A healthy theology of death also embraces the fact that death is a normal part of life. Note I didn’t say a “natural” part of life. Our nature is not to die—it is not how God created us. But after the fall it became a normal part of everyone’s life. Only by accepting this will we be able to say goodbye well.
If “You Only Go Around Once”…
For those who do not believe in the afterlife (better—for those who do not yet understand the reality of the afterlife), life is the ultimate good, since you literally “only go around once.” Therefore one should do everything possible to prolong life. If this worldview were true, this conclusion would follow. However, this worldview is not true (see other blog posts and my bibliography for more on this claim). Therefore this conclusion is faulty.
On the Other Hand, if Death is Not the End…
The biblical worldview offers a different perspective. While life is affirmed as something of great value, the writer of Ecclesiastes also observes, “There is a time for everything, and a season for every activity under the heavens: a time to be born and a time to die” (Ecclesiastic 3:1-2, italics added).
This is not said in a context of hopelessness, because it is not the end for us. We survive it! Therefore our (physical) death is not to be avoided at all costs. At the right time, it is to be embraced as a normal transition to a new season of life. In fact, it is to be embraced as something good, from the hand of our sovereign and gracious God. He has allowed us to live. At the right time He also wishes to allow us to die and enter our rest with Him. When this time comes, saying goodbye well means allowing this normal process to run its course.
Medical technologies can sometimes be used in ways contrary to this truth. Certainly, as part of God’s call to redeem all things, developing medical technologies that alleviate suffering and promote healing are valuable and important endeavors. Yet, like all things, medical technologies can be abused by being applied in ways that do not produce human flourishing.
This occurs when medical professionals assume physical death is to be avoided at all costs, and guide patients or families to make care decisions based on this assumption. It is implied that using “any means possible” (any technology that may prolong life, if even for a short time) is always “the loving thing to do.”
Yet on the biblical worldview, having a healthy theology of death means this is not always the right or loving thing to do. There simply comes a time for each person to die. When that time is immanent, the most loving thing to do maybe to forgo further treatment and simply say goodbye. This is how we said goodbye to my father.
So Do I Endorse Euthanasia?
Allowing a loved one to die well, when it is his or her time to go, is truly a good death. “Good death” in Greek is “euthanasia.” So does that mean euthanasia is moral?
It depends on what one means by “euthanasia.” As with many issues, making distinctions help us be more precise in our understanding and make better decisions. Unfortunately, our sound-bite culture rarely allows us to make these important, finer distinctions. Yet ethicists, including Christian ethicists, have made two important distinctions. They help us see that three forms of euthanasia are morally wrong, but one form is morally appropriate.
Active vs. Passive Euthanasia
The first distinction is between active and passive euthanasia. As the words imply, active euthanasia is the act of actively causing another’s death. It is the act of introducing something “unnatural” that causes or hastens death. This is what “euthanasia” is usually taken to mean. For instance, it is introducing a drug that will cause death, as Dr. Jack Kevorkian became famous for doing for his “patients.”
Active euthanasia is nothing short of taking another’s life. Therefore it is murder. It does not make a moral difference that the person happens to be elderly or incapacitated in some way, or even in agreement with the action. It is still murder, and is wrong. (The same applies if the active agent, which causes death, is self-administered.)
On the other hand, passive euthanasia is allowing the normal progression to continue unabated, even though it will certainly lead to death, perhaps imminently. This may be as an elderly person’s body begins to shut down, or someone has been injured to the extent his or her body can no longer function on its own. In such cases the person’s loved ones would be morally justified to allow the body’s processes continue to death, if intervention will only prolong the life for a short period, or there would be severe side effects of due to medical intervention.
This was the decision we faced with my father. He experienced a severe stroke, was in intensive care and rarely conscious. He developed pneumonia, which caused shallow breathing. His heartbeat was weakening. We were asked what our wishes were if he went into cardiac arrest. On the one hand, doing CPR may be successful and revive him. However, at his age doing so would certainly break some or most of his ribs, resulting is severe and ongoing pain for months as the broken bones healed. Furthermore, this would not address the underlying issues causing these symptoms. Therefore we made the hard decision to sign a “Do Not Resuscitate” (DNR) order, should his heart stop beating.
We were deciding to withhold a treatment that could possibly save his life if his heart stopped beating. It was approving of an act of passive euthanasia (allowing the normal process he was experiencing to continue without intervention via CPR). It was a very hard decision to make. But we made it and signed the DNR directive. It was the right thing to do. And it was the most loving thing to do.
Voluntary vs. Involuntary Euthanasia
However, there is one other distinction that must be made for passive euthanasia is ever morally justified. This is the distinction between “involuntary” and “voluntary” euthanasia. Involuntary euthanasia, as the word implies, is a case in which the person does not have a choice. In such cases someone else makes the decision to introduce a foreign agent (active euthanasia) or allow the normal process to take its course (passive euthanasia) against the person’s will.
For instance, a person may leave explicit instructions that if he becomes incapacitated he wants any and all medical technologies and procedures to be used to keep him alive. This being his expressed will, to do otherwise is to act contrary to his will and thus engage in involuntary euthanasia. Doing so is morally wrong. People are created in the image of God, and therefore have inherent worth and dignity. One aspect of this dignity is the right of self-determination. Involuntary euthanasia is contrary to this inherent right.
On the other hand, in cases of voluntary euthanasia at some point during treatment the person chooses not to continue (thus voluntary passive euthanasia). This inevitable means the disease or illness takes his or her life. Yet, knowing this, the person still makes this choice freely. (Because the person may not be conscious or otherwise able to make this decision if and when the time comes, he may communicate his wishes to a loved one in an advanced directive, also known as a “living will”—something we should all provide to our loved ones).
For instance, a person with cancer may choose not to go through a fifth round of chemotherapy. In doing so she is choosing to allow the cancer to take its course and ultimately take her life (and only accept medications and/or procedures that alleviate her suffering during the process). This is a case of voluntary (it is her choice), passive (allowing the normal progression to occur) euthanasia (good death).
Though agonizing for all involved, this is a morally appropriate option when such a choice must be made. This was the choice we had to make for my dad. His pneumonia was getting worse. Medical procedures may have produced temporary relief. But the underlying cause could not be cured, and therefore within a few days to a week he would have developed pneumonia again.
Thanks to his wisdom and love for his family, just three months earlier had signed an advanced directive indicating that in such cases he did not want his life prolonged artificially. So, though heart-wrenching, we knew exactly what he wanted and we abided by his wishes. We did not intervene. As a result, his pneumonia progressed and he passed away within a few days. It was a hard thing to do, but it was the right thing to do.
To summarize, there are four types of euthanasia. Three are morally wrong, and one is morally appropriate:
Active involuntary euthanasia is wrong because (1) it actively takes human life, and (2) it violates the person’s autonomy and right to self-determination.
Active voluntary euthanasia is wrong because it actively takes human life.
Passive involuntary euthanasia is wrong because it violates the person’s autonomy and right to self-determination.
Passive voluntary euthanasia alone is morally justified, because (1) it does not actively take a person’s life (but rather simply allows the body to stop functioning), and (2) it does so in accord with the person’s wishes, respecting and protecting his or her right to self-determination as an image bearer of God with intrinsic value and dignity.
A healthy theology of death understands and takes all this into account. As a result, one is able to make decisions at the end of life that, although hard, are the right decisions. We had to make these decisions. They certainly were hard. But we knew they were the right decisions, and the decisions my dad wanted. This made saying goodbye much easier.
A proper understanding of God’s sovereignty in all this was also important to us being able to say goodbye well. More on that next week. Until then, grace and peace.
For further reading see Scott Rae, Moral Choices: An Introduction to Ethics.
Would passive involuntary euthanasia include withdrawing a feeding tube, or not starting one at all, in your opinion? Thanks Judy Villani
I was wondering if passive involuntary euthanasia would include withdrawing feeding tubes or not feeding at all if some one was incapacitated? Thanks Judy Villani
Thanks for your question—a very important one. On my view, whether voluntary or involuntary, in most cases withdrawing a feeding tube would be a case of active euthanasia, and therefore wrong. It would be inhumane treatment—withholding basic bodily needs.
Providing food and water are part of what is considered humane treatment. As such they are part of the ordinary treatment all deserve, as people of inherent dignity and worth. “Ordinary” treatment must meet two criteria: (1) providing a reasonable prospect of benefit, and (2) not resulting in excessive pain.
In most cases, insertion or continuation of a feeding tube meets these criteria as “ordinary.” It is (a) a basic and vital element of sustenance, (b) there is a temporary blockage resulting in him not receiving this necessary sustenance (e.g. they are temporarily unable to swallow), and (c) the person’s body is able to process the food once it is received. By resorting to a feeding tube in such cases one is removing the temporary blockage and allowing the body to continue doing what it is able to do (process food). This makes removal of a feeding tube different from not beginning or not continuing “extraordinary” treatment (e.g. CPR or chemotherapy).
An analogy would be seeing someone drowning and not jumping in to save them. In this case (a) the person needs a basic and vital element of sustenance—air, (b) there is a (temporary) blockage such that he cannot get the air he needs (the water) (c) his body is able to process the air if he can get it (his lungs are functioning). By pulling him above water you remove the temporary blockage, and his body is again able to function normally (he again begins breathing on his own). Pulling him above water provides a reasonable prospect of benefit, without excessive pain. Therefore not to remove the blockage (allowing him to drown) would be inhumane. So it is related to feeding tubes.
One of the key issues is “temporary.” Is the body able to function soon after the blockage is removed (e.g. after a relatively short time will the cause leading to the need for a feeding tube be rectified)? If so, inducing or maintaining a feeding tube is morally required, in my opinion.
There will be other factors that must be taken into account, and what a “relatively short time” is will depend on these other factors. Most important will be whether the underlying cause is temporary or not. For instance, it may be the case that the body is clearly shutting down, and the normal process of death is only being prolonged by the feeding tube. In this case, the food is not helping the person live, but only prolonging death a short while (it does not meet the criterion of “(1) providing a reasonable prospect of benefit”).
Furthermore, at this point the body is less and less able to process food, leading to bloating and discomfort (nor does it meet criterion two of “not resulting in excessive pain”). Therefore, in such cases, the continuation of a feeding tube, perhaps for months and even years, constitutes “extraordinary treatment.” So in such a case, in my view, it is morally permissible to remove a feeding tube (as long as other measures are taken to alleviate discomfort during the active process of dying).
There is much more than could be said, but I hope that is somewhat helpful.