It was the phone call from hell. I was on the back porch of our house, resting after a morning walk, when the father called. The doctors had just left his little girl's hospital room. They told him it was time to turn off the machines, that there was nothing more they could do. But he and his wife didn't have to do what they said. They could leave their baby on life support indefinitely while praying for a miracle.
If they removed the machines, were they playing God? Were they taking their girl's life in their own hands? But short of divine intervention, why prolong the inevitable? Through his tears he asked me, What does God want us to do?
This wasn't the first time a phone call stopped my world. Several years ago I was teeing off on the 10th hole of the local golf course when an assistant from the clubhouse drove a cart out to tell me I had an urgent message. He took me back to take the call. A college freshman in our church had put his father's shotgun in his mouth and pulled the trigger.
It was the first time I preached the funeral message for a person who committed suicide. People kept asking me and I kept asking God why he didn't stop the young man from destroying his life and his family with him. And we wanted to know what happened to him when he did.
Is the Bible still relevant in a world where our medical knowledge has outstripped our ethics? Does faith help when we deal with the most horrific decisions of our day--euthanasia, suicide, and abortion? If you haven't needed to wrestle with these issues, be grateful. And keep reading, to prepare for the day you will.
Euthanasia and the will of God
You may remember Terri Schiavo and the national debate which surrounded her death. She had been living in a "persistent vegetative state" (PVS) since suffering a stroke in 1995. Now her husband wanted to turn off the machines, while her parents fought to keep her alive. The courts finally decided in the husband's favor, and she died on March 31, 2005.
Most of us who watched the tragedy unfold wondered what to think. The legal issues involved in her medical care and death were enormous. When should society guarantee a person's right to refuse life support? What kind of statements and/or documents are necessary? Absent these, is the decision best left to the spouse or other immediate family? What role should health care providers play?
Nearly every person I spoke with on this subject said that he or she would not wish to be kept alive under such circumstances. Nearly every parent would want a role in making such a tragic decision. The legal and political issues raised by this tragedy are still being debated.
My interest in this issue is not legal but biblical. I'm writing to try to clarify my own mind on this difficult subject, and perhaps help others as they wrestle with this tragedy. Unfortunately, any of us could find ourselves where Mrs. Schiavo's family was for 15 years.
Types of euthanasia
In trying to understand this issue, first I had to learn the language and history of the debate. Here's a brief description of terms used by the media when they report on the subject.
"Euthanasia" is derived from the Greek word "eu" (well) and "thanatos" (death). It usually means a "good death" or "mercy killing," and is understood to be the provision of an easy, painless death to one who suffers from an incurable or extremely painful affliction. Such an action is considered proper only when the suffering person wishes to die, or is no longer able to make such a decision.
A distinction is usually made between "active" and "passive" euthanasia. Active euthanasia occurs when someone acts to produce death. This is often called "assisted suicide," as in the actions of Dr. Jack Kevorkian and others who have provided medical intervention leading directly to death. "Passive" euthanasia occurs when the patient is treated (or not treated) in a way which leads to death, but actions are not taken to cause death directly.
A third category has become common in recent years. "Letting die" refers to medical actions taken to enhance the patient's well-being during the dying process. Unlike passive euthanasia, the doctor does not intend the patient to die as a result of this decision. Rather, the doctor withholds medical treatments which intensify suffering or merely postpone the moment of death for a short time.
For instance, it is not considered passive euthanasia to discontinue chemotherapy in cases of advanced cancer, especially if the drugs increase the suffering of the patient. The doctor does not intend this decision to cause death, even though death may result from his or her action.
In these terms, Terri Schiavo's death resulted from passive euthanasia, since physical sustenance was withdrawn for the purpose of ending her life. Unlike most chemotherapy, food and water did not heighten her suffering. They were removed for the purpose of causing her death.
Ways to choose euthanasia
The decision to enact passive euthanasia is termed "nonvoluntary" since patients like Mrs. Schiavo cannot express their wishes. However, her parents could call the decision "involuntary," believing that it went against her wishes as she would have expressed them. Her death would have been "voluntary" if she had given "informed consent" while motivated by her own best interests (unlike a person suffering from mental or emotional illness who wishes to die).
If Mrs. Schiavo had executed a "durable power of attorney," she would have signed over all responsibility for her medical decisions to another person, usually her spouse. Because she did not take this action, the court gave her husband responsibility to make medical decisions for her, a decision known as "substituted judgment."
Maintaining Terri Schiavo's life would have required "heroic" or "extraordinary measures." Some patients wish only "ordinary means" which offer reasonable hope of benefit and are not excessively burdensome. A third means of support could be called "basic," providing only nutrition and water.
The doctors treating Mrs. Schiavo were required to help their patient ("beneficence") and to refrain from harming her ("nonmaleficence"). They could ethically provide medical assistance to alleviate any suffering, even if such help shortened her life. This "double effect principle" assures that doctors do not act immorally if they intend only the good effect, do not use bad as a means to good, and create good at least equal to the bad. For example, doctors can prescribe morphine to alleviate the suffering of a terminally ill patient, even if a side effect of morphine in that patient will shorten the person's life, unless they intend the drug to shorten or end that life.
Definitions of "death"
These definitions are obviously very complicated. I thought that at least the definition of "death" would be easy to state, but I was wrong. Doctors usually consider "death" to occur when circulation or respiration ceases irreversibly, or when the whole brain does the same.
But what is "brain death"? The "upper brain" supports consciousness, while the brain stem controls body functions such as breathing and heart rate. If the upper brain has died, the patient is considered to be in a "persistent vegetative state" (PVS). There are estimated to be 10,000 PVS patients in the United States. This was reported to be Mrs. Schiavo's condition.
If the brain stem has also died, the patient is considered to have suffered "brain death." Because nerve cells do not regenerate, both upper-brain and total brain death are completely irreversible.
What are our biblical options?
In cases of PVS ("persistent vegetative state" caused by upper-brain death), what medical options could be considered scriptural? What does the Bible teach regarding the larger subject of euthanasia?
First, let's make it clear that active euthanasia or "assisted suicide" is unbiblical. This practice is the overt, intentional taking of life, and is prohibited by the Sixth Commandment. For the remainder of this essay, we will consider euthanasia only as the subject relates to passive or "letting die" options.
Defining the alternatives
Ethicists seem to agree that in cases of total brain death or upper-brain death, "heroic" measures are unnecessary. Many believe that ordinary treatment is not obligatory, and "letting die" is moral. Some, however, believe that it is wrong to withdraw food and hydration, allowing the body to starve. This approach views the life as "holistic," meaning that a functioning body is still united to the "soul," the "image of God." Such a person is still a member of the human race, and deserves at least basic care (food and water), if not ordinary care (routine medical support).
Other Christians believe that brain-dead or PVS patients are simply bodies, that their souls or spiritual selves have gone on to eternity. Withdrawing food and water from such patients is then considered to be morally right. In this view, without a functioning brain, the body no longer sustains a soul or retains the image of God. Medical personnel should always care for those who possess potential for conscious life. But when a PVS exists, there is no possibility of brain regeneration and the "soul" has left the body.
Still others support "vitalism," the belief that physical function by itself is sacred. In this view, even if the "soul" has departed a body which is brain-dead or in a PVS, the body deserves medical treatment to the very end of physical life. Some "vitalists" support ordinary care or basic care for such a body, while others argue for heroic means to preserve physical function as long as possible.
In these terms, Mr. Schiavo's decision to withdraw food and water would reflect the belief that his wife's soul had departed her body, and that ending basic care was morally right. Given his insistence that this decision reflected her wishes, his directive was followed by her physicians.
Which view is the most biblical?
Created in the image of God
One way to answer our question involves the scriptural description of humanity as created "in God's image." Genesis says that "God created man in his own image, in the image of God he created him; male and female he created them" (Genesis 1:27). What does it mean to be in God's "image"?
Most theologians would focus on humanity's uniqueness. What is it which separates us from other life? Such characteristics make us uniquely "the image of God." Four biblical statements answer the question:
We are created in God's image to "rule over" his creation (Genesis 1:28).
The Lord warns us, "Whoever sheds the blood of man, by man shall his blood be shed, for in the image of God has God made man" (Genesis 9:6).
Paul instructs a man not to "cover his head" in worship, "since he is the image and glory of God; but the woman is the glory of man" (1 Corinthians 11:7).
James criticizes the fact that "with the tongue we praise our Lord and Father, and with it we curse men, who have been made in God's likeness" (James 3:9).
From these specific biblical references to the "image" or "likeness" of God, we can suggest that a person retains this "image" when he or she is able to relate to the rest of God's creation as his representative on earth. We are to "rule" or govern creation, represent God to others, and value each other. In this sense we may be created not so much "in" the image of God but "as" his image on earth.
By this reasoning, we lose the "image of God," that which makes us uniquely human and valuable, when we lose the ability or potential to relate to ourselves, our environment, other humans, and God. A baby in the womb and a comatose patient are each a person, in that they retain the potential for such interaction. But a PVS individual is not.
Dualistic and holistic views
How does this distinction relate to the body? Some believe that the "soul" can depart the body before its physical death. This is typically considered the "dualistic" view, separating the physical and the spiritual.
Jesus cried from the cross, "Father, into your hands I commit my spirit" (Luke 23:46). Stephen prayed before his physical death, "Lord Jesus, receive my spirit" (Acts 7:59). Some interpreters use these statements to separate the soul or "image of God" from the body. In the belief that a PVS patient does not and cannot exhibit the image of God, it is then concluded that the person's "soul" has left the body. Any physical support for the body, even food and water, is thus unnecessary.
Others adopt a holistic understanding of the biblical view of humans. While Greek thought separated body, soul, and spirit, Hebrew theology did not. It is not so much that we "have" a body, soul, and spirit which can be identified as separate entities. Rather, we "are" body, soul, and spirit. These words are different dimensions of the one person (cf. 1 Thessalonians 5:23).
In the holistic view, we retain the "image of God" so long as our bodies retain some dimension of physical life. Mrs. Schiavo's parents spoke passionately of the joy she continued to bring them, the love they felt for her despite her condition. They would argue, I'm sure, that she was still a "person" to them. In the holistic approach, so long as a person is alive physically, that person is the "image of God."
This view would see Mrs. Schiavo, as long as she lived, as a person deserving of basic physical support. Food and water would be essential, appropriate provision for any person. And so the decision to withdraw them would be wrong.
Permission to die?
What if she had previously directed that such withdrawal occur? Then the law would require that her wishes be honored. But should it? Should we be permitted to mandate that heroic or even ordinary measures not be taken to maintain our lives?
The dualistic view believes that a patient loses the "image of God" in certain medical conditions, and would support that person's previously stated right to refuse medical life support. The holistic view, taken to its logical conclusion, would seem to require at least food and water to be provided, in the desire to preserve and honor the "image of God." Some would argue that even heroic measures are required, and that a person should not be allowed to refuse them. Just as we require passengers in cars and airplanes to wear seat belts, so we should require patients to receive all medical support for as long as their bodies survive.
I believe that the holistic view reflects God's understanding of humanity. But I also believe a distinction between heroic, ordinary, and basic life support is warranted. In my view, it is permissible to cease heroic or even ordinary life support for a person who possesses no actual or potential capacity for relational life on any level, as that person cannot demonstrate the "image of God."
But I also believe that so long as the body is alive, the "person" is alive. And persons deserve at least basic (food and water) support, for as long as they live. Although the state allows us to choose passive euthanasia, medical actions which are intended to bring about our death, I do not believe such a decision is warranted biblically.
Let's assume that Terri Schiavo did in fact express her desire to refuse medical life support and even to experience passive euthanasia. Her husband and doctors then acted within the law in withdrawing food and water for the purpose of ending her life. But I do not believe she or they acted within biblical guidelines. In my view, we should not be permitted to request medical steps which are intended to cause our death. Absent our clearly expressed intention, our caregivers should not be permitted to choose such actions.
However, we and/or our doctors can choose to "let die," to take medical steps which do not prolong our lives. When these medical actions enhance the present quality of life, even if they shorten the life span of terminally ill patients, they are especially warranted.
Medical care and the power of God
I wish I had written this essay before my conversation with that father about ending his daughter's life support. The next time I get such a heartbreaking phone call, I'll ask the family about their intentions. Do they intend to hasten or even cause death? I do not believe such a decision is defensible. On the other hand, do they wish simply to allow nature to take over, "letting die" if this is the natural result of the patient's condition? In this situation, medical support is not prolonging life--it is prolonging death.
I will remind such a family that maintaining or ending medical care does not necessarily affect the intervention of God. The Lord Jesus raised Lazarus from the grave after he had been dead four days (John 11:38-44). He does not require medical life support to heal. And if it is his will that the patient not survive physically, no medical means can defeat his purpose.
If all medical options have been exhausted, and there is no plausible reason to believe the patient will ever improve, a family who ends heroic or ordinary life support is not removing the possibility of divine intervention. Rather, they are placing their loved one in God's hands, allowing him to heal physically or eternally.
Then the Lord will heal as he wills. He sometimes heals us physically, continuing our lives in our fallen bodies on this fallen planet. But he eventually heals us eternally, taking believers from earth to heaven, from disease and death to paradise. Either way, we are well.
For further discussion of the terms and issues involved in euthanasia, see David K. Clark and Robert V. Rakestraw, Readings in Christian Ethics (Grand Rapids: Baker, 1996) 2:95-101. Other sources which have informed my study include David Theo Goldberg, Ethical Theory and Social Issues: Historical Texts and Contemporary Readings (New York: Holt, Rinehart and Winston, Inc., 1988) 388-419; and Robert D. Orr, Dvaid L. Schiedermayer, and David B. Biebel, Life and Death Decisions (Colorado Springs, Colorado: NavPress, 1990) 151-65.
A helpful introduction to this complex subject is Robert V. Rakestraw, "The Persistent Vegetative State and the Withdrawal of Nutrition and Hydration," in Clark and Rakestraw, 2:116-31.