The Right to Live and the Right to Die:
An Ethical Reflection on Voluntary Euthanasia
by
Rev. Lou Snead

A Personal Word-
I begin this reflection with a personal explanation of the issues that motivated me to think carefully about this difficult topic.  When I started addressing end-of-life matters, I was struggling to find a way to be merciful to my 101-year-old mother who is in a nursing home slowly wasting away from self-imposed malnutrition because she wanted to die. Shortly after her 100th birthday, my otherwise alert, mobile, and self-sufficient mother was hospitalized after she had a stroke. In just a matter of days, she lost her ability to stand and walk, to feed herself, and to control her bowls. Her speech became slurred and hard to understand. Even though her mind was not impacted by the stroke, the quality of her life suddenly took a dramatic turn for the worse. My mother went from living independently to being placed in a nursing home where she was bedridden, helpless and frustrated with her condition. The doctors didn’t think her condition would improve because of her age. Being very cognizant of her poor condition, my mother began to tell me and my family that she felt she had outlived her usefulness and said emphatically and repeatedly to us that she is ready for “God to take me”. In the following months, she frequently and consistently reiterated her desire to die gracefully rather than suffer what felt to her like an indignity of being a useless person simply taking up space and costing money. She insisted that I had to find a way, in her words, “to put me down” because she no longer felt that her life was worth living. When I didn’t respond as she hoped to this request, she began to beg my daughter, who is a hospital nurse, to please give her some medication “that will put an end to my life”, noting that we put animals down mercifully when they began to suffer from old age, injury or disease.

All of us who were by my mother’s bedside understood and empathized with how she felt about being physically incapacitated and having no hope of ever regaining the quality of life she once enjoyed. While some suggested that my mother was depressed, it was clear to our family that she had made a rational and realistic assessment of the poor condition of her life. So, it seemed tragic to us that this elderly woman who had been blessed with such a long and vital life had to endure what she considered to be personal indignities until she either starved to death, because she is refusing to eat, or died from some other unforeseen natural cause. So, we were all left praying with her that God would be merciful because we agreed with my mother that her feeble condition was not a good way to end a long, productive, and enjoyable life. Since I had my mother’s medical power of attorney, I had signed a palliative care statement on her behalf, but we had no other recourse legally or medically in Texas to end her life and to help her get out of her emotional and physical misery. She kept pleading and sometimes demanding that I do more to bring an end to her life, in what she considered to be an act of love. With no other options, my mother starved herself to death over the next eight months and finally died from what was for her, our family and her friends, and her nursing home caregivers an agonizingly slow death.

As a minister, I know that my family’s struggles in this kind of end-of-life situation is not unique. Many individuals and families reach a point, often in a health crisis, when we contemplate the right to die with dignity. I have stood by the bedside of church members who agonized over their loved ones being in immense pain or slowly wasting away from terminal diseases or unrecoverable injuries. I have listened to church members as they struggled with theological questions about God’s love and mercy when the end of life wasn’t coming soon enough for them or their family members. From my experiences serving as a church pastor, I have had to come to terms, both emotionally and spiritually, with my own mortality and with the inevitability of death in the human experience. Seeing so many people not being prepared to deal with these end-of-life issues, my wife and I have shared with our family our own desires for them to find some legal and medical means to put an end to our lives should something happen to us that suddenly and irrevocably destroys the quality of life we have enjoyed during our lifetimes.

Facing Difficult Issues About Unnatural Death

My experiences with end-of-life issues have impressed upon me the need for individuals, families and for medical and spiritual caregivers to seriously consider the ethical, spiritual, legal, and medical concerns around end-of-life issues that arise particularly in the winter season of our lives, whenever that may arise. In practical terms, my wife and I have completed living wills, bought long-term care insurance and pre-paid cremation services, and prepared directives for our family if terminal diseases or life-threatening injuries were to occur for us. The only other end-of-life issue we have wanted to address with our family is how to hasten our death with dignity and to do so legally if circumstances called for it. For me, having the right and freedom to choose when and how I die is not only a pragmatic issue when it comes to exhausting financial resources and recognizing the emotional burden it places on our loved ones, this also has become a spiritual and ethical issue that our society has been reluctant to address. Regrettably, I find faith communities to be among the most resistant institutions to discuss these complex and difficult issues. In my mind, this is a failure of Christian communities in particular who maintain conflicting notions about the sanctity of life. I have come to believe that end-of-life issues are crucial for the Church to address today when many of us desire merciful medical assistance to hasten our death, especially when we believe our quality of life has come to an end. To be sure, end-of-life issues bring into focus the nature and value of human life as a sacred gift from God and our human responsibility to be good stewards of our lives, particularly when we are facing death. But, beliefs about the sacredness of life should not preclude careful decisions about mercifully terminating a life upon an individual’s request, especially when we live in a society that justifies capital punishment and punishes people for acts of cruelty.

Despite the institutional failures to address end of life issues, I have been impressed with and moved by the compassion and courage I have witnessed from individuals and families who have decided to call a halt to futile medical care and to support decisions to seek death with dignity and grace when they think the quality of their life has ended. I have been inspired by those who have sought the help of compassionate doctors and medical clinics that legally practice physician-assisted suicide or who seek medical assistance to bring an end to a life when it is futile to preserve it. Should the day come when I conclude that the quality of my life has become lost and irretrievable, I hope and pray that my family will exercise the option I have asked them to take to end my life with dignity and mercy. So, it is out of these very personal experiences that I offer these ethical and spiritual reflections that inform my support of the right to die with dignity in what is called “voluntary euthanasia”.

Advocating for Compassionate Death

The idea of voluntary euthanasia is, understandably, a morally ambiguous issue for many people and for medical professionals and religious leaders in particular. As a minister in the Presbyterian Church, I understand the complexity of the issues that arise whenever the issue of ending a life beyond a natural death comes up. Traditional religious values and sensibilities have often led people of faith to see life as a gift from God; a gift that is to be cherished, nurtured and protected from harm. From the viewpoint of the biblical tradition, the value of human life is rooted in God’s creative activity and in the redemptive power of love that calls us to respect and honor the worth of all persons. We are taught to believe that human beings are not only created in the image of God, human life also represents the “crown of God’s creation” to be prized and granted special status within the created order. This honoring of human life is elevated even more for those of us who believe that God’s people are to be a blessing to all of humanity and to fulfill divine commandments not to kill. Christians have taken this commandment even further. Jesus’ compassion and respect for those who were considered to be less valuable than others have served as a demonstration that all human beings are precious and valuable as we are, deserving of respect from one another. Despite our frequent failures to do so, Christians believe we are to live under the moral ideal and obligation to “love others as we love ourselves”. The same kind of objections to initiating an unnatural death have been expressed by the medical community. Doing harm to the life of anyone is counter-intuitive to the accepted moral obligations that both religious and medical communities have long embraced.

Moreover, is also clear that our Judea-Christian society has consistently embraced the ancient biblical social injunction that upholds moral respect for human life with the notion that “thou shall not kill”. This prohibition against the taking of human life not only rules out the willful doing of harm to others but also presents us with a divine obligation to respect the value of human lives, to preserve life that has been created by God, and to promote the well-being of all human life. So, these religious impulses have historically assumed that the gift of human life carries with it a moral responsibility to care for human well-being, to respect its sacredness, and to guard human life from harm and from death. The medical community has likewise accepted this prohibition as central to its creedal practices.

At the same time, both the biblical tradition and the medical community have also recognized the finite character of human life. While we are encouraged to see our lives as precious gifts from God to be respected and protected, we also know that all of us will eventually die. The Old Testament states that, if we are fortunate, we will live a full life of seventy or eighty years at best. From this perspective, we are asked to see that death is a natural outcome of human life. Yet, at the same time, untimely deaths represent a tragic negation of the hope and promise of living “life abundantly”. But, in the final analysis, biblical religion has asked us to see that the death of the human body is not the last word about the value of human life because we are living with and under a hope for a resurrected life after death, where bodily suffering and pain are no longer part of the experience of living with the God of eternity. If death does not negate God’s grace and love for us, then why wouldn’t we honor a person’s decision to bring an unnatural end to their life because the quality of their life has diminished to a point at which they no longer wish to live? Similarly, the medical profession has come to recognize the limitations physicians face in healing diseases and/or keeping someone alive who is terminally ill or who has lost consciousness with little hope for any recovery. Many states today have passed laws to address the issue of “medical futility” in keeping some patients alive when death is deemed to be imminent or quality of life has been completely lost.

All of these affirmations about the value of human life and the eventuality of death come into play when we begin to consider voluntary euthanasia. The term “euthanasia” originally meant “good death”. In modern times the term euthanasia has often been used to refer to the active ending of human life in order to secure release from physical and emotional pain and suffering. It is important to note the distinction that needs to be made between involuntary euthanasia (ending the life of those who cannot participate themselves in that decision) and voluntary euthanasia (the conscious decision of a person to end their own life under certain conditions when a quality life is no longer a reasonable possibility). It is important to note that my reflections here support the moral and spiritual legitimacy of voluntary euthanasia while raising caution about proceeding down the slippery slope of involuntary euthanasia. In more recent years there has been a cultural debate about the ethical and legal legitimacy of doctors to participate in even voluntary euthanasia when someone has good reason to believe that the quality of their life- meaning a person’s sense of worth, purpose, meaning and enjoyment- has deteriorated to the point where simply extending the quantity of our life in terms of days and years no longer justifies continued living.

The moral ambiguity that confronts society regarding voluntary euthanasia is apparent whenever we begin to consider the right of individuals to bring an end to their life before a “natural” death occurs. Here’s a quick list of some of the ethical and spiritual objections that are often expressed when voluntary euthanasia is considered as a merciful option to endless pain or the hopeless perpetuation of life:
a) Euthanasia or “mercy killing”, even when requested by an individual, represents a form of assisted suicide and is, therefore, a tragic decision that should be resisted on the principle of the value of human life rather than embraced in special circumstances or occasions.
b) Life is sacred, even when pain and suffering are involved or a meaningful life has been lost, so to end a life deliberately and prematurely is both a spiritual violation of a sacred trust and tantamount to playing God.
c) Even if someone has a terminal condition or no reasonable hope of regaining health, we are still faced with the issue of finding a humane way of inducing death. Seeking medical assistance or giving permission for medically assisted euthanasia would constitute a violation of traditional medical ethics and a physician’s oath to do no harm.
d) Personal autonomy should never be made an absolute value in a free society and permitting legalized voluntary euthanasia would inevitably lead to some bad or unintended consequences.

Despite these objections to voluntary euthanasia and the complexities involved in making end-of-life decisions, there is a growing appreciation today among people of faith and secularists alike of the moral and spiritual legitimacy of ending one’s life under certain circumstances. In 2000 a CNN/USA Today poll indicated that 55% of Americans are in favor of physician-assisted suicide, while only 37% expressed opposition. Currently, voluntary euthanasia is legal in Belgium, Luxembourg, the Netherlands, Switzerland, and in the U.S. states of Oregon, Washington, and Montana. In the minds of many religious and ethical citizens, there is a moral and spiritual obligation to balance deep respect for the sacredness of life with our responsibility to show compassion, mercy, and dignity toward those who suffer in pain or who no longer have the capacity to enjoy a quality life. Most of us recognize that societies and religious groups often suspend the moral obligation to honor, defend and preserve the value of human life in cases of justifiable wars, capital punishment, abortion, self-defense, or the assassination of monstrous, brutal dictators like Adolf Hitler and terrorists like Osama bin Laden. Obviously, religious people make exceptions to the biblical commandment not to kill and people of faith routinely advocate, under certain circumstances like capital punishment and war, the willful taking of life from those who want to keep living. I believe that compassion and mercy should be, in certain circumstances, sufficient reasons for us to advocate the willful taking of life for those who want their own life to end because he or she has good reason to conclude that the quality of their life has been irrevocably lost.

One of the key issues involved in every end-of-life decision hinges on the idea and primacy of individual freedom and the right of each of us to manage our lives. Individual freedom and liberties are fundamental hallmarks of democracies. Conservative and liberal perspectives alike affirm that all of us have an individual right to personal freedoms as long as we do not infringe on the rights and privileges of others. Legal decisions are being made daily to adjudicate how to protect individual rights in relation to social responsibilities and our obligations to the common good. So, it is not inconsistent to think that individuals have a legal right, unless there are more compelling reasons to the contrary, to make personal decisions about when to bring an end to their life. While it is tragic whenever someone takes their own life, our society has over the years d-criminalized acts of suicide. Therefore, it seems ethically and legally unjust to prevent someone who is in their right mind from making personal end-of-life decisions for themselves, especially when there are compelling medical issues to do so.

Moreover, the medical community today recognizes the ethical and financial limits involved in sustaining life at all costs and for no reasonably good purposes. In certain cases where disease, injury, or aging have ruined the quality of life for a patient, medical personnel are often willing to provide palliative care, withhold nutrition, remove life support systems, and use drug regimens that hasten the end of life. While physicians usually feel bound by the Hippocratic oath to preserve life and do no harm, the advances in modern medicine also have reduced the mortality rates that have historically been associated with diseases and injuries that bring a “natural” end to life (i.e., TB, plagues, etc.). Therefore, modern medical interventions aimed at warding off life-threatening diseases and keeping patients alive with advanced technologies can and do interrupt some natural deaths that would occur without some treatments, presumably for the sake of prolonging life at all costs. Somehow, we are willing to justify doctors preventing some “natural” deaths while raising ethical restraints to prevent physicians from aiding in merciful deaths that are deemed to be “unnatural”. Likewise, if state-sanctioned capital punishment is sufficient reason for the medical development and administration of lethally injected drugs, then we would hope that equal justification could be given for the development and administration of lethal but painless drugs for those who want to request a physician-assisted voluntary form of euthanasia when they determine they no longer have a life worth living.

Affirming the Right to Die as a Spiritual and Moral Decision

As counter-intuitive as some Christians and medical professionals may think, I believe that voluntary euthanasia can represent a morally, spiritually and medically legitimate expression of compassion that respects to the gift of life and its existential limitations. In this era when the earth is rapidly becoming overpopulated, many people are coming to believe that creation care for the common good of all human life is a personal, spiritual and social responsibility that has implications for the desire to perpetuate life at all costs. Likewise, many people today argue we can make the case for authorizing a voluntary ending of one’s life when aging or incapacitation has led to an unproductive life where someone feels they are a burden rather than a blessing for their family and for society. If we claim that our religious orientation to life calls us to love our neighbors as we love ourselves and live on the basis of compassion for our fellow human beings, it seems intuitively right for us to allow those who do not want to be a burden on their family or on our health care institutions to express their desire to bring an end to their life without waiting for a “natural death” to occur, simply as an act of compassion and mercy.

A central issue in this “death with dignity” perspective is the question of individual autonomy; Do individual persons ultimately have the right to choose when they die? This issue, in turn, raises theological, ethical, and legal judgments about the “freedom of conscience” of individuals and the community’s right to overrule personal decisions about the value and quality of our own lives. In recent years, the U.S. government, the medical community, and the Presbyterian Church have made some determinations about individual autonomy in life and death situations. As a Presbyterian Church (USA) position paper has noted:
“In contemporary U.S. culture, public policy and majority public opinion are essentially in agreement with respect to the freedom of individuals to refuse medical treatment, even when it is life-prolonging. However, there is still significant disagreement about whether artificial feeding and hydration constitute “treatment,” and thus, whether they legitimately can be refused. Additionally, while the Supreme Court has clearly affirmed one’s right to refuse life-prolonging treatment, it has not ruled in favor of any right to assistance in bringing about one’s death. The Court did, however, allow states the freedom to permit and regulate such assistance. As of 2015, five states currently allow “physician aid in dying” (PAD), with more than half of other state legislatures considering bills that would permit it. These typically allow for physicians, under certain stringent conditions, to prescribe lethal doses of medications that can be taken by patients, if the patients so choose. In contrast, “active euthanasia,” refers to a situation in which a physician or other person acts directly to cause the death of a suffering person, for example by directly administering a lethal dose of medication. This remains illegal throughout the United States, though it has been legalized in several European countries, in some instances even for persons who are not terminally ill. Our American societal context at present is one in which a growing percentage of Americans support “physician aid in dying,” but currently one must move to one of the five permitting states to receive such assistance legally”.
ABIDING PRESENCE: LIVING FAITHFULLY IN END-OF-LIFE DECISIONS
PCUSA, 2016
In many respects, the question about determining and affirming the quality of human life becomes the key issue in considering voluntary euthanasia or a PAD request. My own faith tradition has recognized for more than 30 years now that our common distinctions about what constitutes life and death are altered whenever “cerebral function (brain activity) which makes possible human relationships is irretrievably lost”. Likewise, when we witness someone simply existing in a nursing home bed as a physically incapacitated person who depends on either life support systems with no reasonable capacity to embrace the joy, pleasures, and gifts of life, we recognize the futility of keeping someone alive. When we add in situations when patients are enduring unrelievable suffering, we become empathetic to the moral virtue of bringing an end to life rather than enduring until natural death occurs. I believe the same capacity to question the quality of life one’s life because of unremitting disease, injury, or aging should be considered in honoring a person’s desire and right to bring an end to their life.

The decisions about when to honor a request for voluntary euthanasia must certainly be made with extreme care and within a larger network of family members, doctors, mental health professionals, religious leaders, and those trusted and respected by the one who is requesting a voluntary end to their life. Before voluntary euthanasia is embraced as an acceptable humane provision for ending life, medical and legal safeguards should be in place to protect both the one who is seeking help to end their life from a narrow view of their health condition or their emotional stability to make such a decision and those who are assisting in bringing a merciful end to someone’s life. I can only pray that in time the Church will take a more active role in helping our society to consider the moral and spiritual appropriateness of giving those who have lost the capacity to have a quality life the option to end their life with dignity and mercy.

Embracing a Voluntary End to Life

As an encouragement for ethically-minded people to help our society address the moral and spiritual legitimacy of voluntary euthanasia, I offer these affirmations for consideration and debate: 

• Voluntary euthanasia and physician-assisted suicides should be permitted only in those circumstances when a medical diagnosis has been obtained that indicates a patient is terminally ill or their quality of life is not retrievable because of physical or mental incapacitation or deterioration from old age.
• As a legal issue, voluntary euthanasia and physician-assisted suicide should be predicated on our individual right to live and to die, as freedom granted to every human being who is compelled to live responsibly within the finitude of life. Legal authorization should be granted only when an individual in a healthy state of mind has requested voluntary euthanasia or physician-assisted suicide under carefully delineated circumstances.
• Voluntary euthanasia should be seen as an act of compassion and merciful regard for personal autonomy condoned, respected, and facilitated on behalf of those who elect to bring an end to their life when the quality of their life has diminished beyond hope of recovering personal joy, fulfillment, and self-sufficiency. Prohibitions against voluntary euthanasia and physician-assisted suicide should be removed to prevent individuals or their families from having to utilize ineffective or inhumane measures to end a life.

Given the increasing number of states that have been considering the right to die, its time for faith communities, both at the congregational and denominational level, to engage in careful and serious conversations about the moral, spiritual, and medical decisions that must be made to advocate for a compassionate and merciful death for those who believe their life should be ended before a natural death occurs. The autonomy of an individual to make a decision about ending one’s life when the quality of life has been severely diminished is an issue that challenges not only medical and faith communities, but also the freedoms that our government extends to us as citizens as inalienable rights.

The desire to provide an option for those who want to bring what some consider a “premature end” to their life has already taken hold in some states through legal provisions for the medical community to engage in physician-assisted suicide. There are certainly a host of complex ethical and legal issues involved in providing this as a medical option. Obviously, great care has to be taken to navigate the emotional, physical, legal, financial, medical, familial, and financial issues that arise whenever someone requests help to bring an end to their life for understandable reasons. Prudence in this matter suggests that it may be necessary to provide an option for medical assistance in ending one’s life only when someone has prepared an advanced directive for ending their life with dignity well in advance of a critical need for making such a decision. Discussions with family members, medical professionals, and trusted spiritual and legal advisers should also be a part of creating an option for such an advanced directive.

Openness to such end-of-life conversations within faith communities, the medical profession, and legal representatives should be encouraged rather than dismissed out of hand, as is often the case. Respect for individual freedom to decide how our life should end is critical to the decision-making process about when and how to bring an end to someone’s life when a person has the capacity and ability to adjudicate such issues for themselves. I am arguing that it is time for serious conversations to take place in this country about the moral, spiritual, and legal legitimacy and appropriateness of extending the right to die to those who are mentally and emotionally competent to decide how and when they want their life to end when the quality of life has eroded to the point they no longer want to live. Compassion, mercy, and honesty call us to address this difficult but important issue when end-of-life issues emerge for clear-thinking individuals who have decided that death is better than continuing to live in misery or hopelessness.  I pray that my children and grandchildren will display such understanding and mercy for me should I reach a time and condition when I conclude that bringing an end to my life is more reasonable and desirable than just continuing to exist.