Right to life / duty to life

[max higgs]

I think I clearly understand the position of the Holy Orthodox Church on the issue of abortion and right to life, and I wholly ascribe to the teaching. However, I am a bit unclear on our obligation as Orthodox Christians at the end of life. Do we have a duty to permit medical doctors and other professionals to extend our lives. If I am given a diagnosis of cancer, do I have to submit to every treatment my doctor recommends, or may I just go home and begin praying and making final arrangements? If a loved one receives such a diagnosis, do I have a duty to persuade him or her to use every medical technique available to extend life?

It would be shameful to not thank the host and those of you who have been my teachers in Orthodox doctrine and practice.

[Fr Raphael Vereshack]

Max asks:


I am a bit unclear on our obligation as Orthodox Christians at the end of life. Do we have a duty to permit medical doctors and other professionals to extend our lives. If I am given a diagnosis of cancer, do I have to submit to every treatment my doctor recommends, or may I just go home and begin praying and making final arrangements? If a loved one receives such a diagnosis, do I have a duty to persuade him or her to use every medical technique available to extend life?

There is no hard and fast rule about this because every situation is different and this needs to be taken into account. By 'situation' we mean not only the person suffering but also the family or legal guardian involved.

Your question though does imply the Orthodox parameters in which these decisions must be made. On the one hand there can be a wrongful extension of life but on the other a wrongful cessation of life. It is within these parameters that we try to discern our way by talking with the doctors, family members and priest & of course if possible the person directly involved. I think the best way to look at this is by just doing your best to go a step at a time.

Often though the above is not a subject of discussion until the person is in danger of death. In these situations when the family is distraught or even in a kind of shock it can be very difficult to discuss these things. So when the person becomes obviously seriously ill it is best as soon as possible to begin talking about these things- not necessarily to come to any firm decisions but mainly to get everyone involved into a mind-set where moral and proper decisions are being made in common.

A last point from experience. Many Orthodox do not fully take into account that the executor of a will has the legal authority to make funeral arrangements as they see fit unless something specific is stipulated in the will. We have had some very terrible situations in our parish- one where the children had the parent cremated, of course without any church service at all- another where the children just decided that a church funeral wasn't needed. In this situation a parish has absolutely no legal standing at all unless the will of the deceased clearly refers to a church funeral and suitable burial (some of our people being good Orthodox Russians also legally stipulate the traditional meal 'pominky' to follow!).

In Christ- Fr Raphael

[Doug Gwinn]

Dear Max,

I am a physician, and I am sure there are many other physicians on the List who could comment as well. Right now I have a patient in the hospital with badly metastatic breast cancer who has fought it for 14 years and had a brain hemorrhage. We are giving her comfort only, as she has no hope of recovery.

There is a very clear distinction between PROLONGING dying, and PROMOTING dying (assisted suicide). Of course when you open the door to killing babies in utero, you have crossed a line that has resulted in the upholding of the assisted suicide law in Oregon by the U.S Supreme Court. The inevitable result of this will be that eventually committees will decide whether any of us have adequate quality of life to preserve or not, especially at the state's expense.

I do not think I have a responsibility to keep a patient in my charge alive with a ventilator or with other mechanical means who has a terminal illness and no hope of recovery, who in another time, or if they had not made it to the hospital would have died. I do not think it is splitting hairs to say that is not the same as assisting someone in their attempts to die. I do not believe there is such a thing as "passively" killing a patient. The key question is whether we are prolonging death. Talking about whether one has a quality of life worth preserving is a VERY slippery slope; that I believe, is God's decision not mine.

When my 84 year old believing Dad was dying of prostate cancer in our family room for 8 weeks in hospice, very much wanting "to go home" with the Lord, and finally slipped into a coma the last 5 days of his life (which of course I did not know whether it would be five days and each day seemed like an eternity), I thought as I lay on the floor next to his bed at night listening to his labored breathing that I could bring home a big syringe of insulin from the office and inject his IV line to which his pain pump was connected in the middle of the night when everyone was asleep and nobody would ever know. I shocked myself! I couldn't believe I was thinking it. Would it have been the compassionate thing to do? Absolutely! But the issue is not compassion. The issue is God is God, and I am man.

Under the Mercy,

Doug

[Trudy]

Doug,

May your Father's memory be eternal! May God grant you His peace and comfort and bless you for the righteous love you have for your Dad.

In Christ, Athanasia

[Byron Jack Gaist]

Dear Doug,

Thank you for your moving personal account of your father's last days, which must have been a difficult time for you.

If I've understood you correctly, your principle is that as a doctor you, or your colleagues, or the state, do not have a right to decide whether the quality of a person's life merits its preservation or not; you see that, rightly in my opinion also, as being a judgment which belongs to God alone.

When you refer to prolonging vs promoting dying, I assume that prolonging dying is what Fr Raphael above refers to as "extension of life", which it seems from an Orthodox perspective can sometimes be wrongful, depending on the situation. In a sense the promotion of death via eg. physician-assisted suicide is a "clearer" issue from a Christian perspective (as "clear" as serious moral dilemmas can ever be, that is); but the wrongful extension of life seems to me to be more complicated. As a doctor you say


I do not think I have a responsibility to keep a patient in my charge alive with a ventilator or with other mechanical means who has a terminal illness and no hope of recovery, who in another time, or if they had not made it to the hospital would have died.

At which point, however, do you decide when it is right to turn off the ventilator? I have the impression you are saying it is OK to make the decision to end a person's life, if they are terminally ill with no hope of recovery (which seems to clash with your earlier statement that the quality of a person's life is not a criterion for deciding whether or not they should live). Or are you saying something different?

In Christ
Byron

[Antonios]

Dear Byron,

As someone who also works in the health care field, I think I understand a little bit where Doug is coming from. When the quality of life as viewed by the family, doctor, etc. becomes poor, and the statistical chances of a medical recovery to a better quality of life becomes dim, if not, nonexistent, than 'heroic' attempts at preserving that life often only prolongs sufferring. Allowing someone to stay in a state of prolonged suffering is neither humane nor anything like an act of love. Often, rather, this is done from selfish reasons of the family (to delay their grief, to avoid any feelings of hopelessness or guilt, sometimes even for financial reasons!)

Of course, this does not mean that the patient should be given a medication to delibrately end their life (i.e. euthanasia), but rather, given what medications we have to make them comfortable and ease their suffering, and allow God to do the rest. Sometimes that means giving them morphine to ease the pain. Sometimes that means turing off the ventilator. Always, such acts should be done reverently and prayerful, and ideally, with the blessing of a priest.

The difficulty arises when people try to judge 'quality of life'. This is where the difficulty is, and this requires great discernment. Being brain dead and being kept 'alive' on a ventilator would medically qualify as an extremely poor quality of life. I think most people agree. It becomes difficult when the person has some remaining cognitive ability, for example a person who suffers from dementia or suffered a large stroke. Then it becomes extremely subjective as to what that person's quality of life is.

We should also be careful not to generalize since every case is unique and different. Saying that euthanasia is sinful, we must understand what we mean by the word 'euthanasia'. If we mean to administer medication to delibrately end life, than I would agree. If we mean to ease suffering and pain by giving medication to reduce such torture, and in the process the patient dies, than I, and the medical community, would disagree. Rather, allowing someone with no hope for recovery to stay in state of pain and suffering would be the greater sin.

While you say that only God can truly judge the quality of a person's life, God also does not enjoy to see His children suffer. There are many instances in the lives of saints where right before the saint was to be tortured and martyred, they would 'fall asleep in the Lord'.

To have metastatic terminal cancer and suffer from constant debilitating pain is not a way anyone should live. Anyone who thinks differently has never had such a condition and should keep their judgement to themselves. Keeping their heart pumping just to maintain vital signs on this earth in constant pain and sorrow while at the same time delaying and denying their vital relief and entrance to the bossom of Christ is an act of selfishness and self-righteous vainglory. May we never have to suffer such a 'quality of life' nor face such difficult life or death decisions.

Lord, have mercy on us.

[Byron Jack Gaist]

Dear Antonios,

Thank you for clarifying these difficult issues around the end of a person's life. I agree that keeping someone alive can be for the wrong reasons. The debate also brings up some interesting questions about the relationship between faith and medical technology, which it probably would be unorthodox (non-Orthodox) to generalise about in any inflexible manner.

Once again, many thanks for your informative post. I would ask anyone who is suffering or who has relatives suffering in such a situation to please forgive me if I sounded ignorant or judgmental in any way in my previous post. My aim was to understand the theological issues involved, not to pass judgment on doctors, nurses, relatives or the afflicted. God bless you all in your suffering and healing.

In Christ
Byron

[max higgs]

I guess the problem I am having with the discussion is the failure to address the fact that we already have some medical techniques or procedures which prolong life in a strictly biological sense but which fail to address life in any meaningful sense. Antonios is correct that "quality of life" may be used to justify euthanasia, but the real problem, as I see it at least, is when does an Orthodox Christian have a duty to utilize the medical procedures currently available.

Let us assume that the case of a 70 year old man. His children are grown and living on their own and his relationships with them are formal and not warm. His wife is deceased or perhaps she is live, but they are not close. The wife is well off financially. He has passed the mandatory retirement age for his profession. Let us further assume the man discovers that he has a disease which will kill him if untreated in the next four years, but if he receives treatment, he may live fifteen or twenty more years. The treatments are invasive and uncomfortable, but the pain is tolerable and can be managed. Under these circumstances, is there an obligation or a duty to live?

[Ken McRae]

max higgs wrote:- " ... the man discovers that he has a disease which will kill him if untreated in the next four years, but if he receives treatment, he may live fifteen or twenty more years. The treatments are invasive and uncomfortable, but the pain is tolerable and can be managed. Under these circumstances, is there an obligation or a duty to live?"

I've heard it said in the past that some ROCA bishops are known to have refused all medical treatment of their heart conditions; which treatment would've considerably extended the length(s) of their earthly lives. It is believed that these bishops in question were masters of the prayer of the heart, having successfully acquired the union of mind and heart through the Jesus Prayer. The physical heart was for them the seat or place of the spiritual heart, similar to the brain being the seat or residence of the reasoning power in man. If a "brain" transplant were possible, in the future, how many Orthodox bishops would accept one, if that was the only way to save or continue their physical life on this earthly plane?

These ROCA bishops chose the path of suffering Orthodoxy, after the pattern of their Master, Christ, who refused to mitigate his own bodily pains on the cross, by the use of wine. And we read in Scripture that the OT saints refused to be delivered from their physical tortures, "that they might obtain a better resurrection." (Heb. 11:35) And the epistles of St. Ignatius, (the God-Bearing Apostolic father,) clearly indicate his overwhelming desire to suffer a martyrs death, over any kind of deliverance that the faithful might strive for and achieve on his behalf. I believe I've read somewhere that St. Silouan suffered from chronic headaches, for which he sought divine deliverance, but never received it. When he believed these headaches were from God, he no longer sought to be freed of them. In this regard, Meister Eckhart wrote the following words:-

"The man who abides in the will of God wills nothing else than what God is, and what He wills. If he were ill he would not wish to be well. If he really abides in God's will, all pain is to him a joy, all complication, simple: yea, even the pains of hell would be a joy to him. He is free and gone out from himself, and from all that he receives, he must be free. If my eye is to discern colour, it must itself be free from all colour. The eye with which I see God is the same with which God sees me. My eye and God's eye is one eye, and one sight, and one knowledge, and one love." ( from his Sermon on True Hearing (http://www.ccel.org/ccel/eckhart/sermons.vii.html) )

It is not difficult for me to see the connection between St. Silouan's headaches and St. Paul's 'thorn in the flesh', which he wrote about in chapter 12 of Second Corinthians:-

"7": And lest I should be exalted above measure through the abundance of the revelations, there was given to me a thorn in the flesh, the messenger of Satan to buffet me, lest I should be exalted above measure.
"8": For this thing I besought the Lord thrice, that it might depart from me.
"9": And he said unto me, My grace is sufficient for thee: for my strength is made perfect in weakness. Most gladly therefore will I rather glory in my infirmities, that the power of Christ may rest upon me.
"10": Therefore I take pleasure in infirmities, in reproaches, in necessities, in persecutions, in distresses for Christ's sake: for when I am weak, then am I strong.

[Antonios]

Byron,

I'm the one who should ask for forgiveness if I came out harsh in my previous post. I am a bit passionate in this area of discussion and sometimes I speak before thinking. I can only speak of my own personal experiences and beliefs and whether this is in accord with Orthodox teaching, I am not sure. I pray it is.

Max, the situation which you illustrated is a great example of many of the difficult choices people everywhere face everyday. I think what makes such decisions so agonizing is because of the fear of death, which although is 'natural' in our fallen state, is unnatural in terms of what we were originally created for. This fear leads people to think of death as a failure, as the thing to be avoided most and foremost. It is this fear which causes people to try to cling on to 'life', to spend exuberant amounts of time, money, and energy and endure rollercoaster rides of emotions of hope and hopelessness, while all the while their remaining days on this earth pass by. Is this what the Gospel defines as the meaning of life? I may easily be wrong, but I have never interperted it that way.

Each person as a child of God is different and their story is unique. Of the billions of people who have walked the earth, no two have been the same in the eyes of God. Each of us have had our own experiences, desires, moments of love and moments of tragedy. Only God knows what our life truly 'means'. From His Divine Justice and deep love, we also shall understand what our life means when we come before Him after we pass to the next life and our book is opened for us to read. The writing in that book will not be about what we did to prevent our death , but what we did to welcome True Life.

in humility and love,
Antonios

[Fr Raphael Vereshack]

Let us further assume the man discovers that he has a disease which will kill him if untreated in the next four years, but if he receives treatment, he may live fifteen or twenty more years. The treatments are invasive and uncomfortable, but the pain is tolerable and can be managed. Under these circumstances, is there an obligation or a duty to live?

There is no obligation in the case of a terminal disease to receive long-prolonging treatment. But we are just talking in general here since in real situations many things need to be taken into account.

For example how often in reality can we be certain that terminal means certain and foreseeable death? There are times when terminal cancers for example go into remission.

What also of the question of 'pain management'? This also is a complex question of balance that shades into the other question of prolonging life.

So I really do not believe that in the situation of a terminal disease there is an obligation about life-prolonging treatment. On the other hand many do choose such treatment without this being sinful. So each situation needs to be governed on a case by case and almost day by day basis.

In Christ- Fr Raphael

[Alec Lowly]

Max Higgs writes:

"Let us assume that the case of a 70 year old man. His children are grown and living on their own and his relationships with them are formal and not warm. His wife is deceased or perhaps she is live, but they are not close. The wife is well off financially. He has passed the mandatory retirement age for his profession. Let us further assume the man discovers that he has a disease which will kill him if untreated in the next four years, but if he receives treatment, he may live fifteen or twenty more years. The treatments are invasive and uncomfortable, but the pain is tolerable and can be managed. Under these circumstances, is there an obligation or a duty to live?"

I believe there is.

First, continuing to live offers the opportunity for the achievement of genuine love in those "formal," "not close" family relationships. That is a godly thing.

Second, continuing to live offers the opportunity to perfect, as far as may be possible, one's repentance.

Third, continuing to live offers the opportunity to serve God and to do His will as future occasions and circumstances indicate.

In XC,
Alec Lowly, sinner

[Byron Jack Gaist]

Dear Max and all,

The above posts #104 by Alec and #918 by Fr Raphael may superficially sound conflictual, but in fact it seems to me they harmonize well. From the point of view of a mental health professional, I would also wonder about "unfinished business" in the relationships between the 70-year old man and his family. Relationships do, thankfully, become less impassioned and dependent as we grow older, but something is not right if they have grown "formal and not warm" as Max says. Of course we may be talking about things which are not going to change; but it seems right to stick around to achieve some form of reconciliation and personal closure, perhaps mutual forgiveness on these issues. As Theophilus suggests, there may be a special meaning in living with illness, but Antonios is surely also correct in very eloquently saying


The writing in that book will not be about what we did to prevent our death , but what we did to welcome True Life

In Christ
Byron

[Doug Gwinn]

Dear All,

Very interesting and insightful comments. Antonios, awesome comments in your post 115, especially the last paragraph. To me, turning off a ventialator which is the only thing keeping someone alive when they have no hope of recovery is okay because it is artificially keeping someone alive. Now, having said that, we need to be very careful, and not paint ourselves into a corner. What if a person is conscious, say, has such bad emphysema that however they got on a ventilator (maybe from a non terminal severe pneumonia), they will not get off, but are fully awake and not in pain. That is poor quality, but I would be loathe to turn that one off. I would be very sympathetic, and very sad, but I would probably have to relinquish care of such a patient if patient and family wanted it off. So I think in GENERAL that prolonging death as a criteria holds up, but as above there are always exceptions. In general, quality of life/compassion are the slippery slope because they are relative--whose defininition of those terms and what criteria? Life is absolute, and is God's decision alone. Lord have mercy for sure!

Maybe I'm delusional, Byron, to think I am not engaged in double-speak. It is NOT okay to make a decision to end someone's life, but IS okay not to keep them alive! Mull that one over! Turning a ventialor off could be morally wrong or morally right. Personally, it helps me to think about whether it is preventing the inevitable. In the example above, death is inevitable if you turn him off, but it is otherwise not inevitable--people live for years on ventilators. I wouldn't do it! It's a moral swamp--we just have to make the best decision we can--with all the grace and humility available.

I should also say that, aside from machines, and interventions, sometimes one has to "help" (but not assist the act) someone graciously die. Sometimes, it is time to tell the patient you ARE dying, and tell them it's okay to die, and tell them they need to call hospice, and permit them to right relationships with God or others by telling them the end is near. To do otherwise is not merciful and cheats them of a God-given last chance to give/get forgiveness.

Max, we got carried away in our moralizing, and didn't answer your question. Again, not being dogmatic, in GENERAL we do not have the duty to live as in your example. Just because we have technology, we do not have to use it. In your example, I think one could come out either way, but I have no idea about how to determine God's will in a specific case except by seeking out one's spiritual father, other wise people, and much prayer. Antonios's comments about "clinging to life" are timely--we see it every day. I would hope to never cling to mine in that sense. Avoiding death should not be one's ultimate goal in life, especially the Orthodox!

Athanasia, thank you for your kind words. My mom died 9 months earlier from kidney failure from breast cancer drugs--on a Sunday. My Dad also wanted to die on the Lord's Day. He was supposed to last 1 week, and lasted 8. Every Monday morning he was extremely bummed he had not passed on in the previous 24 hours. The merciful Father did grant him his heart's desire.

Oh, how I would love to talk to him now that we're Catechumens. While missionaries in the Middle East, he grew to love Orthodoxy. When we came back to the U.S., he taught courses on it. He had a PhD in New Testament from the John Knox holy of holies--the Univ of Edinburgh. Although an ordained pastor, he spent most of his adult life as a college professor. His blood ran Presbyterian. But knowing him, and knowing now what I know of Orthodoxy, I can't believe he wasn't Orthodox!

Doug

[Doug Gwinn]

Dear All,

Once we have exhausted and beat to death the current "right to life" thread, another twist on end of life issues I would be most eager to hear everyone's input on is organ donation. Perhaps it should be a new thread.

I have generally been in favor of this, the "gift of life." However having not very long ago been in favor of cremation ("the body's just a stupid shell, the real me is gone from it"), and now Orthodox and utterly amazed I could have been so unenlightened, I'm not so sure that my erstwhile moral medical logic holds any water at all.

What say you? Is it violation of the body? Is it excessive tampering with life and death?

Under the Mercy,

Doug

[Antonios]

Hi Doug,

We touched upon organ donation in another thread found here (http://www.monachos.net/mb/messages/4225/20184.html) . It certainly is a great question which I am interested in.