How does a Christian worldview, especially the Christian doctrine of Christ’s death and resurrection, give new meaning to death?

How does a Christian worldview, especially the Christian doctrine of Christ’s death and resurrection, give new meaning to death?

If we ask about religion in America, you can see the conclusion which I must draw. The God whom Americans worship as the final and absolute reality is the power of death. Here I do not use the term god to designate the divinity revealed in Jesus Christ. I use the word in a more open way, to name what a people believe to be the final, the ultimate reality which controls their lives. Many Americans (notwithstanding their dedicated commitments to the ethics of success and resistance) still believe that death is the ultimate reality that will finally and permanently determine their existence. (McGill, 1987, p. 18)

When the perishable puts on the imperishable, and the mortal puts on immortality, then shall come to pass the saying that is written: “Death is swallowed up in victory.” “Oh death, where is your victory? O death, where is your sting?” The sting of death is sin, and the power of sin is the law. But thanks be to God, who gives us the victory through our Lord Jesus Christ. (1 Corinthians 14:54–57, English Standard Version)

Essential Questions

How does a Christian worldview, especially the Christian doctrine of Christ’s death and resurrection, give new meaning to death? What affect does this have on health care?

What is the difference between cardiopulmonary, whole-brain, and higher brain criteria of death? What worldview assumptions inform the definitions behind each of these criteria for death? What are the clinical tests used to confirm the criteria for whole-brain death?

What should the Christian response be to euthanasia, physician-assisted suicide, and withholding and withdrawing life-supportive therapy?

That are the stages of grief, and how can knowledge of these stages assist a health care professional in counseling the dying and their families?

What does it mean to die well according to a Christian worldview?

Introduction

The subject of death and dying can be an emotional and distressing topic, especially for health care workers who witness daily the existence of human mortality, trained as they are to use every means that medical science can offer to push back against this inevitable and unavoidable constraint of earthly existence. In this chapter, five aspects of death and dying will be presented. First, the Christian biblical worldview perspective of the meaning of death and dying will be reviewed. Death is not merely a physical phenomenon but has meaning in all cultures and religions that transcends the merely biological. For the Christian believer, death is given its ultimate meaning in terms of Christ’s own suffering, death, and resurrection.

Next, the definition of death will be addressed. While death may seem like an obvious concept, especially for the general public, defining death in an era of advanced life-support technologies and vital-organ-transplantation surgery can be problematic and raises a host of ethical questions. Third, ethical issues at the end-of-life, such as euthanasia, physician-assisted suicide (PAS), and withdrawing or withholding life-supporting therapy will be examined from a Christian worldview. Fourth, the stages of grieving as outlined in Kübler-Ross’s (2014) book, On Death and Dying, will be presented as an aid for health care workers to understand, evaluate, and counsel grieving patients, their families, and loved ones when facing impending death and separation. The final section will explore how a Christian’s hope in the resurrection provides a context for learning to die well and prepare for the final chapter of one’s life with meaning and purpose.

Worldview and the Meaning of Death

Despite the great strides to alleviate pain and prolong life in even the most serious of illnesses, the death of the body remains one of the central, universal, and inevitable outcomes of life. “It is appointed for men to die once” (Hebrews 9:27, English Standard Version). From a purely biological and worldview, death is essentially reduced to nothing more than organic life returning to an inorganic state. As Sigmund Freud (1961) said, “Everything living dies…becomes inorganic once again” (p. 32). Even the concept of personhood, when assimilated into this materialistic paradigm, is merely an expressive part of this living organism that does not survive the death of that organism. Seneca (trans. 1900), a first century Roman stoic philosopher expressed this nihilistic view of death and human mortality in his treatise Of Consolation, To Marcia:

Death is a release from and an end of all pains: beyond it our sufferings cannot extend: it restores us to the peaceful rest in which we lay before we were born. If anyone pities the dead, he ought also to pity those who have not been born. Death is neither a good nor a bad thing, for that alone which is something can be a good or a bad thing: but that which is nothing, and reduces all things to nothing, does not hand us over to either fortune, because good and bad require some material to work upon. Fortune cannot take ahold of that which Nature has let go, nor can a man be unhappy if he is nothing (p. 9.5).

This ultimately pessimistic, if not cynical, view of death remains a part of much of modern rationalistic and materialistic culture and contributes directly to contemporary and seemingly conflicting attitudes toward death, including denial, fear and foreboding, helplessness and hopelessness, heroic acquiescence, and ultimately, attempts to autonomously master and control the timing and means of the end of one’s own existence (Smith, Harvath, Goy, & Ganzini, 2015).

This meaninglessness of death can be a source of anxiety about the value, meaning, and purpose of life itself. Science and reason can reveal only so much of general physical truths, but they cannot provide or become a source of value, meaning, or purpose. Everyone rightly values their individual existence, freedom, and ability to make rational choices in their daily lives. But in a seemingly meaningless and irrational universe, how can one do so unless one defines or creates his or her own meaning and values in life? This outlook on life, that one must create one’s own meaning and value in a meaningless and valueless world, has become very influential in modern culture and secular ethics, especially medical ethics. It is easy to see how autonomy then becomes the central and controlling value for an individual and in ethical decision-making. By contrast, the Christian worldview recognizes the truth of a transcendent source of value, meaning, and purpose in life and death.

This nothingness of death, which is the logical conclusion of many who hold to a naturalist or physicalist worldview, is not affirmed by most human cultures and societies throughout history. Death has always had meaning that transcended the merely biological, even while being coexistent with the biological. Beliefs in an individual essence or soul that survives the death of the individual organism or body in some form persists across all cultures, from the most primitive of peoples to the most sophisticated of religions. Any full concept of the meaning of human death must include both the physical and scientific perspective coupled with a philosophical or religious understanding. In other words, death is given its fullest meaning only through a consistent worldview lens. Differing worldviews on the meaning of death and, consequently, life itself are the root case for many of the current ethical debates surrounding death, including issues such as abortion, capital punishment, euthanasia, and organ transplantation.

In a pluralistic culture, the existence of differing worldviews can often result in simultaneous and sometimes contradictory attitudes toward death. There can be both a defensive denial of death, and at the same time a desire to master it or at least control its disrupting effects on social life (Parsons, 1971; Lidz, 1995). Consider how different worldview attitudes toward death, including both denial and mastery, are reflected in many of the attitudes and practices of modern culture, many of which are good and certainly worth pursuing, such as restricting cigarette smoking in public, health food, physical fitness, firearm control, and environmental movements.

The never-ending quest for eternal youth and avoidance of signs of aging (e.g., the proliferation of beauty aids and treatments for baldness and impotence) may reflect a type of pushback to the signs of an impending and imminent dying process. Institutions, such as public health services, insurance, and estate and retirement planning are designed to deal with and manage the practical aspects of death. Funeral and mourning customs designed to support the survivors of loved ones in overcoming grief and guilt, can be viewed as attempts to mitigate the social effects of death by returning them to normal participation in society as soon as possible. This is not to disparage any of these practices, only to point out how a culture’s worldviews on the meaning, or meaninglessness, of death is reflected in many day-to-day practices.

Death is both unavoidable and, in many ways, uncontrollable. To deny one’s own mortality does not make it less of a reality. Attempting to control the uncontrollable is illusory and ultimately self-deceiving. Medicine, when viewed solely as a project aimed toward controlling life and defeating death, can become complicit in this denial of one’s own mortality and desire to be in control of the uncontrollable. According to Shuman and Volck (2006), the project by which the medical industry has become the chief mediator over the power of death is in many respects a religious one. By religious, they do not mean something akin to belonging to an organized church or religious group, but rather pertaining to those objects of affection around which people’s lives are centered.

According to Lash (1996), by this definition, everyone is religious because all “have their hearts set somewhere, hold something sacred, worship at some shrine” (p. 21). Although the human heart rarely settles on a single object, modern culture’s objects of devotion certainly include “beliefs and practices protective of…things we are too terrified to mention, or of instincts, prejudices and convictions lying at the very heart of who and how we take ourselves and other things to be” (Lash, 1996, p. 20). In today’s materialistic culture, this would certainly include the care, comfort, and longevity of one’s body. Death, as a foreigner and a stranger to life, holds great power over the human condition. Pain, suffering, grief, and physical death become the ultimate powers over us that must be conquered through an almost religious devotion to scientific medicine and the priesthood of the medical and health care profession. Much of the ethics of modern health care centers on defeating the powers of things such as pain, suffering, grief, and ultimately death itself as the highest good. According to Shuman and Volck (2006), health care professionals in our modern culture represent godlike power:

This is not because these people think of themselves more highly than they ought, but because of the social significance we give to the power they represent. This is how the fallen powers function; they cooperate with the disordered appetites of those who use and depend upon them, allowing us to see them not as God’s instruments, but as gods, period. To a significant extent, they are successful because they promise to deliver us (while God appears unwilling or incapable) from the evil of certain contingencies. (p. 38)

According to many secular worldviews, health, or at least the pursuit to be free from all pain, suffering, grief, and ultimately death, becomes the highest good and the ultimate goal that determines one’s values, priorities, and ethics.

In contrast, the Christian worldview does not leave one alone in a meaningless, valueless, and purposeless universe to create meaning, value, and purpose in life and death simply out of thin air. Rather, it looks to Jesus as both the author of life (Acts 3:15) and conqueror of death (2 Timothy 1:10) to find the true meaning, deliverance, and hope in the face of the present human condition. Ultimately, Christian believers do not live with an illusion of autonomy in a meaningless world, but rather live with the comfort and assurance that they have been “bought with a price” and called to “glorify God” in their bodies (1 Corinthians 6:20). This is what ultimately gives a Christian believer true meaning, value, and purpose.

The Heidelberg Catechism, written almost 500 years ago, remains one of the most cherished explanations of the historic Christian faith. The first question of the catechism is, “What is your only comfort in life and in death?” The answer begins, “That I am not my own, but belong—body and soul, in life and in death—to my faithful Savior Jesus Christ” and continues to affirm that “all things must work together for my salvation. Because I belong to him, Christ, by his Holy Spirit, assures me of eternal life and makes me wholeheartedly willing and ready from now on to live for him.”

To seek relief from pain, suffering, grief, and to aid the dying in this fallen world are good and wonderful things to be pursued, as they reflect God’s own love, care, and mercy for his creation. Christians, in particular, are called to pursue these things to the best of their ability as part of the good and gracious gifts of God’s goodness in creation. But these things are not the highest good to be pursued. According to the Bible, the highest good is to love and serve God. All earthly goods are subordinate to and are to be used to glorify and serve God. Even the real, but subordinate goods of medicine and medical technologies, after the fall, are tainted by sin and in need of redemption, that is to serve God in the ways God intended. According to Mohrman (1995), a physician and theologian,

Health can never be anything other than a secondary good. God is our absolute good; health is an instrumental, subordinate good, important only insofar as it enables us to be the joyful, whole persons God has created us to be and to perform the service to our neighbors that God calls us to perform. Any pursuit of health that subverts either of these obligations of joy and loving service is the pursuit of a false god. Health is to be sought in and for God, not instead of God. (pp. 15–16)

A Christian believer understands that God cares for all humanity as part of his good creation, and they need not be anxious or fearful in health, sickness, or death as long as they seek first to serve God (Matthew 6:25–33). The biblical perspective on suffering, death, and hope in an eternal resurrected life molds a Christian believer’s outlook on life, gives meaning and value to their trials and ordeals in life, and transforms the way they make decisions about many end-of-life issues.

Biblical Reflections on Death and Dying

Death is not a natural part of life. It is not, as some professionals in different disciplines might suggest, a part of the natural cycle of birth, death, and rebirth as another individual is born to carry on a species. This well-meaning, but mistaken sentiment implies that death is as natural as life—something to be readily accepted and perchance to control as best as possible. According to the Bible, and in contrast to materialistic and naturalist accounts, death, while certainly a present universal reality, is not a “natural” part of God’s original good creation but was a result of human sin and rebellion. It is truly a familiar stranger to this world (Romans 5:12).

Illness, Disease, and Death as an Effect of the Fall

According to the biblical narrative, both spiritual and physical death are ultimately the result of sin. In the opening chapters of the book of Genesis, the origins of sin and death are traced to God’s command to Adam and Eve, human beings created in his own image, to not eat of the Tree of the Knowledge of Good and Evil, for “in the day that you eat of it you shall surely die” (Genesis 2:17). This was not an arbitrary command and punishment by a capricious God, but a condition and outward expression of love and faithful obedience. The gracious reward for this faithful obedience was eternal life and the punishment for disobedience was eternal death. This covenant, or agreement and promise, that God established with Adam and Eve can never be broken. God is faithful to his promises even if fallen men and woman are not (Deuteronomy 7:9; 2 Timothy 2:13). God’s promises are a sure thing.

Physical death is certainly meant here, but not exclusively. Adam and Eve did not physically die immediately upon disobeying God by eating from the Tree, but much later. The death that immediately overcame them was of a spiritual nature, a separation and breaking of Shalom with God through their disobedience, even as their physical death would be a future certainty. Death, while indeed physical, has a religious and ethical significance, in which the life, in its broadest context, both spiritual and physical, of all human beings is dependent on faithful obedience to their Creator. Both physical death and spiritual death are the penalty and consequence of sin and the universal lot of all mankind because all have sinned (Genesis 2:17; Ezekiel 18:4, 20; Romans 5:12; 6:23; 7:13; Ephesians 2:1,5).

This religious and ethical nature of death is not only clearly expressed in the opening narrative of Genesis, but also is the fundamental and underlying theme of the whole of the Christian Bible and a central theme of the biblical message of salvation. Death, in its broadest context, is the humanity’s separation from their Creator as the source of both physical and spiritual life, with sin being the cause of this separation. The Bible is not as concerned with the physical and scientific contrast between life and death, although it does include this, as it is with the moral and spiritual difference between those who are spiritually alive by way of their fear of the Lord and those who are spiritually dead in their sin. Just as physical death is to be unresponsive and alienated from the realm of the living, spiritual death is to be alienated from God, resulting in a lack of responsiveness to the living God and even hostility to God. Because of the dual nature of human beings as body and spirit, the physical and spiritual concepts of life and death are intimately interwoven in this same duality.

As outlined in Chapter 3, the fall has universal and even cosmic implications (Genesis 3:17–19; Romans 8:19–21). Not only physical death, but pain, suffering, and illness are all effects of the fall and not part of God’s original design. Sin results in consequences that affect the mind, body, and spirit of each human being. While certain illnesses and suffering are direct consequences of one’s choices, such as physical effects and illness caused by lack of exercise, excessive alcohol and/or illicit drug use, and smoking, the Bible does not link individual sins directly to specific illnesses or diseases (John 9:1–3). This is not inconsistent with the biblical concept that all suffering, pain, and illness in this present post-fall world, including death, is a general punishment for and has its ultimate origins in sin. Sinfulness is the general condition of all mankind; all are guilty before God. All men and women are sinners by nature and by their own acts of rebellion against their Creator God. Sickness, pain, suffering, and ultimately death are all the result of this rebellious and sinful nature.

The Death and Resurrection of Jesus Christ

The life, death, and resurrection of Jesus is the central event of the biblical narrative. It is the culmination of the Old Testament covenants, promises, and prophecies and the foundation of the gospel, or good news, that is proclaimed in the New Testament. The event of God taking on flesh and dwelling among us, the incarnation, is proclaimed clearly throughout the New Testament (Luke 1:35; Philippians 2:5–7). This was God’s own answer to the dilemma and tragedy of sin in the world. Because God is both holy and just, he cannot simply overlook sin, allow sinful beings in his presence, or accept them into his holy kingdom. Sin must be punished, and justice upheld. But God is also loving and merciful.

Beginning immediately after the sin in the Garden of Eden, God promised to send a savior, a messiah, to break the hold that sin had on the world and to redeem a people for himself (Titus 2:11–14). A sacrificial lamb was needed, a substitute that would take on the guilt and punishment of sin that mankind deserved and atone for the sins of the world. This substitute needed to be perfect and blameless, not deserving of the guilt and punishment that he would voluntarily bear for the sake of God’s beloved people. Because “all have sinned and fall short” of God’s holy law (Romans 3:23), this substitute needed to be God himself, taking on human nature. This is the mystery of the incarnation: The God-man Jesus Christ. Christ, a title Christians use to refer to Jesus, comes from a Greek translation of the Hebrew word for messiah, which means “the anointed one,” and refers to the one who was promised throughout the Old Testament to come and redeem God’s people. Jesus the Christ is the only perfect and sinless Lamb of God sufficient to atone for the sins of all mankind. Probably the clearest statement of the atonement is found in the Old Testament prophecy of Isaiah:

But he was pierced for our transgressions; he was crushed for our iniquities; upon him was the chastisement that brought us peace, and with his wounds we are healed. All we like sheep have gone astray; we have turned—everyone—to his own way; and the Lord has laid on him the iniquity of us all…he was cut off out of the land of the living…Yet is was the will of the Lord to crush him; he has put him to grief; when his soul makes an offering for guilt. (Isaiah 53:5–10)

Jesus Christ, the innocent and blameless Son of God, took upon himself the sins of the world when he was unjustly executed on a Roman cross, a cruel and torturous experience that was prophesied almost a millennium earlier by Israel’s King David in Psalm 22. This would have been simply another meaningless execution if it were not for Jesus’s subsequent resurrection from the dead that witnessed to the sufficiency of his sacrifice and his power over sin and death (1 Corinthians 15:14). That Jesus’s death indeed paid the full penalty for the guilt of his people’s sins, for all those who put their trust in him, is attested by the resurrection. The prophet Isaiah goes on to say that Jesus, the Messiah, will “see his offspring; he shall prolong his days; the will of the Lord shall prosper in his hand” and “make many to be accounted righteous, and he shall bear their iniquities” (Isaiah 53:10–11).

Jesus’s death and resurrection from the dead made a way of salvation, putting an end to the guilt and punishment for sin every human being deserves, and ending the estrangement and separation that sin brought between God and mankind. Because of this, death itself becomes a conquered enemy for all those who have also died in Christ. The phrase in Christ is used frequently in the New Testament when referring to those who have placed their “hope in Christ” (Ephesians 1:12), making Christ the object of their faith. Good works or living a good life cannot bring about a right relationship with God, as is the case in virtually every other religion. The way to God is not, as believed by so many other religions, about living in a certain way, praying certain prayers, or following certain rituals or customs. Sin is too much an indelible part of human nature and a part of everyone’s life. No one can be good enough. The good news that Jesus brings is not merely good advice on what needs to be done, but an announcement that by trusting in what he has already accomplished, fully and completely, one can obtain salvation, peace with God, and share in his resurrected life. The Apostle Paul succinctly and clearly summarizes this message when he says that, “by grace [God’s unconditional love and undeserved mercy] you have been saved through faith. And this is not your own doing; it is the gift of God, not a result of works” (Ephesians 2:8–10).

Death as a Conquered Enemy

How is death considered in the Bible to be a conquered enemy when, in fact, all men and women, Christians included, eventually die? The answer lies in what was said at the beginning of this section regarding the connection between spiritual death, physical death, and sin. The Bible, especially the New Testament, does not reflect on death as a purely biological phenomenon, nor is this the central concern. Living under the guilt of sin, which separates one from the God who is the source of life, is living in death. Death is a power that dominates the life of a sinner and to that extent is talked about in the Bible as a present reality. As the Apostle Paul says, “The sting of death is sin, and the power of sin is the law” (1 Corinthians 15:56). “‘Spiritual’ death and ‘physical’ death, inextricably bound up together, constitute the reality of a life in sin” (Schmithals, 1980, p. 436). To reiterate, both spiritual death and physical death are the consequences and penalty for sin and are the universal lot of all mankind because all have sinned.

Those, however, who live in Christ, meaning those who place their hope in the finished work of Christ and not their own good works, can experience the present reality and certainty of eternal life and communion with God. This allows the Apostle Paul to exclaim in a joyous rhetorical outburst, “Oh death, where is your victory? O death, where is your sting?” (1 Corinthians 15:55). Physical and biological death remains, even for those in Christ through faith. But the meaning and significance of physical suffering, pain, and biological death now takes on new meaning, new significance, and new consequences within this new life (Romans 6:4) in Christ. Through faith, believers are mysteriously united with Jesus in both his sufferings and death, as he assumes the believer’s sin and guilt in his own death, and in his resurrection (Romans 6:4, 2 Corinthians 4:14). Death is no longer a punishment for sin, but a means whereby believers put off a perishable, mortal flesh and put on an imperishable, eternal, and spiritual body at the resurrection.

Eternal life is a present reality that Jesus explains, “Truly, truly, I say to you, whoever hears my word and believes him who sent me has eternal life. He does not come into judgment, but has passed from death to life” (John 5:24); however, this present eternal spiritual life still awaits a future redemption of the body—a new spiritual body. This is the already and not yet tension of faith that is present in the biblical view of salvation.

The Gospel of John in the New Testament records several miracles Jesus performed that display his power over nature, sin, and sickness. The climax of these miracles is Jesus’s demonstration of his total victory over death in his raising of Lazarus from the dead (John 11:1–46). Jesus announces to those who witnessed the event, “I am the resurrection, and the life. Whoever believes in me, though he die, yet shall he live” (John 11:25). James Montgomery Boice (1985), in his commentary on John, explains the significance of this miracle and Jesus’s claim:

The miracle shows that Jesus is the source of eternal life, that it may be enjoyed here and now, and that the same power which assures it now will also, after the death of the body, raise the dead to a new and better existence beyond. (p. 353)

John’s Gospel points to the raising of Lazarus as a sign that proclaimed Jesus’s power over life and death. It was an event that led many who witnessed it and heard about it to put their faith and hope in Jesus.

Future Resurrected Life

Human death is not the complete annihilation of the person leading to nothingness. According to the Bible, all those who die in Christ will be resurrected and given new spiritual bodies when Jesus Christ returns. A spiritual body, according to the Bible, is not some form of eternal disembodied existence like the popular cartoon view of winged cherubs forever playing harps on a heavenly cloud. This is a form of an ancient Greek philosophy called Gnosticism. Gnosticism teaches that human beings consist of a dualism of soul (i.e., the real person) and body (i.e., the prison of the soul). The goal of Gnosticism is to escape the body through death so that the authentic person can finally be free and live forever. This is not biblical Christianity. As discussed in previous chapters, the Bible speaks of human beings as a duality, or a unity of body and soul (e.g., ensouled bodies or embodied souls).

For those in Christ, physical death is a conquered enemy, and comfort is found in the fact that to be “away from the body” is to be “at home with the Lord” (2 Corinthians 5:8). Nevertheless, the ultimate hope of a Christian believer is not a disembodied spirit existence, but a resurrected bodily life. Biological or physical death of the body does imply a death of this body/soul unity and is not inconsistent with the concept of an intermediate state of the soul between physical death and the resurrection. The Bible does allude to the souls or spirits of the deceased existing after death and before the resurrection (Luke 16:23–25, 28; 2 Peter 2:9). The Bible assures Christian believers that death leads them immediately into the presence of God. But this state of existence is temporary, incomplete, and provisional—a human being is not totally a human being apart from the body (Luke 20:35–38; John 11:25–26; 1 Corinthians 15:52–53; 1 Thessalonians 4:16).

The Bible also distinguishes between living in the flesh and living in the spirit. This is a distinction between a life under the domination of sin and in rebellion from God in which a person trusts in his or her own works, and a life trusting by faith in Jesus and his righteousness. The spiritual resurrected body is not a ghostly disembodied existence, but a renewed bodily creation uncorrupted by sin and its consequences. It is a life that continues to experience relationships with many of the things and people enjoyed during this life, but on a much grander scale. It is not to be less than human, but more. Reflecting on the nature of the resurrection, C. S. Lewis (1996) understood that, “To enter heaven is to become more human than you ever succeeded in being on earth” (pp. 127–128). In his letter to the Corinthian Church, the Apostle Paul stretches the imagination as he attempts to explain the mystery of the resurrection and the nature of the resurrected spiritual body with metaphors drawn from agriculture, comparative anatomy, and even astronomy:

What you sow does not come to life unless it dies. And what you sow is not the body that is to be, but a bare kernel, perhaps of wheat or of some other grain. But God gives it a body as he has chosen, and to each kind of seed its own body.

For not all flesh is the same, but there is one kind for humans, another for animals, another for birds, and another for fish.

There are heavenly bodies and earthly bodies, but the glory of the heavenly is of one kind, and the glory of the earthly is of another. There is one glory of the sun, and another glory of the moon, and another glory of the stars; for star differs from star in glory.

So is it with the resurrection of the dead. What is sown is perishable; what is raised is imperishable. It is sown in dishonor; it is raised in glory. It is sown in weakness; it is raised in power. It is sown a natural body; it is raised a spiritual body. If there is a natural body, there is also a spiritual body. Thus, it is written, “The first man Adam became a living being”; the last Adam became a life-giving spirit.

But it is not the spiritual that is first but the natural, and then the spiritual. The first man was from the earth, a man of dust; the second man is from heaven. As was the man of dust, so also are those who are of the dust, and as is the man of heaven, so also are those who are of heaven. Just as we have borne the image of the man of dust, we shall also bear the image of the man of heaven. I tell you this, brothers: flesh and blood cannot inherit the kingdom of God, nor does the perishable inherit the imperishable.

Behold! I tell you a mystery. We shall not all sleep, but we shall all be changed, in a moment, in the twinkling of an eye, at the last trumpet. For the trumpet will sound, and the dead will be raised imperishable, and we shall be changed. For this perishable body must put on the imperishable, and this mortal body must put on immortality. When the perishable puts on the imperishable, and the mortal puts on immortality, then shall come to pass the saying that is written: “Death is swallowed up in victory.” (1 Corinthians 15:36–55)

A Christian believer’s hope is not in an unrecognizable disembodied existence, nor in an immeasurably long life on a perishable planet with a body constantly fighting against the ravages of illness and disease, the contingencies of nature, and the evils of a culture in rebellion from God. Rather it is a new creation and new life in perfect peace and communion with God, free of pain, suffering, and death.

Human Value and Dignity

A central concept in the ethics of many end-of-life issues is the dignity and value afforded to each and every human being. It has been a fundamental theme of this text that, according to the Christian worldview, every human being is made in the image of God and possesses innate dignity and worth regardless of race, ethnicity, socioeconomic status, stage of development, or mental/physical functional capacity. This dignity and value are given by God and are therefore inviolable.

The term human dignity has become an important and powerful rhetorical instrument that is thrown about carelessly in many of the debates surrounding end-of-life issues such as euthanasia, physician-assisted suicide, and the treatment of individuals in so-called permanent or persistent vegetative state. The term itself is not foundational because it can mean different things to different people depending on how it is used and how it is defined. Because human dignity is not always clearly defined in contemporary medical ethics discussions, it can be used by both sides of many discussions to support different positions. This lack of definition and subsequent confusion contributes to much of the polarization surrounding many bioethics issues. A clear understanding of how this term is defined and used to support varying positions is vital to mapping the contours of many of the current debates on end-of-life issues, especially within a secular culture.

In his 1996 encyclical letter, Evangelium vitae, Pope John Paul II affirmed, explained, and defended the Catholic Church’s pro-life stance against abortion, physician-assisted suicide, and euthanasia. In this pronouncement, he maintained the core belief that “society as a whole must respect, defend, and promote the dignity of every human person, at every moment and in every condition of that person’s life” (John Paul II, 1995, n. 81). During the same decade that Evangelium vitae was published, the Swiss organization Dignitas was established. Dignitas was founded to promote euthanasia and the right of persons to choose the manner and timing of their own death as well as provide individuals with the means to do so. Their motto was “to live with dignity, to die with dignity.”

How can the Catholic Church and the organization Dignitas, both with completely different beliefs and practices, appeal to the same concept of human dignity to support their positions? It is obvious that the term human dignity is being used differently and to represent very different ideas. When John Paul II used the term, he was referring to a specific theological concept, namely, the image of God that all human beings possess. On the other hand, Dignitas’s motto was meant to convey the idea that the rational autonomy of every individual was central to their dignity as a human being. Autonomy, in this case, is understood as individual self-rule, without any controlling interference or limitations.

Autonomy

While the differences can be subtle, it is important to distinguish this use of the term autonomy from what is meant by the principle of respect for patient autonomy as one of the principles of medical ethics. The philosophical term autonomy that is implied in Dignitas’s motto and exhibited in their ethical position is much broader, comprehensive, and absolute than the term autonomy as used by Beauchamp and Childress in their book Principles of Medical Ethics.

On the broader understanding of autonomy presupposed by Dignitas, without the right to self-determination, specifically the ability to control the time and manner of one’s death, one was not truly autonomous and, therefore, deprived of dignity. One author has suggested that Dignitas’s motto should read, “To live with autonomy, to die with autonomy” (Genuis, 2016, p. 8). James Griffin (2002) succinctly summarized this view of dignity when he said that, “autonomy is a major part of rational agency, and rational agency constitutes what philosophers have often called, with unnecessary obscurity, the ‘dignity’ of the person” (p. 131).

Because of the way the term dignity has come to simply mask an appeal to more fundamental concepts such as autonomy without adding any significant content, some contemporary bioethics scholars have referred to the term dignity as “stupid” (Pinker, 2008, p. 28) or as a “useless concept” that “can be eliminated without any loss of content” (Macklin, 2003, pp. 1419–1420). Despite the ambiguities of definition, the problem is not with the term dignity itself. Dignity provides a language for discussion about what makes a human being worthy of honor and respect, a concept that is essential to any discussion of medical ethics. The question is, what it is about human beings that makes them worthy of honor and respect—that which provides for, and is foundational to, their dignity? Is that which makes human beings worthy of honor and respect contingent and relative depending on certain characteristics or is it something that is absolute and inviolable?

According to the Christian narrative, human value and worth is based on the more fundamental concept of being created in the image of God, a concept that has been central to many of the arguments in this text. Human life has incalculable value because it is created, upheld, and sustained in spite of sin, redeemed by God, and is ultimately destined for eternal communion and glory with God.

The Christian tradition also speaks in more theologically grounded terms when it talks about the sanctity of human life rather than dignity. The word sanctity comes from the Latin sanctus, which is usually translated as “holy.” In the Bible, holiness, which can sometimes mean righteousness or perfect goodness, has the deeper connotation of being set apart for a special or sacred use. Human life is sacred because all human beings have been set apart from the rest of creation by their Creator. They have been given special purpose and a special relationship with their Creator. This special sacredness is what makes sin so disruptive and so deserving of God’s judgment. This sacredness, because it is given by God, confers a transcendent or alien dignity that is absolute and inviolable. It is absolute because it does not depend on any arbitrary characteristic that a human being may or may not possess, gain, or lose. It is inviolable because it is not relative or dependent on the changing utilitarian needs of society or the majority.

The Christian concept of the dignity of all human life provides the rationale and guidance for the Christian health care professional’s calling, the call to care for human health. It also forms the underlying justification for the Christian response to many of the ethical controversies surrounding end-of-life issues, including physician-assisted suicide, euthanasia, termination of life support, counseling those who are facing their own death or the death of a loved one, and preparing oneself to die well in Christ. Even the medical definition of death, and the controversies surrounding brain death and organ donation, depend on a view of human worth and dignity dependent on the biblical concept of being created in the image of God.

Death in the 21st Century

Medical Technology and the Shifting Definitions

Before the advent of modern life-support technologies that artificially support ventilation and circulation, death was a relatively simple concept, easily diagnosed by the absence of a beating heart and breathing. It was also a unitary phenomenon. When any single vital-organ system ceased to function (e.g., respiration, circulation, or brain), the other systems quickly stopped as well. The absence of pulse, respiration, and movement were simple and reliable empirical indicators that death had occurred. This classical definition needed to be reevaluated, as the traditional criteria for determining death lost its meaning in an age of advanced cardiopulmonary supportive technologies that can mechanically support some vital functions, such as ventilation and circulation, in the absence of others, such as brain function. The concept of brain death as a fundamental definition of death was derived from the idea that circulation and respiration are vital functions because they ultimately support brain function. Cardiopulmonary definitions of death are valid and sufficient only insofar as they lead inevitably to the irreversible loss of brain function; however, they are not necessary for defining death in the presence of artificially supported respiration and circulation.

The ability to successfully transplant vital organs, such as the heart and lungs, also raises questions about death and when it is appropriate to remove vital organs from a donor. The dead donor rule states that the removal of vital life-sustaining organs should never be from a living patient, which equates with actively contributing to a patient’s death (i.e., active euthanasia or physician-assisted suicide), and has been an important and central requirement of transplantation legality and ethics (Robertson, 1999). While the concept of brain death certainly improved the development and advancement of vital-organ transplantation, this alternative definition and criteria for death developed independently of the developments in transplantation and was not developed solely to benefit transplantation (Machado, Korein, Ferrer, Portela, de la C Garcia, & Manero, 2007).

Despite the philosophical and medical controversies involving the definition of death that are still being raised in the advent of further medical and surgical advances, death should remain a nontechnical term that can be used broadly and correctly by the general public. The definition of death and its timing should not rely on arbitrary social conventions or utility. Death is fundamentally an irreversible biological phenomenon that is an event and not a process (Kass, 1971). “Physicians should be able to determine that death has occurred at some specific time, at least in retrospect, and be able to distinguish a living organism from a dead organism with reasonable reliability” (Bernat, 1998, p. 16), while also recognizing that a precise determination, given the nature of progressive multisystem organ failure in the modern hospital environment, may be technically limited and recognized only in retrospect. The Bible also clearly distinguishes physical life and death. Death is not a process, and there is no transitional physical state of being intermediary between life and death (2 Corinthians 5:8; Philippians 1:23, 24).

Logical Distinctions and Practical Implications

As stated at the beginning of this chapter, the meaning and significance of biological death is determined by broader worldview questions. Even the actual definition of biological death is not a purely medical or scientific question, and advancements in medical technology do not change these fundamental definitions, although they may influence the criteria for this definition and the empirical tests that are available. While this may seem surprising, it is important to recognize the philosophical and theological issues that are raised by any definition of death. One way to do this is to recognize distinctions between a definition of death, the criterion applied to this definition, and the empirical tests that examine and test for the specific criteria. These three aspects must be carefully distinguished and not confused.

Death: Definition, Criteria, and Testing

Many of the ethical and legal problems raised by the medical profession’s seeming inability to adequately define a given point at which death occurs demands an analysis of the conceptual levels of the term death that are involved. Almost anyone can readily tell the difference between a living being and a corpse; however, deciding the exact essence of life, as opposed to death, from a scientific or medical context becomes problematic, especially in the face of modern advances in life-support technology. Life support is sometimes a misnomer, because in many cases life is not being supported. A person can be brain dead while technology artificially supports organ functions. To say life support is only supporting vital signs is also a misnomer in many cases because vital means necessary for life, and in the irreversible absence of whole brain function, things like blood pressure, pulse, and respiration are not contributing to life at this point and by this definition. Words can contribute a great deal to patient and lay person confusion.

An essential concept, or definition, must include a simple and clear formula that is neither too broad or too general for its application. Secondly, the criteria for application are those standards by which one applies the essential concept to an individual situation. Finally, how does one tell if the criteria apply? This involves empirical tests, observational or experimental, that may change as medical science advances.

An example of the application of these conceptual levels is as follows. Suppose one defines death as the loss of personality or consciousness. The essential concept in this case is simply irretrievable cessation of personality or irretrievable loss of consciousness. But what is personality? What is consciousness? One must be able to establish criteria for personality (e.g., the ability to feel, be aware of one’s environment and surroundings, act, reason). How is this tested? What kind of experiments or observations are necessary to assess the presence of personality or consciousness in an individual? Consciousness itself is particularly problematic because every empirical test currently known can only test for the outward effects of or expression of consciousness, not individual consciousness itself.

On the other hand, suppose one defines death as the loss of any essential function of the biological organism. To provide criteria for application, one must first define what is meant by essential functions. Typically, this has been defined as an irreversible, by any known technique, cessation of respiration, circulation, and any central neural function. Finally, one must apply the empirical tests to assess if respiration has indeed stopped: circulation is gone and reflexes are absent. From this framework, one can understand that the Harvard Ad Hoc Committee proposal drafted in the 1970s was not a definition of death, nor was it strictly a criterion for death, rather, it speaks of irreversible coma. The Harvard Committee’s proposal is merely a list of empirical tests for determination of an implied criteria to which there is no definition (Report of the Ad Hoc Committee, 1968).

It is important to understand that science can only provide us with adequate empirical tests for established criteria, and these will change as science advances. Criteria are based on both philosophical and scientific concepts. Because there is both a scientific as well as philosophical aspect, criteria are also subject to change as the science advances; however, a definition of death is a purely philosophical concept. When science purports to provide a definition of death, it becomes scientism. The criteria and the empirical clinical tests for those criteria for different definitions of death discussed in the following section are summarized in Table 4.1.

Table 4.1

Definitions, Criteria, and Clinical Tests for Death

Whole Brain Criteria of Death

Death can and should be defined from a purely biological perspective. This statement does not contradict what was said before but is derived from a philosophical and theological view of what it means to be a human being. This view acknowledges that a human being is a single entity consisting of both a material body and an immaterial soul. It is a duality of body and soul together and not two separate parts. Hence the biological death of the organism, the material body, is sufficient to mark the death of the whole human being. Louis Berkhof (2011), a Christian theologian, describes this complex twofold unity of human beings:

Every act of man is seen as an act of the whole man. It is not the soul but man that sins; it is not the body but man that dies; and it is not merely the soul, but man, body and soul, that is redeemed by Christ. (p. 192)

Together the physical and spiritual aspects of human beings bear the single image of God and constitute the single essential nature of human life. So, the question remains: What is the biological definition of organismic death?

To define death as merely the cessation of life is tautologous (i.e., saying the same thing with no added meaning). Defining death as the soul leaving the body, as expressed in some popular religious expressions, is unhelpful because it does not permit any measurable criterion, is not consistent with the body-soul unity of human beings, and, even if it did, cannot provide a useful and measurable criterion for death. To the lay person, death is simply when a person takes his or her last breath or when their heartbeat has permanently stopped; however, this is not a definition of death, but a recognition of when death has occurred. Neither can death be defined more technically as the cessation of all physiological functions of the body. It is well known that certain tissue groups, such as hair and nails, continue to grow for days after a person has died. Certain cells can be removed from a dead organism and kept alive in tissue cultures for decades.

The answer to what defines the death of an organism is contained in the word organism. Death is the permanent cessation of the function of the “organism as a whole” (Bernat, 1998, p. 17). Organism as a whole does not mean the whole organism or the sum of its individual parts, but rather it refers to those functions of integration and control that contribute to the unity of the organism (i.e., the critical organizing functions) (Bernat, 1999; Condic & Condic, 2005). Death can then be defined as that point in time when there is permanent and irreversible cessation of the critical functions of the organism as a whole. These functions include:

the vital functions of the spontaneous breathing and autonomic control of the circulation,

the integrating functions that assure homeostasis of the organism, and

consciousness.

This definition of death has the advantage of being unambiguous and can be applied to other higher animals. It also accords with a natural understanding of what it means to be dead across most cultures. The whole brain criteria, except for a minority of Roman Catholic and Orthodox Jewish positions, is compatible with the belief systems of the three major Western religions, Christianity, Islam, and Judaism (Veith et al., 1977). The Christian Medical and Dental Associations accept the brain death definition as the “Christian View of Physical Death” in their official position statements (Christian Medical and Dental Associations, 2018).

With this definition in mind, the most appropriate criterion for its application is the irreversible cessation of the clinical functions of the entire brain. The word clinical is important because it distinguishes systemic integrated functioning from mere physiologic activity (President’s Commission, 1981). It also refers to those functions that can be easily observed and measured by bedside physical examination. This criterion does not mean that every single neuron of the brain must be dead in the same way that the death of every single myocardial cell is not required for the determination of circulatory death. All that is required is irreversible global neuronal death sufficient to end the critical functioning of the organism as a whole. The presence of residual spontaneous electroencephalogram (EEG) signals, which can represent the isolated, purposeless, and random activity of a few surviving neurons, does not indicate systematic integrative functioning of the brain as a whole and should not be a sole indicator that a patient is not brain dead.

Permanent cessation of the whole brain includes the brain hemispheres, diencephalon, and brain stem. These three parts of the brain are vital for controlling respiration and circulation (brain stem), the critical integration of bodily functions (brain stem and hypothalamus), and consciousness (the wakefulness component of consciousness is provided by the brain stem and the awareness component of consciousness is provided by the thalamus and cerebral cortex). The whole brain definition of death requires a higher brain and brain stem criterion as neither is sufficient on its own. Neuroendocrine function may be present despite irreversible cessation of cerebral hemisphere and brain stem functions (Nair-Collins, Northrup, & Olcese, 2016), but is not inconsistent with the whole brain definition of death (Russell, Epstein, Greer, Kirschen, Rubin, & Lewis, 2019). Using a thermodynamic model, Korien (1978) argued that the brain is the critical and irreplaceable system of the organism without which the organism can no longer oppose entropy. When this entropy opposing system ceases to function, despite other systems being supported by artificial means, the function of the organism as a whole ceases, and the organism is, by definition, dead.

In 1968, the 22nd World Medical Assembly published a statement on human death, referred to as the Sydney Declaration. From a clinical viewpoint, the Sydney Declaration maintained that death “lies not in the preservation of isolated cells but in the fate of a person” (Gilder, 1968, p. 493). In the same year, the Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death published in the Journal of the American Medical Association a landmark article establishing neurological criteria for brain death (Report of the Ad Hoc Committee, 1968). Although widely accepted, the report generated several subsequent studies and criteria that only served to complicate the actual diagnosis of brain death. In 1981, after suggestions from the American Bar Association, the American Medical Association, the National Conference of Commissioners on Uniform State Laws, and the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavior Research, the Uniform Determination of Death Act (UDDA) was published to establish a uniform definition of death by “accepted medical standards” (UDDA, 1981, p. 7) that would be “clear and socially accepted” (Russell et al., 2019, p. 228). The UDDA is a nonbinding statutory text that was meant to serve as a guide for state lawmakers to emulate. The definition of death by neurologic criteria as outlined in the UDDA is currently accepted as legal death throughout the United States and the District of Columbia. It is not only relevant for medical purposes, such as determining when a patient can be an organ donor, but also has implications for various legal situations, such as criminal cases, tort action, estate law, and life insurance.

The current standards for clinical tests to determine brain death in adult and pediatric patients, accepted by the majority of the U.S. medical profession, were published in the 2010 “Evidence-Based Guideline Update: Determining Brain Death in Adults” (Wijdicks, Verelas, Gronseth, & Greer, 2010) and the 2011 “Guidelines for the Determination of brain death in infants and children” (Nakagawa, Shwal, Mathur, Mysore, & the Committee for Determination of Brain Death in Infants and Children, 2012). According to Wijdicks et al., (2010), the clinical guidelines for adults are:

Clinical Evaluation (Prerequisites)

Rule out reversible causes

Absence of metabolic or endocrine disorders

Hypothermia

Shock

Depressant drugs

Neuromuscular blockade

Establish diagnosis (irreversible and proximate cause of coma)

Clinical prerequisites

Normal core temperature (>36° C)

Normal systolic blood pressure (³ 100 mm Hg) with or without vasopressor support

Neurologic examination (a single examination is sufficient in most of the United States)

Irreversible coma

No motor response to painful stimuli in all four extremities (excluding spinal mediated reflexes)

Absence of decorticate or decerebrate posturing

Absent cortical and brain stem reflexes

No pupillary response to light; pupils remain fixed or dilated (4-9 mm)

No ocular movements to oculocephalic testing and oculovestibular reflex testing (doll’s eye reflex and cold caloric response)

No corneal or eyelid response to touch

No facial muscle movement to painful stimuli

No gag, cough, or swallowing response to posterior pharyngeal stimulation (e.g., esophageal and pharyngeal suctioning)

Apnea Testing

Prerequisites

Absence or reversal of muscle relaxants or respiratory depressants

Preoxygenation (PaOs > 200 mm Hg)

No evidence of prior COs retention (COPD, severe obesity)

Initial normocapnia (PaCOs 35-45 mm Hg)

Ventilator frequency to 10 breaths per minute; positive end-expiratory pressure (PEEP) to 5 cm H2O

Testing

Passive oxygenation and disconnection from ventilator

8-10 minutes of apnea; PaCO2 > 60 mmHg (or 20 mm Hg increase above baseline)

Respiration is defined as abdominal or chest excursions and may include brief gasps. This represents a negative test. If respiratory movements are absent, this represents a positive test and supports the clinical diagnosis of brain death.

Patients with severe COPD may not be able to safely undergo apnea testing

Hemodynamic instability constitutes an indeterminate test

Ancillary tests

EEG, cerebral angiography, transcranial doppler ultrasonography, cerebral nuclear scan, MRI

To be used only if clinical examination cannot be fully performed or if apnea testing is inconclusive or aborted

As of 2010, there have been no reported cases in adults of neurologic recovery after a clinical diagnosis of brain death according to the AAN practice parameters (Wijdicks et al., 2010). Despite this, there remains a significant need for education regarding the clinical tests used to determine brain death among both the general public and health care professionals within all specialties. A 2014 study, for instance, showed that a group of neurologists and neurosurgeons were only able to correctly answer 54% of questions on a standard test related to the intricacies of brain death determination (MacDougall, Robinson, Kappus, Sudikoff, & Greer, 2014).

The concept of brain death can be difficult for families because the patient looks alive. They are warm and have a pulse and blood pressure. Their chests are moving even though this movement is provided by ventilator. Counseling and education are very important at this stage, but it is also very important to remember that there are not two different definitions of death, of which brain death is a special category. Brain death is equivalent to circulatory death. There is no distinction between being dead and brain dead. This also can be a cause of great confusion with families and certain religious cultures. Under brain death criteria, to be brain dead is to be dead by definition, and one cannot say that a patient is brain dead, but not really deceased. Health care professionals and hospitals are under no obligation to care for deceased persons.

Physicians are ethically justified to unilaterally discontinue treatment for patients declared dead by neurological criteria just as they would if a patient had died from cardiopulmonary criteria; however, these decisions should be sympathetic and respectful of the social, moral, cultural, and religious considerations of family and loved ones who may not understand the accepted medical standards or hold to different standards. Requests of family members, loved ones, or surrogates to maintain life-support measures for a patient who meets brain death criteria should be treated with understanding and appropriate counseling. Such requests must be according to the values of the patient, if that can be reasonably determined, and not according to those of surrogate decision-makers. The decision to discontinue artificial ventilatory support should come only after full discussion with the family, clergy if available, and possibly with the assistance of a hospital ethics committee.

Beliefs about death can vary not only between, but within religious traditions and cultures, and there still exists some disagreements even within strict religious orthodoxies (Veith et al., 1977). The question becomes, “Should individuals be allowed to choose their own definition of death based on religious or philosophical convictions?” Only New Jersey has codified this accommodation in its state law: “The death of an individual shall not be declared upon the basis of neurological criteria…when the…physician…has reason to believe…that such a declaration would violate the personal religious beliefs of the individual (New Jersey Declaration of Death Act, 1991, §5).

In California and New York, one must provide reasonable accommodation to objections. What is meant by reasonable accommodation is left up to individual institutions (Lewis, 2018)? In Illinois, a patient’s religious beliefs must be considered when determining the time of death (Lewis, 2018). The American Academy of Neurology (AAN) acknowledges a need to respect cultural and religious perspectives; however, the AAN also recognizes the potential harms for accepting a multitude of different definitions of death in a society that would create medical, social, and legal confusion and difficulties. Potential harms to the patient and/or family can include “mistreatment of the newly dead, deprivation of dignity, provision of false hope with resultant distrust, prolongation of the grieving process, undermining of the professional responsibility of the physician to achieve a timely and accurate diagnosis, and an anticipated societal harm arising from a negotiated and inconsistent standard of death” (Russell et al., 2019, p. 4). The question is how much variation in the definition of death and its declaration can be tolerated in a single society?

Higher Brain Criteria of Death

Alternate definitions of death have been proposed that are based on the loss of higher brain functions rather than the whole brain. These definitions are based on philosophical definitions of terms, such as personhood, and rely on a distinction between being a person and being a human being. According to higher brain definitions of death, it is the loss of personhood, however that is defined, that determines whether a human being is alive or dead, whether it is ethical to remove life-supporting measures, or even if vital organs can be removed for donation.

Proponents of higher brain, or neocortical, criteria of death limit the definition of personhood to human beings whose cognitive functioning is intact, meaning that they are “conscious” and “sentient” (Lizza, 1993, p. 363). An individual’s moral standing within the human community ends “when it is reasonable to deduce that there has been a break-down of the link between bodily integrity and mental and social capacity” (Veatch, 1981, p. 245) or “the loss of integration of bodily and mental function” (Veatch, 2005, p. 353). “The principle is simple. It relies on qualitative considerations: when, and only when, there is the capacity for organic (bodily) and mental function present together in a singly human entity is there a living human being” (Veatch, 2000, p. 111).

For Veatch (2000), consciousness and cognition define that which is essential to the nature of man. Veatch (2000) at times appeals to classical Judeo-Christian notions of the integration of mind and body, but these views are more representative of neoplatonic dualism than the biblical view of man as a single body-soul duality. Contrary to higher brain criteria, a human being is a “sacredness in the natural biological order. He is a person who within the ambience of the flesh claims our care. He is an embodied soul or an ensouled body” (Ramsey, 2002, p. xlvi).

When specific capacities or abilities define one as worthy of respect and dignity, the decisions of which capacities or abilities are necessary can become arbitrary and subject to mere social utility. This is not just a theoretical concern, as is evident in an article in the Annals of Internal Medicine that proposed that medical care, including artificial nutrition and hydration, can be unilaterally withdrawn and organs harvested from persons who have lost the potential for cognitive functioning. The authors’ rationale was ultimately economic, concerned primarily with “the appropriate use of social resources” (Halevy & Brody, 1993). As medical care becomes more expensive, and resources become more limited with an expanding and aging population, there will be an increased temptation to depersonalize individuals and groups, to exclude through redefinition, for the purpose of social needs (Hoehner, 2018).

Higher brain criteria entail serious slippery slope issues when the criteria for death becomes confused or indistinct. One could easily make the argument that if patients in persistent vegetative states are to be considered dead, then patients with severe forms of dementia may reach a stage whereby they similarly lack “experiential and social integrative functions” (Veatch, 1975, p. 28.

Higher brain criteria of death are not univocal and do not apply to other animals of high intelligence because they were intended solely for Homo sapiens. These criteria do not entail what society has traditionally meant by death. Would society condone burying or cremating spontaneously breathing patients in a persistent vegetative state who would be classified as dead by certain higher brain criteria? “The fact that higher brain proponents generally favor stopping their breathing and heartbeat prior to burial shows that implicitly they too regard such patients as alive” (Bernat, 1998, p. 17). Indeed, higher brain criteria of death are a radical redefinition of death and rely on an unbiblical view of the nature of human life. Death is fundamentally a biological phenomenon applicable only to an organism. The concept of personhood (i.e., higher brain definitions) is a psychosocial or spiritual concept. Personhood cannot die except metaphorically (Bernat, 1998).

Cardiopulmonary Criteria of Death

Despite acceptance by most medical professionals, the whole brain criteria for death remains controversial (Shewmon, 2001; Veatch, 2005; Verheijde, Rady, & McGregor, 2009). Because of perceived difficulties with whole brain criteria, alternative definitions of death have been proposed that go beyond brain death and focus on total body somatic integration, which is the structural disruption of all the essential functions of the whole organism, including respiration, circulation, and the entire brain. Proponents of this view cite specific individual cases whereby patients declared dead by whole brain criteria retained many of the body’s normal systematic physiological functions for weeks and even months. Obviously, this definition and associated criteria would drastically decrease the availability of viable organs for transplantation. Further research and future technologies may compel a change in the criterion associated with the fundamental definition of death as the cessation of the function of the organism as a whole.

These alternative concepts remain a minority opinion, but, along with cultural and religious challenges, they have fostered some resistance to whole brain definitions of death in deference to traditional cardiopulmonary criteria, which is the permanent cessation of respiration and circulation. The language of the UDDA does give the impression that there are two distinct definitions of death, one by brain death criteria and another by cardiopulmonary criteria; however, the conceptual argument behind the UDDA is that there is a single conceptual definition of death, which is the permanent cessation of all brain functions. In the absence of effective circulation, the brain will inevitably and permanently cease to function (whole brain criteria).

Organ Donation after Circulatory Death

The success and progress of vital-organ-transplant surgery and immunology has resulted in a demand for life-saving organs that far exceeds the available supply of donors. Most organs are obtained from heart-beating cadaver donors (HBCDs), or brain-dead donors, because their hearts are beating at the time of surgical procurement. Because of the increasing demand for organs, alternative sources and protocols have been devised to procure organs from patients who do not meet whole-brain-death criteria, but do meet cardiopulmonary or circulatory criteria (the terms essentially mean the same thing and are interchangeable).

In the 1990s, the University of Pittsburgh Medical Center developed a protocol to procure organs from patients when they or their families decided to withdraw artificial life support (UPMC, 1993). These patients are referred to as non-heart beating cadaver donors (NHBCDs) because, at the time of organ procurement, they have been declared dead by circulatory criteria. For instance, a donor candidate would be one with a terminal or end-stage disease but does not meet brain-death criteria and consents for, or has a written advance/surrogate consent for, withdrawal of life-sustaining medical treatment or ventilatory support. Under various protocols, life support would be discontinued in the operating room with the expectation that a natural death by circulatory criteria would soon follow and subsequent organ procurement could proceed according to the dead-donor rule. These protocols are referred to as donation after circulatory death (DCD).

DCD protocols, which are now widespread, remain controversial. Central to the ethical evaluation of DCD are the tests for circulatory death being employed. According to circulatory criteria, heart function must be irreversibly absent resulting in no blood circulation. The question revolves around the definition of irreversible and the minimal period of observation required to assure irreversibility. In other words, does the term irreversible mean cannot be reversed under any circumstances no matter what intervention is done, or does it mean will not reverse under existing circumstances, as when no further intervention is intended. When a heart stops beating and circulation ceases, there is a minimal, but inexact interval of time when it is possible for the heart to be restarted, which is why CPR and ACLS algorithms work. In the case of DCD, irreversibility takes on this second meaning as no further intervention to resuscitate the patient is intended or desired. It is not a question of whether the circulatory function can be resumed, as there remains the possibility that it can, but whether it will be, given the intention to not attempt any form of resuscitation.

Complicating this discussion is the possibility of autoresuscitation of the heart, in which the heart spontaneously resumes function following a cardiac arrest that occurs without pharmacologic or mechanical assistance or attempts at resuscitation. This has been reported to occur within a range of seconds to minutes of asystole. In a retrospective study of 73 controlled DCD patients, there was no occurrence of autoresuscitation after a 5-minute period of asystole (Sheth, Nutter, Stein, Scalea, & Bernat, 2012). Five minutes appears to be a safe limit after which autoresuscitation does not occur and is the period of time recommended by the Institute of Medicine (IOM) for determining death by cardiovascular criteria in the setting of DCD (Driscoll, 2012). After a 5-minute period of asystole, irreversibility can be ascertained, death declared, and vital organs removed in accordance with the dead-donor rule.

Despite the IOM’s recommendations, there remains no universally recognized standard, and various organ procurement centers have DCD protocols with mandatory observation periods ranging from 2-10 minutes. The dilemma is that with shorter periods of time, irreversibility cannot be assured, and patients may not, in fact, be dead by circulatory criteria. Longer observation periods increase the ischemic time of the donor organs, which increases their chance of being damaged. The 5-minute period appears to be a reasonable compromise between reducing organ ischemic time and assuring circulatory criteria are met.

Organ procurement after DCD presents many ethical challenges and potential for abuse, especially with societal and medical institutional pressures to increase the pool of organ donors. Christian ethicists and organizations have taken a generally positive but cautious stance, supporting the ethical practice of DCD to enable the altruistic act of organ donation while at the same time having grave concerns about the implementation of DCD protocols in actual practice (Driscoll, 2012; CMDA, 2018). Using DCD as a means of euthanasia and physician-assisted suicide is ethically unacceptable. It would also be morally problematic to broaden DCD donor criteria to include autonomously consenting and cognitively intact patients who are not imminently dying but may, for example, suffer from irreversible neuromuscular disease and paralysis, along with those who are not terminal yet suffer from a perceived poor quality of life.

The dead-donor rule, as a fundamental moral principle, should not be abandoned or compromised merely to increase the supply of organs for transplantation. While it is ethically permissible to employ either whole-brain-death criteria or cardiopulmonary criteria, they should be applied consistently and without compromise to increase organ procurement. In the case of circulatory arrest, a minimum of 5 minutes of postarrest observation should be observed to assure irreversibility in accordance with the definition of cardiopulmonary death.

There are several other moral principles that apply not only to DCD, but to all organ donors (HBCDs and NHBCDs). These include prohibiting any procedures, such as pharmacologic agents or placement of vascular cannulas, prior to a declaration of death that would cause the patient distress or discomfort, which has the preservation of donor organ viability as the sole purpose. Furthermore, interventions that only maintain or improve the quality of donor organs cannot be the proximate cause of the death of the donor.

A patient’s end-of-life care and treatment decisions should also be free from external pressure for organ donation. Discussions of whether to remove life-sustaining medical treatment or ventilator support should be made independently of decisions for organ donation. In the same manner, organ-procurement organizations should refrain from contacting the patient or the patient’s surrogate or family until that decision has been made. Prior to withdrawal of life-support therapies, consent for donation can be withdrawn at any time. Quality palliative care and spiritual care should be provided during the dying process, along with support of the family and loved ones. Health care professionals who have moral objections to DCD protocols should not be coerced into participating but should be allowed the freedom to be excused without the threat of reprisal or condemnation.

Ethical Issues at the End of Life

Euthanasia and Physician-Assisted Suicide

Definitions

The word euthanasia comes from the Greek meaning “good (eu) death (thanatos).” Everyone desires a good death, an end to life that is both peaceful and without prolonged suffering. That is not the issue. What is at issue is the increasingly popular view that a good death must include the option, or even obligation, of taking one’s own life or having someone assist in doing so. Euthanasia has come to mean intentionally causing or hastening a patient’s death for generally good ends such as the relief of suffering and pain. Active euthanasia is when some action is performed, such as the administration of lethal doses of drugs, that intentionally and directly leads to a patient’s death. Passive euthanasia refers to a situation when medical treatments that are readily available, nonburdensome, and clearly would enable a nonterminal patient to live significantly longer are withheld with the direct intent of ending a patient’s life or hastening their death.

A more useful expression for passive euthanasia is intentionally fatal withholding because it distinguishes the lethal intention of withholding useless or excessively burdensome treatment when death is imminent even with treatment. Euthanasia can be voluntary, involuntary, or nonvoluntary. Euthanasia is voluntary when a patient requests that someone end his or her life and that request is honored, involuntary when a patient explicitly refuses to have his or her life ended and their request is not honored, and nonvoluntary when a patient’s life is intentionally ended and the patient’s wishes are unknown or unobtainable.

Physician-assisted suicide (PAS), also referred to as physician aid-in-dying or physician-assisted death, is a special case of voluntary euthanasia with the assistance or supervision of a physician to end a patient’s life, usually by providing access to or making available a lethal dose of medication, instructions, and advice on how to use it. In PAS, the patient is the active agent who may or may not take those drugs or may do so at a time of his or her own choosing (American Nurses Association, 2019). Physicians use their expertise to enable a patient’s suicide. In active euthanasia, someone other than the patient is the active agent. It is common in medical ethics discussions to distinguish PAS from euthanasia, but this may be a distinction without much of a difference. A physician participating in PAS is still morally culpable as an agent or accomplice in a suicide.

The Distinction Between Accepting and Precipitating Death

There is an important ethical difference between intentionally ending a life and accepting the end of life. It should be self-evident that there is a medical and ethical difference between refusing a heart transplant and deliberately ingesting a lethal dose of sleeping pills. To precipitate death is to deliberately introduce a “new lethal pathophysiological state” (Sulmasy, Finlay, Fitzgerald, Foley, Payne, & Siegler, 2018, p. 1396) with the direct intention of ending a patient’s life or hastening their death. To accept death is to either refuse or withdraw medical interventions that impede the progression of a preexisting lethal pathophysiological condition because, in the patient’s or physician’s judgment, a treatment has become too burdensome or is not providing any proven medical benefit.

The difference between accepting and precipitating death is not merely semantic. A refusal of or request for cessation of life-prolonging treatment is not ethically or legally considered a request for euthanasia, but an acceptance of death and acquiescence to the natural process of dying. While some moral theorists may equate these two and view them as morally indistinguishable because they both have the same outcome, namely the shortening of the patient’s life, the distinction is still relative and important in medical, ethical, and legal decisions. In the case of Quill v. Vacco (1994), the U.S. Supreme Court rejected a claim of the Second Circuit Court of Appeals that ending or refusing life-sustaining treatment “is nothing more or less than assisted suicide” (p. 729). The unanimous court decision noted that “when a patient refuses life-sustaining medical treatment, he dies from an under-lying fatal disease or pathology; but if a patient ingests lethal medication prescribed by a physician, he is killed by that medication” (Quill v. Vacco, 1994, p. 729). Suicide is morally and legally distinct from the acceptance of death by acknowledging the limitations of medicine.

Fundamental Worldview Differences

Supporters of euthanasia and PAS are typically sincere and compassionate, desiring to be beneficent and respectful of the dignity of suffering persons. However, these attitudes toward respect for human dignity and compassion, and the difference in meaning these attitudes reflect, illustrate the differences between a Christian worldview and a secular worldview with regard to dignity, human suffering, and what a good death entails. For the secular-minded person, to end suffering by means of ending the life of the sufferer is a rational act of compassion. Conversely, for the Christian, suffering is to be relieved to the extent possible within the boundaries and principles reflected in the biblical worldview and God’s directives to not kill an innocent person (Exodus 20:13; Deuteronomy 5:17; Jeremiah 7:9; Matthew 5:21; 19:18; Mark 10:19; Luke 18:20; Romans 13:9; James 2:11). The words used for kill in both the Old and New Testaments mean “to murder” (Exodus 21:12–14; Leviticus 24:17–21; Numbers 35:16–31; Deuteronomy 19:4–13).

The biblical worldview understands that intentional hastening of death for any reason is a distortion of the idea of a good death. In the Old Testament Book of Judges, a soldier by the name of Abimelech suffers a skull fracture when a woman drops a millstone on his head during the siege of a fortified tower. Assuming his injury is mortal, he asks his armor-bearer to kill him so that he would not suffer the “indignity” of being killed by a woman (Judges 9:52–55). In another example, Israel’s King Saul attempts to commit suicide by falling on his spear when surrounded in battle. After his unsuccessful attempt, Saul implores another to put him out of his misery and kill him (1 Samuel 31:1–10). These two examples are reminiscent of the two main arguments for PAS and euthanasia, to avoid a loss of dignity at the end of life and a compassionate relief from suffering.

Both actions are condemned in the biblical narrative. It is a failure to faithfully acknowledge the sovereignty of God over life, death, and even suffering at the end of life. According to the Bible, it is God who determines (Job 14:5), ordains (Psalm 139:16), and appoints (Hebrews 9:27) all the days of life and the time of death. To request euthanasia or PAS is to abandon one’s stewardship over God’s gift of life (1 Corinthians 6:19–20). For the secular thinker, human dignity is centered on the ability to autonomously control the timing and manner of one’s death. For the Christian, human dignity is based on being created in the image of God, a dignity conferred on each human being by his or her Creator.

Organizational and Legal Positions

During the past decade, there has been an increasing interest by states to legalize PAS. While PAS is not a constitutional right according to the U.S. Supreme Court, states may choose to legalize the practice. As of 2019, PAS is legal in California, Colorado, Oregon, Montana, Vermont, Washington, and the Distinct of Columbia. Most referenda to legalize PAS are defeated. In 2017, referendums were voted down in 27 states, but new referendums appear each year across the U.S. Both New Mexico and New York courts have ruled that there is no constitutional right to PAS in those states.

Professional medical and nursing societies have historically prohibited or opposed PAS. The American Medical Association (AMA), the American College of Physicians (ACP), and the World Medical Association (WMA) have all recently reaffirmed their positions opposing euthanasia and PAS. The AMA House of Delegates voted in their 2019 annual meeting to oppose PAS as “fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious risks” (White, 2019). In doing so, the AMA reasserted the fundamental role of the physician as healer and commitment to the Hippocratic principle to do no harm. The ACP published a position paper opposing legalization of PAS in 2017, calling for improvements in the care of dying patients, including increased awareness and improvement in hospice and palliative care (Sulmasy & Mueller, 2017). The WMA reaffirmed its position at its 2015 council session in Oslo, Norway:

Physician-assisted suicide, like euthanasia, is unethical and must be condemned by the medical profession. Where the assistance of the physician is intentionally and deliberately directed at enabling an individual to end his or her own life, the physician acts unethically. However, the right to decline medical treatment is a basic right of the patient and the physician does not act unethically even if respecting such a wish results in the death of the patient. (WMA, 2017)

The American Nurses Association (ANA) states that, “Euthanasia is inconsistent with the core commitments of the nursing profession and profoundly violates public trust…Nurses are ethically prohibited from administering medical aid in dying medications” (ANA, 2019, pp. 1–2). Other organizations that officially oppose euthanasia and PAS include the British Medical Association (Jaques, 2012), the National Hospice and Palliative Care Organization (NHPCO, 2005), and the Christian Medical and Dental Associations (CMDA, 2018).

Recent developments in public and professional attitudes toward euthanasia and PAS may indicate an erosion of this opposition to PAS, as support for these positions is coming from organization membership. In 2016, members of the AMA and the WMA sought to revise their organization’s opposition to PAS, calling on their organizations to take a neutral stance on PAS and provide advice to health care professionals who participate in PAS in jurisdictions where it is legal (Frye & Youngner, 2016). Sulmasy et al., (2018) warned that by shifting to a neutral position, these organizations are in fact no longer neutral. “To change from opposition to neutrality represents a substantive shift in a professional, ethical, and political position, declaring a policy no longer morally unacceptable; the political effect is to give it a green light. Logically, neutrality implies, ‘We are not opposed.’” (Sulmasy et al., 2018, p. 1395). This was evident when, in 2015, the California Medical Society endorsed a neutral position on PAS, and the next day’s headlines announced, “California Physicians End Opposition to Aid-in-Dying Bill” (McGeevy, 2015, p. B4; Kheriaty, 2019).

Is PAS Justified by Arguments for Autonomy, Freedom, and Dignity?

The most prominent argument used to justify PAS is the argument for autonomy. Autonomy over the control of one’s life and the supremacy of private judgment have become the equivalent of moral absolutes in modern culture. To be autonomous is to have control and freedom to decide what is most valuable and meaningful in one’s life, and this has been extended to having mastery over one’s death, whether to be killed or assisted in suicide, so long as it is voluntary. It has been shown that in Oregon, those who received lethal prescriptions exhibited uncommon personality types fixated on issues of control (Oldham, Dobscha, Goy, & Ganzini, 2011). Proponents of PAS insist that upholding a patient’s control and freedom over the timing and means of a patient’s death is considered a right, and physicians have a duty to satisfy that right. Loss of autonomy is equivalent to a loss of human dignity. To accept a health care provider’s role in PAS is to respect and maintain the dignity of the dying patient.

Autonomy, however, is not a fundamental or overriding principle in isolation from other principles of ethics in medicine and society. While respect for patient autonomy has prima facie priority in most clinical situations, and it must be weighed against other principles of medical ethics such as beneficence, nonmaleficence, and justice. Autonomy is not the isolated exercise of will that can demand anything a person wants to the exclusion of others, higher moral principles, or the goals of medicine and society (Kekewich, 2014). If upholding a patient’s control and freedom by acquiescing to any request, physicians and health care professionals become mere functionaries or technicians. If autonomy always trumps other ethical principles, there would be no principled barriers to withhold or deny any treatments requested by a patient. The ability to decline some patient requests for the good of the patient or the good of society is a requirement of medical professionalism and ethics (Sulmasy & Mueller, 2017).

Legalization of PAS also has societal implications. If loss of dignity and autonomy, meaning one has lost control and is dependent on others, is used to justify PAS, what does this say about those in society who are already heavily dependent on others? This is why certain undervalued groups in society, such as the elderly and disabled, oppose legalizing PAS because it sends the implicit message that dependent persons have no dignity and are better off dead (McDermott, 2010; Koenig, Wildman-Hanlon, & Schmader, 1996). This is not just a theoretical concern. With an aging population and health care resources becoming increasingly expensive, aging and dependent patients may be pressured or coerced into choosing PAS (Hanson, 2018) or denied payment for expensive treatments in favor of PAS (Richardson, 2017). As discussed earlier in this chapter, human dignity is based on being created in the image of God, which is universal and inviolable. All humans possess dignity as special creatures of God, not because society attributes dignity to them. God chose to send his only Son to die for all human beings, “the whole world” (John 3:16). How can such beings for whom God loved and sacrificed so much lose their God-given dignity? Loss of control over one’s life and death cannot be a source of dignity, and the goal of maintaining complete autonomy in this life is a total illusion (Ecclesiastes 6:10,12). Only God has complete providential control over our life and death.

According to a Christian worldview, the arguments for freedom and autonomy given by proponents of euthanasia and PAS present a distorted view of human freedom, denying the gift and stewardship of life given by God. This form of supreme autonomy and freedom also rejects God’s providential control of and purpose for each person’s life. According to Pellegrino (1996), the modern notion of autonomy and freedom,

assumes that the only purpose of human life is freedom from all discomfort and pursuit of each individual’s notion of “quality” of life. It denies any idea of solidarity or community in which each person’s life has its special meaning regardless of how demeaned it may seem to the beholder…it denies that our lives, however difficult, may be instruments in God’s hand to shape the lives of those among whom we reside. (p. 109)

The supreme act of freedom, according to the Bible, is the sacrifice of oneself for others and yielding one’s freedom to God’s purposes. In the Garden of Gethsemane, Jesus yielded his will to that of his Father’s (Mark 14:36; cf. Matthew 26:39–46). Yielding one’s freedom to God’s will and purpose, as the ultimate source of true freedom, is the ultimate act of all true human freedom.

Is PAS Justified by Arguments for Compassion?

The emotionally driven argument that PAS and euthanasia are ultimately acts of compassion and mercy is very appealing to many, as it should be. Christians share this concern for the sufferings of others, looking to Jesus’ whole life as one filled with compassionate and merciful acts, especially for the sick and dying. Compassion means “to suffer with,” and because suffering is a universal human experience, when one feels the suffering of another, that person is compelled to relieve it.

Proponents of PAS differ, however, on the moral status of compassion as compared to the Christian worldview. For many proponents of PAS, the emotion or feeling of compassion justifies whatever means are necessary to end a patient’s suffering, and not doing so is considered cruel or even evil. For Christians, compassion means something different. While being a laudable emotion and motivation, compassion is not a moral principle by itself or a justification for any action deemed as compassionate. “Compassion cannot justify intrinsically immoral acts like usurping God’s sovereignty over human life. Compassion should accompany moral acts, but it does not justify them” (Pellegrino, 1996, p. 110). Like all other emotions, such as rage and fear, compassion must be expressed within ethical and moral boundaries. A Christian’s compassion for others is grounded in God’s love for the world as founded in Christ’s life, death, and resurrection. Without this supreme example of love, compassion is wrenched from its moral roots and has nothing to guide it.

Is PAS Justified by Arguments for the Relief of Pain and Suffering?

Relief of pain and suffering is a central component of medical and nursing care, and the relief of end-of-life pain and suffering is a major rhetorical theme of many arguments in favor of euthanasia and PAS. For advocates of PAS, suffering is a meaningless and unmitigated evil, and to escape suffering is both moral and merciful. Many proponents of PAS view the modern culture of medicine, with its emphasis on curing, to be complicit in end-of-life pain and suffering (Karsoho, Rishman, Wright, & Macdonald, 2016). Modern medicine is viewed solely as a life-prolonging enterprise composed of paternalistic and death-denying physicians. Moreover, many proponents view palliative care to have limited ability to relieve suffering at the end of life and, in some instances, to even produce suffering (Karsoho et al., 2016). This perception supports the view that one has only two choices: a gruesome and painful death in the hands of mainstream medicine or a peaceful end to pain and suffering through medical-assisted death.

This is a false dichotomy. Progress in hospice and palliative care, symptom and pain control, and increased awareness and availability of end-of-life comfort measures does not support this view. It is not necessary for anyone to die in pain, and it is ethically acceptable to refuse burdensome life-sustaining therapies such as CPR, ventilators, a feeding tube, or dialysis when the burdens outweigh the benefits. Evidence shows that those who request PAS where it is legal do so for reasons other than fear of unrelieved pain and symptoms at the end of life. The predominant reasons include loss of autonomy and dignity or the fear of dependence and being a burden to others (Suarez-Almazor, Newman, Hanson, & Bruera, 2002) and not a fear of pain and suffering.

There is a difference between pain and suffering. Pain is the objective unpleasant physical sensation mediated by nerves and the brain that signals something is wrong in the body. Suffering is the subjective way that pain is interpreted and the thoughts, judgments, beliefs, and meaning one gives to pain. All objective pain is accompanied by some form of subjective interpretation and meaning, but suffering is not always associated with physical pain, especially at the end of life. Studies show that patients requesting PAS have higher levels of depression, hopelessness, and dismissive attachment behaviors characterized by independence and self-reliance with limited social support (Smith et al., 2015). All these factors contribute to suffering. One of the strongest predictors of requests for PAS was a low level of spirituality, defined as a sense of meaning, peace, and purpose in life, as well as the relationship between the patient’s illness, faith, and spiritual beliefs (Smith et al., 2015). Without a belief in some purpose to life beyond its outward material pleasures and goods, in a meaningless world of illness, pain, and suffering, it can be easy to accept the alternative nothingness of death over purposeless suffering, even if that suffering is painless. Euthanasia and PAS requests are rare when a patient’s physical, social, emotional, and spiritual needs are addressed.

The Christian worldview gives meaning and purpose to suffering. Suffering and death are ultimately the result of sin, and it is through the suffering and death of Jesus that the meaning and purpose of a believer’s own suffering and death is transformed. By faith, Christians are united to Christ in his own sufferings, but also united in his own resurrected and eternal life. There may be no explicit answer to why someone is suffering in a particular situation, and the reality of pain and suffering can never be minimalized. But God has promised that the sufferings of this world can bring spiritual growth, focus one away from this world and onto the next, and bear witness to God’s faithfulness in a fallen world (Romans 5:3; James 1:2–4). Suffering and pain is temporary, “preparing for us an eternal weight of glory beyond all comparison” (2 Corinthians 4:17). For the Christian believer, suffering has been redeemed through Christ’s own suffering. By faith, a Christian can look forward to a life after death in fellowship and peace with God where there is “no more death or mourning or crying or pain” (Revelation 21:4).

Care for the whole person, a biopsychosocial and spiritual being, entails caring for all aspects of a patient’s suffering, not just physical pain and symptom relief. End-of-life care must also address the psychological aspects of depression and hopelessness, and the societal aspects, which include a lack of social support and the fear of losing independence. All caregivers, especially Christian caregivers, should be particularly aware of spiritual causes of suffering and involve appropriate pastoral care and counseling when appropriate. Good medical care, addressing the whole person, can give patients substantial control over their dying without the need for them to request the precipitation of their own death.

Is PAS Justified by the Argument that There Is No Difference Between PAS and Providing Pain-Relieving Medications that May Hasten or Contribute to Their Death?

Justifying PAS by arguing that providing pain-relieving drugs is no different from PAS is a common argument put forth by its proponents, but there is a real and important difference between PAS and end-of-life palliative pain relief. Sometimes administering pain-relieving drugs can inadvertently hasten a patient’s death as a side-effect. According to a well-accepted principle of medical ethics, referred to as the principle of double effect, it is morally permissible to cause harm as an unintended, yet foreseeable, side effect in order to bring about a good effect (Berger, 2013). This principle was developed in the Catholic Christian tradition and dates to the 13th century teachings of Thomas Aquinas in his work Summa Theologica. The principle states that when an action has two foreseeable effects, one good (pain relief) and one bad (hastening death), it is morally permissible under the following five conditions:

The act itself is good or at least morally neutral (e.g., giving medications to relieve pain).

The good effect is intended, not the bad effect (e.g., causing or hastening the death of the patient).

The good effect is not brought about by means of the bad effect (e.g., relief of pain is not brought about by or dependent on hastening the patient’s death).

There are no alternatives to the good effect that would be safer.

There is a proportionately grave reason (e.g., intense pain) for risking the bad effect (e.g., side-effects of the drug that may cause respiratory or hemodynamic depression).

In the case of PAS, the difference lies in the intent and purpose of providing a medication. The direct means of the patient’s death is a lethal dose of medication. In other words, the means of pain relief is the intended death of the patient. In terms of palliative pain relief, the intent of administering pain-relieving medications is solely for patients’ comfort, not their death. Even though it may be a foreseen possibility, hastening a patient’s death is not the intent of treatment. Even given these arguments, there is increasing evidence that adequate pain relief at the end of life is not associated with hastening death (Mette & Onwuteaka-Phillipsen, 2008).

Should Health Care Professionals be Obligated to Participate in PAS?

In a word, “No.” First, euthanasia and PAS undermine the goals and meaning of medicine (Sulmasy & Mueller, 2017), which is to heal or at least to provide comfort and care. Facilitating suicide is not a healing act, nor is it comfort and care. Symptom relief can provide healing and care, and withholding or withdrawing burdensome or futile treatments acknowledges the limits of medicine and healing, but one cannot claim that healing in any way involves assisting patients in ending their lives.

PAS and euthanasia disrupt the patient-physician relationship. “For whenever physicians use their knowledge and skills for ends other than the promotion of health and healing, medicine is corrupted—indeed, is no longer medicine” (Kheriaty, 2019, p. 33). The Hippocratic pledge to not kill is a minimal condition of trust within a patient-physician and other health care professionals’ relationship. Despite the medical culture’s shift away from any forms of perceived medical paternalism, patients remain vulnerable in their disease and illness, and health care professionals continue, by way of increasing specialized knowledge in health care science, to hold great power over a patient’s life and health. Patients need to trust health care professionals, in whose knowledge and skills they depend. “When the doctor is licensed to provide lethal drugs, patients could be inadvertently steered towards assisted suicide, especially those with low self-esteem or who are viewed negatively as weak, dependent, unproductive, unattractive, costly, and unworthy of the efforts of others.” (Sulmasy et al., 2018).

Even in jurisdictions where PAS is legal, under no circumstances should health care professionals be encouraged or coerced to participate in hastening the death of their patients or participating in PAS. Whereas the state can legitimately limit health care professionals from certain actions, the state does not have the legitimate authority to force health care professionals to commit, assist in, or accommodate actions they believe to be morally wrong, even when their moral objections are based on religious beliefs (CMDA, 2018; U.S. Department of Health and Human Services, n.d.)

Brain Death, Coma, and Permanent Vegetative State

Brain death, coma, and permanent vegetative state (PVS) are very different conditions that are sometimes equated by the general public. Brain death, as outlined above, is the irreversible cessation of all brain functions, including the brain stem, and is equivalent to clinical death. Coma, on the other hand, refers to severe depression of cerebral function with a loss of consciousness resembling sleep. Coma is a pathological state and physiologically distinct from sleep. When a person is asleep, the brain continues to function with highly organized and complex electrical activity that maintains bodily homeostasis and autonomic functions. With stimulation, sleep can easily be reversed to a state of alertness.

Coma is a state of slowing and depression of electrical brain activity and cannot be reversed by stimulation. Coma implies a neurological injury to both cerebral hemispheres or the brain stem caused by either structural injury (e.g., trauma, hemorrhage, ischemia) or metabolic injury (e.g., drug overdose, lack of oxygen). Despite the erroneous title of the Report of the Ad Hoc Committee (1968), which equated brain death criteria with irreversible coma, patients in a coma, even persistent of irreversible coma, are considered alive and do not meet the criteria for brain death. Brain activity can be variable, and there can be some signs of response to external stimuli. In these cases, it can be difficult to assess whether a patient is aware of their environment or not.

The vegetative state refers to a unique disorder that is the “least understood and most ethically troublesome condition in modern medicine” (Owen et al., 2006, p. 1402). A vegetative state is a descriptive term evidenced by severe cortical dysfunction, usually emerging after severe coma, and sometimes erroneously referred to as brain death. Patients in a vegetative state exhibit a form of wakefulness (e.g., eye-opening), normal sleep cycles, reflex movements (e.g., gagging, sucking, withdrawing, grabbing, and grimace or laugh) without appearing to be aware of themselves and their environment. They are unable to interact with others, speak, or respond to commands; however, recent functional MRI studies in PVS patients indicate that at least some patients may be more aware of their environment than originally thought. Evidence suggests that patients may retain the ability to understand someone speaking to them and respond to them through inner brain activity, rather than through speech and movement (Owen et al., 2006).

PVS is a diagnostic term used when this state, after repeated clinical examinations, has continued for a prolonged period. Permanent vegetative state is a prognostic term used when there is no reasonable probability of improvement. These patients do not meet the criteria for brain death. While it is common in both lay and medical literature to refer to such individuals with severe cortical dysfunction as vegetative, health care professionals must be careful to not dehumanize their patients, whether through language, actions, or attitudes. Very little is known about the mysteries of consciousness and awareness, which are for the most part subjective experiences and difficult to study by empirical and objective measures. Patients in PVS are not dead, may have more awareness than originally thought, and should not be viewed or treated as less than human (i.e., vegetables). All patients, regardless of their diagnosis, condition, or ultimate prognosis, should be treated with dignity and respect.

Termination of Life Support and Withdrawal of Artificial Nutrition and Hydration

Modern health care has made available a host of technologies that can support and prolong life. But whether these life-supporting technologies should be used in certain circumstances or are consistent with a patient’s goals of care, values, and beliefs is not a question medical science alone can answer. All patients have a right to refuse any medical treatment, whether it be directly or according to an advance directive. As stated above, honoring a patient’s wishes for nontreatment or withdrawal of treatment is not the same as euthanasia or PAS. When natural death is inevitable, options to withhold or withdraw treatment are always a consideration. Technology should not be used merely to prolong the dying process when death is imminent. According to the writer of Ecclesiastes, there is “a time to die” (Ecclesiastes 3:2). A decision to withdraw medical treatments that are no longer effective is a form of beneficence or prevention of further harm. Withdrawal of ineffective or overly burdensome treatments does not mean that care should be withdrawn. When there is nothing more that can medically be done for the patient in terms of cure, the goals of medicine should shift to comfort and care.

For the Christian believer, death is a conquered enemy, but that does not mean that death always needs to be resisted. Being stewards of one’s earthly life is an important good to be pursued, for sure, but it is not the most important good a Christian can pursue. Christians’ highest or ultimate good is their inner spiritual fellowship with God and a destined eternal life and fellowship with God in the future. A Christian view of the sanctity of life should not be equated with the pursuit of physical life and longevity at all costs. There is a time when it is good to acknowledge the limitations of medicine and the limits to earthly existence. Withholding or withdrawing therapy is to accept these limits that are under God’s sovereign and providential control.

Health care professionals are not obligated to provide treatment that will not be beneficial or impose excessive burden or harm on a patient. In some cases, a unilateral decision to discontinue or withhold treatment (e.g., a “do not attempt resuscitation” order) may be appropriate. Many institutions have written policies regarding when this is appropriate and the requirements for doing so, such as having two physicians concur or the involvement of a medical ethics committee. Unilateral decisions of this type are prone to abuse and should not be undertaken lightly. The decision to withhold or discontinue treatment should come only after full discussion with the patient if possible, the family, clergy if available, and possibly with the assistance of a hospital ethics committee.

Advance care planning is an ongoing process in which health care professionals are in conversation with patients and their families about their personal values and decisions regarding the medical care they want to receive, including life-supporting treatments, when they no longer have the capacity to communicate their desires. This may lead to completing an advance directive or designating a durable power of attorney for health care. Patients or their surrogate may be provided with a physician orders for life-sustaining treatment (POLST) form. These are actionable physician orders that support other forms of advance directives and are transferrable between different health care facilities. Different states may use different terminology and have different requirements for application, such as a signature by a physician, APRN, or PA.

Whether to use artificial means to administer nutrition and hydration (ANH), or whether to withdraw ANH once begun in specific clinical circumstances, is a controversial ethical issue in modern medical practice, and legal precedents have not always agreed with biblical Christian ethics. Furthermore, there are instances in which sincere Christians may differ about the morality of withholding or withdrawing ANH in certain cases. Like all medical interventions, ANH should be initiated only after a careful assessment of the expected benefits and burdens.

ANH is not without complications, such as aspiration and risk of pneumonia from nasogastric tube feedings; complications of total parenteral nutrition associated with central venous catheters, including infection, fluid overload, electrolyte disturbances; and complications associated with inserting a percutaneous gastrostomy tube. Decisions to implement or withdraw ANH should be based on the medical circumstances and involve the patient or designated surrogate. ANH should not be used against any patient’s or surrogate’s expressed desires, or as indicated in an advance directive. There may be unusual cases in which a surrogate’s decision may overrule an advance directive when there is strong evidence that the surrogate knows what the patient would have wanted in the current specific situation.

Physicians are not obligated to use ANH in cases in which it is medically futile, as in the case of patients declared brain dead. An exception would be in the case of a pregnant patient who is declared dead by neurological criteria but remains on life support to preserve the life of the fetus until it can be safely delivered.

Christians differ about the ethics of withholding or withdrawing ANH in patients diagnosed with PVS. While there are compelling arguments on both sides, withdrawal of ANH for the specific purpose and intent of taking a patient’s life or hastening his or her death is not ethically permissible according to a biblical Christian worldview. On the other hand, ANH may be considered an artificial support to life and decisions to withhold or withdraw ANH may depend on weighing the burdens and potential complications against the benefits. When ANH is withheld or withdrawn, food and water by mouth should be offered to all patients if they are capable and when it is medically safe to do so.

Loss and Grief

Death or the prospect of imminent death can be a traumatic and difficult experience for family, loved ones, and caregivers. Even for a Christian, it is important to realize that on this side of the grave and resurrection, death can be a fearsome prospect, fraught with awesome mystery and foreboding. It is a difficult thing to welcome “our sister, bodily death,” as St. Francis of Assisi (trans. 1999, p. 114) sang on his deathbed. Even the sainted friar did not add “sister death” to his song praising God for and through all creation after a lifetime of prayer and practice. Jesus, who is the resurrection and the life (John 11:25), wept before the tomb of Lazarus and was greatly distraught in the Garden of Gethsemane at the prospect of his own death (Matthew 26:38; Mark 14:34; Luke 22:44).

Understanding the process and stages of grieving is immensely beneficial for all caregivers and health care professionals in order to assess and care for patients, their loved ones, and families. While there are many good resources available, one of the most influential studies on the stages of grief and loss was written by the Swiss-American psychiatrist Elizabeth Kübler-Ross (2014). According to Kübler-Ross (2014), the stages of grief include:

Denial and isolation

Anger

Bargaining

Depression

Acceptance

In her groundbreaking book, On Death and Dying, Kübler-Ross (2014) interviewed more than 200 patients and outlined common patterns or stages of grief that both dying patients and their loved ones experience when facing death. Although originally published in 1969, Kübler-Ross’s work has had a profound and lasting effect and was instrumental in the beginnings of the hospice and palliative care movement, as well as the effective treatment of pain at the end of life. Even the concept of pain as the fifth vital sign in current nursing practice can be traced to Kübler-Ross (2014).

While On Death and Dying outlines what has been commonly referred to as the stages of grief, Kübler-Ross (2014) did not intend these stages to be interpreted as a formulaic progression through the dying process. Everyone grieves differently. Each individual is unique in his or her response to grief and coping with terminal disease, the prospect of dying, or the loss or impending loss of a loved one. Each individual faces his or her own unique and varying needs, desires, and anxieties as he or she faces death. It is important to recognize exactly where the patient is regarding his or her ability to cope with the situation and changing needs.

The emotional states and coping mechanisms described by Kübler-Ross (2014) occur in different patterns in different individuals, and sometimes do not progress through the entire series, as Kübler-Ross (2014) interviewed many people who stalled at the denial or anger phase. This can also be true for a patient’s family and loved ones. Nevertheless, the natural and sometimes difficult progression of a patient with a terminal prognosis from initial denial, isolation, and anger to bargaining, depression, and finally a sense of acceptance, or at least acquiescence to their situation, provides a helpful structure for caregivers, families, and loved ones to understand and provide appropriate response and counsel. It is important to understand the influence of a patient’s worldview and their family’s worldview and how it affects each of the stages and the comfort, or lack of comfort, it can provide. “Although death is a fact, something that happens to all, dying and grieving are activities in which one engages according to the attitudes [and beliefs] one holds about them” (Morgan, 1995, p. 523). This section will describe Kübler-Ross’s stages of grief.

The initial and sometimes the most difficult period for a counselor or loved one is the “opening of the door” or initial contact they may have with the dying patient or their family. It is often the case that it is not the patient who initially exhibits the most apprehension, but the counselor, friend, or family member. Even experienced health care workers are not immune to this initial unease at the reminder of their own mortality. When dealing with dying and grieving patients, it is important to examine one’s own attitudes toward dying and talking with a dying patient. In many ways, it can be a very difficult and uncomfortable experience emotionally, spiritually, and even physically. The initial contact serves two similar and important purposes.

First is to become acquainted with the patient as a person. Simple and short conversations with the patient, family, and acquaintances allow the patient to initiate any discussion about death or dying when he or she is ready. It also allows one to evaluate the patient’s willingness to discuss such a fearful and misunderstood topic as death. In prolonged illnesses, one needs also to be concerned with aspects of their illness that may be even more fearful than death, such as pain, suffering, and isolation. One of the great strengths of the Kübler-Ross (2014) book is the way she models sensitive and open discussions of death with those she interviewed.

Denial and Isolation

The initial denial of death, or the familiar, “No, it cannot happen to me. This isn’t happening” response, can be understood as an immediate and reflexive psychological defense mechanism against the fear of the unknown and the shock of loss. For most, this initial stage is a temporary response that helps one to transition through the first initial shock of pain and grief. For others, this denial and isolation can be prolonged and have deleterious psychological effects.

Our modern culture has contributed to this sometime unhealthy denial of our own mortality. The effects of this denial and fear that results from such denial have paradoxically resulted in the basic aggressiveness and loss of respect for life that seems to dominate our modern culture of death (John Paul II, 1995; Smith, 2000). Post-Freudian analysis has always maintained that religion itself is a deep-rooted attempt to deny the finality associated with death (Eissler, 1955). With regards to the life-after-death approach of most religions, Kübler-Ross (2014) comments,

But with this change, also, fewer people really believe in life after death, in itself a denial of our mortality. Well, if we cannot anticipate life after death, then we have to consider death. If we are no longer rewarded in heaven for our suffering, then suffering becomes purposeless in itself. (p. 15)

The Christian biblical worldview makes no attempt to deny the existence of death or human mortality. In fact, the Bible takes great strides in emphasizing the painful and harsh existence of death in this world whether through sickness, old age, accident, or war (cf., Luke 13:1–5). Whatever may be the physical cause of death, the ultimate reason for death is sin (Psalm 90:7–9).

It can be a difficult and challenging time for discussion when a patient, family member, or loved one is unwilling to discuss the possibility of death; however, many patients are often willing to discuss death at this stage in general terms, while still avoiding any personal identification with death. Offering false hope is a temptation that should be avoided. It is important to be both comforting and honest. While in certain situations, a patient’s condition may indeed improve to the point of recovery, all things remain in God’s hands, and the reality of death should not be denied.

The hope of life with God in heaven is an important and central reality that the Christian patient must be brought to examine carefully: “For God so loved the world, that he gave his only Son, that whoever believes in him should not perish but have eternal life” (John 3:16). Even Kübler-Ross (2014) understood the value this holds for the terminally ill patient:

Paradoxically as it may sound, while society has contributed to our denial of death, religion has lost many of its believers in a life after death, i.e., immortality, and thus has decreased the denial of death in that respect. In terms of the patient, this has been a poor exchange. While the religious denial, i.e., the belief in the meaning of suffering here on earth and reward in heaven after death, has offered hope and purpose, the denial of society has given neither hope nor purpose but has only increased our anxiety and contributed to our destructiveness and aggressiveness—to kill in order to avoid the reality and facing of our own death. (p. 15)

Denial and isolation must be approached with patience in this critical period before the patient is truly ready to open up and express a willingness to talk about their own mortality.

Anger

When the period of denial cannot be maintained any longer, patients usually demonstrate a random dispersion of anger toward the world around them. Rather than confronting this anger, it is important to recognize the point of view of the patient and the origins of this anger. Putting oneself in the place of someone who has just been told that their life will soon be coming to an end will provide the necessary empathy and compassion that is necessary at this stage. Family and loved ones’ attitudes may also turn to anger and frustration, especially against superficial platitudes and religious explanations and the God who is seemingly responsible for taking this person from their presence. Well intended phrases such as “God has taken Jimmy to heaven” may paradoxically contribute to furthering negative feelings against a God who would do such a cruel thing to Jimmy’s friends and family. Anger can also be directed at the dying or deceased loved one.

While it is irrational to blame the person, overwhelming emotion can display itself in resenting the person for leaving. Feeling guilty for this irrational and emotional anger can make one even angrier. This can be a most frustrating stage for caregivers who may be the target of anger. Patient resentments and directed anger should not be taken personally.

A Christian patient may soon come to realize his or her own place in God’s plan for the world and that what is happening is God’s will for his or her life, however painful. This can indeed be a radical change and turning point in a person’s life as he or she begins to realize the big picture of God’s plan for the world. Yet, this in no way negates or should be expected to fully alleviate the fear and dread of facing suffering and death, which may reasonably coexist with a patient’s sincere faith and trust in God’s providential care.

Displaced anger at the imminence of death may also stem from a sincere misunderstanding of the purpose of death. The Christian worldview maintains that it was never originally intended by God for people to die, just as He still no longer wishes for people to die (Ezekiel 18:23); however. God is both loving and just, an unusually comforting fact in light of a dying patient’s situation. Death is a part of God’s punishment for sin (Genesis 2:17; Romans 5:12). It is a common and deserved end for all humans. The good news is that Jesus’s death conquered the power of death. The Gospel message that Jesus’s death brings the forgiveness of sin and that death has lost its sting (1 Corinthians 15:55–57) is a radically comforting ministry for the Christian facing his or her own death. Reassurance of the forgiveness of sins, which brings a renewed life that will continue beyond the present, can bring a true situational comfort and hope to the believer.

Bargaining

Bargaining is another mechanism of coping with impending death. This usually takes the form of, “If I’m really good, maybe God will give me a few more days to live,” or, “If I can just correct something I did wrong, maybe this won’t happen to me.” Patients or their families may secretly make a deal with God or a higher power to avoid the inevitable. Bargaining is sometimes also the first real step toward acceptance of death. For a Christian, this may represent an openness and acceptance of God’s will, that what is happening is indeed within God’s good plan, despite all appearances to the contrary, and under God’s control (Job 14:5).

For the Christian, prayer can be very important at this stage. In the modern, religiously cynical world, prayer is often viewed as nothing more than an opiate by which the fears of the believer will be quelled by the feeling that God will help in some way. Prayer does have the ability to reassure a troubled heart, but only because God has promised to hear the prayers of his children (Psalm 50:15; 145:18–19). A biblical worldview understands that “the effective prayer of a righteous person has great power” (James 5:16). This does not mean that prayer acts as a magical charm or therapeutic panacea that will always bring relief from one’s situation (Parks, 2019). While Jesus could pray fervently to avoid his own painful death by crucifixion in the Garden of Gethsemane, his prayer also demonstrated its ultimate purpose: to conform our will to the will of God and his eternal purposes (Matthew 26:39).

A Christian worldview does not deny that God answers prayers (Psalm 65:2) and is able and willing to help us with our physical needs (Psalm 50:15). Nor does it deny that miracles do not occasionally happen according to God’s own will and purposes. Yet the greatest comfort prayer can possibly afford is to the patient who may be guilt-ridden with the fear of punishment for a past sin or lack of faith. The promise of God’s forgiveness through effective prayer can be the greatest comfort and response to a patient’s self-rejection and resort to bargaining. Prayer is effective and can offer a great deal of eternal hope to a patient when their needs and guilt are understood.

Depression

When a patient begins to finally accept the prospect of his or her own death, as more hospitalization becomes necessary, and as symptoms and weakness progress, the ability to garner psychological defenses becomes weaker. It becomes more and more difficult to deny what is happening. Depression is the natural progression of one coping with the great loss that must be faced.

Depression accompanying grief or mourning, both the patient’s and their loved ones’, can take two forms. The first is associated with the practical implications of loss (e.g., financial burdens and burial arrangements) or from unresolved personal affairs. This form of depression can be a tool to prepare for the impending loss of love objects, such as tending to the future needs of surviving family members, business affairs, or unaccomplished personal goals, in order to facilitate the state of acceptance (Kübler-Ross, 2014).Counseling at this stage can take on practical aspects, helping the patient to take care of personal life issues. In the Old Testament the Lord tells King Hezekiah to “set your house in order” in preparation for death (2 Kings 20:1). This is sound and practical advice that may be of great importance to the patient and family.

The second and more subtle form of depression is more private and quieter. It is a private preparation to separate from life, friends, and loved ones. Attempts to cheer up or to tell the patient not to be sad are not helpful and may even be harmful at this point. A patient in this phase of depression may not wish for a lot of visitors and request only the silent company of a close friend. Depression has long been described as a “tool to prepare for the impending loss of all the loved objects in order to facilitate the stage of acceptance” (Kübler-Ross, 2014, p. 85). At this point, encouragements and reassurances are no longer as meaningful. Patients at this stage have a genuine need and desire for a deep understanding of this period of sorrow. In preparatory grief, there is sometimes little need for words, only presence. It is during this period that a patient will begin to occupy themselves with things ahead rather than things behind.

Acceptance

The final stage of acceptance is the most open period a person facing death will have. It is a point when the patient has exhausted all efforts to deny or bargain away the inevitable and comes to the acceptance of their own mortality and end on earth. This is not to be interpreted as a phase of giving up of all hope, but of simple, realistic acceptance. Giving up hope can be in a very real way fatal. Kübler-Ross (2014) recognizes the role the church or faith community can play in providing this last piece of assurance:

If we take part in church activities in order to socialize or to go to a dance, then we are deprived of the church’s foremost purpose, namely, to give hope, a purpose in tragedies here on earth, and an attempt to understand and bring meaning to otherwise inacceptable painful occurrences in our life. (p. 15)

As a patient accepts death, he or she may very well become open to the real truth of their existence. They begin not to look back on the world they are leaving, but rather to the new life ahead. The prospect of an eternal end may be the most frightening imaginable, but the prospect of an eternal life of peace in existence with God can be the most beautiful imaginable, and one that healthy people all too often take for granted. The New Testament story of the rich man and Lazarus (Luke 16:22–23) shows that personal identity is not lost even in death. The Apostle Paul understood the reality of this hope when he wrote that he desired “to depart and be with Christ, for that is far better” (Philippians 1:23).

The Pastor and Health Care Professionals

Humans are biopsychosocial and spiritual beings. Spiritual ministry needs to be a part of good medical care that cares for the whole patient. Because of the delicate balance between the intellectual, social, emotional, scientific, and spiritual aspects of facing death and suffering, health care professionals need to understand the importance of their partnership with spiritual counselors, pastors, or priests. A good working relationship should exist with them regardless of differences in religious outlooks or perceptions. It is the patient’s own views that are most important.

Many of the anxieties and fears regarding death are natural reactions to the unknown. For Christians, Jesus’s own death on the cross and subsequent resurrection should conquer the unknown spiritual aspect of facing death. The Apostle Paul writes that Jesus’s resurrection is the most significant event in history and that faith would be meaningless without it (1 Corinthians 15:14). The resurrection of Jesus, says Paul, represents the “first fruits” of those who have already (metaphorically) “fallen asleep” in death (1 Corinthians 15:20–23). Paul says this to assure Christian believers that in this same way Jesus’s resurrection is merely the first of its kind, a foretaste and first fruit of what is to come for all believers in the future when God gives them new, redeemed bodies.

Finally, a significant and in many ways the most important aspect of the Kübler-Ross (2014) book is to teach health care professionals to be open to what the patient has to say and offer to them. One of the most vital aspects of caring and comforting dying patients is simply to be there, open and willing to listen to them, especially to their fears, different expressions of inner emotions, including questions of any type, along with personal stories. Listening can be an important part of comforting someone in the dying process. At other times it may be only a silent presence that goes beyond words that is most comforting. These special patients have much to say and teach when encountering such a closeness to death. In many cases, a sincere witness to the Christian faith by such a person may benefit the listener more than anything they can offer to the patient.

Ars Moriendi – Christian Reflection on The Art of Dying Well

How one views death and prepares for its inevitability speaks to how one views life and what one values most while living. To live well is not to live in fear of death, but to be grateful for the gift of life and to understand life’s true purpose. The Christian tradition has a long history of ministry to the sick and dying as well as teaching those still in good health how to prepare for their own death.

The Latin term ars moriendi means “the art of dying well.” The word art in this context means skill, or the practical application of knowledge to concrete situations. Historically, the Ars moriendi refers to Christian texts dating back to the Middle Ages. During the Black Death, or Great Plague, in the 14th century there was a shortage of priests to minister to the multitudes afflicted by the plague. To fill the need, pamphlets referred to as “paper-priests” (Osborn, 2013, p. 1) were published and distributed to households throughout Europe that contained prayers and confessions for the sick and dying. Later, more comprehensive manuals were composed to guide Christians through the process of dying and to teach them on how to die well. They instructed the Christian about what to expect as they transitioned from this life to the next, offered prayers, and provided mental and emotional consolations. In a time and age lacking in the advanced medical therapies and life-saving technologies of today, the Ars moriendi sought to comfort a Christian and to ease their spiritual anxiety by reassuring them of the efficacy of repentance and the assurance of God’s love and grace, even in death.

The original long version of the Ars moriendi, written in 1415 by an anonymous German monk, was composed of six parts. The first part consoled the dying person, explaining that death was not to be feared and extolled the positive aspects of death. It then listed five temptations faced by the dying and how to resist them. These included lack of faith, despair, impatience, spiritual pride, and avarice. This was followed by a series of questions about the dying person’s faith, repentance, and belief that Christ died for his or her sins and exhorting the person to emulate Christ in his own suffering and death. The last sections addressed the family and friends of the dying person, concluding with a series of prayers to be said on their behalf.

To a modern, technologically advanced society, a 15th century manual on how to die may seem quaint and antiquated, if not outright morbid. But modern medicine may present even more reasons for the Christian to appreciate this advice and learn to die well (Moll, 2010). While the medieval plague victims had very little choice in how they were to die, Christians today can face many choices, such as choosing too much end-of-life technology or choosing too little. How aggressive should one be at the end of life? Instead of a peaceful death, should one opt for a technological fight to the finish? Or, if one foregoes the possibility of effective medical intervention, does that mean he or she has not been a faithful steward of God’s gift of life? Facing many of these decisions, especially during times of fear, anxiety, depression, and even anger, requires patience, wisdom, prayer, and counsel.

John Dunlop (2011), a Christian physician who specializes in geriatrics, has written what could be considered a modern Ars moriendi. In his book, Finishing Well to the Glory of God (Dunlop, 2011), he outlines nine strategies for the Christian who is imminently facing end-of-life decisions. Dunlop (2011) also addresses non-Christians who want to reflect on a Christian view of the end of life. For Dunlop (2011), to finish life well is not merely to be happy, free of pain and discomfort, and content. Neither is it to maintain dignity, by which he means autonomy and control. Although these are all desirable and possibly reasonable goals, Dunlop (2011) considers a uniquely Christian approach to the end of life that is a reflection of the Apostle Paul’s God-centered view of life as recorded in his Letter to the Philippians:

As it is my eager expectation and hope that I will not be at all ashamed, but that with full courage now as always Christ will be honored in my body, whether by life or by death. For to me to live is Christ, and to die is gain. (Philippians 1:20–21)

In the last phrase, Paul is not talking about his own gain, but rather how God can be honored even in Paul’s own death. Dying meant for Paul that he would be immediately in God’s presence and that Christ’s victory over death would be honored. To finish well, according to Dunlop (2011), is to glorify God in one’s life right until the moment of our death.

Live Well

The current age is one that worships youth and increasingly devalues the aged and elderly who are, more often than not, pitied and treated with condescension. They represent the growing burden placed on the medical system, and ageism is becoming more pronounced in both job discrimination and the rationing of expensive medical care (Hoehner, 2018). But this is not the biblical view. According to the Old Testament, “You shall stand up before the gray head and honor the face of an old man, and you shall fear your God: I am the Lord” (Leviticus 19:32). To honor the elderly is to show reverence for God.

Dunlop (2011) counsels that by clinging to a contemporary view of old age, rather than the biblical view, one can lose sight of the value of his or her life, even in old age, and compromise their prospects for living a continued fruitful and fulfilling life. To live well, is to recognize one’s God-given value at all stages of life, even near the end. It is to find continued purpose for each day, living to glorify God in everything, and to cultivate and maintain deep and lasting friendships, all the while continuing to invest in one’s health, to function as well as possible, and serve others.

Aging can also be accompanied by many spiritual obstacles to quality living. Dunlop discusses such spiritual trials and temptations that may cause one to doubt their faith, along with the discontentment and discouragement that accompanies becoming more and more limited physically and mentally. Worry and the loss of will to keep living, as well as issues related to dementia, depression, and idleness, are all factors that need to be recognized and addressed with the help of family, friends, and professionals. The Apostle Paul urges his fellow Christians to “admonish the idle, encourage the fainthearted, help the weak, be patient with them all” (1 Thessalonians 5:14).

Let Go Graciously

There are some things and values in this world that must be let go of in order to embrace the promise of eternal life fully. Dunlop (2011) offers advice on strategies to accomplish these difficult transitions associated with facing the end of one’s life. This does not mean one cannot enjoy God’s gifts in this world, but there comes a time when it is wise to shift one’s focus from the goods and values of this world to those of Heaven. “There inevitably comes a time when we must say good-bye to the things of this world, a time when we come to embrace the things and values of eternity” (Dunlop, 2011, p. 57). Giving up some cherished things, be it health, home, or activities, can be one of the most difficult and dreaded aspects of death. Loosening one’s ties to this world is not easy, but an essential part of ending life well. This is not giving up hope, but a realigning of hope, to find one’s hope in the Lord and to recognize that the Lord is good and will do what is right.

Treasure God’s Love and Love Him in Return

God created men and women in his image to have communion and fellowship with him. So central was this to God’s plan for his people that it was worth sending his Son to die to regain that fellowship that was lost through mankind’s disobedience and sin. Mankind is ultimately meant to love God and be loved by God in return. Dunlop (2011) shows that cultivating this inner experience of God’s love will result in “a passion for God and godliness as well as a longing for heaven and our resurrected bodies” (p. 17). Because mankind’s ultimate joy is to experience the love of God, this will transform one’s attitudes toward the end of life.

Grow Through Adversity

Any advice and guidance relating to end-of-life issues cannot ignore the reality of suffering, pain, and adversity. Pain and suffering are not a part of God’s original good creation, but the result of sin. God never promised that a Christian would be free from pain and suffering in this world. A running theme in the New Testament, especially for the Apostle Paul, is how Christians are called to suffer in their identity with Christ’s own suffering and death (Romans 8:17). Suffering and hardship still exists for all those in Christ, but now it takes on new meaning. This does not mean that Christians are to seek out suffering or avoid therapies that can reduce suffering and pain. God’s good gifts include everything the medical profession has to offer in providing relief from the effects of the fall; however, for those redeemed in Christ, suffering does not have to be meaningless, but can be productive, fruitful, and allow for growth.

Embrace a Biblical View of Life and Death

This chapter began with a discussion of the biblical view of life and death. A Christian view of life involves much more than a finite physical existence experienced on earth. Death is an enemy, a punishment for sin, and not part of God’s original plan for his creation. But death is also a defeated enemy through Jesus’s own death and subsequent resurrection. In the wonderful irony of the biblical narrative, death is conquered through death. Death is not a return to inorganic nothingness but is used by God to lead a Christian believer to eternal reward (2 Corinthians 4:17; Philippians 3:10; James 1:12; 1 Peter 1:6–7; 4:12–13; 5:10).

Complete One’s Agenda

Dunlop (2011) encourages those in the end stages of life to use the time to strengthen their relationship with God and seek closure with family and loved ones. It is a chance to reconcile and strengthen family relationships. While there are many practical matters to be addressed at the end of life, including financial arrangements and providing for one’s family and survivors, there is also opportunity to bequeath a spiritual legacy. Israel’s King David understood this when he wrote in the Psalms: “So even in old age and gray hairs, O God, do not forsake me, until I proclaim your might to another generation, your power to all those to come” (Psalm 71:18). Dunlop (2011) reminds Christian believers that they have an opportunity “to leave behind something more valuable and lasting than a piece of property or sum of money” (p. 113). Christian believers have the honor and privilege of leaving a lasting testimony of their faith and what God has accomplished in their lives.

Make Appropriate Use of Technology

Modern medicine and the growing advances in health care technology are a gracious gift from God; however, all technology raises difficult questions about how to use it wisely, ethically, and in a God-honoring way. Whether a Christian believer should choose to pursue aggressive treatments at the end life requires wisdom, understanding, prayer, and counsel. While all life is sacred, there are times when the physical, emotional, and even spiritual burdens of being kept alive through unwarranted medical technologies, when there is little prospect for recovery, can become excessive. While biblical principles do not condone taking another’s life (e.g., euthanasia or PAS), there is a real and important difference between killing and allowing death to occur through the natural process of a disease or illness. There are times when it is ethically permissible to do less than everything possible to preserve mere physical existence. When death is inevitable, Christians should view death as a defeated enemy and not resist or fear it.

Making one’s end-of-life wishes known is an important part of end-of-life care, whether this takes place as open and frank discussions between family and physician, or in written documents such as advance directives or living wills that can convey a person’s wishes at a time when he or she is unable to do so. For the Christian believer, this can be especially important. Far from usurping God’s timing, it communicates to others a desire to allow death to occur when medical technology has reached its limits, witnessing to a hope in a future resurrected life. It can also communicate a faithfulness and trust in God’s promise to be present in the face of end-of-life decisions and to comfort the afflicted (2 Corinthians 1:3–4), as well as an unwillingness to allow others to end their life prematurely by succumbing to the temptation of PAS or euthanasia.

Changing Gears from Cure to Comfort Care

One of the most important aspects of end-of-life care is being able to recognize the need for and timing of transitioning to the goal of what medicine is trying to ultimately accomplish. At some point, it may be appropriate to focus more on comfort and care as the goal of medical treatments, rather than curing. These decisions are never easy for the patient or the family and involve a host of physical, emotional, social, and spiritual factors.

Daniel Callahan (1993), a bioethicist, provides a series of helpful guidelines regarding when it is appropriate to transition to comfort care from a medical standpoint. Changing the goals of treatment from cure to comfort may be appropriate when there is a strong possibility of death in which the available treatments and therapies will likely only prolong pain and suffering, become excessively burdensome, or bring extended unconsciousness or alterations in one’s mental state (Callahan, 1993).

Emotions associated with end-of-life decisions can vary from person to person. Earlier in this chapter Kübler-Ross’s (2014) stages of grief were outlined and discussed from a Christian and biblical perspective. Earlier stages of the grief process, such as denial, anger, bargaining, and depression can be obstacles for making an appropriate decision to move toward palliative and hospice care. When counseling patients, their families, and loved ones, it is helpful to recognize the stage of grief at which one is in so he or she may transition toward acceptance, which will provide an easier and more comfortable change in the goals of medical treatment.

A very important point to emphasize is that, in this transition, cure and comfort are not mutually exclusive categories, but merely represent what the ultimate goals of medical care now entail. Many have the mistaken impression that palliative and hospice care are forms of giving up. This is inaccurate and a misunderstanding of what palliative and hospice care are about that can lead to either a reticence to or delays in appropriating this specialized form of care to the point it cannot help as it was designed. While the focus becomes more and more fixed on symptom relief, comfort, and prioritizing a patient’s personal, emotional, and spiritual needs over burdensome and ultimately ineffective cure-directed treatments, hope is never abandoned and options for further treatments can be pursued alongside an increasing emphasis on comfort measures.

Christian believers need to recognize when it is proper to allow for death and switch to comfort and care measures as opposed to cure, to allow spiritual matters to take priority, and for times of closure. But these decisions should be guided by biblical principles and not unbiblical notions such as being a burden to others or fearing loss of control and dignity. Modern society equates a person’s dignity with an absolute autonomy—an attempt to control one’s life and destiny completely (Genuis, 2016). To lose control at the end stages of life and become a victim of pain, suffering, and the fear of death, is equated with a loss of dignity and is usually given as the justification to forego further medical treatment, to refuse life support, or even to opt for radical and unbiblical solutions such as euthanasia or PAS. A Christian, however, understands that God is in control of all things, that physical trials and suffering can be productive, and that our ultimate dignity is rooted in being made in God’s image. The Gospel message of Jesus’s death and resurrection frees the Christian from the ultimate fear of death (1 Thessalonians 4:13–14; Hebrews 2:14–15).

Rest in Jesus

Even though the Gospel message frees the Christian believer from the ultimate fear of death, the process of dying can remain difficult, painful, and unpleasant. Yet even in one’s suffering, God has promised to be there: “Even though I walk through the valley of the shadow of death, I will fear no evil, for you are with me; your rod and your staff, they comfort me” (Psalm 23:4). To rest in Jesus is to trust in his ultimate provision for eternal life, having removed the “sting of death,” and to assure us that there is no longer anything one can do, has done, or left undone to change this (1 Corinthians 15:55–57). The rest Jesus brings is to unburden one from the fear and consequence of death and to give glory to God by entrusting control of one’s life to him.

Case Study: Devastating Traumatic Brain Injury

A 17-year-old female is involved in a head-on motor vehicle accident on the Ohio Turnpike. After taking approximately 45 minutes to extricate her from the wreckage, the patient is air evacuated to a Toledo, Ohio trauma center where she is intubated and comatose. She has multiple long-bone fractures, a pneumothorax, and severe head trauma with multiple cranial fractures and intracerebral hemorrhage. After initial hemodynamic stabilization, the patient is admitted to the Intensive Care Unit (ICU). Although hemodynamically stable (systolic blood pressure > 100 mm Hg) and on a ventilator, her pupils are fixed, dilated, and unreactive. Her core temperature is 37.2° C. She has not had any discernible reflexes or movement, neither spontaneous or in response to pain or airway suctioning, since admission. The parents, who were notified and arrived 2 hours later, are understandably distraught and in a state of emotional shock. They insist that everything conceivable be done for their daughter. After 36 hours, there is no change in her neurological status, although she now makes some barely-discernible respiratory efforts when disconnected momentarily from the ventilator. The attending physician is on his way to the ICU waiting room to discuss the dismal prognosis and possibility of organ donation. As he approaches, both parents jump from their chairs and embrace the physician, thanking him for doing such an excellent job in keeping their daughter alive, expressing continued hope in her recovery as their whole church has been praying fervently, and reiterate their conviction that everything possible be done for their daughter.

Click to load
Check for understanding

Conclusion

Death, dying, and grief are never easy topics to discuss. The ordeal of confronting one’s own mortality or that of a loved one or family member is one of life’s greatest fears. For the Christian believer, the death and resurrection of Jesus transforms the meaning and significance of death and provides a new perspective on the sufferings and trials associated with the end of life. This is never to suggest that there is no longer a real dread at the prospect of dying, even for a Christian believer. Death is still an enemy, but now a conquered enemy. St. Augustine (trans. 2000), the 4th-century African bishop and arguably the most influential early Christian theologian, understood this fear and dread, but also offered a comforting word of hope:

We are constrained to die, and no one wants to. Nobody wants something that constrains us all. No one wants something that will happen whether we like it or not…If it were possible, we would certainly choose not to die…by some transformation that did not involve dying…We want to reach God’s kingdom, but not to travel there through death; yet constraint stands there saying, ‘This way.’ Do you hesitate to go that way, poor mortal, when by that same route God has come to you? (p. 332)

It is the irony of the cross that death has been conquered through the death of God’s son, and it is by sharing in his death and resurrection through faith that a Christian believer can possess the sure hope that suffering and death has meaning that transcends this earthly existence.

The Christian biblical worldview, especially the doctrine that all men and women possess an inherent and inviolable dignity as creatures made in God’s own image, gives guidance and direction when confronting many end-of-life ethical issues. Christian health care professionals need to understand the basis of their calling to medicine, to always provide comfort, care, and cure when possible. The relief of suffering in this world is part of the Christian mandate, but it must never be achieved through killing the sufferer. Euthanasia and PAS are directly opposed to God’s direction, the inherent dignity of every man and woman, and an affront to the profession of medicine.

Additional Resources

Carter, J. (2019). End of life issues: Death and dying. Retrieved from https://www.thegospelcoalition.org/course/end-life-issues/#death-and-dying.

Christian Medical & Dental Associations. (2018). CMDA position statements: Based on scientific, moral and biblical principles. Retrieved from https://cmda.org/wp-content/uploads/2018/05/CMDA-Position-Statementsworeferences18.pdf

Davis, B. (2017). Departing in peace: Biblical decision-making at the end of life. Phillipsburg, PA: P & R Publishing Co.

Dunlop, J. (2011). Finishing well to the glory of God: Strategies from a Christian physician. Wheaton, IL: Crossway.

Dyck, A. J. (2002). Life’s worth: The case against assisted suicide. Grand Rapids, MI: Wm. B. Eerdmans Publishing Company.

John Paul II. (1995). Evangelium vitae. London, England: Catholic Truth Society.

Kilner, J. F., Miller, A. B., & Pellegrino, E. D. (Eds.). (1996). Dignity and dying: A Christian appraisal. Grand Rapids, MI: Wm. B. Eerdmans Publishing Company.

Kübler-Ross, E. (2014). On death and dying: What the dying have to teach doctors, nurses, clergy & their own families. New York, NY: Scribner.

Lewis, C. S. (1996). The problem of pain. New York, NY: HarperCollins.

Meilaender, G. (2013). Bioethics: A primer for Christians (3rd ed.). Grand Rapids, MI: William B. Eerdmans Publishing Co.

Shuman, J. & Volck, B. (2006). Reclaiming the body: Christians and the faithful use of modern medicine. Grand Rapids, MI: Brazos Press.

Steward, G. P., Cutrer, W. R., Demy, T. J., O’Mathúna, D. P., Cunningham, P. C., Kilner, J. F., & Bevington, L. K. (1998). Basic questions on end of life decisions. How do we know what’s right? Grand Rapids, MI: Kregel Publications.

Steward, G. P., Cutrer, W. R., Demy, T. J., O’Mathúna, D. P., Cunningham, P. C., Kilner, J. F., & Bevington, L. K. (1998). Basic questions on suicide and euthanasia. Are they ever right? Grand Rapids, MI: Kregel Publications.

Vandrunen, D. (2009). Bioethics and the Christian life: A guide to making difficult decisions. Wheaton, IL: Crossway Books.