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What kind of contribution can analytic theology make to the very complicated discussions surrounding end-of-life care in bioethics? Dr. Patrick Smith, Associate Professor of Philosophical Theology and Ethics at Gordon-Conwell Theological Seminary and Lecturer at Harvard Medical School Center for Bioethics, provides an answer to this question in his very engaging lecture entitled “On Dying Well Enough: Analytic Theological Bioethics and End-Of-Life Palliative Care.” In this post, I will summarize the essentials of Dr. Smith’s lecture.
Since the Second World War, the practice of medicine in the American context has principally been aimed at the eradication of life-ending conditions and diseases. Research into the development of medical technology to this end receives robust funding, and Americans generally look upon this project favorably. Yet while perhaps most people would hardly wish to return to the state of things at the turn of the previous century, it is not at all obvious that this effort towards the erasure of death has been successful. Though the average life-span in America has numerically increased by around eight years, medical technology has really only managed to find ways of putting off death without thereby guaranteeing patients quality of life in their final years. On the contrary, dying has lately become a medical process, where months- and years-long treatment with drugs can prolong the process of passing over into the next world without making a patient’s time left in this one particularly desirable or livable. The theological-anthropological realities of humanity’s dependence, interdependence, and finitude are brought into stark relief in the face of such a struggle against death.
At once, the problem of the ethics of end-of-life care is raised. Should life be preserved in every case in which it is possible, as the Vitalist position holds? Or are some lives no longer worth living, so that it is not morally impermissible to terminate that life voluntarily, either by the hand of the patient or by that of the doctor, as the Quality of Life position holds? Dr. Smith notes that most Christian bioethicists take these two positions to constitute extremes in the middle of which lies the proper position to take, called the Sanctity of Life position. This view understands life to be a gift and a trust, a good thing given by God to the human person for which she is expected to care and to steward in the appropriate manner. This view proposes its own course for navigating the troubled waters of end-of-life care through the practice of hospice or palliative care. This practice embodies the principles expressed in the parable of the Good Samaritan and provides a way of caring for those who suffer without killing them, without claiming for ourselves the authority to terminate life, which only rightly belongs to God as the creator of all things, nor unnecessarily prolonging the process of death.
Most Christian bioethicists take voluntary active euthanasia — the voluntary, intentional termination of the patient’s life through the assistance of the doctor — to be inconsistent with the Sanctity of Life view. This is not because it “hastens death,” since a person may make a decision that will have an effect on her life expectancy — e.g., she opts against treating her terminal cancer in the hope of surviving another six to eight months — without at the same time killing herself in an objectionable manner. Rather, the practice of euthanasia represents a fundamental option for death, a choosing of death in a way that contradicts the notion of life as a gift and a trust. Other end-of-life practices, however, such as the removal of life-support technology, the use of aggressive opioids, and — under specific circumstances — voluntary cessation of eating and drinking, are not similarly objectionable.
At the same time, one might wonder whether or not the practice of palliative care, supposedly consistent with the Sanctity of Life view, is inconsistent with this view’s very own principles. After all, does not the heavy use of morphine towards end of life lead to the quicker death of the ill patient? Why shouldn’t the use of morphine be considered on a par with the practice of active voluntary euthanasia? On the other hand, doesn’t the Sanctity of Life principle actually collapse into the very Vitalism it wishes to avoid? If a life can in principle be prolonged, how could it be compatible with the notion of Life’s Sanctity to permit some lives to be extinguished by illness without implicitly using Quality of Life-type reasoning? These objections, then, try to collapse the Sanctity of Life position into one or the other of the two extremes which it tries to avoid. The task for the analytic theologian is to find a way of saving the balancing act.
One way of defending the Sanctity of Life position against these arguments — one that is admittedly not uncontroversial — is to appeal to the distinction between what is intended and what is foreseen. Palliative care may foresee the death of the patient as a possible result of the treatment option to be pursued, but the death itself is not what is intended; death itself is not the goal being pursued in the act. At this point, too, the proponent of the Sanctity of Life view can take recourse to the doctrine of double effect in order to maintain her claim that palliative care is morally permissible, because death as the bad effect of the treatment to be pursued is not itself intended or desired. In any case, the distinction between what is intended and what is foreseen is essential to the practice of medicine entirely apart from the question of the validity of the doctrine of double effect, because clearly a medicine can provoke side effects of which the doctor is aware beforehand without thereby intending to cause them. Thus, in contradistinction to the practice of voluntary active euthanasia, where death itself is what is intended as the treatment for a patient’s pain, the practice of palliative care does not intend death, nor does it aim at provoking it.
Now, there is also a common assumption that giving high dosages of morphine to patients leads to death. To some extent, it is reasonable to think this, since the death of a patient often follows, chronologically speaking, from the distribution of high dosages of morphine to treat pain. But the notion of a “high dosage” of morphine ought to be clarified a bit, because it is ambiguous between two senses. First, it can be understood to be “high” in the sense of an inappropriate dosage; second, it can be understood be “high” in the sense of quantitatively substantial dosage. Of course, the Sanctity of Life theorist can grant that the distribution of inappropriate dosages of morphine to patients is impermissible, but it has not yet been demonstrated that palliative care entails doing exactly this. On the other hand, it is empirically questionable whether increased dosages of morphine, although temporally correlated with the eventual death of a patient through respiratory depression, actually serve to cause this death.
Dr. Smith notes that opiates and opioids have relative as opposed to absolute toxicity. Certain drugs, such as tylenol, have absolute toxicity because if you were to ingest a certain quantity of the drug within a day, you would die. Other drugs, however, are only relatively toxic, depending on prior drug use, how long a person has been on a certain medication, etc. In a sense, then, there may not be a “highest” dose after which a person will certainly die, because the effects differ depending on the resistance of the respective patient. The mere increase of a dosage does not translate into the “lethality” of the drug. In that case, death not need even be considered an unintended side effect of the treatment, since morphine need not be taken to precipitate death at all, so that it is not strictly speaking necessary to appeal to the doctrine of double effect at all.
Finally, the Sanctity of Life view does not make decisions on the basis of Quality of Life-style reasoning. It does not make judgments about the purported quality of a patient’s life when it decides against treatment or against prolonging a patient’s life in certain circumstances. Rather, it is concerned with the quality of the treatment: is the treatment worthwhile? For instance, will it preserve the patient’s life only at the cost of excessive pain? Will this treatment improve the patient’s quality of life? How well it work towards accomplishing the goal proposed by the treatment? In this way, the Sanctity of Life view does not implicitly rely on Quality of Life-style reasoning.
This final point may seem excessively subtle to some, but I judge rather that it identifies a relevant difference. Here the distinction between what we do and what we permit to happen becomes relevant. If it should be decided that a treatment is not worthwhile in spite of the fact that it can prolong the life of a patient, this is because it is judged not to do good to the patient. The patient is permitted to die, but the active death-bringing agent is not the doctor or the medical team at all, but the illness. In the case in which active voluntary euthanasia is pursued, a contribution on the part of the medical team and the patient herself is made, one which pursues death itself, and this is impermissible. So the Sanctity of Life view can be properly distinguished from the Quality of Life view and does not implicitly rely on the latter’s modes of reasoning.
I am sympathetic with Dr. Smith’s arguments, so I will not press any critiques here. These matters are very complicated and very troubling, especially for those who must deal with them “from up close,” so to speak. For that reason, it seems eminently necessary that Christian thinkers, pastors, and writers pursue that which Dr. Smith mentioned at the very end of his lecture: Wisdom, which God gives generously to all who ask for it in faith (Jas. 1:5-6). There may be times in which we must be wise by admitting our dependence, our interdependence, and our finitude by no longer running away from death, but putting ourselves into God’s hands and accepting what has come to us.
Steven Nemes is a PhD student at Fuller Theological Seminary whose research primarily concerns philosophical theology.