Science in Christian Perspective

Notes on "Science and the Whole Person "-
A Personal Integration of Scientific and Biblical Perspectives

Euthanasia
I RICHARD H. BUBE
Department of Materials Science and Engineering
Stanford University
Stanford, California 94305

From: JASA 34 December 1982): 29-33.

Many of the problems arising from a discussion of science and Christianity result from the false assumption that certain words have only a single meaning. This is certainly true of discussions about evolution, and in our previous installment we argued that the same was true about the meaning of "abortion." It is no less true about "euthanasia." The word itself is formed from two Greek roots; the prefix "eu-" indicates "well" and the word thanatos means death. Thus to engage in euthanasia is to participate in and to work- to~vard dying well. We cannot make much headway with the ethical problems surrounding euthanasia, therefore, until we know what "death" is and until we specify what dying "well" means.

The ancient Hippocratic Oath appears to rule out some forms of euthanasia:

I will use treatment to help the sick according to my ability and judgment, but never with a view ot injury and wrong-doing. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course.¹

Both the ancient and modern concern of the physician is with the well-being of his patient, presumably in both living and dying. This concern transcends the purely biological processes of the patient and again presumably encompasses the whole person. The problem comes, then, in deciding just what it is that contributes to the well being of the whole person.

Definitions of Death

The popular statement, "He died," implies that death is an event. At one moment she was alive, and then at the next

Death must be viewed as a process and not simply as an event.

she was dead. Such a definition has been adequate for most cases in the past and still for many in the present. A variety of circumstances have forced us, however, to come to the conclusion that death must be viewed as a process and not simply as an event. One of the most dramatic of these circumstances is the development of techniques for organ transplants; in such a case the "donor" must be "dead enough" to justify removing the organ, but "not dead enough" so that the organ is still suitable for transplanting. Another relevant development has been the increase in sophisticated techniques to maintain biological life far beyond anything previously possible, and in some cases far beyond the apparent termination of self-conscious personal life.

Nelson¹ distinguishes four stages in the process of dying according to which criterion for death is chosen. (1) Clinical death is the most commonly encountered and the simplest to ascertain. When respiration and heartbeat stop, then clinical death has occurred. It is evident that clinical death is not irreversible, for there are many cases of patients who have been revived after having been pronounced clinically dead. Presumed reports of life after death described in such books as Life After Life² use death in this sense of clinical-death. If an irreversible stage of death has been passed through, the people who report their impressions after clinical death would never have been revived to tell them.

(2) Brain death is the second stage of death. It is well known that if the brain is deprived of oxygen for a critical period, irreversible changes occur that prevent recovery of the living person. Brain death itself can be separated into two parts: first, death of the higher brain functions that control consciousness, followed by death of the lower brain functions that control the nervous system and operation of the heart and lungs.

(3) Biological death implies the irreversible and permanent end of all bodily life.

(4) Cellular death means the final termination of all life processes of any kind in the body, some parts of the body reaching this final termination more rapidly than others.

As long as a human being is alive (i.e., not "dead"), regard for that human life calls for actions that will preserve it; when a human being is dead, however, a greater freedom of action is possible, as for example in arranging for transplants. It becomes a critical question therefore to consider, "When does death occur?" Recognizing that death is a process and not an event, this question translates into another, "When should efforts to preserve life be abandoned?" 

Various suggestions have been advanced to answer this question. (1) Since the irreversible stage of dying centers on the cessation of brain function, then this cessation is the criterion for death. The test of brain function is, a measurable electroencephelogram (EEG), and therefore a flat time-independent EEG is the criterion of death. Although recovery from spontaneous flat EEG patterns is rarely if ever encountered, it is also known, however, that flat EEG patterns can be induced by certain drugs, from which recovery is commonly encountered. (2) A second suggestion calls for more extensive symptoms of death then simply a flat EEG. In addition to the latter it would include all the criteria of clinical death, lack of any response to stimuli or reflex action. All of these indications of death would be required to persist for a 24 hour period before death itself was accepted. (3) A third and even more stringent perspective downgrades the significance of brain action, and looks instead to the total loss of the integrated functioning of the various parts and systems of the body as the necessary condition for death to be pronounced.

These criteria are of necessity essentially empirical and biological in nature. They leave unsaid, however, other definitions of death that may be as important, or even more important for concern for the whole person. Such other definitions would focus on the value of human life as being centered in personal existence: the ability to experience selfconsciousness, to relate to other human beings and to God, and to engage in rational and abstract thought. We argued in the case of abortion that the situation was different in the period before the biological development necessary for personal experience had occurred; we are led then to argue that problems involving death are different in the period after the biological equipment necessary for personal experience has irreversibly stopped functioning. In addition, we need to realize that the process of dying well includes much more than attention to biological processes. Concern with biological death leads to methods to sustain biological life; concern with personal death leads to methods to sustain personal life. The two are not always compatible.

Abortion is concerned with the ending of a human life before it has a chance to begin; euthanasia is concerned with the ending of a human life after it has run its course. Abortion is the decision to terminate a life which has the potentiality to become fully human; euthanasia is the decision to terminate (or allow to terminate) a life which has little if any further potentiality for being fully human in this life.

On the one hand it might appear that sanctions against abortion ought to exceed those against euthanasia since abortion is carried out against a life with the potentiality to become fully human, whereas euthanasia is carried out against a life without this potentiality. On the other hand, it might be argued that sanctions against euthanasia ought to exceed those against abortion, since euthanasia deals with a life which has been, and perhaps to some extent still is personal human life, whereas abortion deals with a life which has never been personal human life. All readers of this paper might be involved in euthanasia decisions involving themselves; they will not be involved in abortion decisions involving themselves.

acceptable <------------------------------------------------------------------------------------> unacceptable

                        spontaneous             early:            before         harming                killing
                        abortion:                                       viability       fetus to                 viable fetus
abortion                                 pre-personal         save                              -        or
                        miscarriage                                   mother                                    infanticide

                        spontaneous              late:            letting           harming    actively    actively
                        euthanasia:                                  patient          patient      ending      ending
euthanasia                                     post            dies                to             life           life
                        death without           personal       without        relieve       with         without
                         intervention                                 "heroic        pain           consent    consent
                                                                         measures

The spectrum of choices in euthanasia starts with the most acceptable situation for any type of euthanasia being that in which we deal with the termination of biological life only, the death of personal life having already occurred. When both biological and personal life are still in existence, action which allows "nature to take its course" without interposing technological apparatus and techniques to delay death is the most readily approvable. When the patient is in severe pain and death is still some time off, the issue arises

This continuing series of articles is based on courses given at Stanford University, Fuller Theological Seminary, Regent College, Menlo Park Presbyterian Church, Foothill Covenant Church and Los Altos Union Presbyterian Church. Previous articles were published as follows. 1. "Science Isn't Everything," March (1976), pp. 33-37. 2. "Science Isn't Nothing," June (1976), pp. 82-87. 3. "The Philosophy and Practice of Science, " September (1976), pp. 127-132. 4. "Pseudo-Science and PseudoTheology. (A) Cult and Occult," March (1977), pp. 22-28, 5. "PseudoScience and Pseudo- Theology. (B) Scientific Theology, " September (1977), pp. 124-129. 6. "Pseudo-Science and Pseudo- Theology. (C) Cosmic Consciousness, " December (1977), pp. 165-174. 7. "Man Come ofAge?" June (1978), pp. 81-87. 8. "Ethical Guidelines, " September (1978), pp. 134-141. 9. "The Significance of Being Human," March (1979), pp. 37-43. 10. "Human Sexuality. (A) Are Times A'Changing?" June (1979), pp. 106-112. 11. "Human Sexuality. (B) Love and Law, " September (1979), pp. 153-157. 12. "Creation. (A) How Should Genesis Be Interpreted?" March (1980), pp. 34-39. 13. "Creation. (B) Understanding Creation and Evolution, " September (1980), pp. 174-178. 14. "Determinism and Free Will. (A) Scientific Description and Human Choice, " March (198 1) pp. 42-45. 15. "Determinism and Free Will. (B) Crime, Punishment and Responsibility, " June (1981), pp. 105-112. 16. "Abortion, " September (1981), pp. 158-165.

as to whether drugs should be given to relieve the pain if it is known that they themselves will act as a poison to shorten the remaining period of life. The most difficult cases to decide are those in which the patient requests active intervention to shorten his life; the most objectionable are those in which euthanasia is actively forced on a person who is unwilling to accept it, situations that presumably are completely illegal, at least in the United States.

These various possibilities in the spectrum of euthanasia can be considered more completely by considering the three main perspectives on the subject that are usually encountered.

The practice of medicine is certainly a response to the Christian call to service. When confronted with suffering or disease, the Christian is never at a loss to know whether he should do his best to end the suffering and cure the disease, or whether he should allow God's will to take its course without his medical intervention. There is at the same time a reverence for all life which has its foundation more in monistic pantheism than in biblical Christianity. Pantheistically oriented religions have such a reverence for all life that great care is taken not to step on insects, and cattle needed to sustain human life are allowed to wander unhindered and untouchable for use as food. The biblical perspective recognizes the intrinsic value of all of creation as something fashioned by God for His particular purposes; although biological life is therefore valued, a clear distinction is made between biological life and personal life. The commandment, "You shall not kill," is a commandment against murdering a person, not against all ending of life. Although the Christian never hesitates, therefore, to confront suffering and disease as enemy intruders into God's creation, he also recognizes the need to distinguish between non-personal and personal life.

With its intense (and too often reductionistic) concentration on the biological basis for health, the medical profession finds itself by practice and often by law pressed into a consideration of only biological factors. Given the technological possibility of sustaining biological life, medical staff find little alternative except to apply this technology to its fullest, as long as competition among several patients for its application is not a vital factor in the decision. As medical technology advances, the problem becomes more critical; we may approach the day when we are able, if we choose, to maintain biological life in a majority of cases well beyond the termination of personal life.

Here we face another version of a common question in scientific ethics: because we can do something, does this mean that we should do it-or even that we must do it? the question has two typical responses: (1) at least within limits we should and must as an exercise of our overall responsibility, recognizing that the ability to do it has been given to us by God; and (2) our ability to do something calls for us, as responsible stewards of God's creation, to make responsible choices based on the context of our knowledge -a responsibility that may often call upon us to declare a halt in such applications. Both responses are often offered also by non-Christian investigators, and hence have no unique identification with Christian principles. Somewhat curiously there is a poorly defined correlation of the first position with conservative Christians who normally are most critical of science, and of the second position with liberal Christians who formerly embraced science but recently have themselves become much more critical of technological developments. Some of the former argue that the means to sustain biological life are given to us by God, and that therefore refusal to use them is equivalent to suicide.

Keeping the patient alive by all means possible may also be an expression of personal pride on behalf of the medical staff. It is said that nurses have a byword, "Never have the patient die on your shift." I Professionally, death represents failure; keeping alive by all means is therefore an expression of professional ego, as well as of the factors discussed above. Physicians need a social and legal environment that will encourage them to consider the welfare of the whole person, rather than placing professional and legal stumbling blocks in the way of development in this direction.

There are, of course, legitimate reasons for the medical profession to "go all out" to maintain human life in all cases where terminal disease is not absolutely definite. Trust between physician and patient rests on the assurance that the physician will do everything in his power to preserve and restore the health of his patient. 

The question ultimately arises: who shall decide when the physician should forsake extraordinary and unusual methods to prolong life and failing back on ordinary and usual methods, allow processes to take their course? The decision cannot be the physician's alone, for that would place an unfair burden on him, as well as undermining trust in the patient-physician relationship. If he or she is mentally competent to make such a decision, it would seem that the patient ought to have the prime prerogative in arriving at such a decision; the recently instituted practice of preparing a "Living Will" outlining personal desires before the period of terminal illness and questionable mental competence, is an attempt to make this uniformly possible. Judging mental competence in the absence of a Living Will may itself be no easy matter, and ultimately the decision passes to designated officers of the medical profession and/or society, and to the relatives of the patient.

In order to adopt that approach in which treatment of the patient is controlled by the desire to help him die well, rather than to fruitless efforts to maintain his life, the conclusion must have been reached that the process of dying is really all that the medical profession can anticipate for the patient. This must be accepted as a necessary ultimate stage in every personal existence, and not as a failure of the medical profession. Adopting this position does not mean that the patient must therefore die, as though God's healing activity were somehow discounted as a possibility, but simply that from the perspective of human medicine, no ultimate restoration of health is possible.

The desire to aid in dying well, as opposed to keeping alive by all means possible, changes drastically the types of treatment decided on.

The desire to aid in dying well, as opposed to keeping alive by all means possible, changes drastically the types of treatment decided on. So many of the techniques for prolonging life in the case of terminal illness have the effect of sustaining biological life, but of destroying personal life. Instead of being sustained in a friendly atmosphere surrounded by those whom the patient loves and cares for, the patient is isolated in a sterile hospital room separated from any personal contact except that of busy impersonal technicians, and is subjected to drugs and medical apparatus with its tubes, needles, catheters etc. which reduce the patient to a biological mass incapable of dignity, self-expression or personal relationships.

To help the patient to die well, we must know and respect what the patient wishes. At this crucial stage, the biological and the personal must not be separated. A misguided reverence for biological life that leads us to go to all lengths to preserve it, may actually be involving us in an assault on a person.

This process of helping the patient to die well by respecting his wishes and not necessarily invoking extraordinary measures to sustain life is often called "passive euthanasia." It is called "euthanasia" because specific measures are not used to prolong life; it is called "passive" because specific measures are not used to shorten life. Such a distinction overlooks the fact that when measures are not used to prolong life, this in itself is a measure used to shorten life. Attempts therefore to make a sharp demarcation between "passive" and "active" euthanasia may be inappropriate.

If a terminal condition is diagnosed before the patient has entered into extended technological treatment, his decision not to enter this treatment, or the decision of others on his behalf, is regarded as an example of passive euthanasia within the rights of the patient. If, however, the patient has already been under treatment using extraordinary drug and/or machine involvement at the time when the terminal condition is diagnosed, subsequent "pulling the plug" may be regarded as a case of active euthanasia, with the patient being open to the charge of suicide or those who made the decision on his behalf being open to the charge of homicide. There appears to be no fundamental moral difference between these two types of action, and although the latter will undoubtedly have generally more psychological complications, other reasons for considering it less acceptable than the former seem unfounded. 

Another major gray region between passive and active euthanasia is that involving the giving of drugs to remove or reduce pain in the case of terminal illness, when it is known that the biological effects of the drugs will actively shorten life. Again the distinction between maintaining biological is not claimed that it will always be easy to make. Particularly incongruous would be the refusal to grant use of a pain-relieving drug because it was addictive. If care for the person as a whole, i.e., relieving severe pain and permitting personal experience, can be promoted by the use of a drug which has life-shortening properties, there should be no moral sanctions against it if chosen by the patient.

Deliberately Acting to End Life (Active Euthanasia)  

The third major choice in the euthanasia spectrum is that of deliberately acting to end life in the case of a terminal ill ness, whether that act be a self-inflicted gunshot or over dose of sleeping pills, or an injection of poison by a person other than the patient at the patient's request. 

A misguided reverence for biological life that leads us to go to all lengths to preserve it, may actually be involving us in an assault on a person.

 Although all would cry out in repulsion against any schemes by which terminally ill patients were deliberately
  put to death against their will in order to save society the trouble and expense of caring for them, is it totally ap propriate to level similar charges of homicide or murder against the friend who cooperates with a dying patient to provide him with the means of ending his life, or even ac cedes to the pleas of his dying friend to act so as to end his life? While staunchly defending the sacredness of human life and opposing steadfastly in the general case any attempt to violate it, is there no room for understanding com passion and forgiveness for the man who cannot bear to see his wife suffer and who agrees with her on her plea to help her die well? Given such extraordinary conditions, is it truly morally superior to do nothing and permit the dying person life and sustaining personal life is a crucial one, although it to be tortured?  

Summary

The difficult questions surrounding issues related to the ending of human life again emphasize the significance of  distinguishing between simple biological life and authentic human personal life. The Christian concern must be with the whole person, aiding that whole person to a full measure of biological and personal health insofar as this is possible, but recognizing the value of care for the person even when the possibility of cure for the biological system  is no longer possible.

 To truly participate in euthanasia, i.e., helping the in dividual to die well, requires a basic concern for the desires and welfare of the person involved. It requires also, of course, an ultimate concern for the relationship of that person and God, and does not lose sight of the will of God, who is Creator, Sustainer and Redeemer. These joint con cerns focus on the best way to enable the individual to en dure the physical and psychological pains of a terminal ill ness without violating his or her conscience or basic religious commitments.

It is perhaps beyond the scope of human efforts, however, to set forth guidelines so complete and inflexible that they prescribe for every case the course of action that is appropriate for a Christian. Just as abortion may be but indeed need not be. As in the case of abortion, perceptive judgment may be made in at least some cases without examining the details of the cases themselves.

REFERENCES

¹James B. Nelson, Human Medicine, Augsburg (1973)

²Raymond A. Moody, Jr., Life After Life, Stackpole (1976)