Let God be the Judge: Who Will Throw the First Stone?

[1] In Dietrich Bonhoeffer's Ethics he alerts us to the pitfalls of the quest for moral certainty and to the shortcomings of one-principle or one-theme ethical approaches.
 
[2] The typical ethical approach focuses on two primary tasks: one, identifying a fundamental moral principle; and two, applying this fundamental principle to specific ethical issues to determine good and evil, right and wrong, or moral and immoral. According to Bonhoeffer "the first task of Christian ethics is to invalidate this knowledge."^[1] Seeking to secure our knowledge of good and evil separates us from God.

[3] The quest for moral certainty and one-principle or one-theme ethical approaches become particularly problematic in addressing what Bonhoeffer calls an "extraordinary situation of ultimate necessities." Responsible action in an extraordinary situation of ultimate necessities "leaves behind it the domain of principle and convention, the domain of the normal and the regular.^[2] " No law can control such a situation. Bonhoeffer's own involvement in the conspiracy against Hitler was an example of an extraordinary situation of ultimate necessity. Bonhoeffer was compelled to act as he did, but he intentionally sought to avoid justifying his actions, before, during, or after what he did. The ultimate judgment upon his actions had to be left in God's hands.^[3]

[4] The purpose of this paper is to show how Bonhoeffer's concept of an extraordinary situation of ultimate necessities sheds light on the issue of physician-assisted suicide, in particular as we are struggling with it in the state of Oregon.  In November of 1994 the citizens of Oregon narrowly approved Ballot Measure #16, the "Death with Dignity Act," or as it was more commonly known, the "Physician-Assisted Suicide Act." This measure made it legal, within certain established guidelines, for physicians to prescribe medication to terminally ill Oregon residents to end their lives. In 1995 a federal judge in Eugene, Oregon, ruled that the Death with Dignity Act did not adequately protect the terminally ill and therefore it was unconstitutional. Thus it did not actually take effect until the 9th U.S. Circuit Court of Appeals reversed this ruling on October 27, 1997. In November 1997 Measure 51, which would have repealed the Death with Dignity Act, was defeated by Oregon voters by a 3 to 2 margin. On October 27, 1999 the U.S. House passed the Pain Relief Promotion Act  by a vote of 271-156. This law specifies that it is illegal to prescribe controlled substances for assisted suicide. It has been approved in the Senate Judiciary Committee but has not yet been sent to the floor. Senator Ron Wyden of Oregon, who personally opposes physician-assisted suicide, has defended the right of the people of the State of Oregon to make their own law on this issue. He has threatened to filibuster if the Pain Relief Promotion Act is brought to the floor of the Senate. It appears now, however, that Wyden and Senator Don Nickles of Oklahoma, the Senate Sponsor of this act, have reached an agreement that would allow it to be brought before the Senate for consideration in September. Passage of the Pain Relief Act seems likely, but at this time physician-assisted suicide remains a legal option in Oregon.               

[5] The Evangelical Lutheran Church in America (ELCA) of which I am a pastor has taken a definite stand against physician-assisted suicide. A November 1992 "End-of-Life Decisions" message by the ELCA Church Council states: "We oppose the legalization of physician-assisted death^[4], which would allow the private killing of one person by another."^[5] The primary reason given for opposing physician-assisted death is that "deliberately destroying life created in the image of God is contrary to our Christian conscience."

[6] While I affirm a strong Christian presumption to preserve and protect life created in the image of God, I don't believe that necessarily entails an absolute prohibition on physician-assisted suicide. Recognizing that life is a precious gift from God, Christians do not want to encourage anyone to take his or her own life in any circumstances. Nevertheless, Christians need to recognize that in the course of life there may arise an "extraordinary situation of ultimate necessities" in which someone would choose physician-assisted suicide. Even the ELCA Message on End-of-Life Decisions includes an acknowledgment that "responsible health care professionals struggle to choose the lesser evil in ambiguous borderline situations -- for example, when pain becomes so unmanageable that life is indistinguishable from torture." In such extraordinary or borderline situations the responsible action is not to cast the first stone nor to affirm physician-assisted suicide but to suspend judgment and let God be the judge.

Physician-Assisted Suicide in Oregon

[7] Ballot Measure 16, the "Death with Dignity Act," posed the question to voters: "Shall law allow terminally ill adult Oregon patients voluntary informed choice to obtain physician's prescription for drugs to end life?" Mercy killing and lethal injections by physicians were prohibited, but physicians were permitted to prescribe medication and give necessary instructions to qualified patients who desired to use the medication to commit suicide.^[6]

	According to the Death with Dignity Act, in order to qualify for medication to end their lives, patients must go through a series of 9 steps:  1. The patient must be 18, terminally ill (having less than 6 months to live), and an Oregon resident. 2. The patient must voluntarily make an oral request to the attending medical/osteopathic physician for a prescription for medication to end his or her life. A 15-day waiting period then begins. 3. The attending physician makes sure the patient understands the diagnosis and prognosis. The patient is informed of all options, including pain control, hospice care, and comfort care. The attending physician also must inform the patient of the risks and expected result of taking the medication. 4. The attending physician a) determines whether the patient is capable of making health care decisions and is acting voluntarily; b) encourages the patient to notify next of kin; c) informs the patient that he or she can withdraw the request for medication at any time and in any manner; and d) refers the patient to a consulting physician who is asked to confirm the attending physician's diagnosis and prognosis. 5. The consulting physician also decides whether the patient is capable of making the decision and is acting voluntarily. If either or both physicians believe the patient is suffering from a psychiatric or psychological illness or depression that causes impaired judgment, the patient will be referred for counseling. 6. Once the preceding steps have been satisfied, the patient voluntarily signs a written request witnessed by two people. At least one witness cannot be a relative or an heir of the patient. 7. The patient then makes a second oral request to the attending physician for medication to end his/her life. 8. The attending physician again informs the patient that he or she can withdraw the request for medication at any time and in any manner. 9. No sooner than 15 days after the first oral request and 48 hours after the written request, the patient may receive a prescription for medication to end his or her life. The attending physician again verifies at this time that the patient is making an informed decision.[7]

[8] In February 1999 the Oregon Health Division issued a report on the first year of physician-assisted suicide in the state. Twenty-three patients received lethal prescriptions. Fifteen used the prescription to die; 6 died from their terminal disease; and 2 remained alive as of January 1, 1999. According to their doctors, the 15 who died specified the following end-of-life concerns: 12 loss of autonomy due to illness; 10 inability to participate in activities; 8 loss of control of bodily functions; 2 burden on family, friends, or other caregivers; 1 inadequate pain control. No one specified the cost of treating illness or prolonging life.^[8]

[9] Kathleen Foley and Herbert Hendin issued a scathing response to the Oregon Health Division's report on the first year of physician-assisted suicide. They believe the Oregon report does not provide sufficient data to support its conclusion that "patients who were assisted in suicide were receiving adequate end of life care."^[9] They are especially critical of the lack of information on the palliative care offered to patients requesting physician-assisted suicide and on their financial situation and emotional state. They maintain that the Oregon Health Division ought to have asked physicians to provide more medical information about their patients. From their point of view, "the presumption that a diagnosis of terminal illness is sufficient for assisted suicide does not encourage physicians to inquire into the source of the medical, psychological, social, and existential concerns that usually underlie such arequest."^[10] They propose that in addition to asking for more information from the physicians the Oregon Health Division should "appoint a task force made up of physicians from out of the state who are experts in palliative care, psychiatry, and medicine to review the assisted suicide cases."^[11] Furthermore, given that psychiatric evaluation is standard medical practice for patients who are suicidal, they assert that the Oregon law ought to require that the "physician refer the patient to a licensed psychiatrist or psychologist for counseling."^[12] They are also concerned about the lack of an adequate mechanism for resolving disagreement in a particular case - for example, a mechanism such as an ethics consultation committee.

[10] In response to Foley and Hendin representatives of the Oregon Health Division claim the law does not authorize them to gather the information that Foley and Hendin seek. The Oregon Health Division maintains they are trying to operate within the parameters of the legal mandate given to them. However, in anticipation of criticisms of their year two report, they interviewed family members of 19 of the 27 physician-assisted suicide cases in 1999, something they did not do for 1998 cases.^[13] Whether or not the monitoring process by the Oregon Health Division is flawed as Foley and Hendin suggest, their proposals for ensuring medical personnel are adequately trained in end-of-life care, for requiring psychiatric evaluation, and for encouraging ethical consultation would strengthen the safeguards and the guidelines for the Death with Dignity Act.

[11] I share the concern of Foley, Hendin, that the guidelines governing physician-assisted suicide be strengthened. At the same time I am concerned about those who would want to build a categorical prohibition of physician-assisted suicide into the law of the land. The Pain Relief Act if passed into law will effectively make physician-assisted suicide illegal in Oregon. In the long run that could easily strengthen the resolve of the majority who support giving dying patients the option of physician-assisted suicide. It could set up a seemingly never ending legal battle similar to what we have experienced with the issue of abortion.

[12] At least in Oregon, where the voters have spoken once and even more clearly a second time in favor of physician-assisted suicide, trying to overturn the law may not be the most constructive strategy. I am particularly concerned about the strategy the church needs to pursue in a context in which physician-assisted suicide is a legal option. Where it is a legal option, the worst excesses of physician-assisted suicide can be mitigated against, if it does not ever come to be viewed as standard medical practice and is considered an option of last resort in exceptional cases. Utilizing Bonhoeffer's concept of an extraordinary situation of responsibility can be helpful in this respect. If making a decision concerning physician-assisted suicide is considered an extraordinary situation of responsibility, it may be possible to keep cases of physician-assisted suicide from being precedent setting for subsequent cases.

Responsible Action within the Domain of Relativity

[13] Bonhoeffer identifies two basic factors that shape the structure of the responsible life. The first is that the responsible person is bound to God and to other human beings.^[14] The second is that the responsible person is able to respond freely to God and to other human beings. Responsible action is action on behalf of or in the place of another. For example, responsible parents act on behalf of or in the place of their children; a responsible police officer acts on behalf of or in the place of the citizens of the community; responsible teachers act on behalf of or in the place of their students. Bonhoeffer views Jesus Christ as the responsible person par excellence.^[15] Jesus gave himself completely on behalf of and in the place of others. He performs the ultimate responsible action by taking upon himself the guilt of all human beings and dying on the cross.

[14] Responsible action in ordinary situations focuses on fulfilling the four mandates: labor, marriage, government, and church. Bonhoeffer defines a mandate as a divinely imposed task.^[16] Through labor we participate in the action of creation. Through marriage we share in the process of creation by bringing children into the world and nurturing them. Government is not creative but seeks to preserve that which has been created. The primary task of the church is to bear witness to the reality of God in Jesus Christ.

[15] These mandates are intended to work together to accomplish God's purposes. There is no exact formula for balancing them. But God does not want us to wear out in a constant conflict of obligations and decisions. Each moment of life is not meant to be a great crisis. In more ordinary times there is no need for us to be "Hercules at the crossroads."^[17] We are free to fulfill the mandates without having to dissect every action we engage in.

[16] On occasion in the course of life, however, we may find ourselves in a moment of crisis. We may be called upon to engage in an extraordinary venture of responsibility. It is difficult to define what constitutes an extraordinary venture of responsibility, because of its exceptional character. Nonetheless, utilizing insights from Bonhoeffer, we can develop a matrix of characteristics of an extraordinary venture of responsibility. One, the focus is on God and others and not on ourselves. According to Bonhoeffer "responsibility and freedom are corresponding concepts." Responsible persons act in the freedom of their own selves, but that very freedom is given "in the obligation to God and to our neighbor."^[18]

[17] Two, there is no clear theological or biblical or ecclesial precedent that warrants the action being taken.

[18] Three, the action cannot be justified by any law. In fact, the action may require a direct violation of the law.^[19]

[19] Four, in deciding to engage in the venture of responsibility the full range of ethical factors is taken into account. The responsible person will give due consideration to the given circumstances, the relevant questions of principle, the possible consequences, the motives, the values, and the purpose of an action. No one factor ought to be made the governing principle or law of the action.^[20]

[20] Five, the action may oppose ordinary responsibilities-that is, the mandates God calls us to fulfill in ordinary situations.^[21]

[21] Six, other more ordinary options have been exhausted. An extraordinary venture of responsibility is an option of last resort.

[22] Seven, the ultimate judgment upon the action is entrusted to God. No claim is made to an ultimate knowledge of good and evil in the given situation. As Bonhoeffer explains, the responsible action is "performed wholly within the domain of relativity, wholly in the twilight which the historical situation spreads over good and evil; it is performed in the midst of the innumerable perspectives in which every given phenomenon appears. It has not to decide simply between right and wrong and between good and evil, but between right and right and between wrong and wrong."^[22] The responsible action is performed without any claim to self-justification. For Bonhoeffer the deep secret of history is that our responsible actions are ultimately committed to God. Only God can be the final judge of our actions in an extraordinary situation.

[23] This matrix of characteristics helps explain why Bonhoeffer's involvement in the conspiracy against Hitler constitutes an extraordinary venture of responsibility. First, if Bonhoeffer were primarily concerned about his own well-being, it is unlikely he would have gotten involved in an attempt to assassinate Hitler. The safest path for him would have been to stay in the United States in 1939, when he had the opportunity.

[24] Second, there was no precedent for a Lutheran pastor in Germany to be engaged in an attempt to kill the head of state. ^[23]

[25] Third, Bonhoeffer's involvement in the conspiracy clearly lacked any justification according to the law. Bonhoeffer himself was fully aware that he was actually breaking the law.

[26] Fourth, Bonhoeffer was working on his Ethics while he was involved in the conspiracy. The content of Ethics is an indication of the wide range of ethical factors that he was considering. This wide range of factors mitigated against coming to too quick a judgment for or against the actions of the conspirators. Furthermore, it would be hard to identify any one factor that could possibly be made the law governing the action of the conspirators. It is easier to identify some principles that would have prevented Bonhoeffer from engaging in the conspiracy, if he had made those principles the governing law of his action. For example, if Bonhoeffer had in principle refused to lieor deceive,^[24] or if he had in principle refused to be an accomplice in killing another person, or if he had in principle believed that a pastor should not be involved in a political matter, or if he had in principle refused to break the law, he would not have been able to be involved in the conspiracy.

[27] Fifth, being a conspirator against Hitler cost Bonhoeffer an opportunity to get married to Maria, made it impossible for him to serve a parish, and prevented him from teaching in Germany or in the United States. These are precisely the responsibilities he would have been fulfilling in more ordinary times.

[28] Sixth, Bonhoeffer's involvement in the conspiracy came after a long process of pursuing other avenues to work against Hitler and Nazism.^[25] Finally the time came when he felt compelled to help put a "spoke in the wheel." Bonhoeffer would have admitted that he and the other conspirators may have waited too long to take this extreme measure.^[26]

[29] Seventh, the way Bonhoeffer conducted himself in prison and during his execution are signs that he had indeed entrusted the judgment upon his actions to God as the only one who could possibly justify his action. But he also knew that he had no basis on which to claim that justification. He recognized that he was up against the limits of human knowledge. In "After Ten Years" he suggests that the conspirators had no ground under their feet.^[27] The good or the evil of their actions had to be left for God to judge, and they could not claim to have had any special insight into God's ultimate judgment of good and evil before, during, or after the conspiracy.

[30] Although it appears that Bonhoeffer's involvement in the conspiracy against Hitler does constitute an extraordinary venture of responsibility, that does not mean we can conclude such a venture was justified. Instead, it means that we should refrain from judgment upon their action. We have reached the limits of our human knowledge. We are not in a position to cast the first stone, nor are we in a position to affirm the ultimate goodness of their action. We need to let God be the judge. 

Bonhoeffer on Suicide

[31] Bonhoeffer shared a strong presumption to preserve and protect life. He was appalled by the Nazi effort to exterminate the Jews and by their various euthanasia programs. In terms of suicide he asserts in Ethics that human beings must not lay hands on themselves.^[28] However, in certain extraordinary cases he maintains that  "the prohibition of suicide can scarcely be made absolute to the exclusion of the freedom of sacrificing one's life."^[29] 

[32] Unlike other creatures, states Bonhoeffer, human beings can put themselves to death of their own free will.^[30] Because they are free to choose death, they can lay down their lives "for the sake of some higher good."^[31] Thus, for Bonhoeffer the right to live is not an absolute right; and although Bonhoeffer does not state it explicitly, we do not have an absolute obligation to live. The right to live and the obligation to live are always conditioned by freedom.

[33] Bonhoeffer cautions that this freedom to choose death can easily be abused. Human beings can use suicide as a last ditch effort to maintain control over our earthly destiny. Shame and despair over lost honor, financial ruin, rejected love, the death of a loved one, or serious personal lapses can lead to suicide. Thus, explains Bonhoeffer, the primary motivation for suicide is to rescue oneself from this shame and despair, "and the ultimate ground for the action will therefore be lackof faith."^[32] To lay one's hands on oneself for purely personal reasons is an extreme act of self-justification. It is a desperate act to give life meaning by one who has lost confidence in God's ability to give meaning to a ruined life.

[34] To avoid abusing the freedom to choose death, any decision to kill oneself must take into account our responsibility to God and other human beings. As we discussed earlier, freedom is a corresponding concept of responsible action. Freedom is given in the responsibility to God and to other human beings. Thus, we remain accountable to God for what we do with our lives. God maintains the right of life, even against those who have grown weary of living.

[35] Bonhoeffer warns us, however, against categorically condemning those who kill themselves for the sake of others. For example, prisoners may kill themselves for fear that under torture they might betray their country, their family, or their friends.^[33] When Bonhoeffer was first imprisoned, he himself contemplated suicide for this very reason. He was uncertain how he would hold up physically and mentally under the strain of interrogation and torture. Once he realized that he could mislead his interrogators and hold up under the strain suicide receded as anoption.^[34] Nonetheless, Bonhoeffer understood from his personal experience why a political prisoner facing torture would consider suicide for the sake of others.

[36] Bonhoeffer also envisions a case in which someone suffering from a terminal disease might consider suicide. He writes: "If a sufferer from incurable disease cannot fail to see that his care must bring about the material and psychological ruin of his family, and if he therefore by his own decision frees them from this burden, then no doubt there are many objections to such an unauthorized action, and yet here, too, a condemnation will be impossible."^[35]

[37] According to Bonhoeffer, when people take their own lives for the sake of others, "we have reached the limits of human knowledge."^[36] If we have reached the limits of human knowledge, we are dealing with an extraordinary situation. We have no ground under our feet to make a definitive judgment. In such extraordinary cases our response ought to be not to cast the first stone but to suspend judgment. Suicide in an extraordinary situation ought to be arraigned not before the forum of human beings "but solely before the forum of God." Those who take their own lives incur "guilt solely toward God, the Maker and Master of their lives."^[37]

Physician-Assisted Suicide: An Extraordinary Decision

[38] The matrix of characteristics of an extraordinary venture of responsibility as well as Bonhoeffer's specific insights on suicide can assist the church in developing a strategy for addressing physician-assisted suicide in a context such as Oregon in which it is a legal option for the terminally ill. Limiting physician-assisted suicide to extraordinary situations is an attempt to keep cases of physician-assisted suicide from being precedent setting for subsequent cases. The worst excesses of physician-assisted suicide can be mitigated against, if it does not ever come to be viewed as standard medical practice. At the same time we need to avoid an absolute prohibition on physician-assisted suicide. We need to acknowledge that there may arise an extraordinary situation of ultimate necessities in which someone in good faith would choose physician-assisted suicide. Utilizing the seven characteristics of an extraordinary venture of responsibility, what insights can we gain into physician-assisted suicide?

[39] First of all, the patient is not an individual in isolation. A decision to commit physician-assisted suicide ought not be made simply by focusing on the condition of the patient. The patient is a responsible person, a self in relationship. As the ELCA "Message on End-of-Life Decisions" states, when Christians make decisions as patients, they "should take into account and be made in supportive consultation with family members, close friends, pastor, and health care professionals. Christians face end-of-life decisions in all their ambiguity, knowing we are responsible ultimately to God, whose grace comforts, forgives, and frees us in our dilemmas." Thus, a responsible decision will focus on God and those around us and not merely on ourselves. Even those who do not take account of God in their decision-making, which in Oregon is a large percentage, still need acknowledge that they live in a context of relationships. To ignore those relationships would be to ignore the reality of our relational existence.

[40] Second, there is no obvious theological or biblical or ecclesial precedent for physician-assisted suicide. The strong Christian presumption is to preserve and protect life created in the image of God. "You shall not kill" is, of course, one of the Ten Commandments. Perhaps one could cite some precedent in Bonhoeffer's notion of laying down one's life for the sake of some higher good. But only in exceptional cases does one find a good high enough to compel us to lay down our lives. The strong resistance of much of the religious community to physician-assisted suicide is an indication that in seeking physician-assisted suicide a patient is venturing onto uncharted waters.

[41] Third, unlike Bonhoeffer's illegal involvement in the conspiracy, physician-assisted suicide is a legal option in Oregon for the terminally ill. Even if physician-assisted suicide is legally permitted, however, that does not mean we are necessarily justified in exercising that option. For people of faith the law of the land does not dictate what is a responsible decision in an extraordinary situation. If the Senate passes the Pain Relief Promotion Act in September, terminally ill Oregonians will have no legal ground under their feet for seeking physician-assisted suicide. That will heighten the extraordinary character of physician-assisted suicide.

[42] Fourth, the church needs to seek ways to ensure that the full range of ethical factors is taken into account in decisions to seek physician-assisted suicide. Patient autonomy has often functioned as a kind of "boss principle" or trump card in medical ethics. When the principle of patient autonomy conflicts with others, it almost always seems to take precedence. As we have seen, Bonhoeffer is highly critical of any ethical decision-making process that gives one principle excessive sway. Patient autonomy is a key factor, but motives, consequences, values, circumstances, relationships, other principles, and any additional relevant factors need to be given due consideration.

[43] One way to increase consideration of the full range of ethical factors is to build a multi-disciplinary ethics consultation into the process. In the Legacy Portland Hospitals Ethics Program the consultation team is called upon approximately 3-5 times per month to assist patients, families, and/or health professionals struggling to make difficult decisions. These are the toughest cases. The purpose of this consultation team would not be to serve as a gatekeeper but to ensure that all relevant ethical factors in the case are being taken intoaccount.^[38] If a multi-disciplinary consultation were a required part of the physician-assisted suicide decision-making process, the extraordinary character of such a decision would be highlighted and greater responsibility could be exercised in making such decisions. The Death with Dignity Act as it currently stands places too great a burden on physician and patient in the decision-making process. Every potential physician-assisted suicide ought to be treated as a tough case; and thus, consultation with a multi-disciplinary team ought not be merely an option but a matter of course.

[44] Fifth, by the time one reaches the point of considering physician-assisted suicide the terminally ill patient is not likely in a position to fulfill the ordinary mandates or responsibilities Bonhoeffer identifies. Often, however, terminally ill patients will feel a sense of obligation to stay alive as long as possible for the sake of the family and friends. In Bonhoeffer's  example of the terminally ill man who wants to prevent the material and psychological ruin of his family physician-assisted suicide may be a final extraordinary way for him to fulfill his responsibility for his family. In such a case we ought to heed Bonhoeffer's caution about condemning his action.

[45] Sixth, physician-assisted suicide needs to be an option of last resort. Certainly no one can deny the strong Christian presumption to preserve and protect life. Christians ought to be in the forefront of efforts to reduce the desire of persons to turn to physician-assisted suicide. Thus far in Oregon we have not had the groundswell of requests for physician-assisted suicide that many anticipated. Ironically, the Death with Dignity Act seems to have been a catalyst in promoting a far more aggressive effort by health care providers to improve comfort care and pain management, and that effort would appear to be a factor in reducing the desire for physician-assisted suicide. For example, the Legacy Health System has launched a new Comfort Care Initiative. It began with a systemwide daylong "Comfort Care Conference." The stated goal was to "change the culture" of the entire Legacy System concerning end-of-life care. One outgrowth of that conference was the formation of a Comfort Care Consultation Team that is modeled after Legacy Portland Hospital's Ethics Consultation Team. Despite the improvements in comfort care and the relatively small number of patients seeking physician-assisted suicide in 1998 and in 1999, it is still vitally important to work against physician-assisted suicide ever becoming a standard of care. If physician-assisted suicide ever becomes a standard of care, we will have slid far down the slippery slope.

[46] Finally, to advocate an absolute ethical injunction against physician-assisted suicide is to overstep our bounds as human beings. It is to ignore the limits of our human knowledge. We do not need to be advocates for physician-assisted suicide, but we do need to acknowledge that a situation may arise in which we will be compelled to suspend judgment. In such situations we are making decisions in the domain of relativity, and we need to entrust the ultimate judgment to God. Some may not object absolutely to suicide but still want to maintain an absolute injunction against the participation of physicians in the act of suicide. But even this absolute objection can be problematic. If Bonhoeffer had discerned that he would fall apart under torture and would risk endangering his family members and thus decided to commit suicide, and if one of the guards who had befriended him had provided him with a relatively painless means to do so, we would not be in a position to cast a stone at the guard. The guard's assistance would not be murder in any common sense of the term. Similarly a physician's assistance in providing a relatively painless way for a terminally ill patient to commit suicide does not fit our common understanding of murder.

Conclusion

[47] The purpose of this paper has been to develop an approach to physician-assisted suicide, utilizing Bonhoeffer's concept of an extraordinary situation of responsibility, that keeps physician-assisted suicide from becoming standard medical practice and at the same time avoids an absolute prohibition of physician-assisted suicide. Viewing each possible case of physician-assisted suicide as an extraordinary decision is the key step in fulfilling that purpose. In Oregon the Evangelical Lutheran Church in America was at the forefront with several other mainline churches in the effort to defeat the Death with Dignity Act. Having failed twice, the second time miserably, the church needs to redirect its efforts toward minimizing the need for physician-assisted suicide. Rather than occupying the "proud throne of the judge"^[39] and casting stones, the church needs to leave no stone unturned in supporting and encouraging attempts to improve comfort care and pain management and in advocating for increased consultation as a required part of the process of seeking physician-assisted suicide. Improving comfort care and pain management is an act of mercy. Building a multi-disciplinary consultation team into the process will serve to heighten the awareness of all involved of the extraordinary character of any decision to end one's life. Such a decision, as Bonhoeffer writes, cannot be arraigned before the forum of human beings but ultimately must be arraigned before the forum of God. As human beings we have an important role to play in the decision-making process, but we need to let God be the judge.

[1]. Dietrich Bonhoeffer, Ethics, First Touchstone Edition (New York: Simon & Schuster, 1995), 21.

[2]. Ethics, 234-235.

[3]. The "ELCA Message on End-of-Life Decisions" is available online at www.elca.org/dcs/studies.html.

[4]. The "ELCA Message on End-of-Life Decisions" is available online at www.elca.org/dcs/studies.html.

[5]. The "ELCA Message on End-of-Life Decisions" is available online at www.elca.org/dcs/studies.html.

[6]. Kathleen Foley and Herbert Hendin, "The Oregon Report: Don't Ask, Don't Tell," The Hastings Center Report 29, no. 3 (1999): 37.

[7]. Kathleen Foley and Herbert Hendin, "The Oregon Report: Don't Ask, Don't Tell," The Hastings Center Report 29, no. 3 (1999): 37.

[8]. Kathleen Foley and Herbert Hendin, "The Oregon Report: Don't Ask, Don't Tell," The Hastings Center Report 29, no. 3 (1999): 37.

[9]. Kathleen Foley and Herbert Hendin, "The Oregon Report: Don't Ask, Don't Tell," The Hastings Center Report 29, no. 3 (1999): 37.

[10]. Foley and Hendin, "The Oregon Report: Don't Ask, Don't Tell," 40.

[11]. Foley and Hendin, "The Oregon Report: Don't Ask, Don't Tell," 42.

[12]. Foley and Hendin, "The Oregon Report: Don't Ask, Don't Tell," 39.

[13]. A report on the second year was issued in February 2000. In 1999 27 died by legal lethal prescription here in Oregon. This year 19 of the 27 families of these patients were interviewed about the reasons the patient sought physician-assisted suicide. According to these families 10 patients feared losing control of bodily functions; 10 feared loss of self-determination; and 10 were afraid of physical suffering. 8 patients did not want to become a burden to their families or caregivers, and 1 patient was concerned about the cost of life-prolonging treatment ("Statistics Put Face on Assisted Suicide," The Oregonian [Thursday, February 24, 2000]).

[14]. Ethics, 220-221.

[15]. Ethics, 222.

[16]. Ethics, 204-210 and 281-297.

[17]. Ethics, 279.

[18]. Ethics, 245.

[19]. Ethics, 245.

[20]. Ethics, 245.

[21]. Ethics, 245.

[22]. Ethics, 245.

[23]. Cf. Bonhoeffer's essay "What is Meant by `Telling the Truth'?" in Ethics, 358-367.

[24]. Cf. Bonhoeffer's essay "What is Meant by `Telling the Truth'?" in Ethics, 358-367.

[25]. Bethge, Dietrich Bonhoeffer: A Biography, 794.

[26]. Letters and Papers from Prison, the enlarged edition, edited by Eberhard Bethge (New York: Macmillan, 1972), 3.

[27]. Letters and Papers from Prison, the enlarged edition, edited by Eberhard Bethge (New York: Macmillan, 1972), 3.

[28]. Ethics, 168.

[29]. Ethics, 169.

[30]. Ethics, 164.

[31]. Ethics, 165.

[32]. Ethics, 170.

[33]. Bethge, Dietrich Bonhoeffer: A Biography, 832-833.

[34]. Bethge, Dietrich Bonhoeffer: A Biography, 832-833.

[35]. Ethics, 169.

[36]. Ethics, 169.

[37]. Mark D. Sullivan, Linda Ganzini, and Stuart J. Youngner warn against casting psychiatrists as gatekeepers in end-of-life decisions in "Should Psychiatrists Serve as Gatekeepers for Physician-Assisted Suicide?" Hastings Center Report 28, no. 4 (1998): 24-31. The Death with Dignity Act instructs the attending physician to refer the patient for psychological evaluation if the physician believes it is necessary. This decision should not be left up to the physician. A psychiatrist or psychologist ought to be one of the participants on the ethics consultation team. Consultation needs to be distinguished from a gate keeping function.

[38]. Mark D. Sullivan, Linda Ganzini, and Stuart J. Youngner warn against casting psychiatrists as gatekeepers in end-of-life decisions in "Should Psychiatrists Serve as Gatekeepers for Physician-Assisted Suicide?" Hastings Center Report 28, no. 4 (1998): 24-31. The Death with Dignity Act instructs the attending physician to refer the patient for psychological evaluation if the physician believes it is necessary. This decision should not be left up to the physician. A psychiatrist or psychologist ought to be one of the participants on the ethics consultation team. Consultation needs to be distinguished from a gate keeping function.

[39]. Dietrich Bonhoeffer, Life Together/Prayerbook of the Bible, DBWE 5 (Minneapolis: Fortress Press, 1996), 96.