REPORT ON EUTHANASIA WITH GUIDING PRINCIPLES A Report of the Commission on Theology and Church Relations of The Lutheran Church--Missouri Synod October 1979 INTRODUCTION Our culture lives in the stormcenter of a biomedical revolution whose consequences defy description. The cumulative results of countless discoveries and innovations in medical technology have made it possible for us to extend life beyond what were once considered to be its natural limits. Conversely, modem medical wizardry finds itself in a position that provides the know-how to curtail life abruptly and almost painlessly at will and within the context of the discipline itself. In light of such awesome potentials there is talk about "dying with dignity," "the right to die," "merciful release" and "a good death." Out of this way of speaking has developed a rather extensive use of the word "euthanasia," with the innumerable spiritual and ethical problems attending the possibility of its more general practice. That "easeful death" of which the poet John Keats once wrote in "mused rhyme" is today being advocated for persons in great pain with terminal illnesses, for mentally retarded patients and for children with untreatable brain damage. Under such circumstances the church would be remiss in her mission if she failed to seize the opportunity to help inform public opinion by dealing with the problems confronting individuals and society in the wake of massive advances in technology designed to deal with issues involving nothing less than life and death. For in the most profound sense the issue of euthanasia, like abortion, serves as a crucible to test the spiritual sensitivities and ethical fiber of contemporary life. The church, therefore, must attempt to offer some general guidelines especially for those who have an interest in conforming to God's will as it applies to this area of concern. In point of fact, by the very nature of its responsibilities the church is expected to let itself be heard in terms of God's law as this has been entrusted to His people for discussion, evaluation, teaching, preaching and proper application. Firm conviction and strong action have become particularly crucial at a time when a growing segment of humanity clamors ever more loudly for legalizing the practice of mercy killing. Over a decade ago The Lutheran Church--Missouri Synod, acting on a plea for "guidance to Christian people as they face . . . new dilemmas," requested the Commission on Theology and Church Relations to initiate a comprehensive study of euthanasia (1967 Resolution 2-28). In response to this assignment the CTCR submits the following report as prepared by its Social Concerns Committee. It presents first of all a series of essential definitions. This report then takes up a consideration of the major aspects of the issues of life and death as seen in the light of God's will and work as Creator, Redeemer and Sanctifier. It concludes with a statement of some basic principles which may prove helpful in reaching spiritual and moral decisions that bear the stamp of validity in terms of God's Word. I. SOME ESSENTIAL DEFINITIONS 1. _Euthanasia_ The ethical questions raised by the issue of euthanasia are rendered more complex and confusing by various adjectives applied to the word itself. The medical profession uses the word "euthanasia" with considerable hesitation and only in the sense of deliberately shortening life. But persons and groups devoted primarily to "social engineering" have popularized this term and have devised such euphemistic definitions for it as "death with dignity," "assisting nature" and "choosing the moment." Within a context of this kind it is necessary to set forth some basic definitions of the term "euthanasia" as well as the modifications of the word created by the addition of the adjectives "active," "passive," "direct", "indirect," "positive," "negative," "voluntary," "involuntary" and "compulsory," and also to review its legal status. a. Definition of "Euthanasia" The word "euthanasia" literally means "beautiful death." As its derivation from two Greek words would suggest, such a concept of dying developed quite logically in a culture that looked upon death in terms of being a "friend," as in the case of Socrates committing suicide by drinking hemlock. In the Judaeo-Christian tradition, however, dying was and is generally seen to be inimical to man's destiny, since the Scriptures make it very clear that man was created for life. As a result of this influence from the biblical past at work in our culture, euthanasia is understood in medical circles as an act of killing a human being and is often taken to be akin to murder. While _Dorland's Medical Dictionary_ speaks of euthanasia as "an easy and painless death," its second statement calls it "putting to death a person suffering from an incurable disease." The 1975 edition of _The American Heritage Dictionary_ speaks of it as "the act of inducing the painless death of a person for reasons assumed to be merciful." The issue becomes confused when a distinction is made between "active" or "positive" and "passive" or "negative" euthanasia. The former is defined as taking direct steps to end the life of persons who are not necessarily dying but who, in the opinion of some, are better off dead. It is also described as the deliberate easing into death of a patient suffering from a painful and fatal disease. The terms "passive" or "negative" euthanasia, on the other hand, are sometimes used-incorrectly-to refer to the discontinuance or avoidance of extraordinary means of preserving life when there is no prospect of recovery. This practice does not, in a proper medical sense, signify euthanasia. Instead, it nominally belongs to the responsible care that medical personnel exhibit toward patients that appear to have irrevocably entered the process of dying. In this connection it should be noted that the tempts "negative" or even "indirect" are at times applied to situations where a life is snuffed out by the refusal or the failure to take any kind of medical action or to apply any means of healing. One of the most notable cases on record is that of a baby born at Johns Hopkins Hospital in 1971 which was unable to be fed because of an intestinal blockage. Because the infant also suffered from Downs Syndrome, doctors were refused permission to do anything about its intestinal problem. The baby was wheeled away into a corner where it was left to die two weeks later of starvation and dehydration. This incident could be, and has been, referred to as an example of passive euthanasia. In this case doing nothing resulted in unjustified killing. The persons involved perpetrated a sin of omission in one of its most frightening manifestations. Here was euthanasia at work in a passive sense as the refusal by those responsible to use ordinary life-sustaining medical treatment to prolong a life simply because there was no prospect of recovery in the sense of having a normal healthy child. Certainly there was nothing beautiful or good about this death. There was nothing merciful at all about this killing. The story of this infant serves as a reminder of the fact that the morality of an act, whether of commission or omission, depends on what is intended as well as on what is done or not done. Just as "pulling the plug" may not be euthanasia even though a specific action has been taken, so the failure to do something, sheer passivity, may well be an act of unjustified killing belonging to the category of homicide. Other examples of situations which are said to call for euthanasia involve persons suffering from unresponsive, far-advanced cancer with intractable pain, irreversible brain damage resulting in a vegetative state, and individuals with marked senility who suffer from life-threatening illnesses. It is to exceptional cases of this kind that the following statement of the New York Academy of Medicine applies: When, in the opinion of the attending physicians, measures to prolong life in which no realistic hope of effecting significant improvement will cause further pain and suffering to the patient and family, we support conservative passive medical care in place of heroic measures in the management of a patient afflicted with a terminal illness. It should be noted that this statement does not use the term "passive euthanasia." Instead, it speaks of "conservative passive medical care." Here is a reminder that the medical profession is hesitant to use the term "euthanasia," partly because the use of such distinctions as "passive" and "active" euthanasia has tended to blur the ethical dimensions inherent in the possibilities of extending and ending life almost at will. In normal medical parlance the term "euthanasia" stands for "mercy killing." As such this practice plays no rightful role in the profession of healing, and it has no place in the church except for purposes of condemnation. To confound the whole field of definitions still more, the term "euthanasia" is sometimes modified by such adjectives as "voluntary," "involuntary" and "compulsory." If euthanasia is voluntarily administered by and to oneself, it is a form of suicide. If applied by another with the deceased's consent or cooperation, it is both suicide and murder. If the application of a death-accelerating measure is administered by someone else without the consent of the patient or his family, it is called involuntary. If administered in violation of the wishes of the patient and/or the family, it is known as compulsory euthanasia. In an involuntary and/or a compulsory situation it is a form of murder. It is a patient-killer, not a pain- killer. In any form, it is illegal at the present time in every state. The various semantic distinctions which have been indicated here, especially the use of "passive" or "active" and "positive" or "negative," serve to confuse the unwary and to desensitize those who oppose the legalization of mercy killing disguised as "happy death." In some cases the differentiations made may be well-intentioned. Yet the use of various qualifiers in connection with the term "euthanasia" has created great confusion, thereby raising unnecessary hazards for persons committed to a God-pleasing attitude regarding the issues of life and death. Properly speaking euthanasia entails direct intervention, the killing of a human being, with or without his knowledge or consent. It may be briefly defined as the administration of a lethal dose to the patient or the deliberate refusal to use even the ordinary means of sustaining life. It is in this "active" sense that the word "euthanasia" will be used in the present study. b. Legal Status of Euthanasia Presently euthanasia is not legal in the United States, despite the efforts of such groups as Concern for Dying (formerly the Euthanasia Educational Council), the Society for the Right to Die (formerly the Euthanasia Society of America), the American Euthanasia Foundation, and the Good Death Fellowship to cultivate a climate of opinion favorable to the acceptance of legislation that would embody the use of this word and permit the practice of "mercy killing." As a matter of fact, the legal status of euthanasia is more than a little ambiguous. The fact that legislation regarding euthanasia is a matter of state rather than of federal law has produced significant disparities among the various proposals drawn up for legislative discussion and possible action. The present legal situation with respect to euthanasia is criticized for a number of reasons. First of all, critics say that a steady deterioration of the legal handling of the problem of mercy killing has made a dead letter of the existing laws on this subject. Neither judges, juries nor public opinion will support or implement them. Moreover, they argue that uncertainties in the area of liability compel physicians, presumably against their better judgment, to persist in so-called extraordinary measures to extend the dying process. They also observe that the enforcement of whatever legislation applies to this question is sporadic and even capricious, and that, in any case, it is contrary both to the spirit and the letter of the larger body of United States law to equate mercy killing with murder. Explicit legalization of mercy killing has not yet occurred in any nation in the world. Uruguay has, perhaps, the most permissive legislation on the subject. The law in this country, which has been in effect since 1933, prescribes that in case of homicide committed out of compassion and at the victim's repeated request, "the judges are authorized to forego punishment of a person whose previous life has been honorable." Germany and Switzerland also permit a mitigation of punishment where the killing proceeds from "honorable motives." Elsewhere the laws, at least on paper, continue to be more stringent. But even in the three exceptions cited, the offense is not condoned or legitimized; rather, judges are authorized to pardon or to soften the punishments (for murder) normally prescribed by law. In most jurisdictions throughout the world, and decidedly so in the United States, the legality of acts of omission as a means of hastening death, of removing obstacles to its accomplishment, are still clouded with ambiguities. Such acts are at times judged to be murder, when it can be shown that an act of omission is a major contributing factor. Indeed, existing laws do not presume to say, for example, whether turning off a particular life-sustaining apparatus is an act of omission or commission. And, moreover, if it can be established that a particular act is one of omission, the law is still far from clear as to what the legal implications are when such a procedure leads to a predictable death. Even murkier are the questions that arise from the withholding of remedies and medications-e.g., depriving a diabetic of insulin or keeping antibiotic from a patient who is dangerously ill with pneumonia. Meanwhile, physicians are understandably intimidated by the ambiguities that surround the law. Moreover, legislators in all the 50 states have shown a surprising resistance to proposed "death with dignity" bills which have been introduced in state legislatures in recent years. They are somewhat aware of the problems arising out of the difficulties that adhere to changing definitions which, in turn, reflect the rapid development of medical technology. To compound the difficulties authorities inside the medical profession continue to discuss the question as _when_ death effectually occurs. For example, there is disagreement among physicians as to whether or not, in the light of late-20th-century medicine, can be contended that the criterion should be the onset of "brain death" rather than the conventional view that genuine human life goes on so long as heart and lungs are functioning, no matter what the circumstances. Critics of present law at times introduce the matter of motives. They insist that when motives seem honorable voluntary euthanasia, as they refer to cannot properly be defined as murder in either the first or second degree because an action has been undertaken for the relief of suffering and as compassionate ministration. Defenders of current law sometimes rebut this argument, however, by contending for a more commodious definition of "malice." It should be broad enough, they say, to include such aspects as "ill will," "callous disregard," and "hardness of heart." Defenders of euthanasia reply, on the other hand, that mercy killing is usually not the real cause of a patient's death, that it is only a measure for the merciful acceleration of a death already in progress or indeed (by a more imaginative definition) already accomplished. Much of the demand for revision of the laws regarding euthanasia derives from the anomaly that motive may mitigate the punishment but may usually not constitute a defense against the charge of murder-a contradiction that makes, it is said, neither good sense nor good law. Additional refinements in the arguments against the current bearing of law on euthanasia express the numerous and obvious distinctions between the motives of mercy killings and murders. The following might serve as examples: (a) its effect upon the "victim" is radically different; (b) the two acts proceed from totally different attitudes toward law and toward human well- being; (c) the "mercy killer" does not have available to him the wide range of obviously more acceptable alternatives; and (d) there is wide popular support for mercy killing, but none at all for murder. These arguments are frequently bolstered by the claim that a person's body and self are his own, to dispose of as he sees fit, as a matter of right. In fact, protagonists at times insist on these possibilities as a "civil right." The complexities involved in the issues pertaining to life and death help to account for the ambiguity of existing legal formulations and opinions. Much of the current sentiment in favor of "liberalizing" the law with respect to mercy killing finds its source, to a large extent, in the thinking and plans of persons who oversimplify or even ignore the ethical questions raised both by advances in medical technology and by the changing definitions of death as well as the term euthanasia itself. While the foregoing discussion characterizes the current legal climate with respect to euthanasia and the identification of some of the principal arguments adduced by proponents of change, our own position as Lutheran Christians who seek to bring our conduct into conformity with the divine will cannot, in the last analysis, be settled by purely secular sanctions or from considerations of public policy alone. It is appropriate at this time to include a reminder that resort to euthanasia would be sinful even if the time should come when mercy killing may no longer be defined by society as a crime. 2. _Life and Death_ In any evaluation of euthanasia it is essential to have at hand certain acceptable definitions of life and death, for euthanasia is a word that points to the end of the former and to the hastening of the latter. The problems arising from the contemporary and necessary attempts to redefine death, therefore, will be considered after some general statements on life have been set forth. a. Life There is a sense in which life, partly because it is God's creation, defies definition. There are dimensions and depths to living that can never be captured in any verbal formulation. Yet, in a study of this kind, certain definitions need to be set forth, if for no other reason than that they help to provide some general guidance for persons who deal in matters of life and death. Life, for example, has been described as vitality. It is a state of existence characterized by active metabolism. Vegetive life, by way of distinction, is the simple metabolic and reproductive activity of a human being apart from the exercise of conscious mental or psychic processes. Usually it is the fear of existing in a state of vegetive life that moves people to think of euthanasia as a way of abruptly ending a state of being devoid conscious mental or psychic processes. In the fall of 1976 the State of California enacted legislation known as "The Living Will." This is a written, documentation and witnessed instruction to the family or heirs of an individual that extraordinary efforts be used to resuscitate or reestablish his or her respiration or heartbeat in case he or she is afflicted with an apparently fatal and terminal disease. Such a document, certified at a time when the person involved is presumed to be of sound mind, does not request destruction or killing. Instead, it constitutes a request that good medical judgment be exercised does not abjure the use of compassionate care and treatment. Euthanasia not at issue in such cases, for no deliberate attempt to hasten death involved. It is a matter of providing instruction not to undertake heroic extraordinary measures in order to sustain some semblance of life. It is not only a privilege but a duty for Christians to render every possible measure of care and compassion. It need not be extraordinary care, for heroic therapy can also kill despite the good will that may be manifested in such efforts. The medical profession is committed to precise and sensible care based on sound principles and on the considered judgment of the physician handling a particular case. The patient cannot, as a rule, be consulted because of the great confusion and disorientation resulting from the effects of both disease and the medication. The relatives need to be informed, but request of the physician must always be that the patient be given the opportunity to receive that measure of care which, in the doctor's judgment, wit comfort and may provide a cure without jeopardy or the application of h efforts. In order to provide a glimpse into the mysterious dimensions of life and in order to illustrate the kinds of considerations which persons involved administration of medical care must give, it may be helpful to look at examples of patients in various age groups and with different medical problems. i. _Start Birth._ An infant is born with an APGAR rating of 2 (a rating of 10 indicates that an infant is fully responsive, with all systems functioning and considered nominal). The figure 2 indicates difficulty with breathing, abnormal color because of lack of oxygen, flaccid muscles, limpness, and lack of movement. In such a situation the attending physician is faced with the problem of resuscitation: the administration of oxygen, stimulation and the clearing of the airways. Generally speaking such a baby, if these steps of resuscitation are taken and if the infant is at term, will respond and cry. Will this baby be normal? Will it be retarded? These are questions that the physician faces. What should the reaction of the physician be? A heart is beating. There are gasps of respiration. There is some evidence of life in most systems but not in all. The life that is present is not strong. Some of these infants have developed into exceptionally brilliant individuals. Less than 1 percent have a stigma attached by such an experience at birth, but it is also possible that paralysis or mental retardation may result. After a careful and complete evaluation of the infant, is it the doctor's obligation to discuss with the mother, if she is not anesthetized, or with the father, the matter of making a decision as to whether he ought to withhold assistance from this baby or make every attempt to provide the best possible medical care to keep the baby alive? It should certainly be the latter, since in the strange ways of God the baby concerned may become a useful member of society or, by failing to develop fully, provide the occasion for others to exhibit and bestow the kind of care which God's creatures deserve. ii. _Spina Bifida._ This is a defect caused by the failure of the spinal column to form normally. In a large number of such cases there is neurological damage which may extend not only to the lower extremities but also affect the head and brain with hydrocephalic conditions. Since a permanent incapacity could result, is the proper procedure one of evaluating this infant and making the decision that it be permitted to die? In an actual case, to have permitted such an infant to die would have resulted in a great loss to the community. At delivery both the pediatrician and the neurologist indicated that great hazards were involved in performing corrective surgery. An infant who was hydrocephalic or paralyzed could have been the result. It was a case which might have resulted in exciting rewards or serious regrets. In this particular case however, corrective measures were taken and complete recovery occurred. This person, now a college graduate and fully functional, has been of great assistance to many people. Since many spina bifida babies will not be as greatly benefited by treatment as in this specific case, it is important to remember that decisions regarding procedures to be followed in such situations must always be based on what appropriate care for the infant requires, not merely on what the results of such treatment might be. iii. _Advanced Malignancy._ What is the decision that should be made concerning a patient with an extensive, far-reaching malignancy such as a carcinoma of the ovary with metastases to the lung, the diaphragm and intestines? Let us assume that this condition is found at the time of an operative evaluation. We know that at times cancer will respond to modern chemotherapeutic agents, but it is also true that chemotherapy may be very reactive and difficult for the patient to tolerate. This is also true of radiological, cobalt or radium therapy. Should the decision be not to attempt this additional therapy or, on the basis of a 10 percent probability, to "give it a try" under careful monitoring in an attempt to achieve relief and to restore a functioning individual? Let us assume that therapy is administered. Blood may be given to strengthen the patient. Fluids can be added to combat the thirst and dry membranes of the mouth and nose, nutrition may be offered and every effort will be made to sustain kidney function, which is one of the systems which must be kept alive for a person to live. Monitoring indicates that the therapy (chemotherapy, cobalt or radium) has had detrimental effects on the bone marrow as well as on the blood formation and upon the general physical status of the patient and that there has been no progressive reduction in the growth of the cancer. It needs to be remembered that this patient has been inoperable from the outset. Is it necessary to give a detailed explanation of the hopelessness and the hazard of the continuation of this therapy to the patient? The bone marrow and, therefore, the blood, has been depressed not only by the disease but also by the drug. Therapy, if continued, would kill the person. Blood cannot activate and rebuild the bone marrow because of its destruction by disease and by drugs. Therefore medical judgment indicates that therapy must be stopped. Where possible the physician may obtain from the patient a cooperative decision that such therapy should be initiated which will be best for him, but it will not be in the category of "above and beyond the call of duty." It will be giver for compassionate care and for patient comfort. Fluids will be administered to make the patient more comfortable and to alleviate suffering. Oxygen may be given, not in order to add to the length of the life, but to give the patient comfort in his seriously tragic plight. If the patient has no control of the bowels nursing care will see to it that he or she is kept clean and does not have the unfortunate, painful experience of bed sores or a soiled bed. The patient is moved from side to side. In such a situation medication is given for comfort, not for killing. Medication is administered to reduce pain and to permit the patient to sleep. The physician's approach must be based upon the knowledge of the patient and the desire to give accurate and compassionate care. The removal of certain drugs is not, matter of encouraging what some want to call passive euthanasia. Instead, it emphasizes the care given an individual as a result of sound judgment and medical experience. iv. _Brain Damage._ A patient who has suffered brain damage but who possesses, spontaneously beating heart, active circulation, active respirations, and who produces urinary output must be sustained and observed carefully while monitoring determines whether other systems are involved or become involved with the consequence that total death ensues. Anyone who has bee a physician long enough will have had the experience of seeing a patient comatose and morbid on admission to the hospital, being discharged in wheelchair, mentally alert with a smile on his or her face, waving good-by and invoking God's blessing. The processes of life and living are that mysterious. b. Death The usual dictionaries, including _Dorland's Medical Dictionary_, define death as: (1) "the cessation of life"; (2) "the cessation of all vital functions without capability of resuscitation, either in animals or plants." The American Medical Association says that "death shall be determined by the clinical judgment of the physician using the necessary available and currently accepted criteria." In this connection it should be noted that in some circles a new criterion for death is being used in medicine today. It is called irreversible coma or brain death and is determined by the following criteria: (1) unreceptivity and unresponsitivity; (2) no movements or breathing; (3) no reflexes; and (4) flat electroencephalogram (brain- wave test). However, even in the case of the application of these criteria, it is not possible to be fully certain at all times that a patient is dead. Their validity, for example, is dependent on the exclusion of the following two conditions: hypothermia (that is, temperature below 90 degrees Fahrenheit, or 32.2 degrees Centigrade) and central nervous systems depressants such as barbituates. It is clear that euthanasia as the practice of deliberately ending life where some small possibility for continued existence still remains is killing, for total destruction is imposed from without on all body systems. These include the brain, the cerebral and neurological systems, the heart, the circulatory system, the kidneys, the excretory system, the liver, the detoxification system, and thus the entire metabolic system. In many instances recovery and rehabilitation can take place as a result of the administration of ordinary care, given for comfort and cleanliness. 3. _Ordinary and Extraordinary Means_ Some attention must be given to the distinction currently made between ordinary and extraordinary (or heroic) means of preserving life, for the difference between them throws some helpful light on very difficult aspects of the issue known as euthanasia. Ordinary means are usually described as those measures which can be taken on the basis of the judgment that there is a demonstrable or recognizable proportion between the good effect sought and the degree of hurt or hardship involved in their use. They comprise all the help a patient can obtain and undergo without imposing an excessive burden on himself and others. They are considered to be imperative for the sustaining of life and are not, therefore, refusable. By way of distinction, extraordinary treatment refers to the use of artificial means to prolong a patient's life once his vital processes have ceased their spontaneous functions. Furthermore, this term also embraces those measures which are very dangerous, difficult, painful or even costly, whose good effects are not deemed to be proportionate to the difficulty and inconvenience involved. They may, therefore, be refused. There are four major factors to be taken into consideration in extraordinary cases: (a) When irreversibility is established by more than one physician; (b) When a moment in the process of dying has been reached where nothing remains for medical science to do except to offer proper care; (c) When possible treatment involves grave burdens to oneself and to others; and (d) When there are no means left to relieve pain and no hope of recover remains. The very listing of these considerations indicates the degree to which medical judgment is involved in the decision as to whether or not to employ heroic measures in situations where no reasonable hope of benefit or of success appears to exist, or where, in addition, excessive discomfort and/or cost art involved. The facts in a given case do not always present themselves in clear-cut fashion. If medical judgment indicates that a patient is irretrievably if the process of dying, it is possible for a physician licitly to choose, for example not to treat new infections or emergencies, even those which are likely to hasten the death process. II. ETHICS IN THEOLOGICAL FOCUS Having discussed in some detail the definition of important terms, it is now necessary to turn to the major spiritual and moral considerations involved in discussing the question of euthanasia. In order to get a proper perspective on this vital matter which affects both faith and life, it will be helpful to examine it on the basis of the Apostles' Creed. In this formal statement of faith we confess our faith in God who, as Creator, Redeemer and Sanctifier, deals with life in its totality as well as in its everlastingness. It would be difficult to imagine a more comprehensive instrument of appraisal than this formulation of the Christian faith as confessed and taught by countless church members down through the ages. 1. _Life Is the Creator's Gift_ God created human beings to live and not to die. Death in any form is inimical to what God originally had in mind for His creation. Death is the last great enemy to be overcome by the power of the risen Lord (1 Cor. 15:26). To speak of "death with dignity" or "merciful release," therefore, consists of engaging in unholy rhetoric. Death entails destruction, separation and loss. None of these is part of the image in which God once created the human race (Gen. 1:26). Dying, therefore, is not just another point in the cosmic process or in the experience of living, as it is sometimes made out to be. Living is the only proper response on the part of a being created by the God of life. Death is the very negation of what God has given. Had it not been for man's own rebellion against the kind of intended relationship established by having been fashioned in God's image, there would be no death. In that case even the word "euthanasia" would never have occurred to anyone. It is written of man in Gen. 2:7 that God breathed into him His very own spirit to turn him into a living being. When death, therefore, is described only in terms of the total stoppage of the circulation of blood and the cessation of the animal and vital functions, or even as irreversible coma, that may not say enough. For behind such a statement is a view of human life which identifies solely with that of the animal kingdom. This does not do justice to the biblical revelation, which insists that people were not made to die like dogs in a ditch. While the Scriptures depict the animals as also having (or being) _nephesh_ (soul), human beings are described as being unique in the sense that they are endowed with _ruach_ (spirit). Dying, therefore, is called giving up one's spirit as for example in John 19:30, where we read of Jesus' death on the cross (cf. also Eccl. 12:7). The use of the criterion of "brain death" has contributed to a more constructive discussion in depth of the subject at hand. This yardstick is base on the death of the cortex, whose obliteration makes it virtually impossible to distinguish between a living patient and an unburied corpse. Such a person is dead in the most elementary sense of no longer being able to respond within the parameters established by the fact that he or she has been created in the image of God. Death by every definition represents a defeat. It runs counter to every sustained expectation of each person as a living being. Having been made in the image of that God who is Life itself, human beings, even in their fallen estate, have within them a vague awareness that they are in this world not just for the purpose of leaving it by one of "death's thousand doors." The psalmist's resistance to dying typifies the biblical view of death. He expressed his thanks to God in these words: "Thou hast kept me alive, that I should not go down to the pit" (Ps. 30:3b). To be sure, the apostle Paul freely expressed the wish to depart and be with Christ as a status "far better" than remaining in the flesh (Phil. 1:23). At the same time, however, he realized that it was more necessary for him to carry on here in his mortal body on account of his converts to Christianity. At the end of his life, which had been full of suffering of every kind, he was quite ready to acknowledge that the time of his departure had come (2 Tim. 4:6). Yet he did so on the conviction that the moment of his violent death had been established in the counsels of his God and Lord. Unlike Seneca, the apostle gave no thought to taking his own life as a way of nobly leaving the hardships of this present existence. Death is an intensely personal experience. For man is not just "a brother to the insensible clod," to quote William Cullen Bryant. Dying is nowhere described in Scripture as gentle absorption into the Great All. At the same time, death does not occur apart from considerations for the totality of all things. There is a sense in which the individual's death is intricately woven into the fabric of God's permissive will for the whole of His created order. By revelation the apostle Paul could hear the dark language of nature's pathos as it eagerly looked forward to the liberation of all creation from "the servitude of corruption" (Rom. 8:21). John Milton was indebted to the apostle for this insight, when he wrote: Earth felt the wound, and Nature from her seat, Sighing through all her works, gave signs of woe That all was lost (_Paradise Lost_, IX, 780-782). Hence the created world engages in that symphony of sound referred to by the apostle as groaning together in travail (Rom. 8:22). Death and corruption are alien powers that seem to triumph everywhere except for that destiny which is associated with the resurrection of the body to eternal life on the part of those who take God at His word. It is within God's purview alone to decide on the moment when the individual is to share that life which lies beyond death in a world restored to a splendor even greater than that of its pristine purity. Within the context of this certain hope, mercy killing runs squarely against the grain of the will of a gracious Creator, who allows an alien power to fell man by way of death for the purpose of raising him up to the glory of eternal and worship as person belonging to a community of redeemed saints. 2. _Life and Death in View of Redemption_ God Himself has arranged for a super-victory over death by way redemption. God the Creator chose to be the Redeemer by having His Son become incarnate in order to overcome the contradiction between what is and what ought to be. He did so by way of suffering and death, followed by resurrection and exaltation. In accomplishing this task of redemption Jesus Christ offers to all people not only a paradigm for meaningful suffering but also the opportunity to share His distress (cf. Col. 1:24). By such identification men and women can transcend the agony, pain and decrepitude which attend life and are usually the lot of those very individuals whom others might be tempted to exterminate way of "death with dignity." The suffering endured by God's saints can be turned into personal Good Fridays. By virtue of Jesus' own suffering the dark days will turn into the Easter of glorification for all those who love God. Euthanasia, mercy killing, as a way out of such human hurt, may well be a way of circumventing or negating God's will for His children. After all, our Lord did not suffer in order that His followers might escape such an ordeal but that they might learn from Him what pain and illness mean by way of God's dealt with His children. This thought is exhibited in a document that is known as the Christian Affirmation of Life, adopted by the Board of Directors of the Catholic Host Association in 1974. It reads as follows: I believe that Jesus Christ lived, suffered and died for me, and that suffering, death and resurrection prefigure and make possible the death-resurrection process which I now anticipate. But there is another side to all this. Suffering is an intrusion into human life. It "operates under another law," as H. Richard Niebuhr once put it, for, in last analysis, man was not brought into being for the purpose of enduring infirmity and anguish. He was made to live, even to live fully. It was sin brought on death with its attendant vultures that feed on life, defacing devouring it. Redemption is the story of the way God has dealt, and is dealing, with this issue, offering the blessings of eternal life. Does not the prospect of everlasting bliss encourage abbreviating course of the individual's existence here on earth so that he or she might more quickly reach his or her final destiny? The assurance of life hereafter offer excuse for ending life at will by euthanasia. God is Life and sent His Son into the world to be the Source of life (John 1:4). The healing miracles of Jesus, particularly His raising of some persons from the dead, must be seen in this light. They indicate that illness and consequent death are strangers to God's primary intent for humankind. His purpose bring people to glory unending. As a foreshadowing of that destiny, Jesus healed a certain number of people to make the point that everlasting life could and did begin at the very moment of accepting Him as the embodiment of God's kingdom. In this way people were offered what He Himself called a more abundant life (John 10:10). Even today an awareness of this divine intent offers the kind of motivation that persuades people to pursue the art of healing as a way of implementing the paradigm offered in the life and career of the Great Physician. This very fact has created one of the major paradoxes of history: namely, that the mightiest advances in medical care have been made in those cultures which have come most heavily under the influence of the Christian religion with its emphasis on the blessed hope of everlasting life. In fact, this progress has been so steady and unexpected that medical technology itself has become one element in what has been called the "terror of humanity." It can create the fear in people, as they grow older or become desperately ill, that they will be kept alive by extraordinary means without regard to the fact that they are persons rather than mere objects of medical experimentation and observation. Contrary to the tenets of secularized medicine, the biblical revelation does not view the skill of prolonging life as constituting either the ultimate purpose or the last chapter of a person's life. Christian doctrine views the restoring miracles of Jesus as reminders that they are penultimate actions, designed to validate the expectation of the ultimate solution of all of life's problems in the resurrection of the dead, scheduled for the end of time. After all, the persons whom Jesus healed and those whom He brought back from the dead were "gathered to their fathers" in due time, and now, with all the rest of humanity, they await the sound of the last trumpet. Their experiences suggest that death need not be understood in terms of discontinuity. Even as the person who awakes from a night's slumber is the same one who went to sleep in the first place, so the person who lies down to die is the very one to be awakened to his eternal destiny in the resurrection of all people. Thoughts or actions associated with euthanasia, as man's way of deciding when this present life should end, may constitute the sin of _lese majeste_ against the Sovereign in whose hands alone lie the issues of life and death. 3. _Life and Death in Light of Sanctification_ Life is holy. This very conviction must take into account the consequences flowing from the work of the Holy Spirit, with whom individuals are endowed at Baptism. Of Him it is said that even now, during the time of our earthly existence, He serves as the down payment of the age to come. Hence the Nicene Creed speaks of Him as "the Lord and Giver of Life." In terms of life as response, the Spirit's presence is of incalculable significance for an appreciation of what may go on in that dim region which lies between life and death. In some instances it is impossible to determine by ordinary means whether the patient has the capability of reacting to what goes on around him. In such a situation it is of crucial importance to keep in mind that, in a patient's relationship to God, the Spirit has been given the specific task of formulating and articulating "sighs too deep for words" (Rom. 8:26) it such a way as to serve the purposes of intercession at the throne of grace. (This activity on the part of God's Spirit may help to account for the fact the after they have come out of their unconscious state, some persons have been able to remember certain phrases from prayers said for them at their bedside by pastors or members of the family. They can recall such acts of kindness even though, at the time, there was no perceptible hint of comprehension.) Intentionally to bring about the death of an individual so engaged in communion with the heavenly Father would constitute a blasphemous intrusion into sacred relationship prevailing quite beyond the farthest reaches of human knowledge and personal awareness. The presence of the Spirit must also be taken into account for a full. appreciation of the possibilities available to the patient suffering from those various infirmities which attend old age. Even an invalid, totally bedfast, can pray, and that is like the lifting up of holy hands at the evening sacrifice. Rather than considering such a person to be useless and an unnecessary burden, he or she ought to be thought of as precious in the sight of God, so valuable, in fact, that our heavenly Father was willing to arrange for his or her redemption in Jesus Christ and for a life in the Spirit that is ready to give expression to God's presence in a petition like the one that has become known as "A Prayer in Bed." It reads as follows: Dear Lord, one day I shall lie thus and pray Stretched out upon my bed, Within a few days or hours Of being dead; And I shall seek Then for the words to speak And scarce shall find them, Being very weak; There shall hardly be strength To say the words, if they be found, at length. Take then my now clear prayer, Make it apply when shadowy words shall flee, When the body, busy and dying, May eclipse the soul. I pray Thee now, while pray I can; Then look, in mercy look Upon my weakness-look and heed When there can be no prayer Except my need! Such praying is the activity of a life that is appreciated as being sacred because it is intimately bound to God by His Spirit even when it is no longer possible say the desired words. Who, then, with any feeling for the sanctity of life would want to cut short such holy conversation? Cases of lingering and even painful illness provide the opportunity, instead, for the kind of service on the part of those who are well that will exhibit their care even by such everyday means as sick visitation. For of all the fears that haunt the ill and the aged few are more debilitating than the prospect of being left utterly alone with only the personal warmth and dedicated service of medical personnel to attend them amid the gadgetry and impersonal machines. At this point the Christian community can render a number of valuable services. The general prayer in the traditional order of the Sunday service calls for special petitions on behalf of those who are lonely, afflicted and dying. Moreover, few tasks are more noble than that of regular visits to such as are ill and feel forsaken. Visiting the sick is one of the items listed in Matthew 25 as a criterion of judgment, especially when one of Christ's own is involved (cf. v.40). For when these persons profess that they cannot recall doing such a thing, their heavenly King will say to them, "Verily I say to you, whatever you did to one of my brothers here, however humble, you did for me." An organized program of sick visitation within a congregation, therefore, comprises one of the most eloquent testimonies to the Christian faith even, and perhaps especially, to those who do not belong to the assembly of the faithful. The church, moreover, must never neglect to prepare the dying for their journey into the life before them by the use of the means of grace. While these obviously do not work like magic, they do have a power that is sacramental. They offer strength for that experience which each individual must face all alone except for the One who has Himself gone ahead of us through the valley of the shadow. III. BY WAY OF RECAPITULATION The incalculable advances in medical technology which characterize our age have created extremely complex questions that call for a reexamination of fundamental principles in ethics as they apply to the question of euthanasia. This need has become particularly acute since humanity now has the power to shorten or to prolong some form of human life almost at will. We are today confronted in a more disturbing way than ever before by the issues of life and death in their most mysterious dimensions. We have noted the potentials for confusion that lie hidden in the use of such distinctions as active and passive euthanasia as these are advocated primarily by "social engineers" rather than by trained medical personnel. For its basic arguments this study has used the word euthanasia in the sense of mercy killing, lamenting attempts by well-meaning humanitarians to use various modifiers of the word to push their own views at the price of obscuring the central spiritual and moral issues at stake in taking a human life which owes its beginning, its continuance and its ending to nothing less than the life-giving and sustaining power of the Creator. We have stressed the need for care and concern in dealing with terminally ill persons and have rejected the suggestion that every kind of extraordinary measure must be taken to maintain existence. At the same time this study has underlined the responsibility of the medical profession for looking at life as a whole, since, in the last analysis, it is the physician's considered judgment which enters into specific decisions on individual cases. Certain legal questions raised by the irrevocable revolutionary changes in the field of biomedicine have been indicated in the section dealing with definitions. Legislators have great difficulty keeping up with developments, including such challenges as providing an adequate definition of death. As a legal instrument "The Living Will" has raised a whole host of issues crucial to a proper understanding of the fuller dimensions pertaining to the issues of life and death. Some major elements of theological import have been presented to examine the issue of euthanasia from inside the Christian faith as this is articulated in the Apostles' Creed. Over and again we have resumed to underlining the mysterious depths of life as God's gift. Specific medical cases were adduced to flesh out the nature of the question of euthanasia. People have been endowed with life for the purpose of living in response to God's will by virtue of the fact that every human being is fashioned in the image of God. The defacement of that image, brought on by humanity's rebellion against the Creator, has been made good by the work of the Redeemer, whose saving activity is continued by God's Spirit, serving as the down payment of the age to come. While illness and death comprise an intrusion into life, they are allowed to carry on their destructive work under God's permissive will as reminders that we have here no abiding status and ought to look forward to the "city which has foundations, whose builder and maker is God" (Heb. 11:10). At the same time, pain and dying are experiences which can serve the further useful purpose of recalling people to the awareness that they are not autonomous. Life as a gift from God is an endowment whose disposition lies in the hands of God Himself, working as Creator, Preserver, Savior and Sanctifier. Against this background the suggestion of deliberately accelerating death runs counter to what the biblical revelation offers by way of both moral principle and spiritual insight into man's nature and destiny as these are woven into the fabric of God's saving intent. This situation calls for increased acceptance of the disciplinary challenges inherent in personal suffering as well as of the opportunities for service to the ill and the dying. Concurrently, the potentials of medical technology in all of its ramifications for good or ill make it imperative for the medical profession to rethink the whole matter of life and death in such a way as to do justice to the will of Him who created life in the first place and who has redeemed it and still keeps sanctifying it. IV. GUIDING PRINCIPLES The previous pages have set forth the major arguments against the practice of euthanasia as mercy killing. From this extensive discussion it is possible to formulate some general principles that will serve as guidelines for working one's way through the vast array of ethical questions raised not only by the very speed of advances made in the technology of medicine but also by forces at work in our culture which tend to relativize all moral considerations as they apply to the central issues of life. Accordingly, a set of guiding principles is here appended to help individual Christians and groups of the faithful in their response to the issues which confront us in this area: 1. _Euthanasia, in its proper sense, is a synonym for mercy killing, which involves suicide and/or murder. It is, therefore, contrary to God's Law._ Attempts have been and continue to be made to soften the impact of euthanasia as an evil by using modifiers such as "passive" or "negative" and proceeding from there to distinguish between active and passive euthanasia. These definitions tend to dull people's sensitivities to ethical considerations by relativizing moral principles as these apply to matters of life and death. 2. _As Creator, God alone knows with certainty whether a disease or an injury is incurable._ Instances have been cited in this study to show that medical personnel often have no way of being able to foretell the outcome of treatment administered under circumstances that seemed quite hopeless. The extraordinary advances made in medical technology provide new resources that are useful in making life and death decisions. Yet these decisions, too, fall within God's ultimate providence and grace. In the last analysis, He is the only healer. 3. _When the God-given powers of the body to sustain its own life can no longer function and doctors in their professional judgment conclude that there is no real hope for recovery even with life-support instruments, a Christian may in good conscience "let nature take its course."_ The power to sustain life refers to the period of time preceding the point in the process of dying when irreversibility has set in. When that moment of no return has been reached, the discontinuance of what have been called extraordinary or heroic means for prolonging life is not normally a violation of God's Law. It belongs to the category of proper medical care rather than to the issue of euthanasia. In point of fact, the application of such unusual measures could be construed as a technological stretching of existence beyond the powers with which the Creator Himself endowed the patient in question. In seeing a God-pleasing conclusion in this matter, the following persons should nominally be involved in the final decision: a. The _patient_ (if capable of discussing the facts) to help in determining the general reaction to bodily strength and suffering and in making a decision that is legally and morally acceptable; b. The _doctor_ to help determine whether support systems are still helpful and whether there is any hope for recovery; c. The _nearest of kin_ to gain concurrence in decisions reached; d. The _pastor_ to give spiritual guidance and counsel in reference to treatment and care and to provide spiritual assistance and comfort and support. 4. _Administering pain-killing medications, even at the risk of shortening life, is permissible, since this does not entail the choice of death as either a means or an end._ 5. _It is good ethical procedure for the doctor to request and receive a statement signed by the patient, if competent to consent, or by the nearest of kin, agreeing to the uselessness of further "heroic efforts" and consenting to termination of treatments._ 6. _Each person, no matter how infirm and socially useless he or she may appear to be, deserves to be accepted as a being created in the image of God._ Accordingly, medical personnel are expected not to treat a given patient as a mere case. They will, on the contrary, show concern and care in the treatment of even the most hopelessly ill. No person enjoys autonomy of existence. Patients may, therefore, not be treated as though they were units of matter, disposable either on their own terms or on the basis of the judgment of others who may be tempted to view an incurable patient in terms of convenience or utility. 7. _While suffering is an intrusion into life, it provides the opportunity for Christian witness and service._ Suffering provides the occasion for others, particularly members of the family and of the Christian community, to attend the sick and the dying as a way of exhibiting the kind of care which will help the patient to retain a sense of worth. Such acts of kindness will help to relieve the kind of loneliness which may tempt one to ask that life be ended prematurely. 8. _Often the time prior to death is so wrapped in mystery that no one ought forcibly to interrupt the movement of man's spirit as it may be communicating through God's Spirit with his Creator and Redeemer by way of responding in trust and inner yearning._ 9. _Death is not merely a physical but a crucial spiritual event for each person._ The church's means of grace, therefore, ought to be within easy availability for purposes of consoling the dying and preparing them for the high adventure of crossing over into life eternal. With proper consultation between pastor and doctor, arrangements can be made for receiving the full benefits of spiritual help also in the case of patients requiring heavy doses of drugs for medication. Doctors can arrange for periods of medical relaxation to make possible the proper administration of the means of grace. 10. _Any decisions made in this highly complex area, and any actions taken that may later appear to have been wrong, have been redeemed by that forgiveness which is available to all who put their trust in the work and merits of mankind's Savior and Redeemer._ Such forgiveness, proclaimed by the church as it properly distinguishes between Law and Gospel, constitutes a potent cure for any feelings of guilt that may plague individuals making decisions in this very sensitive area of life as response to God's actions as Creator, Redeemer and Sanctifier. 11. _The spiritual and moral questions raised by the issue of euthanasia are of such a nature that their evaluation is an enterprise touching on the very survival of the basic principles which undergird the integrity of our Christian faith and the survival of our cultural heritage. They constitute the primary spiritual and moral crucible of this age._ 12. _Christians are obligated to make their position known, by whatever means possible, as a way of helping to shape public opinion on the question of euthanasia._ The present confused state of affairs places a special burden on all persons of moral principle to use the "marketplace," giving expression to their convictions with a view to eliminating confusion for the purpose of formulating such legislation regarding medical practices as do not violate God's Law. In undertaking these responsibilities it is imperative to remain firm on the principles and clear in the use of terminology. ______________________________________________________________ This text was converted to ascii format for Project Wittenberg by Mark A. French and is in the public domain. You may freely distribute, copy or print this text. Please direct any comments or suggestions to: Rev. Robert E. Smith of the Walther Library at Concordia Theological Seminary. E-mail: bobsmith@ctsfw.edu Surface Mail: 6600 N. Clinton St., Ft. Wayne, IN 46825 USA Phone: (219) 452-2148 Fax: (219) 452-2126 ______________________________________________________________