ate from the tree. Sin took root and death was the ultimate consequence. The fall of Adam and Eve not only affected them, but all of creation. The world as we know it will come to an end, making death inescapable.
Human Free Will
Because of the focus on individual autonomy with regard to end of life decision-making, it is important to consider what Scripture has to say about human free will. Genesis 2 & 3 confirm the reality of human free will. It is recognized and upheld by God in many different contexts throughout the Old Testament (Ge. 2:16-17, Ge 4:6-10, Dt. 5:29, Dt. 30:19, Jos. 24:15-16, 2 Sa.24:12-14, 1 Ki. 18:21, 1 Ki. 20:42, 1 Ch. 21:11-13).
The New Testament emphasizes freedom in the context of knowing and obeying God’s will (Mt 12:50, Mt. 26:39, Jn. 4:34, Jn. 5:30, Jn. 6:38, Ac.18:21, Ro. 12:2, Ro 15:32, 1Co 4:19, 1Co16:7, He 6:3). Free will was given to humanity as a good gift, but those to whom it was given abused it. Many would like to fault the Giver of this good gift for the world’s problems. But Scripture is adamant that God is not only sovereign, but also blameless with regard to human sin.
In his first letter to the Corinthians, the Apostle Paul quotes the Old Testament which proclaims death’s ultimate defeat, “When the perishable has been clothed with the imperishable, and the mortal with immortality, then the saying that is written will come true: “Death has been swallowed up in victory.” “Where, O death, is your victory? Where, O death, is your sting?” The sting of death is sin, and the power of sin is the law. But thanks be to God! He gives us the victory through our Lord Jesus Christ” (1 Cor. 15:54-57). He gives us the victory through the resurrection of Jesus Christ. We must remember that this life is not the greatest good, but our ultimate good is found with Christ in the heavenly realm.
Framing the Issues Ethically:
Autonomy and Decision-Making Capacity
End of life care often involves numerous decisions concerning withholding and/or withdrawing treatment. Bioethicists recognize the right of patients to self-determination and bodily integrity. Bioethicists understand the patient’s wishes to be the most important consideration in medical care in general. The law upholds and reinforces this ethical view. Patients can express their wishes concerning end of life care in advance directives that are legally binding in all 50 states. Some ethicists believe it is important to take into consideration the wishes of close family members in end of life decision-making. However, if there is some kind of dispute between the patient and a family member, the law will usually uphold the desire of the patient first, unless it can be shown that the patient’s decision-making capacity has been compromised.
Sometimes at the end of life, an individual will lose the capacity to make decisions concerning medical care. When that happens, the patient’s care must be based on the decisions they made earlier in life. The law requires that all 50 states recognize the authority of advance directives. The law takes into consideration things that a patient might have said verbally with regard to medical care. These verbal statements could be used in place of an advance directive if a patient did not have one or it could supplement one if needed.
If a patient without decision-making capacity does not have an advance directive and made no verbal statements about medical care, it is legally and ethically required to have a surrogate make decisions for the patient. If a patient did not appoint a surrogate, a close family member should make decisions for his or her loved one. These decisions should be based on that person’s wishes. If a patient for whatever reason does not have a family member to speak for them, a court could appoint a health care proxy to make decisions for that patient according to a “reasonable person’s standard.” That person would weigh burdens and benefits of treatments for the patient to the best of his or her ability.
The Limits of Advance Directives
About 20% of Americans have advance directives and/or living wills. Several bioethicists and lawmakers have questioned their usefulness overall. The reason why is that advances directives can often be either too general or too specific with regard to patient’s wishes for medical care. This renders them less than effective for guidance. The best directives seem to be those that also appoint a health care proxy. But some even question how effective proxies can be. It seems clear that even close family members are often unsure concerning what their loved one would really want with regard to end of life care. Nevertheless, it is better to have an advance directive than not to have one.
Public Policy Issues
While many lawmakers and bioethicists are in agreement about several of the issues related to end of life care, recent developments in medicine need to be addressed by the public and by the church.
1) Denial of Treatment: The issue here has to do with the possibility of some patients being denied life-sustaining treatment because of the belief that they would provide little benefit to the patient, and that they would waste scarce resources. The threat of rationing in this way is a real one that must be submitted to public dialogue.
2) Palliative Care: Because patients want more to be done concerning pain control at the end of life, more physicians are receiving education in palliative care. This has led to laws and policies that allow a patient to be sedated to the point that it unintentionally hastens death. In 2008, the American Medical Association adopted a policy that supports the use of sedation to the point of unconsciousness when a patient’s pain cannot be brought under control. In order to protect those who might not want palliation to this point, more public dialogue must take place.
3) Physician-Assisted Suicide: Though states such as Oregon and Washington have passed laws in favor of physician-assisted suicide, the controversy concerning this practice is far from over. The issue has not reached a final national consensus. Church and society must continue to raise questions concerning the morality of physician-assisted suicide. Just because something is legal, it does not by any means make it ethical or biblical.
4) Persistent Vegetative State (PVS): A diagnosis of a persistent vegetative state is often cited as a reason to forego life-sustaining treatment. But recent developments in brain imaging make it clear that the condition may not be as permanent as once thought. Some people who appear to be in PVS have been shown to have a surprising amount of brain activity, and some have actually awakened from such a state. These new developments raise questions concerning the role of life-sustaining treatments for people with severe brain injury. What should be the criteria for foregoing life-sustaining treatment under these circumstances and who should decide?
The Hasting Center Bioethics Briefing Book, 2008. www.thehastingscenter.org