Christian Ethics 2022

Ultimate Choices - Death and End-of-Life Decisions

May 16, 2023 10:02:40 AM / by Scott Rae

This General Session was recorded live at the Shepherds 360 Church Leaders Conference in Cary, NC on October 17, 2022. For information about the next conference, please visit




This transcript was created by an automatic transcript generator, and may contain minor errors and mistakes compared to the original recording as a result.


So good morning, it's great to be with all of you, thank you for being here. I want to give you a just, I guess, a word of maybe a word of caution at the start, because we're entering into the field of bioethics today. And the part of the reason for that is that God in His providential sense of humor, has seen fit to follow me home with his field. And so I tell my grad students who are entering into this field professionally, you know, be careful there, there may be a bit of an occupational hazard for you. In dealing with this area. I began this when I was a doctoral student back in the mid to late 1980s, when reproductive technologies were just beginning to be marketed widely in vitro fertilization was less than 10 years old. And my wife and I began a very painful four plus year journey with infertility right as I began studying this stuff myself. And in this area, when it comes to the end of life, back in the early 1990s, when the first assisted suicide initiative was on the ballot in my home state of California, I began to speak in debate and spoke in various healthcare settings on this. And it was about the same time that my wife and I began the journey through terminal illness with three consecutively of our parents, a journey that I had never walked before, and felt hopelessly unprepared for. And then in the early 2000s, when the human genome project was completed, my wife was a candidate for one of the first diagnostic tests that became available as a result of that genetic information being published, it was a test to, to demonstrate whether someone had that genetic glitch that gave women an 85% likelihood of developing breast cancer. And it took her three years to decide whether or not to get the test, and another three years to decide what to do with that positive test result that she got back. And by that time, she had already developed a tumor. And it turned out that the treatment for the cancer was the same as the prophylactic treatment that she was anticipating she's fine today, by the way, praise the Lord. But so I guess, just be aware of what you're stepping into here. This is why I'm picking up the prosperity gospel next. We'd love for that one to follow me home too. So I have to admit to I spend a lot of time with seminary students. And I have I admit, I'm becoming a little more dismayed at the number of my seminary students who tell me that they don't plan on doing hospital visits as part of their pastoral ministry. And that's my my reaction to the fact I sometimes I don't, sometimes I don't mince words, probably like I shouldn't say, Well, why are you pastoring? Because what we've discovered is that the end of life may be the most teachable moment that our folks have. Because what we've discovered is that the main questions people ask at the end of life, are not medical ones, they have those. That's true. But those aren't the ones that are at the forefront. And if they their spiritual questions that they're asking about, you know, Where am I headed? What's my legacy? Have I close the loop with the people I care most about in my life, that's what they really care most about. And to miss that moment, I think is a huge missed opportunity. And so I'm delighted to have a chance to talk about this a little bit with you. Hopefully, this will help as you walk with some of these families that you serve through some very interesting and very challenging times. I remember speaking on this in my church, not that long ago. And I remember taking a show of hands, I wouldn't do that here. Because I suspect I already know the answer to most of this, but this was just a group, a group in my church, about group about this size. And I asked him how many of you have walked with a loved one or family member through the end of life? And about 80% of the people raised their hand. Okay. And I suspect that might be similar with with most of you, if not more, so. And then I said, How many of you have had to be involved in decisions to stop life sustaining treatments? And about half the people raise their hand? Right. And then I asked what I thought was the drop the mic moment, and that was how many of you felt well prepared to walk that journey? with your loved ones, and maybe 10% of the folks raise their hand. And I'd like to I'd like to do what I can in the next half hour or so to change that. To give you some what I think is some good theology, that undergirds our view of how we approach the end of life, I'd like to also encourage you to preach and teach on this a little bit more often. Because I know that all of you preach on resurrection and eternity, at least one time a year, if not more, so hopefully, it's more so than that. And I don't think you have to make this the subject matter that I've done this in my church. But I think when you talk about resurrection and eternity, at least think about a little side jaunt into how we how we walk through the end of life, and how our theology of resurrection and eternity actually impacts how we deal with the dying process in the here and now. So we're what we're going to deal with just in these few minutes is mostly this first, termination of life support, withholding withdrawing treatment at the end of life, in my view, that is by far the most complicated, ethically and theologically. And I think the most widely misunderstood theologically airy themed of life, physician assisted suicide and euthanasia. I think the Scripture is fairly straightforward about that. That that is for the follower of Jesus is not an option I had a woman in my church approached me and she said, Are you really telling me that I can't off myself? At the end of the day? I said, Well, don't your beef is not with me on that one. Because I think the Bible is pretty clear about that the issue related to assisted suicide in the US and euthanasia in other parts of the world, more has to do with what the law should be state by state. And so we'll we'll say a little bit more about that in a workshop I'm doing on this, we'll do part two on this this afternoon. In the workshop I'm doing now, we what we figured, you know, you know, this is profound grasp of the obvious, then instead of theorizing about what dying patients and their families need at the end of life, maybe we will be better off if we actually asked them what a concept. And so the supportive care of the dying project, just introduce you to this was was carried out by a consortium of Catholic hospitals across the United States, that range from hospitals in major metropolitan areas to hospitals in rural areas that literally I'm not making this up literally backed up to farmland. And they and they, they said what do you need, at the end of life to dying patients, to their families, to their surviving caregivers, and to the medical professionals who treated them. And here's what they found. dying patients want to know the truth communicated in a timely, regular way they want to know what's happening, and what your best estimate is about what's going to happen to them. And in some cultures that we deal with, particularly in my area in southern California, that's that's often not done in Asian communities in Hispanic communities, that the virtuous thing is to actually shield the patient from the truth. Because they don't want them to have the additional burden of decision making. What we tell them is that what you don't realize is that violates every law on the books that has to do with informed consent. For treatment, that's actually against the law. To do that, unless the patient explicitly says, I want you to make decisions for me. Second, dying patients, their families want to be regarded as a single unit, what impacts the dying patient also impacts the family members, often exponentially. thirds, this is really the third and fourth is really important, I think, is a big part of what the pastoral component is here. As surviving family members need time for taking care of unfinished relation or business. One of the worst tragedies at the end of life is when people go to meet the Lord, with still unfinished business relationally with their loved ones, which suggests to me that patients and families want to be forewarned that the end of life is coming. And let me little known secret, doctors are often reluctant to say that to their patients. And if the doctors and nurses aren't going to do that, guess who that falls to do that. That's part of that's our job. As pastors. I can't tell you how many times I've had physicians say, where is this person's pastor? Who can get through to them? At the end of life is near.



That's, I think part of a sacred calling, dying patients and families wanted vector advance directives discussed and followed. I will take a show of hands on how many of you have advanced directives for yourself. Hey, that would be I think, way too convicting. But I tell my students, if I if I had my way, I would require that all of you have an Advanced Directive as a condition for passing my course. Okay, when our in house legal counsel told me that that would be illegal to require that said, maybe I'll think twice about that. physicians and nurses agreed that there's a general lack of education on care of the dying date, because most of the nation are trained to cure not to care when they can no longer cure. The pressure and pace of medical practice often conflicts with good care for the dying. That's the understatement of the month. And that has gotten worse, not better in the last 10 years. And physicians often feel inadequate in dealing with this area, because they know they're not trained as pastors. In some of the physics, some physicians have great bedside manner, I'm sure you know, some of them, but some not so much. And they need us at the bedside. Because you all are the ones who know these patients, you've walked with them through a lot of their adult life, you know, their families, and they know that you share their spiritual values. You are you are indispensable at the end of life, with the families that you have been serving faithfully as pastors. Let's put this in theological perspective. For a moment. I think this these first few theological principles, I hope is not breaking news. That human life is God's sacred gift. And as a result, innocent human life is not to be taken, that God and Ecclesiastes, it's clear that God is the one who sets the timing and manner of our death. And at the end, we have an obligation to protect the most vulnerable among us in biblical times, that was widows and orphans. I think to update that metaphor a bit, I would say the most vulnerable among us are represented by the unborn and the elderly, today. Now to be a little bit more specific. And again, this hopefully, this is not breaking news. That death came as a result of the general interest of sin into the world and was not part of God's original design. The reason God tossed Adam and Eve out of the Garden of Eden is so they wouldn't eat from the tree of life and live forever in their fallen state. But death is also a normal natural part of someone's life, under the sun. And what we mean by that is something very different than what the culture means by that. When people say that, you know, in in non Christian non religious settings, what they mean by that is that death being a normal, natural part of life makes it morally neutral. In the Scripture, it's no such thing. Death is a normal, natural part of life because of the universality and pervasiveness of sin, but is an enemy nonetheless. So at the same time, death is both an enemy and a normal, natural part of life. Okay, now, if that were where this ended, that would be kind of depressing news and we'd be off on the happy subject of death and dying to do something else. But the good news is, and we proclaim this every Easter that death is a conquered enemy. And there I think there's certain implications of that in my view, we don't often tease out in our preaching and teaching and that's that's this if death is a conquered enemy, it need not always be resisted that under the right conditions, I'll spell those out. No, under the right conditions, it's okay to say stop to medicine. It's morally and spiritually okay under the right conditions to say enough to medicine. And in essence, I think what we are doing when we say that is waiter, entrusting that patient back to the Lord for His care, and for his determination for how many days that person has left. Now, I will never forget, walking my father in law out of his hospital room for the last time. Just a few months before he died. He had just had surgery for a tumor The size of a grapefruit that was in his lodged in his bladder. And what should have been a three or four day hospital stay turned out to be three weeks with predictable complications, he was 88 years old. And so I'm pushing I'm wheeling him out as we're leaving the hospital, and emotions come close, because although he only had a voice strong enough to whisper to me, and you I'll never forget what he said, I'm reeling in that and he says these whispers right in my ear. Don't ever bring me here. Again. I think what he meant by that, I'm pretty sure I'm pretty sure what he meant was it I am done with doctors and hospitals and tubes and treatments, technologies that have put my life in the toilet, figuratively speaking. And what I think of I don't think he quite articulated this way, I think what he was saying was, I will take from the hand of God, whatever days he has left for me. But without artificial means to just proclaim pro prolong the process of dying. And so we didn't. We didn't take him back there. A few weeks later, he had a stroke, took him the emergency room waited three hours for neurologist to see him he told us he had a minor stroke and sent us home. I said that's the last time we're doing that. So when he had a stroke again, another two weeks later, we stayed home. And that's what he wanted. Because he knew that his days belonged in the hands of God to deliver dispense as he saw fit. So, in general, when the prognosis for a patient is very poor. And further treatment is futile. What I mean by that is not what I mean is that further treatment will not reverse an irreversible downward imminent spiral toward death. Now they may, they may work. But they won't stop this downward spiral. And when that happens, I think we can we can welcome death as the doorstep to eternity and take advantage of what I consider to be one of the most sacred moments we have on this earth to usher someone right up to the doorstep of eternity. And this in my view, this is what assisted suicide robs us of it takes away our ability to do that well. Now, I also think, in general, that making what is left of life more burdensome for our loved ones is almost always morally wrong. Here's how this happens. Families. Often, let's just say, How can I put this, families often don't quite grasp that their loved ones are as close to Death's doorstep as they actually are. Because families or families consistently are believing the best. And physicians encourage families to believe the best. Physicians normally are trying to be as upbeat as possible, while at the same time telling, telling the truth as they can. But it's not uncommon for families to not quite be plugged into reality about how their loved one is deteriorating. And so families will often authorize burdensome treatments, where the burden far outweighs the benefit. And they go off to the waiting room or back home for out for a meal. And they don't ever see what they are authorizing physicians and nurses to do to their loved ones. I will never forget a case it came to an ethics committee I consulted with years ago, the nurses simply said why are we torturing this poor man? He was 98 pounds 98 years old, being prepped for a colonoscopy of all things. I think I think he probably could have held him up to a bright light and same gotten the same results. He was so thin. And the nurses finally said why why are we torturing this man?



And the family finally relented But it took way too much time and effort to talk them into the fact that what they were authorizing was a net increase in the level of suffering that their loved one or we thought it was their loved one was going to experience. So let me be a little more specific. I think it's okay to say stop to medicine when a competent patient requests it, a competent adult patient under the law, you have to do that. Any because physicians if physicians under unless there's some exceptions, but if physicians administer invasive treatments to patients without their consent, at least in California, they can go to jail for battery for that. And, you know, we, we dare not treat our loved ones as incompetent, just because they may have lost the ability to speak, or may not be conscious all the time. Now, most of the time, a competent adult where we quill request to stop when the next two conditions are met, when a treatment is futile, I already told you what that means. Or when the burdens outweigh the benefits. That's the best, the most common is pretty unusual that treatments actually don't work. Don't do anything. I mean, antibiotics for viruses doesn't do anything. That's true. But most of the time the issues revolve around what's the burden? And what's the benefit for this particular patient. And most of the time, what we're talking about at the end of life is the burdens. They far outweigh any marginal benefit that can come to the patient. And I think we need to be willing to be very careful, I think that we that we understand and apply the principle of the sanctity of life correctly. Because just keeping someone alive for the sake of keeping them alive, in my view, is not necessarily upholding the sanctity of life can let's be really clear about this, too, that if suddenly, I clutched my chest and have a heart attack after I hope someone would call 911. And would not conclude that I don't want further treatment. Right? Because treatment, there is hardly futile. And the benefits way outweigh the burdens of that. But doing CPR on someone who is in their 80s, an elderly and frail is often far more burdensome than beneficial. This is why hospitals now are increasingly allowing family members to come into the emergency room and a full code is called. And when they're doing full CPR. And often the family will say that's enough. That's a wonderful thing, actually, for the family to recognize that the hospital did everything they could. And they get it in a really nice sense of closure for them. Now, some objections to this. And I've heard them all, I think I've heard them all. For what I don't believe this is playing God. Now, if we were performing assisted suicide or euthanasia, then I think you've got a point on that, because the prerogative here that belongs to God is the taking of innocent human life. And if it were true, that saying stop to medicine was actually killing your loved one, then you might have a point. But saying stop, and allowing death to take its natural course is not the same as actively killing a person. Now there are times when it can when there's not a huge moral difference. I would suggest if you just allow me to die, if I clutched my chest here would be the same, the same, you'd be the same, doing much the same thing morally, as killing me, though, would not technically be the same thing. You'd be just as responsible for that. But it's the disease, the underlying disease or condition that is the cause of death here not the intentional action of the physician to actually in their life at that moment, that distinction, all that clear as mud to you. Amen. Something reasonably affirmative would be helpful here. And I would suggest that this this distinction also holds when it comes to removing artificially provided food and water Because I don't think that is starving someone to death any more than removing a ventilator is suffocating someone against the underlying disease or condition. That is the cause of death for the patient. And I don't believe this violates the sanctity of life. Because if the sanctity of life means that we are obligated to do everything at all costs at all times to keep everyone alive. And I think we're making making a theological statement that I don't think we want to make, the theological statement we're making is that, if that's true, then we think we're obligated to do all of that at the end of life. And what we're saying, theologically is that earthly life is the highest good. Right. But we know theologically, that's not true. Agustin had it right? When he said our highest good is our eternal fellowship with God. And I think I actually think that sometimes we are, we are unnecessarily delaying someone's homecoming. And I don't think I don't think that this, this doesn't negate the fact that we worship a miracle working God either. I think people say repeatedly to me in ICU waiting rooms, is it? Don't you trust God for a miracle? And I say yes, but I want to see if you do. If you really want to trust God for a miracle, then let's go for broke and turn off everything right now. Because last time I checked, I would never I've actually never



said that to someone. I'd be thrown out of the hospital for different saying that.



But I said, it seems it seems to me that what you're asking for is a medically assisted miracle. And it last time, I looked in the scripture, and God doesn't need medicine to work miracles. He didn't in biblical times, and he doesn't today. I've also been tempted, I've never said it. But I've also been tempted to ask believing families who I know believed all the right things about eternity and resurrection, to ask them, Do you really believe this stuff that you say you believe? Because it sure doesn't look like it the way you are holding on to earthly life for your loved one. And reality is that they are authorizing those treatments, not for their loved ones benefit but for theirs. And let me tell you, folks, that is that is almost always immoral. To do that. To impose burdens on someone else medically for for our benefit, not for there's it's almost always wrong. And this is for you all are so important in helping the family navigate this and helping them recognize when the time has come that that time is here. And that your focus needs to be on something different. We moved in, we call this transitioning them to palliative care where their pain is relieved. And you allow them to do the things that they need to do before they go home to be with the Lord, to say the things to their loved ones that they need to say, and vice versa. I'm so glad I got to say all the things to my dad before he died, that I said at his memorial, they should hear those things while they're still living. And this is their opportunity to do that. And we it just grieves me to see how often we squander those opportunities, because we're grasping for one last treatment as a as a Hail Mary pass. And I don't think I don't think we can suggest to that suffering. In this case. Let's let's put it this way. When the Scripture talks about the redemptive value of suffering, they're talking about how trials has shaped our character in being this side of eternity. Right because last time I read the New Testament, when we meet the Lord, we will be fully redeemed. Right? Not only will our physical diseases be healed, but our character flaws will be healed to thank the Lord. And I think there is some there is some suffering that is so close to the end of life that it's hard for me to see how that can have any redemptive value the side of eternity. And so I think the the idea that we would subject someone to treatments that are doing them no good and unnecessarily delaying their homecoming in the hope that that suffering might be redemptive. I, that doesn't make the logical sense to me that we would do that. So I don't, I don't think there's any good reason theologically. Under again, under the right conditions, okay, when the prognosis is very poor, when further treatment is futile, or it's more benefit, or is more burdensome than beneficial. And those are the general condition in the workshop we do this afternoon, I'm going to I've got a couple of cases that I've that I've consulted with and a couple of hospital settings that we're going to talk about, and talk about where, you know, where is the point in which we say, stop to medicine. So for round two on that, if you want to venture into that world a little bit more, a little bit more in detail. Now, you're welcome to join in for that. So when it comes to facing these end of life decisions, I think for ourselves, I think we, you know, we spend a lot of time showing our families how to live in a way faithful to the Gospel. And I think for you know, for some of us as we get closer and closer to that, that last chapter being written in our lives, I also want to show my family how to die in a way that's faithful to the gospel. So please, have a living will and advanced directive, something that tells your loved ones what you want and don't want at the end of life. Because if you don't tell them, they're guessing. And that is a terrible burden to put on your loved ones. And I will be encouraging the folks that you minister to, regardless of their age, to have their wishes at the end of life in writing somewhere, Terry Chavo, who you may be familiar with her from years ago for feeding tubes removed, guess how old she was when she lapsed into a vegetative state. She was 27 when most people that I'm familiar with at that age still think that they're like 100%, bulletproof when we know that they're not. And then talk with them, talk with your loved ones about their wishes. At the end of life, I tell my students this, they cringe every time I tell them this, but talk to your parents about this. You'll see some of my Asian students who think there's just no way I can talk to my dad about this. Because culturally, that's just not something they talk about. And if they do talk about it, it's parents initiating that with their kids, not vice versa. But I tell them, I said, when the day comes that you have to make decisions for your dad, you're going to be guessing about what he wants. Don't be guessing. And then to face death and biblical perspective, I think means that we recognize that death is ultimately been conquered by virtue of the cross and resurrection of Jesus. I'm so grateful for that. But I'm also grateful for how that helps us navigate the end of life. Because that being true means under the right conditions. It's okay to say stop enough to medicine and I'm trying trusting my loved one, have a loved one and who I've been ministering to for years, I've been trusting them back to the Lord. to do with them. However he sees fit to extend their days, or to shorten them, however he sees fit. Amen. All right, let me pray for us. Lord, we are so thankful that your word is so clear about what takes place at the end of life. Thank you that there's so much rich stuff in the Scripture about how we face our mortality. Lord, give us the courage to do that. And give us the presence and the compassion and the sensitivity and the courage to walk with the families that we serve in this incredibly teachable moment. Lord, I pray that we wouldn't miss the opportunity to cement so many things spiritually, in the lives of people we serve people we care for. And people we love, that we trust you Lord with all of that make us much sharper tools to assist and serve our families well as they navigate the end of life and we trust due for all of that Lord in the name of Jesus amen

Topics: Christian Ethics, Life & Death Issues

Scott Rae

Written by Scott Rae

Leave a Comment