By Philip Turner
Death is a fact of life that plays a significant role in the ideation of elderly people. I have in mind the moral probity of advance directives and refusal of treatment. These issues are of particular importance for Christians because in each case social thought and practice are moving in directions that, from a Christian perspective, appear problematic. In discussing these issues I shall use as a point of reference Gilbert Meilaender’s Bioethics: A Primer for Christians, which ought to be in the library of every priest or pastor.
I begin with what are known as advance directives. Ideally, decisions about treatment are made between doctor and patient after full consultation. There are occasions, however, when consultation is not possible. Who then decides on the right course of action? Ours is a society that treasures autonomous choice. There are powerful social pressures to do all we can to preserve that freedom. Advance directives, which spell out treatment or non-treatment preferences ideally before the need arises, are an increasingly popular way to honor and preserve this arena of free choice when free choice in situ is no longer a possibility.
There are two forms of advance directive — a living will and a medical power of attorney. Both provide a way to extend the arena of choice into circumstances where free choices cannot be made in situ. A living will seeks to describe the sorts of conditions that might present themselves at the end of life and dictate the way in which a patient wishes to be treated should these circumstances arise. A medical power of attorney, on the other hand, makes no attempt to anticipate the details of a future state. Rather, it appoints a trusted agent to act on behalf of the patient if for some reason the patient is incapacitated.
In different ways these proposals attempt to project sovereign choice into circumstances wherein free choice lies beyond reach of the patient. Meilaender is right to insist that there is no clear Christian choice to be made in respect to these two options. Indeed, many people make both arrangements.
Nevertheless, there are moral questions that, from a Christian perspective, arise in respect to the living will that do not arise in respect to a medical power of attorney. The living will comes close to self-deception in that it projects the autonomy of the patient into a future state the patient cannot anticipate, fully understand, or control.
An extension of autonomy into circumstances in which the patient will no longer be autonomous immediately sounds a warning in a conscience formed by Christian belief and practice. Both insist that we are born dependent and remain dependent, especially in the hours of birth and death. Both insist that this dependence is an aspect of our created nature and both insist that our dependence on God and one another throughout the course of our lives is a good thing.
In short, vulnerability provides an arena in which we learn, through interdependence, to love our neighbor as we love ourselves. These considerations suggest that a medical power of attorney is a less problematic course of action than a living will. It signals trust in our friends and family. It does not project our freedom beyond our limits to choose. It recognizes the limits of our autonomy and it signals clearly that we recognize our dependence on God and our friends and neighbors, particularly at life’s extremities.
Another issue involving the moral limits of autonomy arises when, in the course of an illness, a person’s family or designated agent might decide to cease seeking a cure and allow a disease simply to take its inevitable course. On what moral grounds might it be right to refuse or stop treatment?
In response to this question, there are some important distinctions to be made. In respect to dying, Christians ought never to act as if the continuation of life is the only and highest good. Neither should they take direct action to bring life to an end. Euthanasia and assisted suicide suggest that we are the owners of our lives rather than recipients of them as a gift from God. We are, in short, stewards rather than owners of our lives.
Nevertheless, there is a limited area of freedom that a right understanding of stewardship opens when death is near and inevitable. When treatment has become not a means to cure but an action that simply prolongs the last stages of dying, from a Christian perspective, it is morally permissible, with full confidence, to give up attempts to cure and switch to protocols designed to provide palliative care.
For Christians, this stage of life is one in which we are free to cease the struggle to find a cure. Even here, at life’s edges, our friends and family are called upon to care for, rather than cure, us. In this last stage of our life we are not alone. Further, we are accompanied by Christ who has made this journey on our behalf and has overcome both sin and death. He has experienced death’s pain and he waits for us on its other side. Along with Christ, we the living can accompany the dying with both love and hope. In so doing we exercise free judgment not by exercising control over life and death but by providing appropriate care in respect to both.
Appropriate care is the right Christian course, but it is accompanied by questions. The primary form of appropriate care for the dying requires pain management. Pain management sometimes involves use of drugs that depress respiration and may lead to death. Is use of these powerful drugs as a means of pain management simply a form of gradual euthanasia? It would be if their use aims directly at the death of the patient. But there is a difference between an action that aims at death and one that mitigates pain without intending death. In this case, one’s direct intent is not to kill but to alleviate pain. Death is a foreknown but unintended outcome. This form of care is not a direct attack upon life.
The moral issues that accompany death invite Christians to consider the way in which we live toward death in a world filled with death and suffering. Death and its attendant issues invite Christians to take note that Christ suffered death for our redemption. Faith that we have been set free from the power of death leads us to the firm belief that our first duty is not to contend relentlessly against the powers of death, but to accompany and care for the sick and dying in ways that are appropriate to their condition.
The Very Rev. Dr. Philip Turner has served the Episcopal Church as a missionary, rector, and seminary professor and dean. He is the author of a number of books including Sex, Money, and Power; Christian Ethics and the Church; and, most recently, Christian Socialism: The Promise of an Almost Forgotten Tradition.