by Between Life
To provide compassionate, gospel-centered care at the end of life, we must tease apart both the theology and the medical insight that fuel such discrepancies. Dogmatic responses usually worsen confusion and heartbreak and dismiss conflicts that strike to the core of our faith. Our priorities run deep. In this disconcerting era that blurs the boundaries between life and death, we must strive always to respond with love and mercy, and to walk humbly with our God (Mic. 6:8). In the following chapter, we embark upon our journey through an exploration of God’s Word.
Take-Home Points
Although the majority of Americans would prefer to die at home, only 20 percent of us do. Most of us now die in institutions, and many in the intensive care unit.
The changing landscape of death places us and our loved ones into heart-wrenching situations when we must make decisions about advanced medical options that we do not understand.
Life-prolonging technology robs us of the ability to communicate, and few of us outline our wishes regarding end-of-life treatment before catastrophe strikes.
Life-sustaining measures can save life, but when administered indiscriminately they can prolong suffering and death without benefit.
Although our Christian faith is central to our approach to death, healthcare practitioners rarely offer spiritual support.
A gospel-centered response to end-of-life critical care mandates consideration of the Word and acknowledgment of the potential benefits and limitations of intensive-care technology.
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Wisdom Begins with the Word
When catastrophe strikes, the Bible offers hope and steadies the ground beneath us. It provides “a lamp to my feet and a light to my path” (Ps. 119:105). Against the dizzying clamor of the ICU, the Bible offers clarity and steadfastness. “The sum of your word is truth, and every one of your righteous rules endures forever” (Ps. 119:160). Our pursuit of a Christ-centered, God-honoring approach to end-of-life care begins with faithfulness to God and his Word.
In this chapter, we explore biblical tenets to guide us as we navigate end-of-life dilemmas. We will unpack Scripture as it relates to life, death, and suffering, with the aim of illuminating God’s will amidst the sighing of ventilators and the clang of alarms. The precepts discussed here serve as a foundation for the ensuing chapters on life-sustaining technology.
Christian theology informs modern medical ethics, and so the principles outlined here may align with the recommendations of physicians. However, as mentioned in the previous chapter, doctors rarely attend to spiritual concerns. Furthermore, autonomy—the principle of self-determination—assumes primary importance in secular medical ethics, while the Christian worldview steers away from rugged individualism in pursuit of God-honoring service, as we see from Paul’s first letter to the church at Corinth: “Do you not know that your body is a temple of the Holy Spirit within you, whom you have from God? You are not your own, for you were bought with a price. So glorify God in your body” (1 Cor. 6:19–20). As Christians, we live not for ourselves but for the Lord (Col. 3:17). As we consider end-of-life care, our goals do not begin and end with our own worldly desires, but instead reflect our identity in Christ (Eph. 1:5; 2:19; 4:24). When confusion arises, I would encourage patients and families to seek counsel with a trusted member of the clergy. Resources in bioethics also appear in the bibliography at the end of this book, and may help.
Four Fundamental Precepts
An approach to critical-care medicine through a Christian lens mandates reflection upon four key principles:1
1. Sanctity of mortal life
2. God’s authority over life and death
3. Mercy and compassion
4. Hope in Christ
Tension between these fundamentals often incites confusion. In the clinical vignette in the previous chapter, for example, the patient’s wife voiced acceptance of God’s authority in her husband’s death, while his son clung fiercely to the sanctity of life. As this case demonstrates, overemphasis of one concept to the exclusion of others often oversimplifies highly nuanced situations in the ICU and, in my experience, worsens suffering. Myriad well-meaning people have inadvertently committed loved ones to burdensome but futile interventions, and a protracted and painful death, for the sake of dogma. The complexities of intensive care, and the boundaries it blurs, do not accommodate undiscerning approaches. To honor God through end-of-life care, we must acknowledge the dynamic interplay of each of the following principles.
1. Sanctity of Mortal Life
Christian opposition to such highly politicized issues as abortion and the “right to die” movement derives—appropriately—from the view of mortal life as a sacred gift from God. As the author of the world, God “gives to all mankind life and breath and everything” (Acts 17:25). As beings created in God’s image, we each possess God-given and irrevocable dignity. Our created origin as image bearers establishes our worth and potential:
Then God said, “Let us make man in our image, after our likeness. And let them have dominion over the fish of the sea and over the birds of the heavens and over the livestock and over all the earth and over every creeping thing that creeps on the earth.” (Gen. 1:26)
The psalmist writes, “You formed my inward parts; you knitted me together in my mother’s womb. I praise you, for I am fearfully and wonderfully made” (Ps. 139:13–14). Furthermore, our worth is magnified in the incarnation: God became true man, dwelt among us, then died and rose for the forgiveness of sins, salvation, and eternal life (John 1:1, 14).
The Lord entrusts us with life and commands us to cherish it through the commandment, “You shall not murder” (Ex. 20:13). He grants us this sacred gift for a unique and exalted purpose, namely, to glorify him through stewardship of his creation: “Whether you eat or drink, or whatever you do, do all to the glory of God” (1 Cor. 10:31). Peter reminds us, “As each has received a gift, use it to serve one another, as good stewards of God’s varied grace” (1 Pet. 4:10). Paul further elaborates in his letter to the Romans: “For if we live, we live to the Lord; and if we die, we die to the Lord. So then, whether we live or whether we die, we are the Lord’s” (Rom. 14:8).
Such verses illuminate our call to treasure the life God has granted us and in everything to strive to glorify him. The sanctity of mortal life mandates that we advocate for the unborn and safeguard against physician-assisted suicide (see chapter 11). It also requires that when struggling with an array of decisions in the ICU, we consider treatments with the reasonable potential to cure.
Yet difficulties arise when patients and loved ones interpret “sanctity of life” to mean “do everything at all costs.” When a disease process is reversible, and “everything” translates into measures that promise recovery, such an approach preserves life. However, the specifics of critical care are usually far murkier. What if an intervention cannot promise recovery at all? What if it offers a minimal chance for improvement but guarantees prolonged suffering? In circumstances when an intervention cannot promise cure, a “do everything” approach may prolong dying and risk harm through ineffective treatments.
Research suggests that those with high “religious coping”—i.e., those who depend upon faith to guide their decisions—seek more aggressive care at the end of life, even in the setting of terminal cancer.2 In my experience, such pursuit often stems from a well-intended yet indiscriminately applied conviction about the sanctity of life. “I understand he won’t get better,” one aggrieved son declared to me, as we discussed care for his dying father, “but I believe in the God of the Bible, and the Bible says killing is wrong. The way I see it, if we stop everything, we’re killing him. And I can’t do that.” Hours later, as we battered his father with chest compressions and jolts of electricity to keep him alive, his son pushed through the crowd of frantic clinicians with tears welling in his eyes. “Stop!” he shouted. “Just stop. It’s enough. He’s had enough.”
As future chapters will elucidate, organ-supporting technology inflicts suffering
and does not necessarily effect cure. The capability of a medical intervention to save life depends upon a host of specific factors, with disease process being paramount among them. An indiscriminate, dogmatic approach to life-sustaining interventions threatens to inflict harm upon the very people we seek to protect. We must be so careful. As we endeavor to preserve life that God himself crafted, we must acknowledge when our efforts prolong not life but rather a painful death.
2. God’s Authority over Life and Death
Although Scripture describes death as the “last enemy” (1 Cor. 15:26), and although the thought if it may fill us with fear and dread, death persists in this earthly kingdom as the consequence of the fall. “The wages of sin is death” (Rom. 6:23), and it overtakes us all. “Sin came into the world through one man, and death through sin, and so death spread to all men because all sinned” (Rom. 5:12). Even Christ, who defeated death, first endured dying in submission to the Father (Matt. 26:36–45).
Although God directs us to honor the life he has created, he also reminds us of its fleeting nature. Like the grass of the fields, we are here today and gone tomorrow. Even long lives, humanly speaking, span a mere handbreadth from God’s perspective (Ps. 39:5). Sanctity of life does not refute the certainty of death.
By his authority and Word, God is at work in all things, even death. Herod hastened his own death when he brought divine judgment upon himself for his impiety: “An angel of the Lord struck him down, because he did not give God the glory, and he was eaten by worms and breathed his last” (Acts 12:23). In contrast, King David, a man after God’s own heart (1 Sam. 13:14), enjoyed a long life before succumbing to the ravages of old age (1 Chron. 29:28). Such texts do not, by any means, suggest the simplistic theology of Job’s miserable comforters, who reduce death and suffering to a retributional, penalty-rewards system.
Death does not necessarily follow as punishment for specific sins (Job 20:27–29; 42:7). Rather, such texts reveal that the Lord engages with us, even as we draw our last breath, to effect good. From the first book of Samuel: “He brings down to Sheol and raises up” (1 Sam. 2:6). Per the psalmist: “You return man to dust, and say, ‘Return, O children of man!’” (Ps. 90:3). Christ reanimated Lazarus from death so that his disciples would see and know by faith alone that he is the resurrection and the life (John 11). In the most breathtaking example, God gave his Son over to death, then raised him again for the forgiveness of sins, salvation, and eternal life.
When faced with the grief and uncertainty of life-threatening disease, fear may drive us to resist death at all costs. We may chase after aggressive interventions even when such measures promise no recovery. Yet when we so blind ourselves to our mortality, we deny the resurrection. We ignore that our times are in his hands (Ps. 31:15) and dismiss the power of his grace in our lives. We disregard the truth that the Lord works through all things—even death—for the good of those who love him (Rom. 8:28).
Christ’s submission to the will of the Father can guide us. The Bible teaches that in the garden of Gethsemane, fear and despair seized Jesus as he anticipated his imminent death and the crushing abandonment he would endure for us on the cross (Matt. 27:46; see also Ps. 22:1; Heb. 12:1–3). “My soul is very sorrowful, even to death,” he lamented to the disciples (Matt. 26:38). He knew his Father wielded the power to rescue him and so pleaded with him for mercy, yet he accepted God’s will. “My Father, if it be possible, let this cup pass from me,” he prayed with his face to the ground. “Nevertheless, not as I will, but as you will” (Matt. 26:39). Even on the cross, while onlookers jeered and provoked him, Christ remained faithful in his submission to the Father: “Like a lamb that is led to the slaughter, and like a sheep that before its shearers is silent, so he opened not his mouth” (Isa. 53:7).
When we confront critical illness, faith embraces and holds fast to this same spirit of acceptance and trust. God can perform miracles. Mountains melt before him, and he halts the sea in its landward charge (Ps. 97:5; Job 38:8–11). Yet the miracles that would fulfill our most desperate longing may not align with his divine and perfect will. As an example, the book of Job illustrates vividly how our own suffering can glorify God in ways hidden from our sight and understanding. After a long and heart-wrenching dialogue while in the depths of grief, Job relents to God in humility: “I know that you can do all things, and that no purpose of yours can be thwarted. . . . I have uttered what I did not understand, things too wonderful for me, which I did not know” (Job 42:2–3).
When deluged with fear and despair, we cling to our faith in the Lord’s goodness and in his power to accomplish the unfathomable. Yet we must never convince ourselves that if we pray fervently enough, he must necessarily yield to our will. “Your will be done,” we recite in the Lord’s Prayer, as Jesus himself also prayed in the garden of Gethsemane (Matt. 6:10; 26:42). Over the years, I have watched numerous patients linger on machines days past the point of hope, as loved ones insist we continue all treatments and wait for God to intervene. “I know he’s dying,” one daughter declared to me. “But you need to keep the ventilator going. I’m praying for a miracle.”
While we should pursue medical therapies with promise of cure, we err when we fight in the face of futility, stalwart in our belief that God will use technology to perform a miracle. Although we can empathize with these sentiments, especially during the heartbreak of sudden critical illness, such statements ignore God’s authority. The Lord does not need a ventilator to save a life. Christ resurrected Lazarus with a word (John 11:43–44). He revived a dead girl with a touch of his hand (Luke 8:52–56). While the Lord has blessed us with medical advancements to combat death, their efficacy depends on his mercy. He does not need our help, nor does he call us to pursue futile interventions to give him time (Acts 17:24–25). When despondency and jargon befuddle us, we must diligently place our trust not in our own meager technology, but in the Lord’s benevolence and power over death. To cling to interventions in the face of futility is to chase after idols. We worship the technology rather than its Creator.
3. Mercy and Compassion
God calls us to love our neighbors as ourselves (Matt. 22:39). “A new commandment I give to you, that you love one another: just as I have loved you, you also are to love one another” (John 13:34). Christ taught that service to God requires ministry to the downtrodden and afflicted. “By this we know love, that he laid down his life for us, and we ought to lay down our lives for the brothers. But if anyone has the world’s goods and sees his brother in need, yet closes his heart against him, how does God’s love abide in him?” (1 John 3:16–17). “Be merciful, even as your Father is merciful” (Luke 6:36). Christ’s sacrifice inspired his apostles to call for compassion toward one another: “All of you, have unity of mind, sympathy, brotherly love, a tender heart, and a humble mind” (1 Pet. 3:8). “Beloved, if God so loved us, we also ought to love one another” (1 John 4:11). “Therefore be imitators of God, as beloved children. And walk in love, as Christ loved us and gave himself up for us, a fragrant offering and sacrifice to God” (Eph. 5:1–2). As God so loved us, as followers of Christ we must also extend ourselves in empathy and mercy toward one another.
Loving one another at the ICU bedside requires attention to suffering. When we inflict distress and pain upon one another unnecessarily, we fail in our mandate to love our neighbor, even when we pursue such measures with good intent. Mercy does not justify active euthanasia or physician-assisted suicide (chapter 11). However, it does guide us away from aggressive, painful interventions if such measures are futile, or if the torment they inflict exceeds the anticipated benefit. The experience of suffering varies between individual people; what constitutes unacceptable hardship for you may not trouble me. A compassionate approach requires acknowledgment of subjective and individual constructs of suffering and a response infused with empathy.
Likewise, as we consider our own circumstances at the end of life, we are not obligated to pursue treatments that threaten our ability to serve God
faithfully. As his image bearers, God grants us dignity and free will in our lives, with the expectations that our choices aim to glorify him. Long life is a blessing but not the ultimate good (1 Kings 3:10–14); richness in life springs from godly service, prayer, and worship (Ps. 19:10; 1 Cor. 11:23–26). God’s Word does not require us to endure suffering to extend life if we cannot direct that extra time toward faithful service to him. Paul illustrates this point in contemplations of his own suffering and death, in his letter to the Philippians:
For to me, to live is Christ, and to die is gain. If I am to live in the flesh, that means fruitful labor for me. Yet which I shall choose I cannot tell. I am hard pressed between the two. My desire is to depart and be with Christ, for that is far better. But to remain in the flesh is more necessary on your account. Convinced of this, I know that I will remain and continue with you all, for your progress and joy in faith, so that in me you may have ample cause to glory in Christ Jesus, because of my coming to you again. (Phil 1:21–26)
Paul was well acquainted with physical suffering (2 Cor. 12:7). In his letter to the Philippians, he reasons that prolonged life in the midst of suffering is a greater good, only if it continues in service to God. While he longs to be with Christ, he presses on so that he may encourage believers in their walk with the Spirit. Our ability to serve God faithfully, then, influences our choices as we consider end-of-life care. We need not pursue life-prolonging treatments if they strip us of our capacity to live for the Lord.
4. Hope in Christ
As Christians, we rest in a hope without equal: “According to his great mercy, he has caused us to be born again to a living hope through the resurrection of Jesus Christ from the dead, to an inheritance that is imperishable, undefiled, and unfading, kept in heaven for you” (1 Pet. 1:3–4). God’s love for us endures even in our final moments on earth: “Even though I walk through the valley of the shadow of death, I will fear no evil, for you are with me” (Ps. 23:4). We rejoice that through Christ’s resurrection, “death is swallowed up in victory” (1 Cor. 15:54–55). So vast is God’s love for us, so breathtakingly superb his sacrifice, that nothing can pry us from him (Rom. 8:38–39). Even as we suffer, we rejoice in the news that Christ has relinquished us from the permanence of death. We savor the promise of the resurrection of the body and the hope of eternal union with God. From Paul’s first letter to the Thessalonians, “since we believe that Jesus died and rose again, even so, through Jesus, God will bring with him those who have fallen asleep” (1 Thess. 4:14).
