How My Mind Changed about End-of-Life Care

Unless Christ returns first, I am going to die. (This is a general truth: as far as I know now, I do not have a terminal illness.)

I was created in the image of the living God.

By his grace, I have been rescued from slavery to sin and am now a bondservant of the Lord Jesus Christ.

My identity as an image bearer of God gives me dignity.

My identity as a redeemed servant of the Lord, united to Christ, comes with covenantal obligations, including how I think about my life and my death.

The principles and presuppositions of the Word of God require that I reject active euthanasia (directly and intentionally taking one’s own life or the life of another). It is never an act of love or faithfulness to use medical means (or any other means) to hasten human death.

In addition to this—and this is perhaps more disputed among Christians—I have now come to believe that that one can in faith (that is, without sin) decline ineffective or excessively burdensome medical treatment.

Dr. Kathryn Butler articulates the principle in her book, Between Life and Death: A Gospel-Centered Guide to End-of-Life Medical Care (Crossway, 2019):

We can:

1. seek aggressive treatments when they offer hope of recovery but
2. decline aggressive treatments

a. when they only prolong death, or
b. when they inflict suffering without commensurate benefit.

Many Christians—myself included—have assumed that being pro-life means extending life as long as possible. If, for example, a feeding tube can provide the food and water, or a ventilator can pump oxygen, then we should always use all the means at our disposal to preserve a human life.

Professor Bill Davis, a Christian philosopher at Covenant College and a PCA elder, makes an interesting observation about this in his thorough and helpful book, Departing in Peace: Biblical Decision-Making at the End of Life (P&R, 2017), showing that the answer to this question—Should we do everything medically possible to sustain life?—has changed even though God’s Word has not changed.

CPR and breathing machines changed death and dying.

Before these life-sustaining measures became common in the 1960s, doing everything medically possible did not result in long periods of unconsciousness before death. If someone’s heart stopped beating, there was nothing to be done. If someone’s breathing stopped, there was no way to breathe for that person. Someone who was unconscious might wake up, but if his or her heart or lungs stopped working, the person was dead.

Now, fifty years into the age of life-sustaining medical treatment, “do everything” covers a much wider range of medical possibilities. It is now possible to keep someone’s heart and lungs working for months even when the person is unconscious and his or her organs are too weak to function without help. When life-sustaining treatments are used to help in curing an infection or an injury, the treatments are a great blessing even when they are quite expensive.

Often, however, life-sustaining treatments do not contribute to a cure, at least not humanly speaking. Ventilator support for someone who is unconscious from a massive head injury is not part of a medical plan to cure the injury. God can always intervene supernaturally, but life-sustaining treatments may be extending physical life only by imposing serious burdens on the person who is sick. . . .

Here is the biblical principle that Professor Davis argues for:

God’s Word permits us in some cases to say no to life-sustaining medical treatment.

He continues:

If I had written on this subject one hundred years ago, I would have rejected this key principle.

Yet the Word of God has not changed.

What has changed is the range of medical options.

I was born in 1960, four years before CPR became a standard part of a medical-school education. Kidney dialysis, defibrillators, and ventilators (machines to support breathing) were developed even later than CPR. In 1960, people who are today kept alive “by machines” would all have died from their diseases. The medical advances of the last sixty years have been exciting, but they have also made it harder to think through our obligations about medical care. The Bible teaches that we must accept medical attention that is likely to cure us of our diseases. As Christ’s servants, we are called to maintain our health so that we can serve him well.

Before the development of life-sustaining medical treatments, this obligation to use medical means to maintain our health would have meant that we were obligated to use all available medical means to stay alive.

God’s Word commands us to defend life, but it does not command us in every circumstance to use medical techniques to extend it as long as possible.

Butler also reminds us—based on her years as a trauma surgeon—that in some scenarios, end-of-life interventions can actually cause harm. For example, ventilators cause pneumonia; CPR breaks ribs; tube feeding increases mortality among people with advanced dementia. Such adverse effects can warranted if the condition is reversible and the interventions can be a means of ushering someone back to health and bringing them home. But in cases when such care is futile, continued medical interventions can be a failure of stewardship and neighbor love.

What Should You Do Next?

I recommend the following steps:

1. Determine to complete an advanced directive. This allows you to put in writing, in a legally recognized document, your desires in advance. This is an act of love for your loved ones to make your wishes known. Don’t wait until you are sick or until you are retired. Everyone age 18 or older should have one.
2. My first choice would not be the standard state forms, which require you to check a box, yes or no, for various scenarios. The logic on the forms can be a bit confusing and have led some readers to misinterpret what it is asking. If, however, this is what you want to use, make sure to use this invaluable resource from Bill Davis, where he has filled out each state’s form in a biblically acceptable way.
3. I personally recommend instead the Five Wishes Document, which has written by a pro-life leader in consultation with the American Bar Association’s Commission on Law & Aging and is recognized in all 50 states. It is written in plain language, allows you to add your own narrative, and to express your wishes for more than just the hard cases.
4. For help in thinking through the issues, I highly recommend consulting Butler’s book and Davis’s book. They are both wise and mature Christians, with different expertises, but complementary perspectives. You could start with this article by Dr. Butler for the general idea and biblical orientation. The biblical principles collected in the back of Davis’s book, which he argues for throughout the book, are incredibly thoughtful and careful.
5. (If you want something thorough, philosophical, and biblical on active euthanasia, consult a book like John Feinberg and Paul Feinberg’s Ethics for a Brave New World, chapter 4).
6. If you are an elder or teacher in the church, consider teaching a Sunday School or Wednesday evening class on this. Bill Davis has done all of the hard work for you. See his free four-week-long study guides and lesson plans for personal and group study available here.