A Christian Worldview Response to Current Bioethical Issues (Part Four)
Through Life to Its End
Difficult end-of-life issues confront all people including Christians. While some unbelievers may seek answers only from secular, naturalistic theories of medicine, Christians believe that God has provided important information about health, illness, and death. God has spoken through our nature as human beings, through Jesus His Son, and through special revelation in the Bible.1 By introducing two classic cases, this fourth article discusses the significance of trusting a Christian worldview when dealing with end-of-life issues in bioethics. An appropriate Christian response to such cases does not always require us to cite Bible passages to those around us, but we should always benefit from such passages and live as godly people following the teaching and example of Jesus. Christian patients, physicians, and other caregivers can all be empowered by their biblical worldview.
God’s purpose does not allow an earthly existence of pure tranquility and peace. Pain and death are inevitable. Jesus told His disciples: “In this world you will have trouble. But take heart! I have overcome the world” (John 16:33 NIV). Today we also have challenges. Trouble, injuries, suffering, and pain are part of this life. However, our hope for eternity allows Christians to see beyond the pain of the moment and even beyond this world’s duration. Believers live in this world like people have always lived on Earth—through life to its end. Nevertheless, their Christian worldview of life and its end differs significantly from secular, naturalistic worldviews that limit one’s perspective on what it is to be human.
Bioethical issues have not always been the challenge that they are today. They may also differ from one culture to another. The Christian view of the world reminds us that all people enter the world in the image of God, and they exit the world by death. Some people struggle in life and in death more than others. Compassionate healers and caregivers seek to alleviate that struggle. A Christian worldview can and should be a powerful influence on how people meet their own struggles and also how they help others cope with life’s opportunities and challenges.
Medical Ethics and Our Human Condition
The science and practice of medicine does not itself have all the answers to the issues of human struggles with pain and dying. Moreover, advanced technologies have complicated moral questions associated with treatment of the sick and suffering. Daniel Callahan provides an important insight about the limits of philosophical assertions from physicians:
The root problem of illness and mortality is both medical and philosophical or religious. “Why must I die?” can be asked as a technical, biological question or as a question about the meaning of life. When medicine tries to respond to the latter, which it is always under pressure to do, it moves beyond its proper role.
It is not medicine’s place to lift from us the burden of that suffering which turns on the meaning we assign to the decay of the body and its eventual death. It is not medicine’s place to determine when lives are not worth living or when the burden of life is too great to be borne. Doctors have no conceivable way of evaluating such claims on the part of patients, and they should have no right to act in response to them. Medicine should try to relieve human suffering, but only that which is brought on by illness and dying as biological phenomena, not that suffering which comes from anguish or despair at the human condition.
Doctors ought to relieve those forms of suffering that medically accompany serious illness and the threat of death. They should relieve pain, do what they can to allay anxiety and uncertainty, and be a comforting presence. As sensitive human beings, doctors should be prepared to respond to patients who ask why they must die, or die in pain. But here the doctor and the patient are at the same level. The doctor may have no better an answer to those old questions than anyone else, and certainly no special insight from his training as a physician.2
Medical professionals are not always candid or even aware of the limits of their role. Medicine as medicine cannot solve all the issues or answer all the questions of our bioethical challenges. Medical professionals focus on alleviating the burdens of injury or disease that may confront us. Sometimes doctors presume a worldview that is exclusively technological and scientific and that may be assumed to mean “in contrast to Christianity.” Worldviews influence the way challenges are met by sufferers and those who care for them. Those ways of thinking about the world affect the way both secularists and Christians deal with the issues of bioethics. Secularist views are limited in ways that are unacceptable to people of faith. Christian views of the world can and should bring awareness of our shared humanity (created in the image of God), compassion, and mercy. Here the nature and purpose of the LORD is reflected in the light Christians bring to the dark moments of life. Christians live life and face death with hope. For them, life has meaning even when it includes suffering, painful therapies, and death.
Classic Cases for Analysis
Case #1: In December 1967, Dr. Christiaan Barnard transplanted 25-year-old Denise Ann Darvall’s heart into 55-year-old Louis Washkansky at Groote Shuur Hospital in Cape Town, South Africa. Washkanksky lived 18 days with the transplanted heart, ultimately succumbing to pneumonia, but news of the transplant had spread quickly around the world.3
Other surgeons recognized the medical barriers broken by this procedure. Some might have disagreed with particular decisions made in the case, but no doubt much was done well in the attempt to save the patient. Even after Washkansky’s death, Barnard’s surgery would be judged perfect. The heart was found to be healthy. Consent for use of Darvall’s heart was obtained from her father. Washkansky consented and re-consented to undergo the transplant surgery. However, some reports indicate that Washkansky refused reconnection to the respirator two weeks after his surgery but that he was put on the respirator anyway.
Issues of consent were found to be complicated. Pressures may have been inappropriately applied, and those consenting may not have had a very clear idea of what they were really consenting to—extensive pain, with little probability of recovery or quality of life, etc.
Defining death was recognized to be more than cessation of breathing or a heart that no longer was beating. Patients could be resuscitated and sustained in ways never understood before. People and physicians were confronted with more complicated issues about the nature of death and dying. Heart-lung machines had been developed and improved from the 1930s to the 1960s, and heart transplant surgeries became a possibility. Physicians recognized other complications that would be associated with transplants and worked diligently to understand and develop immune-suppressive treatments that might prevent rejection of the transplanted heart. Physicians around the world were ready to do heart transplant procedures. However, many of them were waiting to improve chances of patient survival. Pence’s update on this case reported news coverage that called 1968 the “Year of the Transplant,” and he said, “most of these early attempts were failures.”4
Heart transplantation has come a long way since Barnard’s first procedure in 1967, emerging “as a viable therapeutic strategy for select patients with end-stage heart disease.”5 Since that time there have been many highly publicized cases including Barney Clark’s surgery to receive the Jarvik-7 artificial heart in December 1982 (fifteen years after the first heart transplant) and Baby Fae’s transplant in October 1984 (receiving the heart of a young baboon). Clark lived 112 days with his artificial heart, and 15-day-old Baby Fae lived only 20 days with her transplanted animal heart. These cases seem so long ago, but significant issues surfaced and remain significant today.
The definition of death changed and became more complicated. Brain death entered our common vocabulary, but sometimes that meant a combination of factors. Not breathing and having no heartbeat had long been associated with death. Now, new technology and tests, like electro-encephalograms (EEGs) changed the way physicians and legislators spoke about dying. Declaring a patient dead came to mean more than just saying: “Someone died.”
In addition, it became apparent that transplant teams should in some way be separate from the team harvesting organs. The transplant surgeon is not now, and should never have been, the physician declaring a donor patient to be dead. Both the donor and the recipient are patients in morally significant ways. The donor is a dying human being without any hope of survival and is the patient of one physician. The recipient is a dying human being with a chance of survival thanks to the donor organ and the skills of the transplant surgeon.
Case #2: Karen Ann Quinlan was reportedly seen taking pills and drinking alcohol on the night of April 14, 1975. At least two periods of 15 minutes each without breathing led to a coma, and she was placed on a respirator when she arrived at the hospital. Quinlan’s weight dropped from 115 pounds to 70 pounds within a few months, and she was eventually described as having reached a persistent vegetative state with no prospect of recovery. Other physical symptoms like muscle rigidity and twisted joints were observed. Anguished family discussions brought a request to discontinue extraordinary means of sustaining the patient. Her physicians refused saying there was no legal or medical precedent for such action. The subsequent court case ended in the New Jersey Supreme Court in November 1975 with the court asserting that an individual’s right to privacy overcomes the state’s interests. The Quinlan family did not seek to remove her feeding tube, asserting that such treatment was not causing her pain. She died 10 years later in June 1985. Quinlan’s parents had continued to visit her regularly in the months before her death, her father every morning before going to work.6
The Quinlan case forced our society to struggle with even more issues than the definition of death. People found that distinguishing between being brain dead and being in a persistent vegetative state introduced new emotional and conceptual trauma to bioethics discussions. Seeing a patient, especially one’s beloved family member sometimes appear dead, but also appear conscious and aware at other times was a new complication of developing life- sustaining technologies.
Comments from healthcare.findlaw.com are useful, for example: “An individual with severe cerebral damage who has been in a chronic state of unconsciousness for at least four weeks is considered to be in a persistent vegetative state (PVS).” This entry also explains that such individuals are sometimes thought to be in a coma, “but comatose patients are never conscious (while someone with PVS may exhibit limited wakefulness, including eye movements, spontaneous body movements, and groaning).”7 A living will (advanced directive) or designation of someone to have durable power of attorney for healthcare decisions can clarify what may be done for a patient. When documents that identify the wishes of a patient are missing, courts must sometimes appoint an individual to speak on the patient’s behalf.
The Quinlan case was part of a context that helped identify the difference between coma, PVS, and brain death. Other issues also surfaced while society struggled with such cases complicated by new life-sustaining technologies. People wrestled with moral choices introduced by the use of respirators and other extraordinary means of sustaining or restarting life at points where patients might formerly be declared dead. Not all of this was completely new. Some technologies like feeding-tubes had been a part of healthcare for many, many decades. However, so much came so fast to families and their healthcare providers that society was reeling from the impact of the “new” bioethics issues.
Some Christian Insights
Christians may at first think all of this is new, and in some ways it is. However, not all such considerations are truly new. Excruciating pain associated with childbirth has been with us since the tragic mistakes in the Garden of Eden, but bringing children into families is still good. Tragic continued suffering, misunderstood by others, has been a part of the historic biblical worldview since Job’s story was recorded. Some like Job’s spouse may press for surrender to death, but those ephemeral dreams of release are not the only options. We do not always have to give up on earthly life. Sometimes coping with suffering or pursuing painful healthcare options is reasonable and appropriate as we search for improved living. At other times, we have no choice but to endure suffering. A Christian worldview brings acceptance of death, but it also brings meaning to coping with pain. It brings openness to care while also acknowledging the reality of futility even in healthcare.
We should not suggest that the process of surgical incisions, intensive care units, transplants, or extended painful recovery is always right or always wrong. Sometimes it may be best to choose painful life rather than death. There are occasions when long-term endurance of medical treatments may be appropriate. Other times patients may reach some point where they feel that enough is enough. We can let biblical Christian values bring new perspective to painful experiences. It may be right to accept death even when we could clearly avoid it—witness the cross of Christ and perhaps the martyrdom of some who had been given miraculous powers like Stephen (Acts 6:6-8). Paul was torn between life and death not always knowing which was better (Philippians 1:21-23). People today face situations that are even difficult to identify as life or death, and those perplexing situations sometimes extend for years and years.
Karen Quinlan moved from coma to PVS within months, but her death did not come until 10 years later due to mounting respiratory failure, ultimately acute pneumonia. Many following the case as it developed and those reading of it decades later found themselves emotionally affected by such events and their description. To call this case “tragic” seems unsatisfactory, an understatement about the misery endured by the family and caregivers, even when the nature of the patient’s misery cannot be clearly known.
As Bob Crumby told me: This is not the loss of something to someone, but the irreversible loss of some one. Consciousness and cognition “were the functions, irretrievably lost in the brain of Karen Ann Quinlan and later in the brains of Howard Brophy, Nancy Cruzan, and Terri Schiavo.”8 Crumby is concerned that people in PVS “might languish technologically in clinical settings throughout this land because of a sharply limited definition of death. If that were to happen, [Crumby says] my family and others would be subjected to chronic despair and long-term financial deprivation.”9 After more than three decades of discussing brain death in the United States, our society is still debating and revising opinions and judgments about what the standards should be.
Christians know that whatever we may say about the blessing of life, we must also acknowledge the inevitability of death (Hebrews 9:27). Our shared humanity means that all of us are made in God’s image, and if children of God are to properly love others, we must show His mercy (Luke 6:35-36). Crumby chose three passages for the title and epilogue of his volume, So Falls a Sparrow— Psalm 84:3; Matthew 10:29; and Matthew 10:31.10 Like all things living on Earth, sparrows die. However, sparrows do not die without God’s notice; and human beings are more valuable than sparrows. “Persons of faith believe that there is hope for perpetuity beyond this life.”11 When we, as Christians, discover and share the compassion of Jesus; we, as Christians, show the mercy of God. Maybe we should be more merciful with the sick and dying (and with their caregivers) and less critical or judgmental of those dealing with bioethical issues. At times, I fear that we have reacted inappropriately. Sometimes people have rushed into print or into pulpits to proclaim answers as if they alone have the best and most complete answers for all such challenges. Even Jesus took time others considered inappropriate delay to arrive and comfort the family of his friend Lazarus (John 11:1-21), and He spent long nights in prayer (Mark 1:35-37; Matthew 26:36-46). As we struggle with our life struggles and assisting others with their life’s struggles, our Christian worldview introduces us to the place for prayer and patience.
Conclusion
We can know how Christians should respond to many of life’s most perplexing struggles. Some issues of bioethics can help us discover how our biblical Christian worldview should guide us toward compassion and mercy. Christians can become better friends than Job’s friends. We can see in Jesus what it means to be healers and compassionate helpers. A Christian worldview changes our response to suffering, and such a worldview can also shape caregivers reflecting on what it means to be human in a world where pain is compatible with our understanding of God’s plan for now and for eternity.12
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Rolland W. Pack earned the M.A. degree in Christian Doctrine from Harding University and earned the Ph.D. in Philosophy with an emphasis in medical ethics from Georgetown University. He was a research and teaching fellow of the Kennedy Institute for Ethics while at Georgetown. The former professor at Lipscomb University, was Professor of Philosophy and Biblical Studies at Freed-Hardeman University and also Dean of the Honors College and Associate Vice President there. Dr. Pack was 2014-15 Visiting Professor of Philosophy at Heritage Christian University, serves as an Editorial Consultant for Sufficient Evidence, and is now a consultant available for lectures, preaching, and workshops. He may be reached at Rolland.Pack@gmail.com.
Notes
1Pack, Rolland W. “A Christian Worldview Response to Current Bioethical Issues.” Sufficient Evidence 4.1 Spring 2014: 15, Note 3.
2Daniel Callahan. “Physician-Assisted Dying: Self-Determination Run Amok.” in Gregory E. Pence, Ed. Classic Works in Medical Ethics: Core Philosophical Readings. Boston: McGraw-Hill, 1998. 79-80. Reprinted from Hastings Center Report 22 (March-April 1992): 52-55.
3Gregory E. Pence, ed. “Christiaan Barnard’s First Heart Transplant,” in Classic Cases in Medical Ethics: Accounts of the Cases That Have Shaped Medical Ethics, with Philosophical, Legal, and Historical Backgrounds. NY: McGraw-Hill, 1990. 206-24. I have chosen Pence’s two fine works as references herein because they provide an overview of both classic cases and classic works in medical ethics at the end of the twentieth century. Much of the same information can be acquired from other anthologies or, even more easily, through current searches of the Internet.
4Pence, Classic Cases, 221-22.
5Mohamad H. Yamani and David O. Taylor, “Heart Transplantation,” clevelandclinicmeded.com, August 2010. Yamani and Taylor reported a 1- to 2-year mortality rate approaching 50% with approximately 4000 heart transplantation procedures annually worldwide, 2000 annually in the United States. Lack of appropriate, available donor hearts reportedly meant that about 3000 were awaiting the procedure. Others have reported larger numbers in other publications. For example, a 2007 article by Taylor, Edwards, and Boucek in Heart Lung Transplant that reported 5000 transplants worldwide per year with 50,000 transplant candidates.
6Robert D. McFadden, “Karen Ann Quinlan, 31, Dies; Focus of ’76 Right to Die Case,” 12 June 1985, nytimes.com 22 Oct 2015; also Gregory E. Pence, ed. “Karen Quinlan,” in Classic Cases in Medical Ethics: Accounts of the Cases That Have Shaped Medical Ethics, with Philosophical, Legal, and Historical Backgrounds. NY: McGraw-Hill, 1990. p. 6 from 3-24.
7“Brain Death vs. Persistent Vegetative State: What is the Legal Difference?” healthcare.findlaw.com. 20 Oct 2015.
8Robert Henry Crumby, So Falls a Sparrow: Sanctity of Life Pitted Against Quality of Life, Ethical Medical Decisions Made at the Bedside With and For the Sole Good of the Patient. Nashville: Crumby, 2012. 111-12. Paul Brophy (1937-86), Nancy Beth Cruzan (1957-90), and Terri Shiavo (1963-2005) were famous patients who, along with their family and caregivers, have significantly affected legal and moral discussions about life, brain damage, and dying. This is not “Howard Brophy,” but “Paul E. Brophy” as Crumby mentions in a later discussion of the same individual. Crumby, 132.
9Crumby, 114.
10Crumby, 180 and 199.
11Crumby, 180.
12My indebtedness to friends and colleagues like Bob Crumby is evident from the treatment of this subject above. This article is better from such collaborative associates, and the best of all for this article has been my wife and friend, Rebecca Pack. Finally, I wish to express my appreciation to the Editor of Sufficient Evidence for the invitation to provide this series of articles that spans two full years. His patience and encouragement has been invaluable.