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End of Life Issues

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Q&A on Pulling the Plug

QUESTION: My husband and I are having a will drawn up. We're having conflicting views on end-of-life issues. I say "pull the plug" if the only thing keeping me alive is a feeding tube and/or oxygen. He says if the basics like that are withheld, you are basically killing a person.

ANSWER: In the past couple of decades the public tone of this conversation has been a conflict between “quality of life” and “value of life.”  However difficult it may be, Christians need to step back from the public conversation and probe Scripture to resolve the question, “What would God have me to do?”

Biblically speaking, the matter has a simple starting point – we are not to unjustly take life (anyone’s or our own) [Exodus 20:13] and we are to care for life [1 Timothy 5:8].  These are commands from God and our obedience is evidence of our allegiance, faith and love for him [1 John 5:3].

In our complex times this sounds overly-simplistic, if not naïve.  Because Scripture does not talk about feeding tubes and the artificial administration of oxygen, we tend to dismiss its guidance as being too general.  Not so!

The Apostle Peter speaks about the “basics” of Scripture by referring to it as “spiritual milk” [1 Peter 2:2].  The Apostle Paul contrasts this “milk” with “solid food” [1 Corinthians 3:2].

The writer to the Hebrews, however, provides some clarity [Hebrews 5:11-6:3].  He points out that “milk” are those essential or “elementary” elements of the Christian faith, such as repentance, faith, baptism, etc.  This is the mandatory instruction every pastor is to provide for his members – most often through sermons.  The writer to the Hebrews, however, indicates that a Christian needs more understanding of Scripture to distinguish “good from evil.”  Stated simply, the “teachings about righteousness” is that growing and thorough study of Scripture that communicates not only for a priority of God’s wishes in our lives but a tenor for God’s will on matters not explicitly spoken of in Scripture.

It is that “tenor” for the will of God that drives us into his word, digging deeper for how we are to address matters like tube-feeding and artificial assistance in breathing.

I will speak only of tube-feeding as I think the logical applications can be adapted to fit the artificial assistance of providing oxygen.

We begin with the knowns: 1) We cannot take life; 2) We are called upon to protect life; 3) We have a circumstance where eating is either not possible or cannot be done (i.e., loss of swallowing reflex, insufficient staffing in a nursing home to provide oral feeding, etc.); and 4) We have the technology available to us in this place (the United States) to provide tube-feeding.

We also have some other lesser knowns but equally-true facts: A) A time in life requiring tube-feeding is a time of lesser quality; B) Generally speaking, talk of permanently implanting a feeding tube suggests the quality of life will not return to its “norm”; C) Feeding is not curative but sustaining care; and D) Suffering in life plays a role for the Christian.

It is these latter points that require us to move on to solid food to distinguish between the right and wrong decisions in this matter.

Point A – Lower Quality of Life: Scripture is not ignorant of the fact that people have lower qualities of life.  Some people are very poor in contrast to others [Mark 12:42].  Some are also ill [Mark 6:55], and some are disabled [Luke 7:22].  There is condemnation in neglecting those with a poor quality of life [Luke 16:19-31].  Without a doubt, caring for those with a diminished quality of life is both burdensome and often costly.  There is, however, no justification anywhere in Scripture to permit the termination or self-termination of life for reasons of cost or burden.  Rather, where lower quality of life is recognized, Scripture venerates the reprioritizing of life to provide for their care [Matthew 25:31-46 and Philippians 2:3-5].  In summary, a lower quality of life only means that the quality of life has diminished.  There is, however, an intrinsic or absolute value to life regardless of its diminished quality, and it is to be respected as such for it is a life for which Christ died [John 3:16].

Point B – Irreversible: Aging, illness and malady all diminish the quality of life and that diminished condition is often irreversible.  Scripture recognizes this reality [2 Samuel 4:4; Ecclesiastes 12:7; Isaiah 46:4, 65:20; Zechariah 8:4].  As previously stated, the diminishing or irreversible nature of lower quality of life is not justification for its termination but for its care.

Point C – Not Futile if It Sustains: The medical community is increasingly-confusing terminology.  For example, a person has a devastating stroke and has lost the ability to speak or walk.  Some medical professionals will argue that you should not feed them because it is futile – “they will not be getting better, the damage was too extensive.”  Feeding is not curative.  Feeding sustains life.  It is not an antibiotic or an anecdote or a vaccine.  It cures nothing but without it life comes to an end.  It can be withheld specifically to bring life to an end.  It is rightfully called “starvation.”  Starvation with the intent to end life is a violation against God’s will prohibiting murder or self-murder.

Point D – There Is a Value to Suffering: To some extent this thought seems contradictive.  On the one hand we are to feed and care and visit those who have a diminished quality of life and to ease their suffering.  On the other hand, we are to accept suffering for having value.  Proactively, we are to act to ease the suffering of others.  Reactively, when our own suffering cannot be relieved or avoided, we recognize that God would have a purpose in it.  Such purposes include glorifying him [John 9:1-3], making us more aware of God’s providence over all things [1 Peter 2:19] and simply making us the outlet for the faith of others [Luke 10:30-37].  On this latter point, God brings cares and burdens into our lives to realign our priorities or to teach us deeper values relating to sacrifice and concern.

Some might think this all means that we are always to do everything medically possible to preserve life, even if we know statistically or anecdotally that it won’t work. That would not be true.  A simple example of this is when the body is no longer able to process food or fluids.  This can be a shutdown of the bowel area, an intestinal blockage or some related condition in which the body just cannot dissolve food and break it down.  In those circumstances it is the underlying condition and not the cessation of food and water which brings death.

Sometimes circumstances can be much more challenging in which there may need to be a decision to “pull the plug” or not to pursue treatment.  It is, admittedly, a gray area, but it is in that murky area between clearly “right” and clearly “wrong” that a Christian’s most valuable asset goes on display – faith!

As a general rule I look to justify stopping feeding, stopping treatment, etc. when there is an occurrence of  “cascading effect” of medical conditions.  The kidneys may be failing, the lungs may be restricted, the heart is getting weak, etc.

In this situation I encourage people to engage in a discussion of “reasonable expectation.”  Admittedly, this sounds like an inexact conversation, and it is, but such is the uncertainties in a world of sin.  Because of our imperfect knowledge about the human body, disease and prognosis, we essentially must make a “best guess” rooted in the solid food of God’s Word.  If there is a “reasonable expectation” that the tube-feeding will work (i.e., sustain life) then you keep doing it.  If there is a “reasonable expectation” that it will not work and that a patient will die regardless of tube feeding, then stop it.

What encapsulates this entire discussion is what makes Christians fundamentally different than the rest of the world – our faith.  That is why pastors, in consulting with families on tough decisions, will first of all try to get a bearing on where there faith lies.  That is why we say that “Christian Bioethics” is the only bioethics discipline in which “motive” is the first determinant of right or wrong [Hebrews 11:6].  Pulling the plug because one does not like the quality of life is not a faith-based decision.  Insisting on always feeding even when it no longer sustains life, because we are afraid of death, is also not a faith-based decision.

“Pulling the plug” is what we do when maintaining something is no longer accomplishing what it is supposed to do.  Because tube-feeding is to sustain life and not cure it, it can be “pulled” only when it fails to sustain life.

A simple verbal test on this issue would be to ask the attending physician, “If I leave tube-feeding in place what would happen to the patient?”  If the answer is that they could live in this debilitated condition (i.e., poor quality) for weeks, months or years, then you have your answer.  Tube-feeding is doing what it is supposed to do – sustain life.

If the answer otherwise is that to keep feeding will increase pain and possibly accelerate the dying process because the body cannot process the food, then you have your answer – stop tube feeding.

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