EUTHANASIA: A MATTER OF LIFE AND DEATH
The mystery of human existence is that we belong to God
is that we belong to God
and have been made in the divine image.
In God we live and move and have our being.
Living Faith 2.2.1
Life in its physical, social, emotional, rational and spiritual dimensions has been entrusted to our care by God. As good stewards of this gift of life, we relate faithfully to our Creator and to each other. We have been created for community and have a responsibility for the life of the neighbour. Community is possible only in interdependence and we are all, at one time or another, dependent on the neighbour for our life, as the neighbour is dependent, at times, on us. Life is lived in relationship. To honour this life, no matter how diminished, means to support, protect and nurture all possibilities of relationship.
What constitutes the faithful stewardship of life is not always easily determined, especially in situations of extreme suffering and of terminal illness. Yet, arising out of a study of Scripture, an understanding of the nature and will of God and the experience and wisdom of the Christian community of faith, certain principles can be derived to guide our thinking and our activity.
Created life is limited by death. It is in this sense that death can be viewed as enemy. Death represents a loss of being, a destruction of the psycho-physical unity in which we are constituted, and a manifestation of the power of evil that seeks our separation from the source of life. Yet death is also part of life. It is a part of the process of the natural order, an order affirmed by Scripture as being good. (Gen. 1:25, 3:19) As a part of life, death is not the end of life but a transition from one form of life to another. (1 Cor. 2:9, 15:49-52) It can be both a liberation from unrelieved suffering and an entrance into an existence in which there is that fulfillment of life which is our destiny. (Jn. 10:10)
Euthanasia: The Current Context
The Presbyterian Church in Canada has not adopted any statement on euthanasia. Several times the value and dignity of human life has been affirmed. In 1982, the Board of Congregational Life produced a study booklet on euthanasia which outlined the then current arguments and positions. Because euthanasia has become a topic of intense debate and controversy, the Life and Mission Agency believes that it is appropriate for the Church to speak to the debate.
Defining ‘euthanasia’ is no easy task. While the Greek words from which the term derives mean ‘good death’, our society means more than this. People also use the modifiers ‘active’ and ‘passive’. ‘Mercy killing’ comes closer to the range of meanings associated with active euthanasia, which can be seen as taking steps to hasten death through administering a lethal drug. Passive euthanasia may be used in the context of withholding or withdrawing inappropriate medical treatment. Palliative care or treatment for symptoms should be continued. This is what is meant when the phrase `death with dignity’ is used. Considerations surrounding this issue have been discussed in a previous study. (George Tattrie, Euthanasia: A Christian Perspective) Death with dignity has to do with responding to the dying person’s physical, social, emotional and spiritual needs. In this process the focus is on the soundness of clinical reasoning and appropriateness of the medical response to the patient and to his or her condition.
Assisted suicide is an issue of active euthanasia in that it involves the direct termination of life. Assuming that an individual is suffering from an illness that is irreversible and irreparable, and that his or her death is imminent, does the person have the right to take his or her life and does a medically competent person have the right to assist the individual in this endeavour?
Some believe that in certain instances, when the medical criteria of irreversibility, irreparability and imminent death are present, an individual does have the right to request assistance in terminating his or her life. An individual has the right to accept or to reject the benefits of medical technology with respect to medical treatment. Similarly, then, he or she should have the right, it is said, to determine when his or her medical condition is such that it is no longer possible to maintain the relationships that sustain human life. In other words, it should be the right of an individual to determine for himself or herself when it is no longer possible to continue to live.
Also, some have argued that taking such a decision is a final act of self-determination in the sense of taking responsibility before God for the conduct of one’s life. Our previous study stated: “The ability to take responsibility is one of the distinguishing characteristics of those who bear their Creator’s image. Unwillingness to legitimately exercise that ability constitutes a disavowal of that image and of one’s humanity”. (George Tattrie, Euthanasia: A Christian Perspective) If an individual has the right to selfdetermination in such situations, it is argued, a person assisting the individual should not be subject to criminal prosecution. But this position takes what we have said out of context.
We know that our life is not our own, to do with as we please. In life and in death, we are the Lord’s, (Rom. 14:8) and subject to God’s sovereignty. Our times, therefore, are not in our hands and we must trust with our life the author of life, who both gives and takes away. In God is our ultimate security, the one to whom praise and thanksgiving are due, whatever the circumstances of our life. (1 Cor. 15:57, 1 Thess. 5:18)
For the Christian, the issues of euthanasia and assisted suicide are faith issues, to be reflected on and responded to, both in the reverence for God and in the freedom of a child of God. (Prov. 9:10, Gal. 5:1) In such circumstances different people will, in faith, arrive at different conclusions. While such differences are to be respected and mutual support given, as together we journey through “the valley of the shadow”, the weight of Scripture endorses a standard of death with dignity.
Further, while individual situations may be compelling and tragic, they cannot justify disregard of basic values that are critical to the maintenance of a just and humane society. The Presbyterian Church in Canada holds that the value given human life by God and by human relationships precludes any support of assisted suicide. Euthanasia or assisted suicide are not private matters of individual morality. They have profound implications for society because the way we treat the dying affects the way we treat the living.
Death with Dignity
When facing terminal illness, certain questions arise. What has been the significance or meaning of that part of my life that has been lived? What is the significance of the life I now live, a life which is greatly restricted? What is the significance of the suffering I am now enduring? What difference does it make whether I live or die? Such questions can overwhelm a person in a crisis situation. Of all the questions the terminally ill person needs to explore, the question of meaning is paramount. He or she needs to be helped to reflect on the significance of a past life, including its darker aspects, to face squarely the tragedy of some situations, to reflect on what immediate goals he or she now wishes to accomplish, and to enquire what life continues to require of him or her. Such a focus not only produces courage and hope, which are antidotes to despair, but also helps the person see the value of his or her life and to invest his or her days with meaning even to the very end. In this way, the person is enabled to live as fully as possible using available opportunities to make a contribution to those with whom he or she daily comes in contact.
Perhaps the most dominant anxiety that surfaces at a time of crisis is fear of abandonment. At the approach of his own death, Jesus himself had to face this issue. (Mt. 26:30ff) Abandonment can be both physical and emotional. People can feel abandoned both by significant others and by the medical establishment. Changes in treatment, changes in routines, changes in attitude or reactions by family, friends or medical personnel deeply affect the patient.
In coming to terms with a terminal illness a person experiences a variety of emotions. That person needs those who will accompany him or her on an emotional roller coaster, accepting, without judging, conflicting reactions. As we perceive the relentless advance of death, forcing us into a state of relationlessness with others, and even with our self, we become increasingly anxious and afraid. In such circumstances isolation is torture. This is especially critical in situations where the patient is unable to communicate needs, thoughts and feelings. What is required is reassurance both of presence and of acceptance.
The terminally ill might have feelings of guilt or anger, along with feelings around unresolved grief, unresolved relationships and unfinished business. Time and care need to be taken by care givers to elicit and confront underlying issues that heighten the natural anxiety that accompanies the approach of death.
This fear of loss of control of one’s life, made real by invasive disease, is heightened by invasive medical procedures, an alien environment, unfamiliar routines and the continuous presence of strangers in one’s personal space. In such a situation, legitimate affirmations of the person’s ability and right to make his or her own decisions give to the patient a critical sense of making a needed and appreciated contribution to his or her own health care.
Patients need to know that their illness is taken seriously and that they will receive the treatment necessary to alleviate at least physical pain and/or other unpleasant physical symptoms, if a cure for their illness proves impossible. This is especially the case when pain is chronic and unrelenting, and the patient can no longer cope. They also need to know that everything will be done to promote and to sustain their life and that they will not simply be allowed to die. On the other hand, most patients do not wish to be sustained indefinitely in a vegetative state in which they cannot function, cannot contribute to their own life or that of others, and have become to others a financial, emotional or physical burden.
Quality of life is an issue for patients. An open, forthright relationship between patient and care givers is required. The patient must be given the freedom to ask questions relating to his or her programme of treatment, the benefits and risks of various procedures, and about medical prognosis and possible outcomes of different courses of action. Care givers, on the other hand, need the freedom and have the responsibility to ask of the patient why certain treatment procedures, either verbally or non-verbally, are being requested or are being refused. The patient is encouraged to share with care givers his or her goals and values so that treatment might reflect these. Where certain goals are unrealistic, this is discussed. Again, the health care provider has the responsibility of ensuring that the patient has as much information about his or her medical situation as possible, and that he or she understand this information.
Reinforcing the patient’s ability to understand and experience meaning and value in his or her life, even in the midst of distressing circumstances, encourages the person to live victoriously in the present, and to grow in relationship with the One to whose future he or she is being called.
Health Care Issues
Health care professionals also struggle to come to terms with the reality of a terminal illness. Victor Frankl maintains that when a doctor has to deal with an incurable disease he or she “should not only treat the disease but also care for the patient’s attitude towards it”. (Victor Frankl, Psychotherapy and Existentialism, p. 90) This, however, presents a difficulty for the medical professional who may be undecided as to what attitude to adopt in such situations.
Physicians and other medical professionals are trained to fight disease and to save life. Situations in which the advance of disease cannot be stayed and the loss of life is inevitable can be viewed as personal defeats or failures on the part of care givers. The temptation, then, is to throw everything into the battle, to employ every technology and to use every technique in the attempt to avoid as long as possible the final outcome. Frequently, also, professionals feel the need to be in control of the treatment process, a need which makes it difficult to change a course of treatment once it has begun.
Beneath the professional’s reluctance to let go when appropriate is the uncertainty about how to understand death. Is death an event of unrelieved despair or is it an event infused with hope? Is it understood to be part of the human condition and a part of life, and therefore something to be accepted, even with gratitude, or is it understood to be an alien intrusion into our humanity? Is death always an enemy or can it at times be viewed as a friend? Is death the end of existence or does it represent the transition to a fuller existence?
Very often the uncertainty of the care giver is masked by an objective professionalism. Communication with the patient is limited to treatment procedures and the reporting of symptoms. The professional’s inability or unwillingness to confront his or her own death, to listen to what the patient needs to communicate, or an inclination to take treatment decisions without sufficient discussion, can transform a natural fear of death into the deep anxiety of abandonment. There are also times when the professional wishes to communicate with the patient but, because of the nature of the illness, cannot. Reluctant to take responsibility for decisions that will fundamentally affect the life of the patient, and wishing to respect patient autonomy, the professional in such instances can feel pressure to maintain a holding action when another course of action might be indicated.
External pressures impinging upon the health care system include those of the allocation of financial, human and material resources. On what basis are decisions regarding such allocation to be made? What patients and what treatment are to be given priority, and in what situations? Revised expectations, due to the availability of new and expensive technologies and treatment, also add to the pressure felt by health care professionals as they struggle to come to terms with questions of who and how to treat and in what circumstances.
The possibility of conflict within families is heightened when a family is required to watch over a member who is terminally ill. Conflict most often centres on treatment procedures and on what form of treatment is most appropriate at a given time. Family members can be in conflict over this issue with professional care givers, with institutional policy, with themselves or even with the patient. There are numerous reasons for conflict. Family members, individually and as a unit, in order to come to terms with the situation, must enter into the grief process. Some people will be at different stages in the process. Hence the likelihood of conflict is increased as denial, anger, guilt, depression and acceptance continually run into one another, both within and among family members. Sometimes the presence of someone external to the family can be useful in facilitating communication and helping those concerned understand both their own needs and those of the patient. This is especially the case if communication with the patient is either difficult or impossible.
Compounding the emotional stress and spiritual issues surrounding terminal illness are external factors over which one rarely has much control. There are times when family members must simply carry on with their lives while attempting to attend to the terminally ill. Often this places a great strain on physical energy. The pressure of time becomes a reality as one attempts to respond to a multitude of responsibilities and to the conflicting demands and needs of others. Financial resources are often stretched, limiting the amount, type and quality of care the family is able to provide for the patient. Frequently, community health care resources are also insufficient to meet the need, placing additional pressure on the family to provide what it cannot. Feelings of frustration and guilt often arise in situations where families feel they should be doing more, yet they cannot.
It is helpful to both the family and the terminally ill to maintain as much of the rhythms of family life as possible. By so doing the family reinforces its cohesiveness at a time when it is deeply needed. Maintaining these rhythms also provides for a necessary emotional and physical renewal. It allows for a proper stewardship of emotional and physical energies, and guards against collapse when the time comes for those energies to be tested. It will also provide for a gradual adjustment to family life without the presence of a particular family member.
During a period of terminal illness a family should be especially sensitive to the presence and needs of children. Children have their own understanding of what is happening. Honesty in communicating with them about what the ill person is experiencing, what others are trying to do, and what can be expected to happen during the course of the illness and beyond is essential. Children intuitively know when someone close is terminally ill. Attempts to hide this from the child will ultimately fail. These will be perceived by the child both as deception and as rejection. Children need to be included in the decision-making process in ways that are appropriate for them. They will then know they are a wanted and needed part of the family with their own recognized feelings and needs.
Ministry with the Terminally Ill
Ministry with the terminally ill involves a realistic assessment of the needs both of the patient and of the care givers and a willingness to honour those needs.
Certain questions invariably surface in situations of terminal illness, and they often represent spiritual concerns. These are usually questions which relate to purpose, meaning, value and identity. The Christian has resources to bring to those questions. What is required is sensitivity and understanding to determine which resources are most helpful, and which approach is most useful in addressing both the questions and the spiritual concerns which underlie and give rise to them. This determination involves a knowledge of the patient and his or her medical condition, a sensitivity to timing and a realistic assessment of one’s own strengths and limitations.
Fundamental to the care giver’s ability to be comfortable in relating to the terminally ill is the care giver’s vision of ultimate reality, vision which he or she can share when it is appropriate to do so. Involved in such a view of ultimate reality is an understanding of the nature and role of death. Such an understanding has been set forth in our previous study and is outlined above. Death represents a necessary limit on our human existence. It is the revelation of the sovereignty of a creator God, who has overcome the power of death. Therefore death is not the end of existence but the continuation of an existence that has no end. Death is a part of life, the dimensions of which are beyond our understanding or knowledge. (1 Cor. 2:9)
Ministry with the terminally ill thus involves a sensitivity to knowing when “to let go”. There are times when a person has completed living here and is prepared to enter upon the next stage of existence. He or she has reached the stage of acceptance. In such a situation, it is incumbent upon care givers to listen to the patient, to support this acceptance and strengthen the patient’s hope. This is difficult when care givers themselves have not worked through the stages of the grief process. At such times, the needs of the care givers can become confused with those of the patient.
We believe that our relationship with our Creator cannot be broken. However death is understood and experienced, we cannot die alone. Both in life and in death we are subject to the sovereignty of God who claims us. (1 Sam. 2:6, Ps. 9:3, Rom. 8:35ff) The reality of death is subordinate to the reality of the sovereign love of God made manifest in the life, death and resurrection of Jesus the Christ. (Rom. 6:4ff) “In death we commit our future confidently to God.” (Living Faith, 10.4)
When death is untimely it can be viewed as tragic. It constitutes robbery of life, a cutting short of the realization of the possibilities inherent in the gift of life. The right to our time is given to us by our Creator who wills the full flowering of our humanity.
Death attacks our dignity as a child of the creator God, fashioned in God’s image. The power of death in all its aspects is, therefore, to be resisted. Yet there can be a point beyond which the attempt to delay the death of a physical organism is unwarranted because of the effects this attempt has on a person, and because it constitutes an indignity to him or to her. We support life but do not seek to prolong the process of death.
The Christian stewardship of life requires us to preserve and care for that life. Suffering does not destroy the meaning of life nor, does it necessarily obliterate hope. Even in the most difficult circumstances, witness can be made to this meaning and hope, both by the dying and by those who attend them. However, to suggest that there is a time “under heaven” both to live and to die means that while saying no to euthanasia (the direct termination of life) we can say yes to dying with dignity.