Preface⤒🔗

As medical technology has become more complex we are confronted, both as individuals and as office-bearers, with questions of great difficulty. What course should be taken or advised in circumstances of serious illness? Are living wills proper? Should all treatment always be used or accepted? Can or should treatment sometimes be refused?

These questions are vexing yet common ones throughout our congregations. Synods of 1993 and 1994 appointed a committee to examine these issues and provide advice from a biblical perspective. The committee's report was presented to and approved by Synod 1996. In due time we hope to publish it in booklet form for availability in the congregations. We hope that you will keep a copy of this booklet for reference in the event that you are confronted with decisions of this type.

We hope that the report will be helpful to many. May we learn to bring our questions and needs to the Lord, imploring Him to shed light on His Word and apply it to our lives. The Moderamen of Synod 1996

We propose to consider the subject of medical decision-making from a number of perspectives. First, we shall present without detailed explanation some biblical and theo­logical premises which underlie our subsequent discussion. Next, we shall discuss the philosophical view of death which forms the backdrop for much of the contemporary approach to the subjects of living wills and medical decision-making and contrast that with a biblical view. We then review the various legal instruments in common use for dealing with medical decisions when an individual is unable personally to participate in these decisions. Medical technology and the decisions which may confront individuals are surveyed next. Finally we present our analysis of these areas.

Biblical and Theological Premises←⤒🔗

Since medical treatment and medical technology have changed dramatically over the past 100 years, one cannot look to the Bible and to the writings of our forefathers for specific guidance on the subjects dealt with directly in this report. Nonetheless, the Bible is not silent on the subjects of sickness, suffering, and death. General premises which must form the foundation of any right understanding of these matters should be derived from Scripture.

Man was created in God's image, endowed with an immortal soul, and was the crown jewel of creation. The image of God has been fully lost in the narrower sense characterized by true knowledge, righteousness, and holiness but is retained by man in the broader sense and distinguishes man from the rest of creation. We are therefore obliged to treat man with special respect and with special regard to the sanctity and dignity of his life.

Sickness and Sin←↰⤒🔗

Sickness, suffering, and death were not present from the beginning. When God saw that all was very good in His creation, man experienced none of these matters. Death was not natural in man's original state. Only after the fall did death, and with it sickness, enter the world. "In the day that thou eatest thereof thou shalt surely die."

Sin, then, is the root cause of the suffering in the world, also of the suffering brought on by illness and disease. Care must be taken, however, not to assign an individual's particular illness or circumstances to specific sins in that person's life. Jesus condemned such efforts when discussing the fall of the tower of Siloam and the man born blind. An illness may be sent by God as a warning or chastening, but specific connections may not be apparent to us. Our thoughts are not God's thoughts, and our ways are not His ways.

Sickness and Providence←↰⤒🔗

All of life's circumstances are in God's hand. His providence directs all that transpires in our lives, including "health and sickness." Nothing in our lives or in human experience is meaningless or purposeless, although our ability to discern His purposes is limited. We are called upon to submit to His will in all things, including our health. Yet we are also to act responsibly and to employ lawful means. The doctrine of providence does not permit us to become fatalistic nor does it encourage a mere stoicism.

Suffering or adversity clearly have different roles in the lives of the unconverted than they do in the lives of God's people. For the latter, suffering may reflect God's chastening hand or may be His method of keeping His people close to and dependent upon Him. This is obviously not the case for the unconverted, for whom suffering may be intended as a warning or as a punishment for sin. How an individual reacts to suffering or sickness, and our assessment of that reaction, will be determined in part by his spiritual state. The propriety of an individual's particular health care decisions will likewise be determined in part by the individual's state.

Death←⤒🔗

We must all die. The inevitability of death is apparent to all, even to those who are not religious, but the significance of this event is not equally apparent to all. Modern man has increasingly adopted the notions of death as either a passage to oblivion or a passage to universal happiness. Consequently, death is feared not for its significance with regard to a future state but rather because it means an end of our earthly existence. When that earthly existence becomes unpleasant or is no longer desirable for whatever reason, death is seen as a good. Death is therefore viewed as something which man ought to be able to summon to control the circumstances of our life when they are perceived to be intolerable. Man as an independent and self-governing being thinks he should be able to choose to die.

Parallel to the notion of death as a choice for an independent and self-governing being is the notion that death is yet another technological problem which may be solved or treated by advances of medical care. Death is increasingly viewed as an evil which could in theory be pushed back indefinitely by technology. This notion represents an attempt to deny the inevitability of death. The think­ing of those who hold high views of the sanctity of life can easily be tainted by this notion because of a perceived obligation to pursue all available means to sustain life.

Whereas death historically was part of the fabric of daily life, it has now become a technological and formal affair. No longer does death usually occur at home or in the presence of family and friends. No longer are last respects paid at home. Death typically occurs in the hospital or in a nursing facility, with the trappings of medical technology. Funeral homes attend to the needs of families and friends, and death is removed from consciousness for many. This process tends to compound the erroneous conceptions of death outlined above.

A biblical concept of death, however, recognizes death as the consequence of the fall. Death is not a problem to which a technological solution should be sought or will be found. Death represents a passage to eternity, to either eternal well or eternal woe. It is the end of the time of grace for the unregenerate and the entry into eternal glory for the regenerate. For the latter, the passage through death is the last enemy, but it is also a great gain. The time of our death is not in our own hands but in the hand of the God who numbers the hairs of our heads. For the living, the death of a loved one or acquaintance should be an occasion to reflect on the certainty of eternity. It should not be something to treat lightly or to ignore. Yet the very nature of modern medicine makes death a technical event even for God's people in many cases. This presents serious moral questions which merit further exploration.

Current Legal Instruments←⤒🔗

Current medical and legal practice require the participation of the patient in the decision-making process regarding his health care. For a given illness, the individual circumstances usually are such that there is no single correct way to proceed. There are usually a number of treat­ment options. These options will have differing potential risks and potential benefits. The risks and benefits need to be weighed in recommending treatments, and often the wishes of the patient are the deciding factor in the final treatment plan. As long as the patient is mentally competent to participate in the decision-making process, living wills or similar documents are not important. A living will is only relevant when the patient is unable to participate on his own behalf.

The Living Will←↰⤒🔗

The simplest document is the living will. This is a brief expression of one's desire not to have life support in the event of a terminal illness. This document takes its philosophical basis from a perceived natural order of which death is a part. It is thoroughly humanistic in outlook, as it treats death as just another event in human existence, one with no further significance. Its brevity makes it very difficult to interpret since the varied circumstances which arise at different junctures in an individual's terminal illness do not always neatly fit the description provided in the document itself.

The Advanced Directive←↰⤒🔗

In an attempt more precisely to describe what forms of treatment an individual would assent to and under what circumstances this assent would be given, other forms of "advanced directives" have been developed. These documents outline in some detail treatment wishes regarding life support systems, other "heroic" measures, surgical or other medical treatments when potential benefits are small, and even antibiotic therapy and artificial feeding and nutrition in the event of terminal illness or irreversible coma. In spite of the greater detail of the specifications in these documents, the enormous complexity and variety of individual illnesses and circumstances often leave uncertainty as to the applica­tion of these wishes. Advanced directive documents do have the advantage, however, of permitting a person to direct his physician to provide treatments. This is in contrast to living wills which generally direct the physician not to treat under particular circumstances.

The Durable Power of Attorney←↰⤒🔗

An even more sophisticated instrument for medical decision-making in the event of a person's inability to make his own decisions is the designation of another person to make those decisions when necessary. This has become the most commonly used instrument and is far superior to a simple living will. In most states or jurisdictions this is done by appointing a "durable power of attorney for health care." This person, whose power to act arises only when the patient is incompe­tent, has full legal authority to make any and all decisions regarding the health care of the patient. Such an arrangement obviously precludes the necessity of spelling out wishes under a variety of circumstances but does necessitate that the appointed individual be aware of the wishes of the patient and be willing to act on his behalf. Usually the appointed individual is a spouse or child, but any trusted individual can usually be named. The appointed individual can then weigh the subtleties of the risks and benefits of any proposed course of treatment, including the moral issues, and direct the health care providers in accordance with the patient's own wishes.

Medical Technology and Medical Decisions←⤒🔗

As a result of advances in medical science, many diseases can be cured or treated in ways unknown a few decades ago. Life expectancy has been prolonged. Coincident with this has been an increase in the number of those suffering with chronic diseases. These chronically ill persons often suffer slow declines in their physical condition and become susceptible to a wide range of complications. The application of existing technology for treating the underlying illness and the superimposed complications in these cases often leads to the patient and his family being confronted with difficult decisions. The boundaries between proper use and abuse of this technology is not always clear. Does the existence and availability of a therapy or technology require its use in all circumstances? This question is a central one in addressing the moral issues surrounding living wills or advanced directives.

Types of Decisions←↰⤒🔗

We will first examine some of the types of decisions which may confront patients and families. These decisions may be relatively simple, as when there are two or three possible modes of therapy for a particular illness, all with reasonably good likelihood for succeeding and with relatively low potential for adverse outcomes. In other circumstances, a new or experimental form of treatment with an increased chance of success but with greater risk of side effects may be an alternative to older treatments. How much risk should be taken in this case? In yet other circumstances, no treatment with any great likelihood of success is available, but some therapy is offered which may be of little benefit. Should it be accepted? Is it proper to decline therapy? If so, under what circumstances may this be done?

Once a form of therapy is chosen, further decisions may be confronted. The therapy may be achieving some benefit but at the cost of significant adverse effects. Should it be continued or can it be withdrawn? If no other treatment is available, does that obligate the patient to continue a risky treatment? If the treatment is not successful, does one seek less tested or non-traditional treatments? Is it proper to participate in medical research where different forms of treatment are compared?

Decisions About Unsuccessful Treatments←↰⤒🔗

Yet other decisions are confronted when it is clear that a treatment is not succeeding and other treatments have already been unsuccessful or are unavailable. When this occurs in the setting of a chronic stable or slowly progressive illness, the patient may suffer its effects for a long period of time. When it occurs in the setting of a progressive or terminal illness, other considerations arise. Should attempts be made at resuscitation in the event of a cardiac arrest? Should intervening infections, such as pneumonia, which may in themselves be treatable, be treated aggressively? Should artificial feedings be administered? Should blood transfusions be given? If a form of treatment is initiated and the patient continues to decline, can it be withdrawn? Should artificial feedings be withdrawn if they are prolonging a terminal condition? If so, under what circumstances should this be done? Should needed pain medications be administered or requested if they may hasten death?

It is not possible to list all the potential decisions which may confront a patient or family. Those described above are fairly commonly encountered. The circumstances in which these encounters occur are often filled with uncertainty. Medical science remains imprecise; predicting outcomes and treatment success is difficult. We must confess that our times are in His hand and we must look to Him for blessing on the treatments and for guidance in the decision-making process.

Analysis of Principles←⤒🔗

We first emphasize the unique nature of man in God's creation. Man alone was created in the image of God and remains an image-bearer in the broader sense. Although man has "lost all his excellent gifts which he had received from God and only retained a few remains thereof," God still commands us to respect human life. Murder is explicitly forbidden by biblical example and precept. Man is endowed with an immortal soul which will appear before his Creator at death.

We also affirm the lawfulness of using the means of medicine to treat illness. We further affirm that the gift of life entrusted to us by God obligates us to use the means at our disposal to extend life when possible. We reject the view of those who hold that the only proper means of treat­ment is prayer or faith in divine healing. There is no biblical condemnation of resorting to the physician for treatment. Man was created as a responsible creature and was given gifts of understanding, also in the science of medicine. These must be seen as gifts of God through common grace, and we are not to neglect or despise them. The means must be used, however, with prayer and in reliance upon God to bless them.

Experimental Therapy←↰⤒🔗

We do not believe that the obligation to use the means extends to seeking out experimental or non-traditional forms of treatment if no standard treatment is available. We do not, however, condemn participation in medical research protocols if the patient and family wish to do so. Any research or treatment, however, which is not morally justified is to be condemned regardless of its particular benefits to the patient. We therefore condemn therapies which involve the use of foetal tissue or cause harm to others.

Euthanasia←↰⤒🔗

We strongly condemn any actions which are taken with the express purpose of causing the death of oneself or another. This extends to physician-assisted suicide and to active euthanasia, in which the physician directly administers or orders the administration of a lethal medication. Such actions are in conflict with the sixth command­ment. I am not to "kill my neighbor, by myself or another" and am not to "hurt myself or wilfully expose myself to any danger." We do not include in this category the adminis­tration of pain-relieving medications to control severe or intractable pain, even if doing so carries some risk of hastening death. Relief of pain is a morally unobjectionable act, and the medication used for this purpose is not administered with the express purpose of causing death.

We do not believe that there are circumstances which permit the non-dying patient to refuse life-sustaining treatments even though suffering may be prolonged. Chronic illness, even though fraught with suffering, does not justify an attempt to control the circumstances of one's death. Doing so denies the sovereignty of the Lord over our life and death. We are to submit to the Lord, confessing that "all things come, not by chance, but by His fatherly hand." Our suffering, too, has a purpose in His eternal counsel. We believe that this applies to the non-dying but permanently comatose or vegetative patient as well.

Decisions by the Dying←↰⤒🔗

The irreversibly dying person, however, poses the most difficult situation. In this category we would include not only those with obvious terminal illnesses such as cancer, but also those with the end-stages of chronic illnesses such as heart, lung, or kidney disease, and those who are seriously ill with processes for which there is little hope of recovery. These latter cases would generally be patients who are critically ill with multi-system diseases (involving more than one organ or body system) and also have had progressive deterioration in spite of aggressive medical management of their illnesses. We recognize that medical science does not permit precise prediction of chances of recovery, but it does permit reasonable estimates, especially after a period of observation and treatment.

Here we believe that some decisions must be left to the individual conscience. We do not believe that all patients with such illnesses are obligated to submit to therapy or continued therapy for their illnesses. An elderly person with a terminal disease for which therapy is of limited likelihood of benefit may law­fully decline therapy for that condition. He may also, however, lawfully choose to undergo the treatment. In making these decisions, legitimate consideration may be given to the likelihood of benefit from the therapy and to the risks attendant upon its use. We do not believe that binding moral rules about the rela­tive benefits and risks which would make a particular therapy obligatory or optional can be formulated. Further, we believe that an irreversibly dying person may elect to discontinue a therapy which is not providing significant benefits or which is itself causing significant suffering.

Heroic Treatments←↰⤒🔗

We do not believe that an irreversibly dying person is obligated to accept heroic measures, such as resuscitation or major surgery, for expected complications of his illness.

We do not believe that the withholding of normal food and hydration, even in the case of an irreversibly dying person, is permissible. Food and water must always be offered, but feeding need not be forced if the person refuses or is unable to take it. We do not necessarily extend this to artificially administered nutrition (e.g., via a tube through the nose or stomach wall or via a vein) in the event that the patient is no longer able to take sufficient nutrition in a normal manner. We believe that the decision to accept or reject treatment for complicating and potentially life-threatening illnesses in the irrevers­ibly dying person is best left to the individual conscience. In general, we believe that such treatment should be used if it is not especially burden­some and if it does not simply extend an agonizing process of dying.

Recommendations←↰⤒🔗

Within the context of these principles we return to the issue of living wills and advanced directives. We reject the use of a living will which simply refuses treatment based on a notion of avoiding suffering or a desire for a "good death." We also condemn advanced directives which preclude the use of the means of medicine when the therapy may be beneficial but risky or painful. We do not, however, reject advanced directives which inform the treating health professionals of the individual's beliefs regarding the nature of human life, suffering, and death. We find that the most appropriate mechanism for guiding those who will care for us is the designation of another person as a decision-maker on our behalf in the event we are unable to participate ourselves. We would encourage all who do so to have careful and prayerful discussions with that person regarding the issues involved.

Memento Mori (Remember to Die)←⤒🔗

"To everything there is a season, and a time to every purpose under the heaven: a time to be born and a time to die." Modern medicine has made many advances, yet for all of us there will be a time to die. We should not avoid thinking about the manner of our death but should not place so much emphasis on the physical aspects of death that we neglect its eternal significance. May we by grace learn to say with Paul,

"For none of us liveth to himself, and no man dieth to himself. For whether we live, we live unto the Lord; and whether we die, we die unto the Lord: whether we live therefore, or die, we are the Lord's. For to this end Christ both died, and rose, and revived, that He might be Lord both of the dead and living."