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The facts as they appear at present:

The value behind these facts

Mrs Thompson is clearly under strain. The physical and emotional demands of caring for her dying husband indicate a likelihood of heightened sensitivity to apparently relevant nuances, such as the sermon on euthanasia and the nurse’s apparent remarks. Her own poor health will also contribute to this.

It would be good to ascertain exactly what the nurse said but if she had been hinting at some form of euthanasia her speech is likely to be oblique and imprecise so exactitude is unlikely to be achievable.

There seem to be two key sets of issues here: what to do with regard to Mr Thompson’s future treatment and how to help Mrs Thompson find clarity about what is right in this case. The latter should be tackled first.

Resources from Bible and Tradition

In order to help Mrs Thompson it is worth looking for resources and perspectives which can be brought to bear on the issue. The key moral principle here is the question of the morality of euthanasia—which I will define as the active and intentional ending of a human life by one or more third parties solely for the purposes of sparing that person distress or suffering. As requested, I will use the four-fold framework proposed in the course:

Cultural

In our current culture a number of contrasting ideas and beliefs are in play:

In an individualistic age, death too becomes a private matter.

When freedom of choice is paramount, freedom of choice about death is increasingly seen as a personal right. (Arthur Koestler, Exit, etc.)

It is expedient for the state to have a law prohibiting euthanasia since assisted death may be performed for lots of different reasons and case law could get very complicated.

Most world religions, for different reasons, have condemned euthanasia.

Euthanasia gives too much power to doctors:

A survey of Dutch physicians (where euthanasia is lawful) was done in 1990 by the Remmelink Committee. They found that 1,030 patients were killed without their consent. Of these, 140 were fully mentally competent and 110 were only slightly mentally impaired. (Finigsen 1991)

A more recent survey found that 60 percent of Dutch physicians do not report their cases of assisted suicide (even though reporting is required by law) and about 25 percent of the physicians admit to ending patients' lives without their consent. (Hendlin et al 1997)

Euthanasia may be the beginning of a slippery slope to eugenics.

Biblical

Instances of euthanasia in Bible: Judges 9:52ff. There appears to be no note of condemnation for the action of the armour bearer.

⁵²So Abimelech came to the tower and fought against it, and approached the entrance of the tower to burn it with fire. ⁵³But a certain woman threw an upper millstone on Abimelech’s head, crushing his skull. ⁵⁴Then he called quickly to the young man, his armour bearer, and said to him, “Draw your sword and kill me, so that it will not be said of me, ‘A woman slew him.’” So the young man pierced him through, and he died.

Indeed, Saul’s armour bearer may have acted ignobly by refusing (1 Samuel 31:4ff)

⁴Then Saul said to his armour bearer, “Draw your sword and pierce me through with it, otherwise these uncircumcised will come and pierce me through and make sport of me.” But his armour bearer would not, for he was greatly afraid. So Saul took his sword and fell on it. ⁵ When his armour bearer saw that Saul was dead, he also fell on his sword and died with him.

However, 2 Samuel 1:6ff tells another side to the story:

⁶The young man who told him said, “By chance I happened to be on Mount Gilboa, and behold, Saul was leaning on his spear. And behold, the chariots and the horsemen pursued him closely. ⁷”When he looked behind him, he saw me and called to me. And I said, ‘Here I am.’ ⁸”He said to me, ‘Who are you?’ And I answered him, ‘I am an Amalekite.’ ⁹”Then he said to me, ‘Please stand beside me and kill me, for agony has seized me because my life still lingers in me.’ ¹⁰”So I stood beside him and killed him, because I knew that he could not live after he had fallen. And I took the crown which was on his head and the bracelet which was on his arm, and I have brought them here to my lord.”

David slays the young man, not for the fact that he committed euthanasia but because he struck down the Lord’s anointed. (He uses the word shachath, to destroy, corrupt, pollute rather than ratsach—see below.)

Suicide, too, seems to bear no stigma (2 Samuel 17:23):

²³Now when Ahithophel saw that his counsel was not followed, he saddled his donkey and arose and went to his home, to his city, and set his house in order, and strangled himself; thus he died and was buried in the grave of his father.

The sixth commandment, though much quoted in this context, does not appear to be relevant here since the word ratsach seems to have had a range of meanings from “a type of slaying which called forth blood vengeance” in its most technical sense to “acts of violence against a person which arose from personal feelings of hatred and malice”. (Childs, cited in Durham 2002)

Sovereignty of the Lord, e.g. Job 1:21. Though Job wishes he had not been born (3:11, 10:8) he makes no move to end his own life or ask others to do it for him,

²¹He said, “Naked I came from my mother’s womb, And naked I shall return there. The LORD gave and the LORD has taken away. Blessed be the name of the LORD.”

Time of death is God’s to determine: Ecclesiastes 3:2, “A time to be born, a time to die; Job 7:1, “Is there not an appointed time to man upon earth?”; Psalm 31:15, “My times are in thy hand”.

On the other hand, the comparison of Ecclesiastes 3:3, “A time for killing, a time for healing” might offer support for euthanasia. (The word for ‘kill’ is harag which usually seems to mean to slay or kill violently, so this argument is probably a bit thin.)

Analogy with parousia; no-one, not even Son of Man, knows the hour. That is, God is sovereign and we should accept his will and his timing. So with the hour of our death.

Suffering is good for the soul?

1 Peter 2:19—

“For this finds favour, if for the sake of conscience toward God a person bears up under sorrows when suffering unjustly.”

Hebrews 2:10—

“For it was fitting for Him, for whom are all things, and through whom are all things, in bringing many sons to glory, to perfect the author of their salvation through sufferings.”

But 1Peter is about unjust suffering and doesn’t seem to apply here. If the author of Hebrews is right and Jesus was perfected through sufferings (a metaphor presumably derived from Hellenistic ideas of the champion who wins through trials and suffering to release those in captivity) then perhaps we too should suffer to become perfect.

Finally, Paul’s struggle with living & dying is interesting (Philippians 1:21ff):

²¹For to me, to live is Christ and to die is gain. ²²But if I am to live on in the flesh, this will mean fruitful labor for me; and I do not know which to choose.

The notion that Paul can choose whether to live or die suggests a degree of control over the decision which is consonant with ideas of euthanasia. His reason for choosing life is that the Philippians and others will need him, not that to choose death would be wrong. Paul, of course, is already ‘in Christ’. This argument, even if worth pursuing, might not be applicable to those who have not yet become Christians.

In neither OT nor NT was there specific condemnation of euthanasia or suicide, whether assisted or not. Paul’s example suggests that it may be wrong if there is profitable work still to do on earth. Furthermore, if the subject is still ‘of this world’, as Paul was not, the case may be very different. On the other hand, the sovereignty of God is proclaimed long and loud in the Bible and this includes his authority over time of death. To my surprise I find that the Biblical evidence is unclear and that a case could be made for either point of view.

Technological

Technological changes have sharpened some of the issues around euthanasia:

Increased life span means more degenerative disease such as cancer.

Range of drugs gives more control & sophistication over effects.

Improved pain control gives rise to higher expectations about pain management.

Advances in palliative care—hospices etc.,—are claimed to make euthanasia unnecessary.

New definitions of death (brain activity, etc.)

Philosophical

A key question is the desire of the subject. It appears that so far no account has been made of Mr Thompson’s wishes. Perhaps he has not been asked. Perhaps he is no longer compos mentis and so incapable of making effective decisions. There seem to be four possibilities:

Mr Thompson wishes to for euthanasia—the most complex case. Any form of assisted suicide requires the collaboration of at least one other party. There is a sense in which the subject abdicates responsibility to the other.

Mr Thompson does not wish for euthanasia—the most simple case. If Mr Thompson does not wish to die, any attempt on his life is murder or manslaughter.

Mr Thompson is not competent to decide—the most subjective case. Questions of competence are notoriously difficult to decide. Even if Mr Thompson is in a coma and the prognosis is that he will remain so there is still the faint chance that he may recover consciousness long enough to make a decision.

Mr Thompson has not been asked—the most subtle case. Why has he not been asked? Is there a conspiracy of silence? Is there a model of “I only want what’s best for you” in operation? Is there an assumption that Mr Thompson does wish euthanasia but will not say so? For instance, Mr Thompson may wish that he could die as soon as possible but that does not necessarily mean that he wishes for euthanasia. If the question is not asked there is scope for creative ambiguity.

Examining motive, action and consequence might give something like this:

Motive—In the case of euthanasia, the motive is crucial. If the reason for the act is not selfless it is not solely for the purpose of relieving the suffering of the subject. But what about Mrs Thompson’s suffering? If Mr Thompson’s suffering has a right to be relieved, does not she have a right to be relieved too? In practice it is hard to imagine unmixed motives and motive alone is unlikely to offer a cast-iron guarantee of propriety.

Action—The mode of killing should be humane and proportionate; it should not increase the suffering of the subject. It should also be effective.

Consequence—there are two sets of consequences to consider. For third parties the consequence (assuming that the action was effective) is that they can move on: to grieving, to a new patient, to a new source of health care expenditure, etc. For the subject the consequence is less clear. He or she is dead, certainly. But how the manner of death affects the subject’s state after death is uncertain. That uncertainty needs to be taken into account.

Debate has been going on a long time: the Pythagoreans opposed euthanasia, while the Stoics favoured it in the case of incurable disease. Plato approved of it in cases of terminal illness.

Hippocratic Oath: “I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them. I will not give poison to anyone though asked to do so, nor will I suggest such a plan.”

The analgesia itself may hasten death; this is generally considered not to be euthanasia as long as the intent is not to cause death—sometimes known as the doctrine of double effect.

The options

Out of many possibilities I have isolated five:

Mrs Thompson could speak with Mr Thompson about his wishes

Because euthanasia always involves more than the subject, the subject’s wishes can never be paramount. By speaking to Mr Thompson his wife may open up an area which is too painful or difficult for him to deal with in his present condition. As noted above, he may want to die but not to be assisted to die.

One result of any conversation may be a desire to find hospice care for the last few weeks of his life. My own mother, when dying of lung cancer spent her last few days in a hospice and was much comforted that this gave her a quiet and dignified end. She was able to be clear about her wishes; helped, I am sure, by her faith. Others may find this sort of conversation very difficult.

Mr Thompson may be strongly of the opinion that he wishes an assisted death. If so, Mrs Thompson will have to decide what her own reaction will be.

Mr Thompson may be considered no longer mentally competent to make any meaningful decision about the manner of his own death.

Mrs Thompson could make it clear that no intervention beyond pain relief is acceptable to her

Mrs Thompson cannot help but be a party to whatever happens; they have, after all, become ‘one flesh’. Therefore, if she is definitely against euthanasia she will need to convey this to whoever is involved—her husband, if he is capable, and the nurse.

Her wishes may not be obeyed; the nurse may take matters into his or her own hands or the nurse and husband may jointly agree on a course of action with which Mrs Thompson cannot agree.

Mrs Thompson could encourage the nurse to help Mr Thompson die

If Mrs Thompson becomes convinced that euthanasia is acceptable or is a ‘lesser evil’ she may take the initiative by encouraging the nurse or by speaking with her husband. Even if he is against it she might adopt a “I only want what’s best for you” attitude and still encourage the nurse. The result may be an act against Mr Thompson’s wishes but one performed with largely selfless motives.

Mrs Thompson could report the nurse to the police or hospital

Mrs Thompson may decide that the nurse’s comment is sufficient evidence of intent to commit a crime and proceed to report him or her to some appropriate authority. The probable result would be increased stress and a denial from the nurse but in some cases (probably where there had been previous suspicions about the nurse) it might result in a criminal prosecution.

Mrs Thompson could do and say nothing

Of all the options, the one most frequently adopted is probably the ‘three wise monkeys’ approach. Wilful ignorance is a commonly adopted strategy in the face of situations which give rise to ethical or cognitive dissonance. In this option Mrs Thompson can pretend that she is not involved, the nurse can take silence for assent and Mr Thompson’s suffering will end sooner than it might otherwise have done. Whether God will be pleased will remain to be seen.

What I would say to Mrs Thompson

I would firstly try to clarify with Mrs Thompson what she heard the nurse say. Is she sure of the implied meaning? Had she been thinking about euthanasia since the sermon? From before the sermon?

I would then ask her whether she had ever spoken about this sort of issue with her husband. How did their discussion go? Were they in agreement? Had either of them changed their views since he became so ill?

It might then be appropriate to explore some of the biblical evidence. Although pointing out how equivocal it is, I would also need to point out that the church has been firmly against euthanasia for most, if not all, of its existence. This does not mean that any other view is necessarily wrong but it does need to be taken into account and given due weight. We may also explore some of the other factors mentioned in the analysis above.

At this point she might want an opinion from me. If she has never spoken with her husband and she has no reason to believe that he wants an assisted death I would probably counsel her to remain silent. As far as the nurse was concerned, I would suggest to Mrs Thompson that she ask that Mr Thompson’s dose of pain killers be high enough to keep his pain manageable but no higher.

I would also suggest that she consider the possibility of hospice care because of their pain management expertise and their positive attitude to death. This will also ease her own burden of care, though it will probably bring other emotional difficulties.

From the information available, this does not seem an appropriate time to argue a case which goes against the teaching of the church nor is it likely to help either Mr or Mrs Thompson to do so. If new information came to light in the course of our conversation I might have cause to reconsider this but for the moment it appears to be the best course, preserving Mrs Thompson’s integrity and Mr Thompson's rights and dignity.

References

Durham, J. I. 2002, Word Biblical Commentary: Vol. 3—Exodus, Word Biblical Commentary (Ex 20:13), Dallas: Word, Incorporated.

Finigsen, R. 1991, “The Report of the Dutch Committee on Euthanasia,” Issues in Law and Medicine, July, 339-44.

Hendlin, Herbert, Rutenfrans, Chris, and Zylicz, Zbigniew 1997, “Physician-Assisted Suicide and Euthanasia in the Netherlands: Lessons from the Dutch,” Journal of the American Medical Association, 277: 1720-2.

Richard Seel May 2003.