Keep that verse in mind as you ponder the fate of a young British soccer fan named Tony Bland, who, in 1989, was caught amidst a thronging mob at a big game and left mortally crushed, suffocated by the unruly crowd. He remained permanently unconscious, sustained for a time by a ventilator and receiving water and nutrition through IVs, until his parents sued in British courts to be allowed to remove him from these life-support measures. In a case that reached all the way to the House of Lords, these parents’ request was ultimately granted. When those life-support measures were removed, Tony Bland quickly died. But his case sparked a prolonged investigation in England about what it meant to die and to be allowed to die. What were the moral, medical, legal, societal and religious issues involved in allowing this young man to die?
These might be questions that you might not face for another thirty years. These might be questions you face next week. Looking out upon this congregation, I see so many families who have had to face such thorny questions as what constitutes extraordinary medical means? What constitutes allowing someone to die with dignity? What constitutes the active helping in the ending of someone’s life? What is the most loving thing to do in a terminal situation? And where is God in all of this?
The Bible offers us this beautiful picture of Abraham, having lived a long and good life, fruitfully and faithfully obedient unto God, breathing his last, as he is surrounded by loves ones who commend him to his heavenly Father in the hope and expectation that he shall dwell in the house of the Lord forever. It is a scene of serenity and triumph even amidst the moment of death.
However, in our modern world, while we live in a miraculous medical age where modern technology and the advance of knowledge means that countless lives are saved that would otherwise be lost; nevertheless, paradoxically, our extraordinary technology and amazing knowledge often makes dying very difficult. The very machines and advances that make it possible for us to live also make it difficult for us to die. Recognizing this, as early as 1968 a blue-ribbon Harvard panel was given the responsibility for defining when a person was considered medically dead. They decided that when brain activity had ceased, a person was legally and medically dead, regardless of what their heart might be doing. The panel recognized that there are situations where, in the case of traumatic injury or heart attack, a person could be resuscitated, rescued from death temporarily and kept alive by means of machines that maintained a person’s heartbeat even when the brain had ceased to function. Such situations present us all with some very difficult challenges, because our loved one can be placed on instruments that keep them alive, but offer no hope of healing or recovery. We then face the question: when we remove these instruments, are we sentencing our loved one to death?
Many of you have asked me this very question, and there is a principle that I have often articulated privately that I now share with you as a congregation publicly: our sophisticated technology often gives us the illusion of choice about whether we are the ones making the decisions as to our loved one’s life or death. Our technology often fosters the impression that we are the one making the decision about life or death when our loved one is being removed from some extraordinarily sophisticated medical machine. In other words, when a loved one is hooked up to some machine that is temporarily sustaining them, and we make the choice to remove that machine, are we taking their life? The answer is NO! And yet, even when doctors assure families that there is no way their loved one can recover or improve, there are many families who feel tremendous guilt in removing a ventilator or nutrition from a patient. There should be no guilt!
Families think, “Oh, if I tell the doctor to remove that ventilator, I am killing Grandma or I’m killing Daddy.” No! Grandma’s body or Daddy’s body has already made its choice. If Grandma or Daddy had been in the same situation thirty years ago, they would have already been dead. Removing them from wondrous sustaining machines is not killing them: you are simply acknowledging the choice that their body has already made. In removing extraordinary means from a dying patient, we aren’t making the choice to kill them: that choice has already been made; we are simply ratifying the decision that their body has already made. There should be no guilt!
There is a second principle crucial to our understanding crucial end of life issues: what is extraordinary medical means and what is ordinary medical means is defined not by the sophistication of the technology. Extraordinary means is distinguished from ordinary means by the context in which that technology is used. Tony Bland, that mortally wounded soccer fan, was sustained for a time by a ventilator and IVs, and the court came to deem these technologies extraordinary. When they were removed, he died. But looking out upon this congregation I take note of several of you who have had heart bypass surgery during my tenure. All of you who have had that surgery were also sustained for a time by a ventilator. Many of you have had occasion to receive nutrition and hydration through an IV. The same technology that was ruled extraordinary in Tony Bland’s situation was considered perfectly routine in your own. The sophistication of the machinery alone is not what makes its use extraordinary.
How does this issue come to the fore in real life? Mrs. Jones has a living will that stipulates that she doesn’t want to be left on life support systems in the case of a mortal medical situation. Mrs. Jones faces heart bypass surgery at age eighty-five. She has the surgery successfully, but shortly thereafter suffers a minor stroke. To ease the pressure on her heart, the doctor places her on a ventilator and heavily sedates her so her body can rest. She appears unresponsive, even comatose. Is that extraordinary means or no? The family is angry at the physician because they think the doctor has contradicted Mrs. Jones’s wishes not to be sustained by heroic measures. What the family must understand in that situation is that the ventilator, hydration and nutrition IVs are not extraordinary; they are part of a normal medical procedure intended to restore Mrs. Jones to health and wholeness. These technologies are intended to abet her recovery. In utilizing those procedures the doctor is not contravening Mrs. Jones’s living will. However, if she suffers a subsequent debilitating stroke or a massive heart attack, then those very same technologies could well be extraordinary means, prolonging her mere existence to no good purpose. In that case, the demands of her living will should be honored and that technology removed. In other words, it is not the sophistication of the technology, but the context in which it is used that determines how “heroic” a measure is.
Every adult needs a living will, an advance directive that can be a helpful guide for families and doctors in crisis medical situations. I have faced several situations over the last twenty-five years where someone in their 90’s suffered heart failure, and the doctors were prepared to put this person through the same medical routines that they would order for a 35-year-old who had suffered a heart attack. The person was spared that kind of torment because I could document the patient’s wish that heroic measures not be taken to prolong his/her life in a terminal situation. Particularly if you live alone, you need to have a living will. You need to be specific about your wishes, and you need to make sure that your lawyer, doctor, children and even your pastor keeps one on file. A living will helps your family make the right decision in difficult times.
Naturally, we must face another question: is there a true ethical difference between removing life-prolonging technology and actively participating in the ending of someone’s life? Absolutely! There are gray areas to be sure, but it is important that we recognize this distinction between easing a person’s discomfort in dying and actively causing death. I know no better way to dramatize the distinction I am trying to make than by offering the real-life example of Janet Adkins, whose life was ended by Dr. Jack Kervorkian. Janet Adkins was 54 years old. She had been diagnosed with early Alzheimer’s. She was vigorous enough of body to have beaten her 33-year-old son in tennis the week before, passionate enough to have gone off on a romantic weekend with her husband just a few days prior to her death. True, she couldn’t play some of her favorite piano pieces from memory any more, and she forgot the names of friends, but beyond those frailties she showed no real symptoms. Nevertheless, she arranged to take her life with Dr. Kervorkian’s help, believing that her quality of life was going to deteriorate too rapidly. Dr. Kervorkian saw his deed as an act of mercy. The state of Michigan saw it as an act of murder. In my opinion the state of Michigan was right.
Of course we live in a complicated world where medical ethical issues are not always as clear-cut as they might appear. There are medications that physicians administer to dying patients that are given to palliate the discomfort that those patients might be experiencing. Yet these medications also may have the consequence of hastening a patient’s demise. Is that murder, too? No. For example, it is common for a person suffering congestive heart failure to experience such a desperate shortness of breath, such an uncomfortable constriction of the chest, that medications are administered as a way of giving comfort. Some of these medications manifest what is known as a “double effect,” aiding a person’s comfort but also inhibiting that person’s respiration, in fact, hastening their death. Nevertheless, such a “double effect” is not murder. It is simply a standard procedure intended to help the patient and his or her loved ones know that this patient can die peacefully, with a minimum of struggle, as nature takes it course.
Again, gray areas abound in medical ethics, but it is important that we can trust our physicians to do what is best for us even when we are beyond healing or cure. When physicians are granted the power to assist us in actively ending our lives, then they have violated the very oath that they took when they began to practice their profession – for they have vowed to do no harm.
Of course, many of us, seeing friends go through long terminal illnesses, vow that if we are diagnosed with a horribly impaired condition, we will take Janet Adkins’ way out. That vow is understandable. (I confess if you had offered me a loaded gun last week when I was in the throes of the flu, I might have accepted the offer.) Yet I return to God’s assertion: “I am the Alpha and the Omega, the God who is, who was, and is to come.” I remind you of the profound theological truth that life is God’s gift, and we are not to treat that gift cavalierly. Life is God’s gift in its beginning, but also in its ending. From God we come and to God we go. And when someone who is dying has been put in touch with organizations like Hospice who can assure patients and their families that they will be cared for, that their pain will be palliated, that their dying will not be in loneliness, then that patient’s attitude toward their dying changes dramatically. When a dying patient is surrounded with medical, spiritual, psychological and communal resources of hope, the immature wish simply to end one’s life quickly is replaced by a recognition that the process of dying is simply one more stage in the process of living, and God’s grace and power and reality can be manifested clearly and powerfully in the process of our taking leave of life. Some of the most powerful testimonies I have witnessed are in beholding the faith of terminally-ill people who have borne the cross of their dying as a divine gift, and in their passing they have given profound evidence of the providence of God in their life. Such people give evidence of a faith that knows that they have come from God and they are going to God, and in the process they remind us that dying is but one more stage in the process of living and every stage is to be lived in conversation with the divine.
These are not abstract issues for me. Both of my parents are 90 years old, and one suffers from advanced dementia, and the other has nearly died several times recently from complications related to diabetes. Melissa’s father is 97. We both know that in the near future we will have to face tough decisions related to our surviving parents’ health, decisions where answers are not always clear. But it is a comfort to know that God is the One who has given us life. God is the Alpha from which we come and the Omega to whom we all go. And this God promises to guide us in making tough choices in a perplexing world. So we go on in faith.