Full Text for The "Death With Dignity" Debate: Why We Care (Text)

THE SPRINGFIELDER October 1974 Volume 38, Number 4 The "Death With Dignity" Debate: A gtudy paper presented to the Conzruittee on Social Concenzs of the La~thcrn~~ Chz,~rch-Alissouri Synod on Arovenzber 13-1 4, 1974. Prologue: The reillarkable advances in medical technology and the life sciences, particularly in the last quarter-century, have posed a critical range of ethical and social dilemmas. The gap between the \videspread recognition of the issues and a reasonable and informed response on the part of the Christian community is enormous, szirpassed in magnitude and ethical urgency only by the gravity of the conse- quences of the "biological re\lolutionn for individual human lives, their dignity and tllcir future. Bioethics, still an infant discipline, encompasses a hroacl range of critical issues in medicine, biology, and allied disciplines. Abortion, hr~nlan experilllentation, genetic engineering, organ transplantation, behavioral control, and death and clying are the most frecluently identified problem areas. Ethical scrutiny of the great potential for good and evil in the rapicily expanding horizons of the bionledical sciences does not arise from idle curiosity or from a detached ben:usemen.t. Unless the. Christian witness of a carefully considered ethical response is brought to bear upon the technology of medicine and its use there is danger that we will have to copc, as the Reverend Charles Carroll has warned, with ''medicine without an ethic; the la~v without a norm; and the religio~is community without a theology of life and death, man and nature."' In this ethical vacuum, where even to make no morally informed decision has consequences, the final victim will be man himself. In the face of an overriding utilitarian ethic, the indii~idual person, with an "alien dignity" given by Gocl, will be oire.rnrhelmec1 by the consequences of "the coming co~ltrol of life," symbolically identified as the "Second Genesis" by the noted science writer, Albert Rosenfelcl." From "1vom11 to tomb," as the clichk aptly puts it, the full range of human experience is affectecl by the new powers to control life and death, raising the spectre of men "playing Gocl," in the sense of making God-like decisions, who have forgotten how to "play man." iVllen, as in the Supreme Court pronouncement of January 22, 1 9 7 3 (Roe 11. Wade), a particl~lar point of view on a vital life- concerns issue is sanctioned and fornlalized as public policy, the forum of concern is rvidened beyond the private decisions of indi- viduals in the doctor-~atient relationship. Abortion legislation, pro or con, was and is not a sectarian issue, but one of the broadest public morality. Chdstian citizens cannot rest content with assuring themselves that their personal choices are in keeping with the \Bill of God; they must work out a responsible social ethic that conforms, as in our own case, both to the Biblical witness and the T,utheran ~~nderstanding of the Christian's dual citizenship. - Like the abortion debate, the current controversy concerning euthanasia leaves few Americans, Christian or non-Christian, un- moved or unaffected. There can be no doubt; it is a life-coilcerns issue that invoIves fundamental theologcal principles. 'Thc core of the problenl is suggested by the query: Can a Inan, or otllers for him, exercise any control over the nlanner and time of his death? Behind this concern are cven more fundaniental questions about the very nature of man, the ~ncaning of our hzit~ia~zum, and the freedom and responsibilities of man before God. A 1nyr1ac1 of specific problems, sonlc of definition, some of ethical analysis, some of practice, and some of appropriate Christian response, are subsuil~cd within thc "death with dignity" slogan. 1 do not propose to offcr a solution to each one of thcm, but sinlply to sort out the il~ost pertinent questions, especially those to which a clear and unequivocal Christian reply can now be given, and isolate those areas .cvhich xvill need additional consideration ." Since ancient times it has been assumed that a man is clcad when he stops breathing and his heart stops beating, criteria ~vhich are still traditional to forensic medicine."- 'Technology's new possibili- ties, the availability of cardiac resuscitation, electric shock, trans- f~lsions, infusions, transplants, respirators, defilIibrators aild similar marvelousl!r ingenious nlachines, have created chaos ~vith the once commonplace definition of the moment of death as the cessation of heartbeat and respiration. Heartbeat and breathing, through the aid of suppIementa1 machinery, can be artificially n~aintained in a person wl-mosc brain is crushed or even deteriorated to the point of liquefica- tion .' 111 its battle against untimely death, due to infectious diseases, for cua~nple, rnedic~ne has made' significant and very praiseworthy contrib~~tions to the public's physical well-being. Under the present conditiolls nearly two-thirds of the population reach the age of seventy. iis a result many people fear the isolation and suffering which accompany chronic deterioration lnore than they clo death fro111 some quick, acute illne~s.~ The progress of technology has put into the physicians' hands the ability to intervene in the course of a patient's illness to such an extent that questions are raised as to whether medical wizardry is not in fact prolonging the dying process rather than prolong!ng life. . More dramat~cally, the question can be aslted: When are we dcaling with a living patient and when are we dealing with an un- 1)uriecl corpse whose bodily processes (traditionally thoug11t of as itill ill sig11s") are being ;~rtificalIy maintained? "Putting it in religious language," writes the ethicist Daniel C. Maguire, "can the Will of God regarding a person's death be manifested only through disease 01- the collal~se of sick and wor~nded organs, or co.~dd it also bc dis- covered through the sensitive appreciations and reasonings of ~lloral ll?arl ?l'; Ilcath With Dignity . - - - - - - - -. - - - - - - . 2 6 7 ~, Agreeing upon and updating criteria to ascertain the cessation of lifc is not, of course, the same as defining death itself. To deter- mine 1v7zerz deth has occurred is not the same as defining death, which has various meanings at various levels of thought. The theo- logical understanding of death as the separation of the soul fro111 the body is not thc sallle as biologica1 death, namcly the cessation of the sinlplc lifc processes of the various organs and tissues of the bdy. Science cannot give us a litmus test for determining when death, in the theological sense, has taken place. But our notion of death, be it theological or not, does have bearing upon the medical criteria we fasten upon for telling us ~vhen death has occurred. And it certainly has serious implications for both pastoral and medical care, for again the watershed question in a particular case is, as Paul Ramsey writes, whether or not we have "a life still among us who 1a)is claim to the in~nlunities, respect, and protection wl~icl~ in ethics and/or law are accorded men to a fellow n~an."~ The pronouncement that biological death has taken place is a rnedical question. Updating the clinlcal procedures for asiertaining biological death raises no new n~oral concerns, unless the nlotivation for pronouncing the clinical fact of dcath lies in interests outside of thosc of the patient. The urgency of obtaining a transplant for soine- onc else, for example, should not color the marking of the borderline l~et\vecn life and clcatll of the patient in the first instan~c.~ Under most circumstances thc clinically observed cessation of spontaneous cardiac activity and spontaneous respiratory activity will be adequate indications that tleath has occurred, but in the borderline situations thc addition of what has come to be called "brain death" is a neces- sary criteria. In thosc cases in ~vhich there is pern~anent brain damape and, conse(l~iently, an irreversible coma, and where the tradit~onal signs of death are obscurred h) the intervention of resusci- tation machinery, the addition of the criteria of "brain death," verified by a flat or isoelectric elcctroencephaIogram is, as the "Report of the Ad Hoc Conlmittce of the Harvarcl Medical School to Examine the Definition of Brain Death" states, "of great confirmatory value."10 Once the patient is determined to have suffered "brain death," death is to bc declarcd and then the respirator turned off. Two states, Kansas and Rlarvlancl, have modified statute law to inclucle "brain death."" In additio~l to the refinement of the methods for cleterrnining that death has occurred, attention has been given to the traditional notion of the "moment of death." Even the "monlcnt of death" was, of course, a span of time in which, at various degrees, biological death encompassed the whole organism (clinical death, psychological death, organ death, cellular death). But now the concern seems to be to movc away from an understanding of "death" as a clearly defined event and toward one that views death as a process, in ~vhicll, as Robert Morrison has written, "the life of the dying patient becomes steadily less conlplicated and rich, and, as a result, less worth living or preserving." As the pain and suffering mount, along with escalating costs and decreasing benefits to the patient ancl to society, the process of death is said to be hastening onward. As the process continues, since lifc and death are part of a continutim, some decision n~ust be made, Morrison agrues, about the "quality of life" of the patient, some decision as to whether or not it is worth prolonging.]' While we can, in the restricted sense, agree that death is a process, we must still affirm that the synlbol of tlie "~~lonlent of dcath" has important moral content. "The tro~zble with Morrison's position," contends Leon IOI> ccasing tcj rescue the perishing, in the sensc of curi~lg, ancl n1ovi11g to (only) cari~zg for the tlying, the Christian may speak of the "will of God" in the sensc of God's lxrn~issive will, or his "will of goocl pleasure," to which our response is one of acceptance and ' entrustment of the dying to the mcrcy of God. But having concluded, in a l,articulnl- case, that death, and not recovery, is God's will, we. can rlevcr go on to concludc that it is part of God's "prescribed will" that wc itrC to ti~lurgatory.".'" Suffering is never re- demptive in the sense that it can be man's last act of positive obedience in co-operation with thc suffering of Jesus. But I~theran Christians can asscrt that even suffering, while not willed for its own sake, nor to hc allowetl to be left unchecked, is not outside the L ( purposeful will of God. As thc Apostle Paul writes, suffering pro- tiuces endurance, and endurance l~roduces character, and character produces hope, and hope does not'-disappoint us, because God's love has been poured into our hearts through the FIoly Spirit which has been given to 11s" (Romans 5 : 3-5). Postscript: Justice \:Villiam 0. Douglas reports that his father, when facing death, commented: "If I die, it will he glory; if I live, it will be Delrth With Dignity --- - 275 .- orace."." In capsule fornl, this captures the Christian perspective on b life aid death. The Christian 'view of death, which cannot be un- derstood apart froin the rleath of Adam and the death and resurrec- tion of Ch.rist, is, as J'aroslav I?elilrutc nature. Sec his pioneering Morals and Medicine (Princeton, N.J.: Princeton University l'ress, 1954). For a concise summary of his typology of electivc death in at least four forms of euthanasia, sec his "Elective Dcath," in Ethical Issues irt Medicine: The Role of the Physician in Today's Society, ectitcd by E. Fuller Torrey (Boston: Little, Brown and Company, 1968), pp. 141-57. 15. Althollgh A Living Will is not legally binding, it is being widely dis- tributed. The inadequacies of A Living Will, from thc lioman Catholic perspective, ,ire pointed out l>y Kevin A. O'Hourke, O.P., "Chris.tian Affirmation of Lift," Hospital Progress (July 1974). Recently the Catholic Hospital Association has introduced a variant on the living will, entitled "Christian Afirmation of Iife." Should we havc a Lutheran "living will"? 16. For a collection of statements in this direction, see The Mcrcy Icr, 1958), p. 322. 27. Quoted by James B. Nelson, Human Illedicine: Ethical I'erspectives OIL ATew Mc~Eical Issues (Minncapolis, Minn.: Augsburg Publishing House, 1973), p. 130. Pilot studies on those who choose rncdicine as a career have led several psychiarists to suggest that nledical professionals view their craft as a means to control and govern thcir own fears of death (thanatophobia), fears that arc stronger than those of both thc physically sick ancl healthy normal groups. Cited in Hendin, Death As a. Fact of Life, 1). 115. See also Richard Trubo, An Act of Mercy; Euthanasia Today (Los Angeles : Nash Publishing Corporation, 1973), pp. 64-66. 28. Nelson, Hzrman Medicine, p. 28. 29. "Statement on Measures EmpIoyed to Prolong Life in Terminal Illness," Bzrllctin of the New York Academy of Medicine, Second Series, Vol. 49, No. 4 (April 1973)) p. 351. 30. Richard A. McCorniick, "To Save or Let Dic," America (July 13; 1974), p. 7. 3 1. Quoted in "Dying with Dignity," Focus on Public Afairs, Vol. 6, No. 15 (Scptcmbcr 1, 1972), p. 1. 32. liamscy, Patient As I'crson, p. 134. 3 3. Elizal~eth ' I