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A Time to Assist in Dying?

This column explores the ethics of taking actions which may hasten death for a person who is in the last stage of a terminal illness, or whose suffering cannot be ameliorated by physical, emotional or spiritual means.

This column explores the ethics of taking actions which may hasten death for a person who is in the last stage of a terminal illness, or whose suffering cannot be ameliorated by physical, emotional or spiritual means.  <?xml:namespace prefix = o ns = “urn:schemas-microsoft-com:office:office” />
 
Said bluntly, is the decision to assist a suffering person to die ethical? Consider the following cases:
 

  • John is a very active 60-year-old man with average financial and family resources. He was struck by a car while riding his bicycle. He suffered a very high spinal fracture that left him totally paralyzed, including not breathing on his own. His brain was not injured so that he was totally alert. (Yes, this unusual circumstance is very similar to Christopher Reeves.) In conversations with the doctors, the patient’s family reported that John had watched and read news stories about such injuries.  He had frequently said , “I would never want to be imprisoned that way.” He indicated by eye movements, and his family agreed, that he wanted to be removed from the respirator and understood that he would receive a large dose of morphine in order that he would not experience pain or panic. As pastor for the family, how do you respond?
  • Bob is a 34-year-old married man with no children. He was diagnosed with a very aggressive brain tumor. In spite of all standard and experimental therapies available, the cancer progressed and he was near death. Burns and lesions from the various therapies created pain that could be partially suppressed, but less so over time. He and his wife agree that when his pain increases and other symptoms leave him out of control, he wants to end his suffering. As pastor, you know he is carefully hoarding narcotics so that he can end his life. How do you respond?
  • Brenda is a 55-year-old widowed woman with young adult children. She developed cervical cancer that was treated. However, it recurred, including in her bones. She has been told that she has at most a few weeks to live and is in such great pain that no interventions seem to work unless they render her unconscious. During a lucid moment, she asks you to help her talk with her doctor about providing a dose of medication that would end her suffering. How do you respond?

The dilemma is politically named “physician-assisted suicide,” “physician assistance in dying” or euthanasia. The role of the physician and pastor in relationship to the patient who wishes to die sooner rather than later is controversial on ethical and religious grounds.
 
Most pastors experience spiritual anguish when confronted with such situations in real life (contrasted with theoretical people). On the one hand, pastors experience deep compassion for patients and families who suffer. On the other hand, pastors live by deep convictions concerning the sacredness of life and the presence of God in every situation. Their anguish revolves around compassion and conviction. What are some of the religious and ethical resources for clarifying this dilemma and dealing with one’s anguish?
 
We should first recognize that a very thin but important line exists that is almost universally recognized in medical ethics. When a person is near death, and has not given indications otherwise, the highest value of the medical community is to relieve pain and suffering. While most physicians who care for the dying recognize the importance of emotional and spiritual interventions that reduce pain and suffering, they also know that physical interventions must also be offered. The powerful narcotics used to relieve intractable pain have powerful side-effects; they reduce respiration and/or heart function. Thus, in order to prescribe sufficient medication to relieve pain, the physician may hasten final breaths. 
 
In ethics literature this action is considered ethical due to “the principle of double effect.” This principle holds that if an action’s intended consequences are ethical, and the action is an ethical action, then unintended though foreseeable results are not unethical. The physician intends to suppress pain and prescribing sufficient (but not excessive) morphine to relieve pain is ethical; therefore, the fact that death results does not constitute an unethical outcome.
 
There are some who would like to extend this principle to include prescribing medications that cause death with the intention to cause death. Such actions are legal in <?xml:namespace prefix = st1 ns = “urn:schemas-microsoft-com:office:smarttags” />Oregon, provided that clear conditions are met and documented. Such actions are not prosecuted in Holland, provided that clear conditions are met and documented. Everywhere else, such actions may be prosecuted as criminal. Usually they are not.
 
What perspectives must the pastor consider in creating a Christian stance toward assistance in dying?
 

  1. Care providers have a duty to benefit the sick person. When it is clear that cure of a disease is no longer possible, is it not an act of care to hasten death thereby reducing pain and suffering? If it is ethical to forgo interventions in order to allow death, why is it not ethical to shorten the time of suffering? The counterargument frequently focuses on the possibilities for abuse (“slippery slope”). If physicians and pastors support active assistance in dying, may those who are not terminally ill, but of less social value, be included (e.g., the fragile elderly, the socially undesirable, the chronically ill). In addition, many theologies articulate the moral and spiritual value of suffering. 
  2. Competent people are autonomous people; they can choose their own destiny. Advocates for assistance in dying argue that a person who is terminally ill or experiencing intractable suffering has the right to choose death. Since medical providers are the gatekeepers to medications that may ease one into death, they should assist. Those who argue against this assistance note that no individual exists apart from a larger community. The effects of such a final decision cannot be purely autonomous. In addition, the autonomy of the medical practitioner must also be respected so that if such an action is considered unethical, the physician must be free to not participate.
  3. A clear, if fine, boundary must be maintained between palliative care and euthanasia. Palliative care intends to provide the full range of services available to minimize debilitating pain and suffering. The patient or surrogate decision-maker reaches a decision that includes deep sedation on the basis of personal preferences and life values.  If such deep sedation ends in death, then that is an acceptable consequence of relieving pain. Euthanasia intends to end the patient’s life at the time that the patient or surrogate decision-maker has decided. While this decision can be motivated by escape from pain, research from Oregon and Holland indicates that the greater intention is control. Some dying people want to control the manner and timing of their dying. Others want to die rather than extend their suffering. They want control.

What then is the pastor’s and congregation’s role in this conflicted ethical arena?
 

  1. Generate study groups in which the difficult, confusing, ambiguous, personal and deeply spiritual dimensions of this issue are explored. Include physicians, nurses and terminally ill people and their families in these discussions as much as possible. Such study groups should consider biblical perspectives, ethical values, current medical practices, and the life stories of those who have faced such decisions.
  2. Provide excellent spiritual support to terminally ill people and their families. Many dying people feel abandoned by their pastors and congregations, which increases their suffering. It is immoral to argue that suffering people should not be able to choose their own fate, while at the same time ignoring suffering people within one’s own community.
  3. Speak as informed, individual participants in civil discussions. Many legislatures, medical governing boards and other public decision-makers need input in this arena. Speak from conviction shaped by accurate knowledge, and compassion tempered by personal experience.

Steve Ivy is vice president for values, ethics, social responsibility, and pastoral services of Clarian Health Partners in Indianapolis, Ind.
 
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