The End of Life

A word first, because this lesson is about death and some who read it will be carrying more than an academic interest. If you are thinking about ending your own life, please stop reading and tell someone today: a friend, a pastor, a doctor, or your local emergency or crisis service. You do not have to carry it alone, and there is help. The Pastoral Care track has a whole lesson on this, When Someone Wants to Die, in its fifth module, and every pastor should read it before he needs it. Feeling that you want to die is not a sin and not a lack of faith; Elijah, Job and Paul all said it. It is a sign that you need care, and care is what scripture gives in answer.

Christians hold two truths about death that pull against each other, and every hard case at the end of life is a place where they meet. The first is that death is an enemy. It entered the world through sin (Romans 5:12), Jesus wept at the tomb of his friend (John 11:35), and Paul calls death the last enemy to be destroyed (1 Corinthians 15:26). The promise at the end of the Bible is that there will be no more death or mourning or crying or pain (Revelation 21:4). So Christians fight death. They built hospitals, nursed plague victims when others fled, and have usually welcomed medicine as a gift of God. A Christian who shrugs at preventable death has not understood the gospel.

The second truth is that there is a time to die (Ecclesiastes 3:2), that our days are determined (Job 14:5), and that for the Christian death is not the worst thing that can happen. Paul could say that to live is Christ and to die is gain (Philippians 1:21). The Psalms say the death of the LORD's saints is precious in his sight (Psalm 116:15). Jacob, when he had finished blessing his sons, drew his feet into the bed and breathed his last (Genesis 49:33), and the scene is told as a good death. So Christians are not bound to resist death by every means at any cost. A Christian who cannot let a dying parent go, who demands one more machine and one more operation when there is no hope of recovery, may be showing fear rather than faith.

The medieval church wrote little books on how to die well, the ars moriendi, the art of dying, which circulated widely in the fifteenth century, and the Anglican Jeremy Taylor wrote The Rule and Exercises of Holy Dying in 1651. They taught people to prepare for death, to make peace with God and neighbour, to receive the sacraments, to resist despair, and to die surrounded by prayer. Modern medicine has made this harder in one way, because it can now keep a body alive long after any hope of recovery has gone, and it has turned dying into a series of decisions. The distinctions in the next three sections are the church's tools for making those decisions without betraying either truth.

The first distinction is between killing a patient and allowing a patient to die. To act with the purpose of ending a patient's life is to kill. To stop a treatment that is no longer helping, or not to begin it, and to let an illness take its course, is to allow death. Almost every Christian tradition has held that the first is forbidden and that the second can be right. The Catholic Church teaches it, the Orthodox churches teach it, and Protestant ethicists from Paul Ramsey, whose The Patient as Person (1970) argued that when curing is no longer possible the duty becomes only caring for the dying, to Gilbert Meilaender in Bioethics: A Primer for Christians, have defended it.

The distinction rests on intention and on cause. When a doctor turns off a ventilator that is only prolonging the dying of a man whose lungs have failed, she intends to stop a burdensome treatment, and the man dies of his disease. When a doctor acts to end the life, she intends the death, and the man dies of what she did. The first act accepts death; the second chooses it. The same principle of double effect you met in the last lesson applies to pain relief. A doctor may give strong pain relief to a dying patient, increasing the dose as the pain requires, even if she foresees that it might shorten life, because what she intends and what she aims at is the relief of pain. Palliative care doctors report that, given in carefully adjusted doses, such medicine rarely hastens death in practice, but the principle holds even where it might.

The distinction has critics, and they are not foolish. The philosopher James Rachels, in a well-known article in the New England Journal of Medicine in 1975, argued that there is no morally important difference between killing and letting die when the motive and the result are the same, and that letting a patient die slowly can be crueller than ending the life quickly. Christian supporters of assisted dying, whom you will meet in section 5, often make a version of the same point: if it is right to withdraw treatment knowing the patient will die, why is it wrong to help the death come gently? Defenders of the distinction answer that the difference lies in what the act is aimed at. A doctor who withdraws a useless treatment would be glad if the patient lived; a doctor who acts to end the life would have failed if he did. And they argue that the distinction protects the patient by keeping the doctor's hands always on the side of life. You should be able to state both arguments.

Note one thing the distinction does not permit. Withdrawing treatment in order that the patient should die, as a way of ending a life judged not worth living, is not letting die in the sense the tradition means. The question is always whether the treatment has become useless or too burdensome for this patient, not whether the patient's life has become useless.

The second distinction goes back to the Spanish Dominican theologians of the sixteenth century. Francisco de Vitoria asked whether a sick man was bound to eat expensive foods or to travel to a healthier land to prolong his life, and he and his successors, Domingo Báñez among them, came to distinguish between ordinary means of preserving life, which a person is normally obliged to use, and extraordinary means, which a person may refuse. The test was never simply whether a treatment was common or technical. It was whether the treatment offered a reasonable hope of benefit and whether it imposed a grave burden: great pain, great fear, or great expense.

Pope Pius XII restated the distinction in an address to anaesthetists in 1957, and the Vatican's Declaration on Euthanasia of 1980 offered a clearer vocabulary: proportionate and disproportionate means. A treatment is disproportionate when the burden it imposes on the patient, and on the patient's family and community, is out of proportion to the benefit it can bring. Protestant ethicists have generally adopted the same reasoning, often in their own words. One area remains disputed within the Catholic tradition and beyond it: whether feeding by tube for a patient in a long-term unconscious state is ordinary care that must always be given or a medical treatment that may be withdrawn. John Paul II, in an address in 2004, said that it should be considered in principle ordinary and proportionate; other Catholic moralists, and many Protestants, have disagreed.

This distinction matters in poorer countries in a way it does not always matter in rich ones. Where there is no national health system, a family may sell its land, its cattle or its children's school fees to pay for one more week in a distant hospital, and then lose both the patient and its livelihood. The tradition is clear that a grave burden of cost on a family is a legitimate reason a treatment need not be accepted. A pastor can say to such a family, with the weight of centuries of Christian moral teaching behind him, that choosing to bring a dying father home to be cared for and prayed over, rather than ruining the family for treatment that cannot cure him, is not a lack of love and not a lack of faith. Sometimes it is the most faithful thing they can do.

The opposite pressure exists too. Some families are told by a preacher that taking a dying relative off treatment, or declining treatment, shows they do not believe God can heal. That is false. God can heal with or without a machine, and choosing not to prolong dying is not a refusal of his power. Pray for healing, and if it does not come, let the dying go in peace. At the same time, do not let the language of burden become a reason to neglect the old and the disabled whose lives are simply inconvenient to others. A burden is a reason to refuse a treatment; it is never a reason to refuse a person.

The strongest answer the church has given to the fear of a painful death is not an argument but a practice. Cicely Saunders, an Englishwoman who trained as a nurse, then as a social worker, and then as a doctor, and who became a committed Christian in her twenties, founded St Christopher's Hospice in London in 1967. She developed the regular use of pain relief before the pain returned rather than after, and she taught that a dying person suffers what she called total pain: physical, emotional, social and spiritual. She insisted that the dying were to be cared for as whole persons until the end. From St Christopher's the hospice and palliative care movement spread around the world.

In Africa the pioneer was Anne Merriman, a doctor who had served as a missionary sister, who founded Hospice Africa Uganda in 1993 and promoted the use of cheap oral morphine for the dying. Uganda later allowed specially trained nurses to prescribe it, so that pain relief could reach villages without doctors. That matters because the greatest injustice at the end of life in much of the world is not too much treatment but too little relief. An international commission reporting in The Lancet in 2017 found that the great majority of the world's people who need pain relief at the end of life live in low and middle income countries, and that most of them have almost no access to it. People die in pain that cheap medicines could relieve.

Scripture does not describe a hospice, but it has the instinct. The mother of King Lemuel, teaching her son, tells him to give strong drink to one who is perishing (Proverbs 31:6), which was the ancient world's pain relief. At the cross, Jesus refused the wine mixed with myrrh he was offered (Mark 15:23), which many read as a drink to dull pain, choosing to meet his death awake, and some Christians have followed him in refusing sedation so as to be clear-minded at the end; others have accepted it with thanks, and both are honourable. And Jesus, dying, gave his mother into the care of the beloved disciple, who took her into his home (John 19:26-27). Caring for the dying, and for those they leave behind, is work the church has always known how to do.

Palliative care is the practical common ground of nearly every Christian position on the end of life. Those who oppose assisted dying argue that good palliative care removes most of the reasons people ask for it. Those who support assisted dying usually agree that palliative care must come first and should be offered to everyone. Wherever you stand on section 5, you can work for this.

Assisted dying is the umbrella term for a doctor ending a patient's life at the patient's request, which is usually called euthanasia, or providing the patient with the means to end it, usually called assisted suicide. Switzerland has long allowed assistance in suicide where the motive is not selfish. The American state of Oregon allowed doctors to prescribe for terminally ill adults from 1997. Euthanasia laws in the Netherlands and Belgium came into force in 2002, and Canada legalised what it calls medical assistance in dying in 2016. Several other countries and states have followed. The laws differ widely in who may ask and under what safeguards.

The historic churches stand overwhelmingly against it. The Catholic Church's teaching, restated in Evangelium Vitae (1995) and in the Vatican letter Samaritanus Bonus (2020), the Orthodox churches, the Church of England, and the great majority of evangelical, Pentecostal and African churches all hold that intentionally ending the life of a patient is a form of killing that a Christian may not do or ask for. That is the consensus, and it should be stated plainly. There is also a minority of serious Christians who disagree, and they should be heard in their own terms.

The case for assisted dying, as its Christian defenders make it, runs like this. The Swiss Catholic theologian Hans Küng, with the writer Walter Jens, argued in Dying with Dignity (1995) that God has given human beings responsibility for their lives, including the end of them, and that a person facing a long and degrading death may in conscience ask to die. Desmond Tutu, the former Anglican Archbishop of Cape Town, wrote in 2014 that he had come to support the right of terminally ill people to choose assisted dying, and the same year George Carey, a former Archbishop of Canterbury, announced that he had changed his mind and supported a change in the law. Paul Badham, an Anglican priest and theologian who taught for many years at Lampeter in Wales, set out the argument in Is There a Christian Case for Assisted Dying? (2009). Their arguments are these. Compassion: Jesus never told a suffering person to endure suffering for its own sake, and the golden rule asks what we would want for ourselves. Stewardship: life is a gift entrusted to us, and a gift entrusted can be responsibly laid down. Honesty: modern medicine already decides when people die, by withdrawing and withholding treatment, so the line between that and helping a death come gently is thinner than the tradition admits. And humility: a church that does not itself bear the patient's suffering should be slow to forbid relief to someone who asks for it in full knowledge of what he is asking.

The case against, as the consensus makes it, is just as serious. Life is not a possession but a gift that remains God's: none of us lives to himself alone, and none of us dies to himself alone (Romans 14:7); we are not our own (1 Corinthians 6:19). The commandment against murder protects the life of the innocent whatever the person's own wishes, which is why the church has always opposed suicide while caring deeply for those tempted to it. Nigel Biggar, an Anglican moral theologian, argued in Aiming to Kill (2004) that the intention to kill, not only the result, is what matters morally, and that the old distinction holds. Opponents point to evidence from the countries where assisted dying is legal: the reasons patients give often include fear of being a burden on their families, which suggests that the vulnerable may feel pressure to choose death; the categories of people who qualify have widened over time, in Belgium to children and in Canada beyond those whose death is near, with an extension to mental illness alone planned; and disability groups, such as Not Dead Yet in the United States, have argued that such laws send the message that some lives are not worth living. They argue that it changes the doctor from someone who always stands for life into someone who may end it. And they point to the answer section 4 describes: most of the suffering that leads people to ask for death can be relieved, and where it cannot, the church is called to stay with the sufferer, not to end the sufferer.

Each side has an answer to the other. Opponents say that no safeguard can remove the quiet pressure on someone who already feels a burden, that the widening is what happens when a principle of choice is accepted, and that in countries where palliative care barely exists, legal death would be offered to people who were never offered relief. Supporters say that strict safeguards can protect the vulnerable, that the widening of some laws is a reason to write better laws rather than none, and that the existence of good palliative care elsewhere does not help the patient in front of you for whom it is not enough. In the global south the point about palliative care has special force: a law that offered death to the poor before it offered them morphine would be a terrible injustice. Both sides agree on that much.

Assisted dying and suicide are discussed together because the arguments overlap, but a pastor must never let the debate about laws for the terminally ill blur the plain duty to every person who says they want to die. That person needs to be asked directly, listened to, kept safe and helped to get care, as the Pastoral Care lesson When Someone Wants to Die teaches. When someone has died by suicide, most churches today no longer refuse burial or speak of the dead as beyond hope, and where older rules survive they are usually applied with mercy; the church entrusts them to the mercy of God, cares for the family, and watches over those left behind. Speak of suicide as a death that came from great pain, never as a way out, and never describe how anyone died.

Head a new page in your casebook The end of life in my setting. Using the page you wrote in the inquiry, set out the situation in general terms: where people in your community usually die, who decides about treatment, what treatment costs, what pain relief is available, whether there is a hospice or palliative care service near you, and what your country's law says about assisted dying.

Then work one composite case, made up from what is common and not from any real family. An old man is dying of a disease that cannot be cured. The hospital offers more treatment that may give him a few weeks at great cost, and the family will have to sell land to pay. Write down, in a few lines each: what the distinction between ordinary and extraordinary means says about the choice; what pain relief and care he would need if he goes home; what you would say to a relative who says that stopping treatment shows a lack of faith; and what you would do if the old man himself asked you to help him die. For that last question, write the answer your church would give and the answer the minority view in section 5 would give, each as its holders would put it.

Finally, at the bottom of the page, write two lines of practical information you will need one day: the nearest place a dying person can get pain relief, and the number of the local emergency or crisis service for anyone who says they want to die. If you do not know either, find out this week, and if your Pastoral Care notebook already has them, copy them here as well.