Hester, a forty-five-year-old wife and mother of three almost-grown children, is diagnosed with ovarian cancer, after it has spread throughout her body. In the final stages of the disease, the cancer has spread to her brain, causing frightening hallucinations and intractable pain. Increased doses of morphine do little to alleviate her symptoms. The care she receives fails to reduce the level of fear she feels in her clearer moments—fear of losing sanity and control, and of dying alone. She chooses, with her family at her side, to take a lethal dose of pain medication that she has been saving up. However, once the truth of her decision is discovered, her family is denied the life insurance benefits that could have helped provide the money she had intended to earn for her son’s college education.
Considering the reality and the difficulty of such situations, it is understandable that Ballot Measure 16, the “Death with Dignity” act, is on Oregon’s November (1994) ballot. If approved, this measure will make it legal in some circumstances for physicians to prescribe medication to a patient to end his or her own life in a “humane and dignified manner.” In Hester’s case, the legal right to end her own suffering would have allowed her family the death benefits to which they would have been entitled had she died naturally two weeks, or two months, later.
The motivation for such a measure is a merciful pragmatism, with the goal of alleviating pain and suffering in terminally ill patients. Proponents argue that since pain and suffering are not always manageable, assistance in suicide protects the patient’s dignity. Having legal suicide as an option provides a comforting sense of control to the terminally ill patient. Instead of being at the mercy of a merciless illness, the patient is allowed to choose how and when death comes.
Comfort care and hospice care are not available to all patients, argue proponents of Measure 16; therefore, physicians should be permitted to help terminally ill patients who desire to end their lives. And Measure 16 provides “safeguards” to protect the patient from being pressured by the doctor; the patient, not the doctor, must initiate the request for life-ending medication. It would also be a Class A felony for anyone to coerce the patient, alter or forge a request for medication, or conceal a withdrawal of the patient’s request for life-ending medication with the effect of causing the patient’s death.
Opponents of the measure are also motivated by a desire to alleviate suffering, arguing that if physicians did a better job of controlling pain, patients would not wish to end their lives. Such a measure, opponents argue, could result in decreased efforts toward better pain control, comfort care, and hospice care.
In addition, although the measure is designed to avoid abuses, opponents consider assisting patients in suicide an inappropriate role for physicians. Despite safeguards, in an age of managed care when doctors’ earnings can be related to how well they control costs, suicide could become the most economical treatment option for the terminally ill, especially for the elderly or those without good medical coverage. Under Measure 16, physicians without training in the treatment of terminal illness could establish suicide clinics specializing in aiding the terminally ill to end their lives. Legalization of assisted suicide creates a slippery slope, leading the way toward the practice of active euthanasia by judgement call of the physician on hand. Granting this kind of authority to a fallible physician is considered at best unwise, and at worst, dangerous.
Opponents also point out that the federal “Patient Self-Determination Act” of 1990 protects the right of an individual to refuse unwanted medical treatment and allows for the formulation of an Advance Directive to that effect upon entrance to a hospital. Additional legislation is considered unnecessary and confusing. Proponents of Measure 16 argue, though, that even with this protection, the specificity required in the Advance Directive can leave the patient vulnerable to being resuscitated involuntarily.
How to Decide?
With both sides issuing compelling arguments motivated by compassion, how are we to decide on this issue? Is there a right and a wrong answer? What do we believe about what it means to be human, to have dignity, and to suffer? How we define what it means to be human, with value and dignity, and on what basis, is central to this debate. Our beliefs about human suffering play an important part as well.
Our actions are based on what we believe to be true. We each hold assumptions about reality that direct how we interact with our world. These assumptions make up our ‘world view’, and consciously or not, dictate the decisions we make. We interpret new information and form conclusions consistent with what we already believe to be true. In order to hold a world view with integrity, we must examine what we believe and why we believe it. Therefore, we must step into the presuppositions that lie below the surface, and examine the assumptions we bring with us into this and any other debate.
Historically, these questions have been answered in the context of a Judeo-Christian world view, which assumes that humans are creatures created in the image of God and ultimately at His mercy. Accordingly, we humans do not have the authority to make such decisions concerning our own death. Recently, however, our consensus as a culture has moved away from these beliefs, toward a secular, subjective view of humanness. We are left with humanness being whatever we decide it to be. Therefore, we have the authority to decide for ourselves what is or is not true, and to choose for ourselves when and how to die.
The dominant secular view of what it means to be human is rooted in philosophic ‘naturalism’, the assumption that human life came on the scene as a culmination of evolutionary process, and that time, chance, and matter are the essential ingredients in the universe. This assumption gives rise to another assumption: life is a complex machine, and humans are merely adapted to reign supreme in this age, much like dinosaurs were adapted to reign supreme in theirs. Within the world view of philosophic naturalism, then, an impersonal universe plus time, chance, and matter has given rise to the biological phenomenon known as ‘humanity’.
The problem with this view is that the material universe in and of itself gives no basis for values. Unavoidably, the basis for human value becomes relative and subjective. Ultimate truth—explanations which would be true for all time and all people—is non-existent. We have value because we assign it to ourselves. Self-determination becomes the greatest good. Hence in this framework, controlling my own destiny, especially with regard to how and when I die, is a valid conclusion.
Within the dominant secular view of humanity, a second component, ‘eastern pantheism’, often accompanies naturalism to bring about various ‘New Age’ ideologies. Much eastern thinking assumes that all things are a part of the ‘One’, an impersonal force out of which all things emerge and re-emerge. External reality is considered illusory, as are concepts such as good and evil. The culmination of all life is to return to the essence of the One, to lose distinctiveness, and to attain the metaphysical state of oneness. When applied consistently, eastern philosophy provides no real basis for the existence of unique human value. Since value constitutes a distinctive, and distinctives must be lost in order to attain true fulfillment, human dignity is illusory. Again, the basis for human value is ultimately subjective.
Both naturalism and pantheism have one thing in common: they assume that the universe is ultimately impersonal. In an impersonal universe, the existence of distinctive personality, and therefore of human uniqueness and dignity, is problematic; it is an added feature, one that we design for ourselves, apart from any accountability outside of ourselves. But if the universe is impersonal, is there any basis for a belief in human dignity? If the universe is composed of the impersonal, plus time, chance, and matter, why would we experience our lives as having inherent value?
Our intuitive rationality as humans demands that we make sense out of our world. Our world view must provide the most coherent, comprehensive explanation for the “evidence” with which our senses and experiences confront us. Historical, biblical Christianity provides what I believe to be the best explanation for this evidence.
A Basis for Human Dignity and Value
Christianity begins with the existence of a personal but transcendent God who created humankind in His image. Our rationality, along with our intuitive sense of worth and value, all flow from having been created. According to the Christian view, the basis for human dignity and value rests in the assumption that God has created us with dignity and value. ‘Human’ and ‘dignity’ are inseparable by virtue of God’s design; the human creature was given dignity and value by the Creator. The implications are staggering. If God, who is objectively outside of us and outside of our universe, defines being human as intrinsically valuable, then we are valuable. This is true despite what career or profession one is able to pursue. This is true despite what economic status one is able to achieve. And this is true despite the toll that a terminal illness is able to take on the body.
Suffering, then, has a vastly different role in human experience depending on the world view from which it is seen. In an impersonal universe, there are no ultimate and universal moral values. From a naturalistic world view, pain and suffering have no purpose and so should be eliminated whenever possible in order for life in the here and now to have its best result. Modern technology, therefore, seeks to make our lives and work easier and less painful. From within a Christian world view, however, suffering has a profound role to play in human experience. The existence of our concept of right and wrong is explained by the view that God exists and that the universe is His creation. (For more on this, see C. S. Lewis, Mere Christianity, “Right and Wrong as a Clue to the Meaning of the Universe.”) And if moral virtue exists and is grounded in God’s existence and nature, then there is something more important in this life than the absence of suffering. According to the biblical authors, patience, perseverance (in faith), proven character, and maturity of spirit are all virtues forged in the furnace of affliction and suffering. In a moral universe, these virtues are more valuable than the absence of pain. If we see suffering as something to be aborted at all costs, then these virtues will also be aborted.
When we set aside the Judeo-Christian framework, we lose any basis for human dignity. Instead, dignity is defined subjectively as “level of comfort” or “lack of embarrassment.” In other words, if I must suffer terrible physical pain and cry out in my suffering, I have lost the dignity of being human. Or if at the end of my life I become a bed-wetter, I have lost the dignity of being human. But with God as the definer of human dignity, we are truly human in whatever circumstance we find ourselves.
A Basis for Right and Wrong
When we set aside the Judeo-Christian framework, we also lose any basis outside of ourselves for a definition of right and wrong. We are left with many finite authorities for deciding on good and evil, rather than an authority which is universal, grounded in the character of the God who exists and who created the universe. If God is not our universal authority on matters of life and death, then the only authority remaining is human authority. And once a universal authority for right and wrong is abandoned, we have no basis for thinking that we are immune from the errors of Nazi Germany.
The analogy with Nazi Germany may seem strong or reactionary, but in point of fact, death with dignity was a major issue debated in the pre-Nazi era. In 1920, a book entitled The Release of the Destruction of Life Devoid of Value was published in Germany. In it, the phrase “death with dignity” was used as the motto for what became a movement to legalize the killing of a person who had the “right to the complete relief of an unbearable life.” If “unbearable” was at first defined as a grossly deformed child, we know that it later came to be defined as anyone not of Aryan descent.
In setting aside the belief in universals, we set aside any basis for saying that anything is inherently right or wrong, including the basis for deciding what is the appropriate role for the physician. Dr. Mildred F. Jefferson, a surgeon and professor at Boston University Medical School, has said, “The doctor who willingly accepts destroying life will have no grounds on which to object if the State should compel that doctor to destroy life. I will not accept the proposition that the doctor should relinquish the role of healer to become the new social executioner.”
Having set aside the belief in universals, our society is in the process of assigning the authority to physicians for deciding when life has become unbearable. Although portrayed in Measure 16 as a patient’s individual decision, the physician is the one who decides to prescribe a lethal dose of barbiturate for his patient. In case of error in dosage or administration, it is unclear whose decision it becomes to end the life. If the dosage or administration is not sufficient to end a patient’s life, but only sufficient to produce coma, it will then be someone else’s decision whether to become actively involved in the termination of that life.
In the Netherlands today, it is reported that fifty-one percent of the euthanasia practiced is involuntary. Doctors take upon themselves the role of sparing families the “difficult decision” of whether to put a loved one on life support following a serious car accident. A three-day-old Down syndrome baby can be euthanized to spare the family the life of difficulty ahead of them. (Unfortunately, the severity of Down syndrome, which is quite variable, is not knowable at three days old.) Is it appropriate that as a society we assign the authority for the definition of an “unbearable” life to the medical community?
In conclusion, the “Death with Dignity” act provides an attractive illusion of control over our suffering as humans. As humans, we do not usually get a choice of when or how we die, any more than we get a choice of when we are born. Our lives and our destinies are ultimately in the hands of God. And, if the Christian view is right about the God in whose hands we find ourselves, He is trustworthy. We can trust Him to end life at the right time. More importantly, we can trust Him to be involved for our good even in the depths of our pain. Not only this, but He is mercifully sympathetic with our suffering, having Himself suffered and died as a human.