Introduction
The Present Crisis
Theological Perspectives
Definitions of Assisted Suicide and Related Terms
Ethical Issues
Points of View
Christian Commentary on Assisted Suicide
Questions for Reflection
Action Steps
Feedback
Bibliography
Addenda
Assisted Suicide and Quality of Life
of Persons with Disabilities--A Study Document
Issued by the National Council of Churches
Committee on Disabilities
January 2000Note: A Study Document is a study and analysis of a subject or a problem which substantially involves ethical, moral or religious elements and on which it is deemed important that the members of the churches be more thoroughly informed as an aid to the formulation of Christian opinions and judgments, or on which the judgment of individuals or groups is desired.
This document is issued by the National Council of Churches Committee on Disabilities. It is a Study Document, it is not a Policy Statement. It is not to be construed as an official statement of attitudes or policies of the Council.
As Christians, we are concerned that legalized assisted suicide may make persons with disabilities more vulnerable to involuntary suicide. Throughout church history we have been in the forefront of healing the sick, caring for the people with disabilities, and comforting the dying. It is no surprise that when confronted with the specter of assisted suicide Christians want to develop resources and mobilize forces to challenge those who want assisted suicide as an alternative to living with a disability.
The purpose of this study paper is to provide information about the issue of assisted suicide and the danger it poses for persons with disabilities. We will examine the problem of assisted suicide and quality of life issues for persons with disabilities. Also, we will define terms, explore legal and ethical issues, and propose theological responses.
Our focus is on the disabled person's quality of life and who should make decisions about their usefulness or potential cost to society. We are concerned that some may attempt to pressure or intimidate persons with disabilities or their family to seek assisted suicide. Because some among the disabled community are dependent on family and community services for survival they may be more vulnerable to such pressure or intimidation. This paper provides information for churches to consider and act on this issue.
A Tale of Two Proposals
We present these two proposals so that the reader may compare them and consider the possible effects they may have on persons with disabilities. One states: "An adult who is capable, is a resident of .., and has been determined by the attending physician and consulting physician to be suffering a terminal disease, and who has voluntarily expressed his or her wish to die, may make a written request for medication for the purpose of ending his or her life in a humane and dignified manner in accordance with this Act."(1)
The other suggests a "carefully controlled juridical process" for assisted suicide. It includes an evaluation "by a three-person panel (a general physician, a psychiatrist, and a lawyer). A patient who has given his consent to be killed would have the right to withdraw that consent at any time, but there was also an emphasis on the legal protection of physicians involved in the killing process."(2)
Where do these proposals come from? The two proposals are separated by 75 years, 8,000 miles and one world war. The first proposal is Oregon's Death with Dignity Act, first passed in 1994 and reaffirmed in 1997. The second proposal is from Germany in 1920. The document quoted 3 is a book, The Permission to Destroy Life Unworthy of Life written by "two distinguished German professors: the jurist Karl Binding, retired after forty years at the University of Leipzig, and Alfred Hoche, professor of psychiatry at the University of Frieburg."
Binding and Hoche further define the scope of their work which, obviously, moves far beyond anything that the Oregon bill allows. The authors(4) write about the "killing of 'incurable idiots." They describe the process as "compassionate and consistent with medical ethics" and characterized people with psychiatric disturbances, brain damage, and retardation as "human ballast" and "empty shells of human beings" and suggested that "these people are already dead."(5)
We are not suggesting that the Oregon act is the same as that of the German doctors' proposal or with what occurred in Nazi Germany in the 1930s and 1940s. We do suggest that the Oregon Death With Dignity Act serves as a warning to the millions of United States citizens who are disabled. It is a warning since common law in the United States does not differentiate between those with terminal illness and those with disabilities. That is, if one has a disability it is the same as having a terminal illness in 47 of the United States.(6) We may say that this genocide could never happen in the United States. However, in 1942, an article(7) by Foster Kennedy, entitled, "The Problem of Social Control of the Congenital Defective: Education, Sterilization, Euthanasia," appeared in the American Journal of Psychiatry. Kennedy was rebutted by Leo Kanner in the same issue. Kanner, a leading American child psychologist, did, however, favor sterilization. This is why people with disabilities are troubled by any attempt to legalize assisted suicide.
Go to Study Questions on "Introduction" Section
Dr. Jack Kevorkian
A jury found Dr. Jack Kevorkian guilty of second degree murder in killing 52-year old Thomas Youk of Oakland County, Michigan. The judge sentenced him to 10-25 years in prison. In the ten years that Kevorkian has been helping patients die, he has assisted in 93 documented suicides, although he asserts that he has been a part of more than 130 deaths. Kevorkian had been tried on assisted suicide four times and escaped conviction each time. Youk's death resulted in charges of first degree murder and illegally delivering a controlled substance. The defense was not allowed to rely on evidence of pain and suffering by other people Kevorkian helped to die. We will not know how all of this plays out until all appeals have been exhausted by his lawyers.
The State of Oregon
In 1994, voters approved, by a 51-49% majority, Oregon's Death with Dignity Act. Legal challenges ensued and the law was not used in the intervening years. U.S. District Judge Michael R. Hogan, in 1995, ruled against the assisted suicide law, but a 9th U.S. Circuit Court of Appeals overturned Hogan's decision. In October of 1995, the U.S. Supreme Court declined the case.
The Oregon legislature decided to place a repeal of the law in the hands of the voters. On November 5, 1997, voters overwhelmingly rejected the repeal by 60-40%. Observers feel that the voters were tired of dealing with the issue and angry that the state legislature would not deal with the issue, but turned it back to the voters. (See addendum for more details.)
Christians have generally viewed suicide, in any form, as an unacceptable way of ending life. Assisted suicide is particularly repugnant because it involves another person in a suicidal act. While the Scriptures contain no specific prohibition against suicide they uphold the sanctity of life.
Biblical Stories
Two stories from Scripture tell of suicide, another appears to tell of an assisted suicide. Samson's death came about as a result of his being captured by the Philistines. He was chained to the pillars of the house of their god, Dagon. He pulled down the pillars killing all assembled there including himself. (Judges 16:23-31) Judas hanged himself following his betrayal of Jesus to the Romans.( Matthew 27:5) Saul's death as told in 2 Samuel 2:1-10 might be considered assisted suicide. Saul is wounded by the Philistines and rather than fall into their hands he asks his armor bearer to kill him because, "Convulsions have seized me, and yet my life still lingers." The armor bearer killed him. He, in turn, was killed by David for his action.
Killing or Murder
"You shall not murder," Exodus 20:13
Suicide is undeniably the killing of oneself; thus, assisted suicide is abetting a killing. There are times when killing may be morally justified, and a quick reading of the Hebrew Scriptures shows a variety of killings, many at the direct or indirect command of God to the Hebrews.
Meaning of Suffering
"Are any among you suffering? They should pray. Are any cheerful? They should sing songs of praise." James 5:10-13 NRSV
As Allen Verhey(8) writes: "We can only know another's suffering imperfectly. If we know something of a person's life and of the values and purposes that constitute a person's identity, and if we are capable of discerning judgments concerning the events in a person's life then we may be able to enter into or understand that person's suffering." The compassionate Christian community can listen and feel and empathize with one who is dying and offer hope beyond the deadly medications provided to end his or her life.
Giving and Taking of Life
"Then Job arose, tore his robe, shaved his head, and fell on the ground and worshipped. He said, 'Naked I came from my mother's womb, and naked shall I return there; the LORD gave, and the LORD has taken away; blessed be the name of the LORD.'" Job 1:21
Who is it that gives and takes life? Is it God alone? Life can be extended even in the face of what would have been death not too many years ago. When tubes are pulled or respirators shut off, is it really God who is taking our lives?
Eschatology-Life after Death
"For to me, living is Christ and dying is gain. If I am to live in the flesh, that means fruitful labor for me; and I do not know which I prefer. I am hard pressed between the two: my desire is to depart and be with Christ, for that is far better." Philippians 1:21-23
Some might say that their desire is to depart this life and be with Christ, as Paul asserted. It may be that a Christian facing the devastating pain that accompanies chronic disabilities or illnesses would want to choose death and the promise of being with Christ. What would our answer be?
A God Breathed Life
"Then the LORD God formed man from the dust of the ground, and breathed into his nostrils the breath of life; and the man became a living being." Genesis 2:6-7
Scott Peck wrote: "The soul is a God-created, God-nurtured, unique, developable, immortal human spirit. In our secular and self-autonomous glorifying society, when we fall prey to the temptation to either take our own lives or assist another in taking theirs, we are denying the soul."(9)
Community
"So we, who are many, are one body in Christ, and individually we are members one of another." Romans 12:5
Since we are one body in Christ, because we are members one of another, we must not allow any member to die in isolation. Too many people in this world lack supportive and meaningful relationships. What is the response of the Christian community?
Self emptying
"Let the same mind be in you that was in Christ Jesus, who, though he was in the form of God, did not regard equality with God as something to be exploited, but emptied himself, taking the form of a slave, being born in human likeness." Philippians 2:5-7
Peck writes about that point when we know we are dying. "At this point, if we ever reach it, we embark upon the journey of kenosis, 'the process of the self emptying itself of self,' of purification, of the ego bumping itself off. The kenotic path is hardly encouraged in our 'live without limits' culture."(10)
Go to Study Questions on "Theological Perspectives" Section
Definitions of Assisted Suicide and Related Terms
We find a variety of terms used in different sources related to assisted suicide. Here are three as found in the 17th Edition (1993) of Taber's Cyclopedic Medical Dictionary.(11)
Assisted Suicide
The rendering of assistance to a person who wants to end his or her life but is not able to do this alone. This may be due to a physical disability or lack of knowledge of how to accomplish suicide. Whether or not physicians should become involved in helping patients commit suicide is debatable.
Euthanasia
Euthanasia comes from two Greek words "good" (easy) and"death." Euthanasia, today, is the act or practice of killing or permitting death of the hopelessly sick or injured persons. Ethical considerations of this act are being actively debated. One difficulty is how will the physician or society determine that the time for acting to kill the patient has come.
Euthanasia has been accepted legally and morally in a variety of forms in many societies. Ancient Greece and Rome allowed persons to help others die and euthanasia for the elderly was an approved custom in many societies. Euthanasia became morally abhorrent in organized religion. Judaism, Islam and Christianity agree that life is sacred and condemn euthanasia. Because our laws are based on English Common Law which, in turn. is based on religious precepts, the act of helping someone die is homicide and subject to legal action. In spite of the legalities, euthanasia occurs in most societies, usually secretly. Assisted suicide is a form of euthanasia. Some, to soften its impact, call it active euthanasia.
A Christian Definition of Assisted Suicide
A Christian definition of assisted suicide might be "to ask God to end one's life" or "to pray for death in the face of pain and suffering." This puts the action of dying into God's hands. In 1 Kings 19:4, Elijah asks for death: "He asked that he might die: `It is enough; now, O Lord, take away my life'."
Cultural Definition
A culturally acceptable definition might be: to end pain or suffering by helping one to kill oneself intentionally. This brings in the idea of "assisted" but doesn't shy away from the notion that suicide is killing. No matter what it is called, it is still the act of terminating a life, even if done for 'humanitarian' purposes.
Definition of Disability Terms
Impairment: any loss or abnormality of psychological, physiological , or anatomical structure or function.
Disability: a) a physical or mental impairment that substantiality limits one or more of the major life activities such as walking, speaking, breathing; b) a record of such as impairment; or c) being regarded as having such an impairment.
Handicap: a situation or barrier imposed by society, the environment or oneself.
Quality of Life-a Definition
Jesus said: "I have come that you might have life, and have it more abundantly." John 10:10 NRSV Jesus came to show us a quality of life that was abundant, beyond measure. Jesus demonstrated that quality of life even through his suffering and dying.
Quality of life is a concept that differs for each person and may vary for the same individual as that person's life situation changes. The holistic treatment of a patient requires that the health-care team assess what is most important to that individual. In some cases, it is not possible to establish a situation in which there is complete freedom from the signs and symptoms of disease. In those cases, the goal is to have the quality of life be as good as possible despite the disease. Also, in persons who have suffered disabilities or loss of mental or physical skills, it is important to emphasize the positive features of their remaining capabilities rather than dwell on the negative aspects of what has been lost.
Pain and Palliative Care
The World Health Organization (WHO) defines palliative care(12) as: The active, total care of patients whose disease is not responsive to curative treatment. Control of pain, other symptoms and psychological, social and spiritual problems is paramount. The goal of palliative care is the achievement of the best quality of life for patients and families. Unfortunately, some feel that to a significant extent euthanasia is practiced as a substitute for palliative care. Doctor Herbert Hendin studied the Dutch experience with assisted suicide, "which inevitably led to euthanasia and then to non-voluntary medical killing. He recognized that since that country accepted assisted suicide, studies have demonstrated how inadequately physicians are trained in palliative care in the Netherlands.(13) It is clear from the above mentioned testimony that pain medication for the seriously or terminally ill can improve. New and more effective drugs are continually reaching those in pain. These new drugs are more effective and cause fewer side effects than those currently being used.(14)
Medical Ethical Decisions
In the middle of the controversy that roils the waters on assisted suicide is the medical profession. That doctors are not required to use "extraordinary means" to prolong life, is commonly agreed upon by religious organizations, governments and the medical profession itself. Medical technology helps keep people alive for long periods of time through respirators, and artificial kidney machines even when patients are permanently unconscious or irrevocably brain damaged. Proponents of euthanasia believe that prolonging life by these means causes great suffering to the patient and family, to say nothing of the medical expenses surrounding such care.
Opponents fear that the great success in organ transplants coupled with the lack of organ donors may lead to abuse of the practice of assisted suicide. While the medical community is trying to allay these fears, the disabled community wonders how often a dying patient's death is hastened because of the need for his or her organs, even without legal sanctions.
Two doctors interviewed by the author state that a doctor's responsibility is to preserve life and do no harm. These issues are not consonant with assisted suicide. Both also feel that adequate pain management is either being ignored or not understood by too many physicians. With new pain medications now available and a better understanding of pain, doctors should provide better palliative solutions for patients.
Health Insurance Company Ethical Decisions
What is the role of health insurance companies in this matter? If health insurance companies are trying hard to contain costs, what is to prevent them from cutting back on medications for palliative care? When someone from Physicians for Compassionate Care called a Health Management Organization (HMO) and asked what their benefit for home palliative care for the terminally ill was, he was shocked to hear that it was a mere $1000. As he testified: "What is this HMO going to do when that $1000 is gone in a few weeks? When the seriously ill ask what their options are, will the HMO remind the patient that their assisted suicide benefit has not been used yet? This kind of financial incentive for HMOs will inevitable pressure patients to accept lethal prescriptions instead of good medical care. These incentives to offer suicide instead of medical care clearly pose a serious threat to public health and safety."(15)
Just after implementation of Oregon's assisted suicide law, that state decided to fund assisted suicides for the poor and disabled on its rationed Oregon Health Plan, while cutting needed services for the same patients. The Oregon Health Services Commission did this even though every organization representing the poor and disabled at their hearings objected to funding doctor assisted suicide, because it endangers the poor and disabled. The Oregon Health Plan carves out mental health care and provides what treatment it does through HMOs on a fully capitated basis. That is, contracting mental health clinics or groups are paid in advance per enrolled patient; they can actually profit by failing to deliver care.
The associate medical director of one HMO, feels that HMOs need to stay out of the assisted suicide decision making process and that HMOs need to develop ethics proposals so that the situation just described never happens.
Who Defines "Quality of Life"
Who is it that assesses a person's quality of life? Unfortunately, this term has created doubt, confusion and misunderstanding among practitioners, researchers, policy makers, and patients. Are we talking about health status or quality of life? Are we examining it from the patient's point-of-view? What about cross-cultural issues?
Drs. Alain Leplege and Sonia Hunt, suggest definite weaknesses in the current approaches to the issue. They state, "quality of life as an outcome could be explored more clearly (i.e., defined) if quality of life were replaced with a more easily handled notion such as that of 'subjective health status.' However, the idea that a patient's perspective is as valid as that of the clinician when it comes to evaluating outcomes has a great deal of legitimacy and should certainly not be abandoned."(16)
Quality of Life and People Who Are Disabled
How do disabled people view their quality of life? A recent study reported that long-term spinal cord injured (SCI) survivors report a good or very good quality of life, especially in the face of major difficulties. Results of one study of survivors injured more than 23 years indicate that over 76% of the participants rated their quality of life as either good or excellent. Interestingly, the level of injury and degree of paralysis have little effect on the quality of life. Following a catastrophic injury or illness, people tend to re-prioritize their lives. They often express great joy and gratefulness for life itself, however compromised they may be. In SCI studies 17, researchers discovered the following traits associated with high quality of life: "feelings of control, good social support, high activity level, positive self-image and self esteem, finding a positive meaning to disability and spirituality." A general population happiness study found these traits associated with high quality of life: "feelings of control, extroversion, high self esteem, religiously or spiritually active, good marriage or relationship, and optimism." (18)
Research with both disabled and general populations shows that quality of life is an internal concept; it is more dependent upon how we think than what we have. With life so drastically altered following a chronic injury or illness, adequate adjustment demands that individuals change their frames of reference and stop measuring their lives with pre-injury, pre-illness or non-disabled comparisons. Also, to cope with the challenges of disability, Trieschmann found that individuals tend to focus on the positives of life while minimizing its obstacles.(19)
In the words of disability activist, Anne Peters: "What gives life quality? We know it isn't the things society says it is. We've lived without those things; and yet we are human-and reasonably happy. Average people, who have no disabilities yet, look at our lives and see deprivation. They conclude that our disability has prevented us from having a quality of life. They are wrong: a life without the luxury of autos, restaurants, jobs and condos can still have a quality of life. And they are also wrong to believe that disability is the villain that prohibits quality in our lives. The villain is usually society."(20)
Medical Views of Quality of Life
A major problem that persons with disabilities have when they try to convince others that their quality of life is good is the medical community. In a study to measure emergency care providers' attitudes towards quality of life after spinal cord injury (SCI) and to determine if their perceptions influence the care they provide, two-hundred thirty-three emergency nurses, technicians, residents, and attending care physicians were surveyed. Responses were compared to reported quality-of-life ratings of a group of 128 high-level SCI survivors.
The study concluded that the quality of life, self-esteem, and outcomes that emergency care providers imagine after SCI are considerably more negative than those reported by SCI survivors. Because the providers' knowledge and attitudes may affect the care they provide and may influence patients and families struggling with critical treatment decisions, emergency care providers must be aware of outcomes, well-being, and life-satisfaction following severe SCI.
Legal Aspects
Efforts to legalize euthanasia have been going on since 1906 when the first euthanasia bill was drafted in Ohio. In 1938 the Euthanasia Society of America was founded and, in 1974 changed its name to the Society for the Right to Die. In 1980 The Hemlock Society was founded. It advocated changes in laws to allow assisted suicide and distributed how-to-die information, such as found in the book, Final Exit, by Derek Humphrey.
In the last few decades, Western laws against passive and voluntary euthanasia have slowly been eased, although serious legal and moral questions still exist. The "right to die" movement has received considerable backing by the passage of laws in most states that allow legally competent individuals to make advanced directives or living wills. These directives empower doctors to withhold life-support systems if the individuals become terminally ill.
In the 1997 case of Washington v. Glucksberg, the Supreme Court of the United States ruled that the state of Washington's law prohibiting assisted suicide was constitutional. The court's ruling essentially allows each state to determine whether or not to prohibit or permit assisted suicide. Also, in November, 1998, voters in Michigan defeated a referendum to legalize doctor-assisted suicide. Over 20 other states have defeated similar proposals. Thirty-five states have a statute prohibiting doctor assisted suicide, and nine states prohibit doctor assisted suicide through application of common law. Five states have neither a statute nor common law which prohibit doctor assisted suicide.
The economic problem for people with disabilities is that there are too many disincentives to work. It is easier for most to be supported by Social Security Disability Insurance (SSDI) than to work. Fortunately, President Clinton has committed $20 million in FY 2000 and $857 million over five years in Medicare and Medicaid spending to support opportunities for people with disabilities to return to work without losing their healthcare. The initiative increases flexibility for states to set higher income and resource standards for Medicaid. It also provides incentive grants to states to expand Medicaid coverage for the working disabled and to build the capacity to provide home and community based services in order to offer an alternative to institutional care. In addition, the initiative would allow people with disabilities who leave SSDI in the next ten years to go to work but continue receiving free Medicare Part A coverage. This is a big step in the right direction towards helping people with disabilities to finding meaningful work when they are able.
Finally, in California, on March 1, 1999, Assemblywoman Dion Aroner (D-Berkeley) introduced a bill seeking to legalize physician-assisted suicide in California. The bill is reportedly patterned after Oregon's law. Under this proposal, patients would have to be within six months of dying and would have to take the medications themselves. In 1992, California voters rejected a slightly different bill that sought to provide a means by which terminally ill patients could experience a "death with dignity."
Rehabilitation Viewpoints
Remarkable discoveries in health sciences, in recent years, are providing new techniques for preventing disorders, eliminating some diseases, and improving acute treatment of injury. These advances are lengthening the average life span of Americans with and without disabilities. Among these advances are:
+ The interdisciplinary approach for treating individuals with disabilities, solving their sometimes complex medical and psycho-social problems, and filling their needs in vocational, home, and social settings.
+ The development of specialists in rehabilitation, continuous refinement of medical rehabilitation treatment programs for specific problems, and technological advances.
+ Creation of educational programs to train individuals with injury or disease, as well as their family members, in self-care aspects of treatment.
+ Advances in the medical emergency system, pharmacological interventions, and surgical techniques that have saved the lives of many who would otherwise have died as a result of their congenital anomalies, injury, or disease.
+ The independent living movement of the past two decades has empowered consumers with skills that allow them to be full members of society. All of these medical advances promote empowerment of individuals with disabilities in their efforts to lead healthy, independent, and fulfilling lives. (See addendum for more information).
Go to Study Questions on "Points of View" Section
Christian Commentary on Assisted Suicide
National Council of Churches of Christ
The National Council of Churches policy statement, "Disabilities, the Body of Christ, and the Wholeness of Society" listed four theological principles as a basis for their commitment to people with disabilities. This policy statement implies a commitment to and respect for each and every human, whether "productive" or not, whether financially dependent or not. Following these four principles are others that readers may wish to explore.
All people are created in the image of God
"Then God said, 'Let us make humankind in our image." Genesis 1:26
God creates all human beings in the divine image or likeness. This image is not a measurable characteristic or set of characteristics. God's image is reflected uniquely in each person.
All people are called by God
"For we are what (God) has made us, created in Christ Jesus for good works, which God prepared beforehand to be our way of life." (Ephesians 2:10) God calls all human beings to express the divine image through their unique characteristics. Each person's characteristics, including disabilities, are inseparable and valuable features of the unique, indivisible person.
All people have special gifts
"Now there are varieties of gifts but the same spirit." 1 Corinthians 12:4
God supplies all human beings with the unique gifts needed to obey the divine call. The gifts God has given to each person are needed by all other people, and no one is dispensable or unnecessary.
All people are invited to participate in God's ministry
"To each is given the manifestations of the Spirit for the common good." 1 Corinthians 12:7
God invites all human beings to rely on and participate in the ministry of the church. God continually empowers each member of the Body of Christ to reflect the divine image in ways that will serve and benefit the church and the broader community.
Denominations' Statements
The following ideas were culled from denominational statements about assisted suicide and end-of-life decisions. The full text of these documents is available from the denomination's national office. The addendum provides a list of documents produced to date. Not all documents are included in the commentary below.
The Evangelical Lutheran Church in America says that "life is a gift from God, to be received with thanksgiving and it refers to the reality that hope and meaning in life are possible even in times of suffering and adversity."
The National Catholic Office for Persons with Disabilities says that a culture of death is in existence in society. This office takes a comprehensive stand in its document as it states, "We stand in opposition to abortion, infanticide, direct and indirect euthanasia, assisted suicide, capital punishments, and every form of violence and abuse against human beings."
The Presbyterian Church (USA) considered the end-of-life decisions necessary for those who are dying. The document did not expressly consider assisted suicide for people with disabilities yet its chapter on "Scriptural Perspectives on Suffering and Death" states that suffering may have redemptive possibilities, is a mystery of God's way, and that God may even ask us to suffer on behalf of others. It further states that pain, suffering and death may be the consequence of human oppression and human evil which God asks us to resist.
The Seventh Day Adventist document on this subject refers primarily to end-of-life decisions and it encourages the nourishment of people within a family and a faith community.
The Mennonite Church document again considers end-of -life decisions with a focus on seeing death as part of life's journey.
The Evangelical Covenant Church says that it is their policy to provide care to those individuals afflicted with communicable and related diseases, those who ar terminally ill, and those who are mentally, emotionally or physically disabled. They further state that decisions to limit or not limit care are to be made through consultations with the person, the family and with reference to previously stated wishes.
The Reformed Church in America produced a "response" to assisted suicide in which it states, "One obligation is to eliminate the suffering of others, but it is accompanied by the constraint that people may not eliminate suffering by eliminating the sufferer. God's people may not eliminate suffering by any means possible."
The Episcopal Church produced a resolution published in the Journal of the General Convention of The Episcopal Church 1994, pp. 289-90 that states, "It is morally wrong and unacceptable to intentionally take a human life in order to relieve the suffering caused by incurable illness." It further states that palliative treatment done to relieve pain, even when it may hasten death, is consistent with tenets regarding the sanctity of life.
The Church of the Brethren prepared a study of euthanasia in which it states that "Those who oppose abortion, capital punishment, war, murder and euthanasia have an important point. To take a life is to play God. That is, humans have no way to know the future. Unwanted children can become loved and wanted. Criminals can be redeemed. Certain death may be averted. For a person to be so certain about their life is nothing less than hubris or a pride that places one above even God. The one who commits suicide too often assumes there is no other possibility."
Closing Thoughts
+ Right to life is the right of every person who is disabled, no matter what the cost. Are we willing to pay the price?
+ Our society focuses on doing, on accomplishments. For many who are chronically disabled their focus is more on being than on doing. What can we learn from them?
+ Grieving over loss of function is a long process. For the chronically disabled person, it often takes months or years. How do we support persons as they adapt to their disabilities?
+ Quality of life means that anyone who is alive has quality of life; it is not dependent on what you can do. How can the church enhance the lives of persons with disabilities and enable them to have "life abundant?"
+ Spiritual growth can come from facing suffering and death honestly.
+ It is within the family and the congregation that feelings, dilemmas, and decisions can best be explored.
+ A caring congregation that provides ministries of visitation, presence, counsel, worship and prayer is a primary resource for issues such as these.
Go to Study Questions on "Christian Commentary on Assisted Suicide" Section
1. What are the main differences between the two proposals noted above? Are there any grounds to be concerned about assisted suicide from the point-of-view of a person with a disability? If so, what are they?
2. Do you think that Oregon's Death with Dignity Act might become a basis for such acts in other states or even U.S. Congressional action?
3. What is your state's position on assisted suicide?
4. Who should have the responsibility determining the quality of life of person's with disabilities? Doctors, therapists, psychologists, family members, patients themselves?
Theological Perspectives Section
1. Are there times when assisted suicide might by a viable option? If so, what would be the circumstances? Is there any biblical or theological rational for assisted suicide?
2. How would you respond to from a biblical and theological point-of-view someone who is thinking about assisted suicide?
3. What biblical or theological concepts help you to understand quality of life?
1. How many persons do you know who have disabilities? How do they view themselves? How does society view them?
2. How many people with disabilities attend your church? Is your church accessible?
3. In what ways does your community help or hinder people with disabilities?
4. Are any legal steps being taken in your state regarding assisted suicide?
5. What organizations in your state are working for or against assisted suicide?
6. On a scale of one (poor) to four (excellent) how would you rate your quality of life at the present time? What aspects of your life influence your current quality of life?
7. Think of the persons that you know who have chronic disabilities or illnesses? What do they think their quality of life is?
8. What criteria would you use to judge another's quality of life?
1. How can we dare to eradicate the life of anyone who is made in God's image?
2. How dare we presume to act to end a human life whose intellect, moral character and dignity bears God's stamp?
3. Should we help people at the end of their life to go through this kenosis, self-emptying, process? Assisted suicide is the process of someone else doing the emptying.
1. Read the study paper and discuss it in a Church school class, Church board or department meeting, or study group.
2. Plan a meeting to which you would invite persons such as a doctor, nurse, pastor, person with a chronic disability or illness as part of a panel discussion on the issues presented.
3. Suggest to your official Church board a resolution and steps toward addressing the issues presented here.
4. Ask that the Church board request denominational action in the form of a resolution or statement of concern be presented at a region or national level.
5. Consult with persons with disabilities to make your church more accessible to them.
6. Discover persons in your congregation who have chronic disabilities or illnesses and find ways to minister to them and be advocates for them.
+ In what ways has this study guide been useful?
+ What was missing that you felt needed to be addressed?
+ Are there other resources needed to help Christians understand this issue?
+ What steps will you take to address the issues?
Please send your comments to: NCC Committee on Disabilities, Ministries in Christian Education, 475 Riverside Drive, Room 848, New York, NY 10115
Assisted Suicide and Euthanasia: Christian Moral Perspectives. Committee on Medical Ethics, Episcopal Diocese of Washington, D.C.: Morehouse Publishing. 1997
Denial of the Soul: Spiritual and Medical Perspectives on Euthanasia and Mortality by M. Scott Peck New York: Harmony Books. 1997
Euthanasia: Opposing Viewpoints. Bender and Leone, Series Editors. San Diego: Greenhaven Press. 1995
Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying by Derek Humphrey. New York: Dell Publishing. 1992.
Medical Ethics, Human Choices: A Christian Perspective. John Rogers, Editor. Pennsylvania: Herald Press. 1988
The Moral Imagination: Confronting the Ethical Issues of Our Day by Edward Tivnan. New York: Simon and Schuster. 1995
The Nazi Doctors: Medical Killing and the Psychology of Genocide by Robert Jay Lifton, New York: Basic Books, Inc.1986
The following is a listing of denominations that have provided resolutions and/or resource materials on the issue of assisted suicide and related topics.
Church of the Brethren
"End-of-Life Decision Making," a packet of materials for congregational study and worship.
"Introduction to Euthanasia," a four session study guide.
Episcopal Church
"Report of the Task Force on Assisted Suicide to the 122nd convention of the Episcopal Diocese of Newark."
"Resolution to Establish Principles With Regard to the Prolongation of Life"
Evangelical Covenant Church
"Resolution on Life and Death in Relation to God and Others-Assisted Suicide"
Covenant Benevolent Institutions: Mission, Values and Ethical Guidelines and Ethics of Caring. These include statements regarding death and euthanasia.
Mennonite Church
"Healthy Living Series: A time to live, a time to die." A discussion guide on the issues of dying, pain and suffering, and death.
"Medical Ethics, Human Choices: A Christian Perspective" edited by John Rogers. Pennsylvania: Herald Press. Thirteen chapters devoted to the wide variety of ethical problems Christians face. It includes suggestions for group study.
Reformed Church in America
"A Christian Response to Physician -Assisted Suicide," a guide for congregational study and action., accompanied by a separated booklet, "Discussion Questions on A Christian Response to Physician Assisted Suicide."
Presbyterian Church (USA)
"In Life and in Death We Belong to God: Euthanasia, Assisted Suicide, and End-of-Life Issues, A Study Guide"
Roman Catholic Church
National Catholic Office for Persons with Disabilities "Resolution on Defending and Celebrating the Culture of Life."
Seventh-day Adventist
Seventh-day Adventists "Statement of Consensus on Care for the Dying."
Oregon's Death with Dignity Act
The Act( 2)1
The Death with Dignity Act allows terminally ill Oregon residents to obtain from their physicians and use prescriptions for self-administered, lethal medications. The Act states that ending one's life in accordance with the law does not constitute suicide. However, we have used the term "physician-assisted suicide" rather than "Death with Dignity" to describe the provisions of this law because physician-assisted suicide is the term used by the public, and by the medical literature, to describe ending life through the voluntary self-administration of lethal medications, expressly prescribed by a physician for that purpose. The Death with Dignity Act legalizes physician-assisted suicide, but specifically prohibits euthanasia, where a physician or other person directly administers a medication to end another's life.
To request a prescription for lethal medications, the Death with Dignity Act requires that a patient must be:
An adult (18 years of age or older)
A resident of Oregon
Capable (defined as able to make and communicate health care decisions)
Diagnosed with a terminal illness that will lead to death within months
Patients who meet these requirements are eligible to request a prescription for lethal medication from a licensed Oregon physician. To receive a prescription for lethal medication, the following steps must be fulfilled:
The patient must make two verbal requests to their physician, separated by at least 15 days
The patient must provide a written request to their physician
The prescribing physician and a consulting physician must confirm the diagnosis and prognosis. The prescribing physician and a consulting physician must determine whether the patient is capable. If either physician believes the patient's judgment is impaired by a psychiatric or psychological disorder, such as depression, the patient must be referred for counseling.
The prescribing physician must inform the patient of feasible alternatives to assisted suicide including comfort care, hospice care, and pain control.
The prescribing physician must request, but may not require, the patient to notify their next-of-kin of the prescription request. To comply with the law, physicians must report the writing of all prescriptions for lethal medications to the Oregon Health Department. Reporting is not required if patients begin the request process, but never receive a prescription. Physicians and patients who adhere to the requirements of the Act are protected from criminal prosecution, and the choice of legal physician-assisted suicide cannot affect the status of a patient's health or life insurance policies. Physicians and health care systems are under no obligation to participate in the Death with Dignity Act.
A One Year Report
What has happened in Oregon since the Death with Dignity law was affirmed in November, 1998? A special report in the February 18, 1999 issue of the New England Journal of Medicine detailed the data on all terminally ill Oregon residents who received prescriptions for lethal medications under the Death with Dignity Act.
Twenty-three persons received prescriptions for lethal injections in 1998 as reported to the Oregon Health Division. "Of the 23, 15 died after taking their lethal medications, 6 died from their underlying illnesses, and 2 were alive as of January 1, 1999."(22) The median age of persons who died was 69, 15 were white, 8 were male, and all were residents of Oregon for more than 6 months. The underlying illnesses of all 23 patients were: Cancer (all types, with 9 having lung, ovarian, or breast cancer); congestive heart failure, 1; and chronic obstructive pulmonary disease, 1. The report indicates that none of the patients expressed concern about the financial impact of their illness, one expressed concern about pain at the end of life.
This research compared persons who took lethal medications prescribed under the act with those who died from similar illnesses but did not receive prescriptions for lethal medications. Researchers discovered, "Similar proportions of case patients and control patients were receiving hospice care at the time of death, had advance medical directives, and died at home. Case patients were more likely than the control patients to express concern about loss of autonomy or loss of control of bodily functions. At the time of death, the case patients had a higher functional status than the control patients; 21% of the case patients, as compared with 84% of the control patients, had a score of 4, indicating that they were completely disabled."(23)
At the conclusion of the article the authors write: "Many people feared that if physician-assisted suicide was legalized, it would be disproportionately chosen by or forced on terminally ill patients who were poor, uneducated, uninsured, or fearful of the financial consequences of their illness. In our study we found no evidence to support these fears."(24)
Pain, financial problems, and loss of independence or bodily functions have been listed as reasons that people might want physician assisted suicide. In the article just noted only one expressed concern about pain, none about financial problems, and only 21% as against 84% of the control group stated that they were completely disabled. There is a discrepancy between what supporters state as reasons for PAS and what those who chose PAS actually experienced.
Emergency Medical Technicians' Attitudes Toward PAS
In a recent Academic Emergency Medicine survey, researchers sampled 498 intermediate and advanced emergency medical technicians, with 343 completing the survey. Researchers discovered that 68% agreed that physician assisted suicide should be legal, 77% thought not attempting resuscitation would be immoral. Only 6% stated that they would be unable to work in a system that directed them to withhold resuscitation after a PAS attempt. Nearly 3 out of 4 Oregon EMTs report seeing at least one terminally ill patient who has attempted suicide.
When you read this in relation to the study of emergency medical personnel's feelings about disabilities as referred to in the study paper, it only confirms our belief that assisted suicide is something that should not be ever considered.(26)
Disabilities: The Numbers
Today, disability is a critical fact of life as the numbers of Americans with disabilities increases and access to medical and rehabilitation increases. Consider these facts:(26)
-Between 35 and 43 million Americans have a disabling condition that limits their activities
-Thirteen million of these people require assistance with activities of daily living. Another 9.7 million are unable to carry on the major activities of someone their age.
-The National Health Interview Survey (NHIS) identified major groupings of disabilities:
-Mobility limitations, 38 percent of disabilities
-Chronic diseases (respiratory, circulatory, cancer and diabetes), 32 percent
-Sensory limitations, 8 percent
-Intellectual limitations (including mental retardation), 7 percent.
-Other 15 percent.
Here is a brief rundown of the most frequently cited diseases or disorders causing disability.
Traumatic injuries: Approximately 2.3 million Americans are hospitalized each year as the result of traumatic brain injury (TBI), spinal cord injury (SCI), amputation, burn, or disfigurement, An additional 54 million require outpatient medical care.
Spinal cord injury: Affects about 250,000 Americans with 6,000 to 10,000 new cases each year
Traumatic brain injury: Occurs in about 500,000 people yearly
Amputees: 150,000 new amputees annually
Stroke: 500,000 experience strokes each year. About 2.1 million stroke-survivors are alive today.
Multiple Sclerosis: Affects between 250,000 and 500,000 individuals.
Arthritis and Musculoskeletal Disorders: More than 37 million people in the U.S. have some form of arthritis.
Osteoporosis results in 1.3 million fractures a year.
Acquired Immunodeficiency Syndrome: More than 200,000 persons have been diagnosed with AIDS.
Cardiovascular Disorders: Over 6 million people who have had heart attacks are alive today
Cancer: About one-half of the 1 million Americans who will be diagnosed with cancer this year will be alive in 5 years. Cancer treatment often results in functional deficits caused by segmental bone, joint, or limb amputations or removal of a diseased organ; therapy can also cause severe disfigurement. Cancer is the major cause of amputation in children.
Developmental Disabilities: Many children with developmental disabilities have mental retardation, learning disabilities, or other cognitive impairments.
Among the many causes of physical disabilities in children are cerebral palsy (2-4 per 1,000), spina bifida, muscular dystrophy and associated disorders, traumatic injury, congenital heart disease, visual or hearing impairment, juvenile diabetes, juvenile rheumatoid arthritis, and cystic fibrosis. Physical impairments often coexist with mental retardation.
Chronic Conditions: 40 percent of people age 65 and older report activity limitations due to disability. Almost 60 percent of all people over 65 have some functional limitations in physical activities. 45 percent of people age 65-69 report functional limitations, and 72.5 percent of people over age 75 have functional limitations. For some, functional limitations result in reduced activity levels and an increased dependence upon others for assistance. About 1.3 million adults over the age of 65 are so severely disabled that they live in nursing homes or other long-term care facilities.
Mental Illness: statistics according to the National Institute of Health( 27) indicate that 19 million adults suffer from depression annually, 2.3 million adults suffer from manic-depressive illness (20 percent die from suicide), 2 million people have schizophrenia (10 percent commit suicide) and 2.3 percent of adults in the U.S. are obsessive-compulsive.
Mental Retardation (28) 6.2 to 7.5 million people have mental retardation.
Disabilities: the costs
One analysis of spending for health care estimated that 16 percent of the population with activity limitations account for $63 billion in 1990, about 40 percent of all health care expenditures for that year.
Annual costs for a few specific disabilities are as follows:
Traumatic brain injury--$25 to $36 billion
Stroke-$25 billion
Cardiovascular disorders--$50 million
Approximately $1,406 per year is spent for health care for a child with a disability, compared with an average of $487 per year for other children.
Spinal cord injury--$9 billion. The average cost for the first year postinjury (1992 dollars) for a high quadriplegia injury (Christopher Reeve for example) is $417,000. For persons with lower level paraplegia injuries, the average first year cost is $123,000. Average charges incurred annually after the first year postinjury is $75,000 for high quadriplegia injury and $9,000 for paraplegia injury. Finally, the average lifetime direct costs of a 25-year-old person with high quadriplegia is close to $2 million, and for a 25-year-old person with paraplegia is approximately $700,000. These estimates are conservative because some persons will have unmet needs that have not been included, and some records indicate that charges rise rapidly in the last few years of life for persons with SCI.(29)
Footnotes
1 The Oregon Death with Dignity Act 1997.
2 R.J. Lifton, The Nazi Doctors: Medical Killing and the Psychology of Genocide (New York: Basic Book, Inc., 1986) 46.
3 Ibid p 47
4 Ibid p 47
5 Ibid p 47
6 Carol Cleigh, "A Disability Perspective," Death--Whose Choice Is It Anyway?, Minnesota State Council on Disability, St. Paul, MN, July 31, 1998.
7 Ibid p 51
8 Allen Verhey, "Suffering and Compassion: Looking Heavenward," Perspectives (Feb 1995): 19.
9 Scott Peck, Denial of the Soul: Spiritual and Medical Perspectives on Euthanasia and Mortality (New York: Harmony Books, 1997) 139.
10 Ibid p 22
11 17th Edition, Taber's Cyclopedic Medical Dictionary (Philadelphia: F. A. Davis Company, 1993)
12 Ibid p 970
13 Ibid p 1412
14 Physicians for Compassionate Care, "Testimony," Hearing of the Subcommittee on the Constitution, Committee on the Judiciary, U.S. House of Representatives, Washington, D.C., July 14, 1998.
15 Ibid p 4
16 A Leplege and S Hunt, "The Problem of Quality of Life in Medicine," Journal of American Medical Association 278, No. 1 p 47.
17 S. Charlifue, "Quality of Life," Phases: SCI & Aging Vol 3, No 2 p 1.
18 Ibid p 5
19 RB Trieschmann, Aging with Disability (New York: Demos Publications, 1987) 43.
20 A. Peters, "When the Cheering Stops," Disability Rag March/April (1985): 5-9.
21 Oregon's Death with Dignity Act. 1997
22 Chin A. E., Hedberg K., Higgintson, G.K. & Fleming, D.W., "Legalized Physician Assisted Suicide in Oregon--The First Year's Experience," The New England Journal of Medicine Vol. 340, #7 p. 578.
23 ibid p 580
24 ibid p 582
25 Schmidt, T.A., Zechnick, A.D. & Doherty, M., "Oregon Emergency Technicians' Attitudes Toward Physician-Assisted Suicide." Academic Emergency Medicine 5 (9) (September 1998): 912-918.
26 Center for Disease Control, Statistical Analysis for Disabilities. 1995
27 National Institute of Health Publication No. NIH 99-4594
28 ARC of U.S. web site: http://www.thearc.org/faqs/mrqa.html
29 Stover, S.L., Whiteneck, G.G., Spinal Cord Injury: Clinical Outcomes from the Model Systems (Gaithersburg: Aspen Publications, 1995) 190-238.
About the NCC Committee on Disabilities:
The committee is comprised of representatives from mainline Christian churches and organizations. Members have direct experience of disability.
Member Communions, NCC Committee on Disabilities
AMERICAN BAPTIST CHURCHES USA
CHRISTIAN REFORMED CHURCH
CHURCH OF THE BRETHREN
THE EPISCOPAL CHURCH
EVANGELICAL COVENANT CHURCH
EVANGELICAL LUTHERAN CHURCH IN AMERICA
MENNONITE CHURCHES
PRESBYTERIAN CHURCH (USA)
SEVENTH DAY ADVENTIST
UNITARIAN UNIVERSALIST ASSOCIATION
UNITED CHURCH OF CANADA
UNITED CHURCH OF CHRIST
UNITED METHODIST CHURCHMember Organizations, NCC Committee on Disabilities
RELIGION DIVISION, AAMR
NATIONAL APOSTOLATE FOR INCLUSION MINISTRY
CHRISTIAN COUNCIL ON PERSONS WITH DISABILITIES
NATIONAL ORGANIZATION ON DISABILITY--RELIGION & DISABILITY PROGRAMJohn Pipe is a retired American Baptist clergy who works part-time as a research assistant at Craig Hospital in Denver. He lives with a spinal cord injury resulting from an accident. He is married and teaches Sunday school.