Adopted by the Eleventh Biennial Convention, Louisville,
Kentucky, September 3-10, 1982.
Today it is commonplace to speak of the triumphs of modern
medicine- achievements such as open heart surgery and organ
transplants, dialysis machines that substitute for the kidneys,
pacemakers that regulate the beating of the heart, and vaccines
that have made once-dreaded diseases almost forgotten words. Each
of these discoveries has saved countless lives and relieved much
suffering. None of this, however, has changed the fact that death
still occurs. The new technologies do not always cure but sometimes
only prolong the dying process, at times with great suffering. The
irony of modern medicine is that with the new technologies that
vastly expand the range of what it is possible to do has also come
the anguish of deciding when it is appropriate to use these
capabilities.
Nowhere are these ethical dilemmas more pressing than with
respect to death and dying. A terminal cancer patient who is
experiencing 'great pain suffers cardiac arrest; should the patient
be resuscitated? A newborn infant with massive and multiple birth
defects is unlikely to survive without surgical intervention; is
such intervention appropriate? A family member with a
life-threatening illness refuses to undergo treatment; should
treatment be administered in violation of his or her expressed
wishes? In these and countless similar situations, we confront not
only the grief and anguish always associated with death and dying,
but also new and difficult moral decisions that call for prayerful
reflection and the support of a caring community.
Theological Perspectives on Death and Dying
Perspectives on death and dying within the Christian tradition,
both in its biblical origins and in its subsequent development,
reflect several contrasting and complementary themes:
Death as Natural
Death is frequently viewed as a natural part of the life
cycle. Like all other creatures, human beings have a limited life
span. "The years of our life," the psalmist observed, "are
threescore and ten, or even by reason of strength fourscore" (Psalm
90:10). The fact that our span of life is limited serves to remind
us that we are finite. We are created by God; we are not God. Both
living and dying are part of the dynamic processes of the created
order, which biblical faith affirms as being good. The story of
Abraham's death reflects this view: "Abraham breathed his last and
died in a good old age, an old man and full of years, and was
gathered to his people" (Genesis 25:8).
Death as Tragic
Death may also be experienced as an unwelcome event that involves a
tragic dimension. Sometimes this is because death seems untimely,
as in the case of the death of a child, a youth, or an adult in the
prime of life. Or its unwelcomeness may be due simply to the desire
to continue living rather than depart life, a desire that in its
own way gives eloquent testimony to the goodness of the life that
God has created. Sometimes the reluctance to die arises from dread
of the suffering which may accompany the dying process. Thus it is
in keeping with a wide range of human experience that the psalmist
prays for deliverance from mortal illness: "Turn, 0 Lord, save my
life; deliver me for the sake of thy steadfast love" (Psalm
6:4).
Death as Friend
When dying involves prolonged suffering, death can be experienced
as a deliverance, and in this sense as a friend. This does not
imply that one should deliberately end life to avoid suffering, for
the Christian witness is that meaning and hope are possible even in
deepest adversity. It does imply that death, when it brings relief
from suffering, can be understood and accepted as merciful.
Death as Enemy
Even though death must be viewed as part of the created order and
can sometimes be a friend, the sinfulness of the human condition
makes death an enemy. As the apostle Paul puts it, "The sting of
death is sin" (I Corinthians 15:56). The alienation and
estrangement that are pervasive in our lives make us unready to
face death, an anxiety that may be heightened by fear of what lies
beyond the grave.
Victory over Death
The New Testament message of Christ s victory over death speaks
directly to this alienation and anxiety. Through Baptism, the
believer is buried with him "into death, so that as Christ was
raised from the dead by the glory of the Father, we too might walk
in newness of life" (Romans 6:4). The new life of faith enables the
Christian to face death with courage and with the assurance of
forgiveness. The promise of the resurrection of the body and
eternal life provides comfort and reassurance that death is not the
end.
Whether death is viewed as natural or as tragic, as a friend or
as an enemy, all who experience death-and-dying situations can be
certain of God's love. Thus the apostle Paul asserts, "For I am
sure that neither death, nor life, nor angels, nor principalities,
nor things present, nor things to come, nor powers, nor height, nor
depth, nor anything else in all creation, will be able to separate
us from the love of God in Christ Jesus our Lord" (Romans
8:38-39).
Ethical Decision-Making
Careful and prayerful reflection in the immediacy of the
situation is an essential ingredient in a responsible
decision-making process. At the same time, Scripture, tradition,
and the shared wisdom of Christian people provide important
resources for making these decisions.
While the exact nature of death-and-dying situations can never
be anticipated fully, it is possible to identify interpretive
principles that are useful in shaping our response. These include
the following:
- Life is a gift of God, to be received with
thanksgiving.
- The integrity of the life processes which God has created should
be respected; both birth and death are part of these life
processes.
- Both living and dying should occur within a caring
community.
- A Christian perspective mandates respect for each person; such
respect includes giving due recognition to each person's carefully
considered preferences regarding treatment decisions.
- Truthfulness and faithfulness in our relations with others are
essential to the texture of human life.
- Hope and meaning in life are possible even in times of suffering
and adversity-a truth powerfully proclaimed in the resurrection
faith of the church.
The decision-making process involves not only the question of
what principles should be used in responding to death-and-dying
situations but also the questions of who should make such
decisions. If the person is capable of actively participating in
the decision-making process, respect for that person mandates that
he or she be recognized as the prime decision-maker. At the same
time, to relegate such decisions solely to the individual facing
death is to deprive that person of love and care. Therefore, it is
appropriate that the physician, family members, close friends, the
pastor, and other members of the health care team play a supportive
role.
If the person in question is not capable of active
participation, the situation is somewhat more complex. In some
cases, the person's clearly stated preferences, made before he or
she lost the capacity to participate, are on record; respect for
that person requires that these preferences be given recognition.
In other cases, no preferences are on record because the person
never gave expression to his or her preferences while still able to
do so, and is now too weakened to respond. If the situation
involves a child under the age of majority, who is therefore
legally incompetent, or a person who is mentally impaired and hence
unable to participate fully in the decision-making process, a
shared decision-making process is preferable. Collective wisdom is
likely to result in better decisions, and no one should be left to
bear alone the full burden of deciding. Participants in this
decision-making process may include family members, the physician
and other health care professionals, the pastor, and others close
to the person. If it is not possible for those immediately involved
to reach a consensus, a hospital ethics committee, if one exists,
can be an important resource. Appeal to the courts should be
avoided unless so doing is the only way to protect individual
rights or to resolve the controversy.
Withdrawing and Withholding Treatment
Among the most difficult decisions which confront family members
and others in death-and-dying situations are those that involve
withdrawing or withholding medical treatment. Opinions differ as to
whether there is a significant ethical difference between
withdrawing a treatment (e.g., a respirator) that has already been
initiated, and simply deciding not to administer it in the first
place. Both, essentially, are decisions not to treat.
The situations in which these treatment decisions arise vary
widely. At least three different types of situations can be
identified, each of which demands a different response:
The Irreversibly Dying Person
The first type of situation involves persons whose disease
is progressive and for whom no effective therapy is available. As
the final stages of the dying process occur, there comes a time to
recognize the reality of what is happening by refraining from
attempts to resuscitate the person and by discontinuing the use of
artificial life support systems. To try desperately to maintain the
vital signs of an irreversibly dying person for whom death is
imminent is inconsistent with a Christian ethic that mandates
respect for dying, as well as for living. This does not, however,
in any way preclude supportive care intended to maintain comfort
and otherwise respond to the needs of the dying person. Indeed,
quite the opposite is the case; when no cure is available, the
responsibility to extend loving care not only continues but assumes
even greater importance. This includes not only controlling
physical pain, but also responding to the fear, guilt, and anger,
the sense of isolation, the blocked communications, and the family
stress that are often experienced by the dying.
Burdensome Treatments
In some cases there are forms of therapy which offer prospects for
sustaining life but which themselves involve considerable
discomfort, thereby necessitating a choice between quantity of life
and quality of life for the patient. Examples of this type of
situation include persons with widespread malignancy who are
experiencing extensive side effects from chemotherapy and
terminally ill children whose lives can be sustained for a greater
period of time if they are hospitalized, but who will be separated
from their familiar home environment. In such cases, the issue is
whether it is preferable to have a greater number of days that are
overshadowed by the rigors of therapy or a lesser number of days
that are more peaceful, i.e., whether quantity of life or quality
of life should be accorded priority.
Factors to be considered in making these decisions include the
following:
- The probability that a particular form of medical treatment
will help sustain the life of the patient
- The length of time that the life of the patient is likely to be
sustained
- The anticipated risks and side effects of the treatment
- Other forms of treatment available, if any, and their relative
advantages and disadvantages
- The patient's adjustment to hospitalization or to the
treatment
- The extent to which the treatment will interfere with the
person's most cherished activities
- Available support systems at home or in alternative
institutional settings
Second opinions and consultations are often useful in clarifying
and assessing these factors.
Chronically Ill Individuals
The foregoing should not be taken to imply that
chronically ill persons should be allowed to die because their
lives are judged to be not worth living or because they are viewed
as burdensome or useless to society. Whether the person in question
is a newborn infant with serious birth defects or an aged person
whose capacities have begun to wane, the Christian response in such
cases must be a strong presumption in favor of treatment.
Exceptions might arise in cases of extreme and overwhelming
suffering from which death would be a merciful release, or in cases
in which the patient has irretrievably lost consciousness.
Just as abandoning the chronically ill to die is inconsistent
with Christian conscience, so also is abandoning the family members
who, along with the patient, must bear the psychological, social,
and economic costs of chronic illness. Responding to these needs
involves the stewardship of time (e.g., offering to share in the
responsibility of caring for a chronically ill person) as well as
seeking to make adequate financial resources and supportive
services available, whether by public or private means. Finally, to
assert that all lives are worth saving does not eliminate the
necessity of establishing priorities when available medical
resources are inadequate to treat all who are in need. In these
tragic situations, it is inevitable that the priorities that are
established, regardless of what they might be, will result in
reduced levels of treatment for some, perhaps even to the point
that death occurs earlier than would be the case if adequate
resources were available.
Refusing Treatment
If the patient has the prime decision-making role, the question
then becomes one of refusing treatment for oneself, rather than
withdrawing or withholding treatment from another. Since our
responsibilities for stewardship of our own lives do not differ
significantly from our responsibilities for the lives of others,
the general guidelines outlined above are pertinent here also.
Thus, for example, one may in good conscience refuse burdensome
treatments in some situations.
A further question, however, also arises: Should persons be
allowed to refuse treatment in situations in which such refusal is
not supported by these guidelines? Or should they be treated in
violation of their wishes? Here the principle of respect for
individual self-determination comes into play. To treat a patient
in violation of his or her deeply held, carefully considered, and
clearly expressed preferences is to do violence to that person just
as surely as would physically assaulting that person or
deliberately destroying his or her property. This is as true in the
case of an incompetent patient who has made his or her preferences
known while still competent as it is in the case of a competent
patient who can actively participate in the decision-making
process.
At the same time, it must be emphasized that pain and other
factors often distort the decision-making process, resulting in
expressions of preference that may not represent a person's true
wishes. In such cases, it may be appropriate to administer
treatment (by authority of court order, if necessary) if so doing
would sustain the life of the patient.
In all cases-including those situations in which a person's
considered judgments are unmistakably clear- there is a continuing
responsibility to care for and to extend the warmth of human
community to that individual. A decision to allow refusal of
medical treatment must never become an excuse for abandoning that
person.
Use of Pain-Killing Drugs
In certain instances, some drugs administered in order to
control pain experienced by terminally ill patients also have the
effect of hastening the dying process, thus securing a better
quality of life at the expense of quantity of life. As with
burdensome forms of therapy, it is appropriate to ask whether there
are alternative courses of action that do not pose this
conflict-i.e., whether there are available means of controlling
pain that would not hasten death. If there are not, the choice
between quality and quantity of life cannot be avoided. In cases of
great suffering, administering pain-killing drugs is justifiable
even if this hastens the dying process. At the same time,
adjustments in administering such drugs should be made so as not to
deprive the patient of consciousness prematurely. In all cases,
recognition should be given to patient preferences, when they are
known. Deliberately administering a lethal drug in order to kill
the patient, or otherwise taking steps to cause death, is quite a
different matter. This is frequently called "active euthanasia" or
"mercy killing" (as contrasted with the cases discussed above,
which involve withholding or withdrawing medical treatment, thereby
allowing death to occur from a disease or injury).
Some might maintain that active euthanasia can represent an
appropriate course of action if motivated by the desire to end
suffering: Christian stewardship of life, however, mandates
treasuring and preserving the life which God has given, be it our
own life or the life of some other person. This view is supported
by the affirmation that meaning and hope are possible in all of
life's situations, even those involving great suffering. To depart
from this view by performing active euthanasia, thereby
deliberately destroying life created in the image of God, is
contrary to Christian conscience.
Whatever the circumstances, it must be remembered that the
Christian commitment to caring community mandates reaching out to
those in distress and sharing hope and meaning in life which might
elicit a renewed commitment to living.
Caring for the Living and for the Dying
Health care includes not only attempting to cure disease and
repair injury, but also caring for and relating to the patient as a
person. As noted above, in the case of a terminally ill person for
whom no cure is available, the responsibility to care not only
continues, but assumes even greater importance, so that life may be
lived to the fullest until death occurs.
Moreover, the responsibility to care includes extending care to
the family and to all those who are involved in such situations.
Hospice programs (which provide a wide range of supportive services
for patients and their families) and other supportive care programs
represent useful and constructive ways of assisting the patient and
family members in relating to the human dimensions of death and
dying and subsequent bereavement. Such support for family members
is needed in cases of sudden death, as well as prolonged terminal
illness.
Health care professionals as well as family members have a
responsibility to be truthful in relations with patients.
Information must be shared so that the person can understand the
disease and the options for treatment. Being informed of terminal
illness is also essential so that one can prepare for death.
In death-and-dying situations, the Church's ministry of Word and
Sacrament through its members and ordained ministers is of great
significance. Remembrance of Baptism renews the Christian's sense
of unity with Christ and the Church, and the Sacrament of Holy
Communion serves as a reassurance of Christ's living presence and
offers hope for the life to come. Simply to be with those for whom
death is approaching-to pray with and for them, to listen and to
respond, to comfort and to console-is also an essential
ministry.
A commitment to caring community must also give recognition to
the humanity of health care professionals, who are frequently asked
to bear tremendous burdens. They, too, have a need for grief
therapy sessions and other supportive programs, which in turn will
enable them to minister more effectively and compassionately to
patients and their families and friends.
A particular responsibility of each individual is making
treatment preferences known, after careful consideration, so as to
facilitate the decision-making process and relieve the burden on
others. Living wills (signed and witnessed statements completed
while a person is still in sound mind indicating treatment
preferences) represent one way of doing this. Other areas of
broader responsibility for patients and family members include
considering the possibility of organ donation as a means of sharing
life with others, authorizing an autopsy, and the donation of the
body for scientific purposes.
Forgiveness and Thanksgiving
There is much that we do not know. We do not know when a
debilitating disease may strike, what course that disease might
take, and when death will occur. And there is much that we do not
understand. Sometimes the death of a child or the large measure of
suffering that may accompany the dying process seems to make no
sense at all. Our finitude not only involves the fact that our life
spans are limited; it is also reflected in the limitations of what
we know and can understand.
Moreover, in responding to the dilemmas that are thrust upon us
in death-and-dying situations, we sometimes make the wrong
decision, or at least are uncertain as to whether we have made the
right one. And we are often woefully inadequate in extending
compassion and understanding to our fellow human beings. Even in
the best of circumstances, our sins and shortcomings are
manifold.
But this we know: God is merciful and forgiving. Thus, by grace,
we can both experience forgiveness and forgive others, as God
forgives us.
We also know that God may be closest to us in times of
adversity, for then the pretensions that alienate us and the
diversions which preoccupy us are stripped away. It is then that we
learn to rejoice again in the marvelous gift of life, and the
privilege of sharing this life with family and friends and all
those we have known and loved. Thus even at the moment of death we
can proclaim with the psalmist:
O give thanks to the Lord, for he is good;
for his steadfast love endures for ever! (Psalm 107:1)
Implementing Resolution
The Lutheran Church in America recommends to its congregations
and their members, synods, agencies, and institutions, the
following as appropriate ways of implementing the principles set
forth in the statement "Death and Dying."
I. Congregations
A. Provide an educational program that includes sessions on
death and dying, so as to encourage members to reflect about these
issues within a Christian context.
B. Sponsor training sessions to help members learn how to minister
to the chronically ill and to those in death-and-dying situations,
and to members of their families.
C. Encourage the development of mutual support groups within the
congregation.
D. Join with other congregations and community groups to establish
and maintain supportive care programs, including hospice care.
II. Churchwide Agencies, Synods
A. Prepare study material on death and dying to be used in
educational programs.
B. Provide continuing educational opportunities and supportive
services for clergy and laity to help them relate effectively to
death and dying.
C. Encourage the development of hospice programs and other
supportive care programs designed to respond to the human
dimensions of death and dying.
D. Advocate with federal, provincial/state and local governments
legislation and administrative regulations that advance the best
interests of persons with respect to dying and death.
E. Advocate and support public and private measures designed to
relieve the economic burden of terminal illness and to promote the
just distribution of medical resources.
III. Church-Related Health Care Institutions and Social
Service Agencies
A. Review and discuss institutional policies in terms of the
guidelines outlined in the social statement.
B. Introduce and maintain programs designed to help health care
professionals deal with death and dying.
C. Introduce and maintain programs designed to help patients and
members of their families relate to death and dying.
IV. Educational Institutions (Seminaries and
Church-Related Colleges)
A. Design college courses and programs on issues related to
death and dying.
B. Provide seminary courses and programs to train future pastors
and lay professionals for their ministry to the dying and to
members of their families.
C. Cooperate with the synods in offering continuing education for
clergy and laity in this area of concern.
V. Individuals
A. Prayerfully examine the ethical questions related to death
and dying and make treatment preferences known to family members
and to others as appropriate (e.g., by completing a living
will).
B. Share time and Other resources with those whose lives are
affected by chronic illness or by death and dying.
C. Consider the possibility of organ donation as a means of sharing
life with others.