Physician Assisted Dying

The debate about physician assisted dying has been given added impetus with the recent trial in the High Court regarding Lecretia Seales.  Those who are seeking a change in the law wish that no prosecution would follow if a terminally ill person had reached a clear, voluntary, settled, and informed decision to end their life and the assisting physician was motivated wholly by compassion.

There are a number of Christian denominations[i] that support passive euthanasia, namely the withdrawal or withholding of medical treatment for the terminally ill when warranted.  Passive euthanasia is legal in New Zealand.  Active and passive euthanasia though in a hospital setting are sometimes not as easily separated in practice as it is in theory.

While Christian leadership is generally opposed to physician assisted dying there are some important exceptions.  These include the renowned Roman Catholic theologian Hans Kung, the former Anglican Archbishop Desmond Tutu,[ii] and the former Archbishop of Canterbury George Carey.  A UK poll (2015) showed 62% of religious adherents supported physician assisted dying.

The problem of having to endure a painful end to one’s life has long been recognized.  What is different today is that firstly, due to medical advances, people are able to be kept alive longer – usually, but not always, in a way that is beneficial to them.  There is a fear of being powerless in a system often seemingly driven by a cult of medicalisation.  As Hans Kung says, “Medicine can deny a patient a humane death.”[iii]

Secondly, there has been significant growth in the belief in personal autonomy and the right to make decisions affecting oneself.  Today, for example, in NZ an individual usually chooses one’s marriage partner and career path (both of which were predetermined in times past).  Should not the person most directly affected have the biggest say?

Personal responsibility and freedom of conscience is also fundamental to religious thinking.  It is part of the Christian doctrine of Imago Dei.  That doctrine asserts that human reasoning, autonomy, compassion, and responsibility are reflective of the essence of God, and should be encouraged.  It also asserts that every person has an innate God-given dignity and should be treated with respect.  Therefore it can be argued that assisted dying is justified as part of the difficult responsibility of using our reasoning and compassion.

This doctrine needs to be considered alongside that of the sovereignty of God – namely that life is a gift given by a deity who is sovereign over life and death.  However the metaphor of a sovereign God – like a feudal king determining the beginning and end of a life – needs to be reconsidered.  Our living conditions, our climate, our medical history and genes, and our culinary choices significantly determine whether we live and die.  As does medical technology and drugs.

The well-known verse from Ecclesiastes 3:2, “There is a time to be born and a time to die,” does not specify who does the choosing.  In previous eras it was assumed both were pre-ordained by God, but humans have in the last century acted in lieu of God at both ends – e.g. conception via test-tubes, and prolonging death by heart transplants.

Other Christians, while affirming life as a gift, would re-frame God as primarily ‘love’ rather than ‘sovereign’.  The love called God therefore would be the backdrop and potential inspiration for living; and in this way would be a/the source of meaningful life.  God as the giver of life is understood therefore not in a literal way as the instigator of every conception, or the taker of life in tsunamis and wars.

As part of these notions of God as source or sovereign is the guiding principle of the sanctity of life.  It has encouraged Christians to care and intervene in situations beyond moral and political borders, for example in opposing infanticide, capital punishment, and war.  It has encouraged great and noble feats of caring for the vulnerable.  It has inspired the Human Rights movement.  It has inspired scientists to seek ways to make life better, to find new treatments, and new medicines.

However belief in the sanctity of life does not mean believing in the sanctity of suffering, or disregarding steps to avoid it.  If a terminally ill person does not wish to live out his/her last few months in pain, for what purpose should they be forced to do so, and in whose interests?  When does doing no harm[iv] to a patient become hindered dying?  Prolonging life may be causing harm.

There are those who argue that suffering is religiously beneficial to prove character or teach humility, or to encourage others to care for the ill.  But, as Rabbi Romain says, “it is a cruel God who uses human agony as a divine blackboard for relatives looking on.”[v]

There are those too who argue that modern pain control has eradicated undue suffering. Palliative care is of great importance in terminal illness, but it is not the universal panacea that some claim it to be.  Drs Munglani and Bhaskar for example, eminent UK consultants in pain medicine conclude that “some pain is unresponsive to the most powerful analgesics.”[vi]

The rebuttal that such patients should be maintained in a permanently sedated state is ethically unsustainable.[vii]  Dr Atul Gawande, who was at the recent Auckland Readers and Writers Festival, draws the more sustainable conclusion that it is “heartless not to offer people in unbearable suffering the opportunity to end their lives.”[viii]

Alongside guiding principles of personal autonomy and responsibility, and the gift and sacredness of life, is therefore the principle of compassion.  The Bible, like other great sacred scriptures, is clear on the importance of compassion – as both a practice and a guide.  It is belief in a God who is indiscriminately compassionate that informed the Christian belief in the sacredness of all life.

WWJD?  [What would Jesus do?]  He asked people to make choices.  He saw choices as set within a common good.  He understood the dynamics of power, political as well as religious, in determining outcomes.  He understood that the vulnerable are usually the recipients of outcomes determined by the powerful.  He acted with compassion.

What then is the most compassionate thing to do?  Is the principle of supporting a person in extreme adversity to live, contrary to the principle of supporting a person in extreme pain (that can’t be relieved) in their choice to die?  Is it not possible to affirm both? Is facilitating a good dying, in addition to a good living, part of the practice of compassion?

For those who try to argue either way from biblical verses there is a significant lack of resources.  Simply this issue, as we know it today, did not exist in biblical times.  Yes, there are examples of biblical characters not being morally sanctioned for committing suicide, but they are all of individuals facing a traumatic future rather than being terminally ill.[ix]

The Hospice Association in Oregon opposed that state’s assisted dying legislation [1997].  Interestingly, in the 8 years since it was enacted hospice has changed its mind.  ‘Absolutely none’ of their ‘dire predictions’ had been realised.  Instead they had experienced a massive expansion of palliative care.[x]  There has been no change in the commitment to improvement in medical geriatric services.

Oregon’s experience is also that only 1 in 25 who makes a formal request will actually use a prescription.  In other words there is comfort for the dying in knowing the option is there if needed.

Theology tries to affirm both resistance to death as an enemy and acceptance of death as a friend.  It affirms the sacredness of life, human freedom, and compassion.  It is therefore theologically defensible that where a terminally ill person is suffering from unmanageable and constant pain, and has made a clear, voluntary, settled, and informed decision to die, that a lethal dose may be prescribed or administered by a person legally mandated to do so.

That said there are a number of stringent safeguards needed, including robust legal review processes, to protect the vulnerable – including those who are disabled, feeling coerced, suffering from depression, the chronically ill, or the confused.  There is also the need to consider the role of medical practitioners.  The legislation being considered in the UK for example understands physician assisted dying to refer to the provision of a lethal dose not the administration of it. [xi]

While these concerns are significant, and need very careful consideration and monitoring, they are not insurmountable.  Assisted dying is currently permitted in 10 European and North American jurisdictions.  It is important to learn from and assess these.  We need to find ways for the dying to exercise their personal sense of dignity, ‘at a time when for many, nothing dignified is happening’.[xii]  As Archbishop Carey says, “The intention is not to kill but to assist those whose personal request is to end their lives on their own terms, with tenderness and love.”[xiii]

 

[i] http://www.deathwithdignity.org/historyfacts/religion

[ii] http://www.theguardian.com/commentisfree/2014/jul/12/desmond-tutu-in-fav…

[iii] Rosie Harper ‘Hans Kung’s Theses on Dignified Dying’ in Modern Believing Issue 56, Vol 2, 2015, p.124.

[iv] ‘Keep from harm’ is a quote from the Hippocratic Oath.

[v] Jonathan Romain ‘A Jewish View of Assisted Dying’ in Modern Believing Issue 56, Vol 2, 2015, p.106.

[vi] Rajesh Munglani & Arun Bhaskar ‘Pain and Suffering in Cancer Patients’ in Modern Believing Issue 56, Vol 2, 2015, p.159.  Note the extensive medical bibliography at the conclusion of this article.

[vii] Professor Biggar Aiming to Kill: the ethics of suicide and euthanasia (2004) writes, “there is no such thing as pain that cannot be relieved in so far as permanent sedation can always be used as a last resort.”

[viii] A. Gawande, Being Mortal, Aging, Illness, and What Matters in the End London: Profile Books, 2014.

[ix] Samson (Judges 16:20), Saul (I Samuel 31:4), Achitophel (II Samuel 17:23) and Abimelech (Judges 9:54).

[x] This quotation is from a talk on ‘The reality of assisted dying in Oregon’ by Ann Jackson, Chief Executive of the Oregon Hospice Association 19/4/2006 in the UK House of Lords, Committee Room 4b.

[xi] This is the case in the five US states where physician assisted dying is legal, too.

[xii] A quote from Dr Philip Culbertson.

[xiii] George Carey ‘Reassessing Assisted Dying: A personal statement’ in Modern Believing Issue 56, Vol 2, 2015, p.119.