5-29-2016 Bioethics Part 59

The speaker begins by praying and discussing the topics of physician-assisted suicide and active voluntary euthanasia. They argue that ending someone's life to relieve their pain and suffering is always wrong and creates problems in society and healthcare. They then shift the focus to the decision of accepting or foregoing treatment at the end of life, emphasizing that this is a separate issue from euthanasia. They address the question of whether one is morally obligated to accept all possible treatments to sustain life, even if the chances of success are low. They highlight the importance of considering advancements in medical technology and the increasing number of people facing end-of-life decisions. They also discuss the complexity of understanding what it means to be "pro-life" and how the desire to avoid medical killing can sometimes burden both the living and the dying. The speaker acknowledges the delicate balance in this issue and explores the concept of "needless" pain and su Let's pray and get started this morning. We thank you for your presence here with us through the power of your Holy Spirit and pray that as we think about these things that are not easy to think about and some of us would rather not think about, you would give us sound minds and clear eyes to see truth and think well about how it is we ought to approach the end of our lives in order that we might live well and help others die well and die well ourselves in Jesus' name. Amen. So for the past few weeks we've been looking at both physician-assisted suicide and active voluntary euthanasia. We saw that even if it's done with the best of possible intentions and even if it is done with the most highly regulated system humanly imaginable, which will always be a failure to some degree, ending somebody's life in order to quote-unquote relieve their pain and suffering is always and at every single point wrong. It creates intense and unqualified problems in society and in health care itself. These practices, while understandable and sometimes, as we've seen, apparently, at first glance, merciful or loving actually teach us to view life, death, suffering and ultimately God in all the wrong kinds of ways. So this week we're going to be dealing with the realities of how we humans ought to go about the practice of deciding whether to accept or forego treatment. I'm particularly thinking at this point about treatment at the end of our lives. I'm not speaking about whether or not you should take aspirin if you have a headache or if you should take depression meds if you're depressed. We've covered some of that stuff in the past. Thinking particularly of accepting or foregoing treatment that may well result in the termination of your life. This is something we would have to deal with regardless of our stance on physician-assisted suicide and active voluntary euthanasia because, of course, physician-assisted suicide or active voluntary euthanasia is not always, in anybody's mind, the very first thing you should do when you find out you have cancer or you're going blind or something like that. It is the last step but there are many steps before that and so you would have to consider whether to accept or forego treatment regardless of your stance. However, it is particularly pressing that we give attention to this today as we've seen in the past that the taking of life and the taking of your own life is impermissible. Some ethicists would ask at this point, okay, if you don't believe that you can't take your own life or receive help in taking your own life and you can't have somebody else take your life, you voluntarily asking them to do that, then don't you have to accept at every single point any kind of medical treatment to sustain your life as long as humanly possible because if you forego treatment at any point, isn't that like you committing suicide? That's the charge. So, let me put it in kind of a practical example. If I find out tomorrow that I have stage 4 brain cancer and I have the option of doing chemotherapy and that chemotherapy has either a 90% chance of success or a 10% chance of success, it doesn't really matter, don't I, am I not morally obligated to say, yes, let's do it because I do not believe in physician-assisted suicide or active voluntary euthanasia? Because if I say, no, we're not going to go there, knowing that that might result in my own death, isn't that just like killing myself? I don't want to argue that at every point is in no way the same thing. So, thinking through this kind of stuff is important as a result of a few factors on top of the one that we don't think that active voluntary euthanasia, or at least we shouldn't think that that's a viable option. One is that medical technology is going to continue to improve. As much as you might love that idea or hate that idea, it's going to continue to, quote-unquote, improve or progress. Why is that something? We brought this up before, but why does that entail us thinking hard about this? Okay, so new questions are going to arise going forward. Yes, what else? The better the healthcare system gets at keeping people alive, then the longer we live and, at least statistically speaking, more of us will live. So, the generation that has come after us, so essentially kids who are 15 years old and younger, are going to have an extraordinarily higher percentage of persons who must deal with the reality of accepting or foregoing care at the end of their lives. 50 years ago, not a whole lot of people were dealing with, should I do this or should I do that. A whole lot of people 50 years ago just dropped dead. And even then, a lot more people 50 years ago had to make those kinds of decisions than people had to do 100 years ago. You just keep going back in time. As medicine progresses, and as we are able to keep people alive more and more, which is a blessing, right, we've seen that, it's also very much a semi-curse because we are stuck in the awkward position. As I said near the beginning of the time in death and dying, you can't pull the plug if there's no electricity. I guarantee you, right, we are getting into the summer months. Is it officially summer? Yes? Okay, we are in summer. We are in the summer months. And as a result of living in the blessed south during the summer months, it is extraordinarily warm. And even if you are one of those sick and twisted people that hates air conditioning, you still love fans. I guarantee it. Even if you are like, I am totally opposed to electricity, you still like somebody using their own energy to fan you, which is super weird. So, you love electricity. You use electricity. Electricity provides a large number of servants in your life. Imagine how many servants you would need to accomplish all the tasks that electricity provides for you. A large number. The moment you have electricity, then at least you have the potential of doing things to human beings that you could not do before, including good things. What's a good thing we could do with electricity? For somebody else. Especially like, let's think of the medical setting. Breathe for them. Great. What is something terrible we could do to a human being with electricity? How? There you go. Electric chair. Great example. Electricity is not the problem. Electricity just makes new and interesting and sometimes terrifying moral questions arise. The second reason this is so important is because Christians struggle to understand what it means to be, quote-unquote, pro-life. I won't ask you for your definition of that this morning, but I would assume that two things are probably true at the same time. Number one, you would probably, to some degree, though you would want a definition from somebody, you'd probably say, yeah, okay, I'm pro-life. But then if somebody goes, okay, what does it mean to be pro-life? You'd be like, uh... I mean, I like... I know down somewhere, I just don't know, have the words to express to you what it means to be that thing. The assumption all too often is that what it means to be pro-life is to be obligated at every point to extend life for as long as possible without exception. So, that applies to an unborn child that has microcephaly, for example, which is a common thing today, or at least prominent in the news, or a child who was born without a brain or something. You say, okay, I understand that that is a complication of real, we must do what we can to keep that person alive. The question is, do we do everything always, without ceasing to the very end, without stopping, in order to avoid death? That also applies to people who are alive today. I applaud very much and understand many Christians' desire to avoid medical killing. And I agree, we do not want to be a part of medical killing. However, this desire to avoid medical killing at all costs, at times, unduly burdens both the living and the dying. We force people to continue to live, and we force ourselves to make ourselves pursue people's lives at any and all costs. Like most of these things that we've dealt with, there is very much a delicate balance that must be held in this issue. All burdensome pain and suffering is not warranting of death, correct? Name something that is a real burdensome pain and suffering that would not be necessarily meriting of death. A migraine. That's right. And if you think, well, Jake doesn't know anything. Migraine is nothing. That's what I'm saying. I'm getting to that. You've never had a bad enough migraine. There are migraines that will lay you out on the floor, make you curl up in field position, and literally make you contemplate jamming something sharp and long up your nose to poke your brain. Yes, I've been there. So, that we would not say is necessarily warranting of death. Or, in my case, if I tear a toenail completely off, just like there's some jagged stuff on the edges or whatever, while I would desire very much to die in that moment, that is not warranting of death. However, however, the prolonged pain and suffering needlessly of a human being is not required. Now, what is the key word in that sentence? The prolonged pain and suffering needlessly of a person is not required. Key word? Needlessly. That's right. A lot is bound up in the definition of the word needlessly. For the next couple of weeks, we're going to be looking at what that word needlessly means. Needlessly is not toenail off. What does it mean? Per usual, this question is particularly difficult because we cannot chapter and verse this thing. You cannot open the Bible to me and show me where it says, At this point, this is needless, and anything above and beyond this is needless, but anything below this line is not needless. That would be nice and very helpful. We can save ourselves a lot of time. There is also not a modernistic way to set up a flow chart. We all love flow charts. You ever seen a flow chart? If you don't know what a flow chart is, just go on Facebook. I'm sure within the first 60 feet, there's going to be some kind of stupid, usually humorous flow chart about who to vote for for president or whether you like tacos or something. I don't know. It's going to be about something. It's just yes or no, and if you answer yes, you go this way, no, you go this way. We cannot set that up, that kind of flow chart up, in order to figure out everything we're supposed to do in this life. We would like to think that, but unfortunately, it's not possible. While a struggle, though, we might... A struggle we don't always appreciate. A struggle we might really kind of wrestle with ourselves. The truth is that we should be thankful for it, even though it might lead to disagreement amongst ourselves sometimes, because to think, work, and pray, and talk through these issues is what it means to become wise and to salvation. This is part of what it means to be a disciple of Jesus. So once more, what we're seeking to do here, in the time that is remaining, is to love the Lord our God with all of our minds. Something we are not particularly good at in the Christian Protestant America we currently live in. So, we're going to go through some common categories about how to determine whether or not to accept or forego treatment at the end of your life, or near the end of your life. And what we're trying to do is both give negative and positive components. Here's an illustration, if you like illustrations. This is for Tim, right? So, when we talk about the negative things, what we should not do, those things are important because that's really like the fence, right? Imagine that we are all sheep and we are living in a pasture and the negative things are the fence area. These are beyond which we ought not and cannot go. Why is a fence important? Keeps things in and keeps things out. Yes. Why is it not merely sufficient as sheep to have a fence? Or is it? We can jump. That's interesting. Right? Okay. Yeah. Also, if there's just a fence around us and there's nothing to kind of nourish us while we're inside the fence, there's nothing to guide us, in our case as human beings, although this doesn't apply to sheep necessarily, if there's nothing that gives us purpose in life or to tell us how we ought to be sheep. Sheep just kind of do what sheep do. I understand that. Humans do what humans do as well. That usually goes very poorly. We don't know what we're supposed to do. So, the positive, we're not going to look at the positive this week. This week it's all negative. Some real encouraging Sunday school. So, the negative kind of makes the fence. Can't go past here. The positive tells us what we ought to do now being inside the fence. As we deal with this very difficult thing of making the decision whether to accept or forego treatment. So, doing all of this, going through this negative stuff is not futile. It might seem like it. You're going to help me with defining all these categories. It's not futile because we are actually, as we say what it's not, we're actually getting closer to what it is. Okay? So, here is the first unhelpful category distinction. You should determine, this view goes, whether to accept or forego treatment on the basis of something being ordinary or extraordinary. Okay? If it is ordinary, the view goes, then a person has no right to refuse the treatment. However, if we're over here, if it's extraordinary, then the person can make the determination. So, what we are supposed to do under this category distinction is say, well, is this ordinary or extraordinary? Give me an example of something that would be ordinary treatment, something you do not have the right to refuse, or at least should not have the right to refuse. Ordinary treatment for a strep thalassophage and antibiotics. Antibiotics. Right? Okay. So, you say, in that case it's a little tricky, right, because somebody could totally say, I don't want to take the antibiotics. Right? But it would at least be like, well, you'd be foolish to do that. Right? We should be able to say, yes, you need to take this, and encourage you to do that. Cleaning out a wound. Cleaning out a wound. Yes. If I come into the hospital, and I have a festering, maggot-filled, gangrenous wound, and you as the doctor and nurse team are looking at this thing and secretly taking pictures and posting on Instagram, going like, dang, look at this, this is nasty. Right? And you say, okay, here's what we're going to do. We're going to cut some stuff out. We're going to clean it out. We're going to pack it. We've got to leave it open for a while. You can't just throw something like that up. Right? We're just going to scrub it out, and it's going to be, ooh, it's going to be bad. But you can have a divot in your leg for the rest of your life. Chicks dig scars, though. It's going to be okay. Settle down. It's going to be fine. What if I say to you as the medical team, I'm fine. What is the very first thing that you will do? Why are you here? Great. So you'll ask that question. Yes? That's correct. I will get a psyche valve. Okay? Which is the right thing to do. I will have a professionally trained psychologist who is on staff at the hospital come into my room and be like, hello, Mr. Meeks. How's it going? What's up with your leg? How are you feeling today? Right? Because I am clearly not in my right mind if I think that this maggot-filled grossness should just keep going. Right? It's fine. Just, hey, look, maggots got to eat. Right? It's fine. That would be under the ordinary. Okay? What would be over here in the extraordinary category? Something I should have the right to refuse. You got some kind of wound. It could be, you could actually do, you know, clean it out. Yeah. Ordinary way, but you got something to cut your leg off. Is that? Okay, I'm going to cut your leg off. What if, okay, that would be sketchy because maybe that's the only way to, like, that's it. Well, then they're not going to cut my leg off. That's the problem. They would never cut my leg off. They could just clean it out. Yeah, yeah, yeah. Yeah. So if I come in and they're like, cancer. Okay. And what thing in cancer? Chemo. Right. That's extraordinary. Right? I should have the right to be like, okay, I'm going to forego that or not. Right? Depending on kind of some determinations. I might be coached one way or the other. But still, here's the, and you say, okay, good. So we have to determine if something is ordinary or extraordinary, and we're fine. There's only a couple problems with this. The term ordinary seems basic enough, but it also includes things like we say ordinary treatment is reliable treatment or common treatment or easy, simple, affordable, readily available. That would be in the common category. Something that is not that way would be deemed extraordinary. Here's the only problem with that. There very well could be something that is easy, simple, and affordable, but not readily available. Okay? Here's a good example. In Nicaragua, my wife found out that she is RH negative. Okay? Which I don't even know what the heck that means. It's a blood thing. Right? And something happens between her and the child that's growing inside of her. It's like bad news, and you have to get this shot. Simple shot. Right? No side effects or anything. You just gotta get this shot, and the shot, like, fixes the whole deal. It is affordable. It is simple. And it's easy to do. The problem, though, is that in Nicaragua, hardly anybody either has this condition or realizes they have it and then receives treatment for it, so it is very, very hard to get a hold of the thing. Because it is not readily accessible. And because it's not readily accessible, if we just roll with the ordinary-extraordinary distinctions, then her receiving that shot is extraordinary. It's going above and beyond the call of duty in order to receive that thing. So, if it's extraordinary, what do we say about it? It's optional. You guys either receive that thing or not receive that thing. Now, you go, well, Jeremy, what did you do? Well, I drove three and a half hours, and I bought the thing, and I took it back to my wife, and I gave her the shot, and it's fine. Piece of cake. However, let's imagine a scenario that's not too hard to imagine where something is very cheap. Let's think about that we live in Pakistan, right? We are in a small village, and inside this small village, we have, like in the current problem in Pakistan, we have a problem with polio still. Now, the polio vaccine, I think, costs seven cents. It comes in this tiny little packet, and you take it by mouth. Pretty simple. There's only one problem. The CIA has been active in Pakistan for so long that certain leaders in Pakistan have convinced tribes that the drops are from the CIA, who is part of the American government, and what that does is it controls your brain, or it makes you act crazy, or it makes you sterile, or it does all kinds of stuff to you, so people don't want to take it. So it's easy, it's affordable, right? But there's all these other kinds of things that are associated with it, so people don't take it, and as a result, people get polio. It's seen as this extraordinary thing. We could also fit all the definitions of ordinary. It could be something that is cheap, basic, reliable, but could be absolutely wrong to administer to a person. Here's a good example of this. If I am at the very end of stage four pancreatic cancer, taking over everything, and we are trying to make the determination of whether or not to give me a new lung, you might go, look, there's a patient in the next room, there is a transplant specialist in this wing of the hospital, we're ready to go, and everything matches up, we've got to take it out, put it in, done. It would be an ordinary thing, but it's all of a sudden the wrong thing because I'm on my very, very, very last leg, as they would say. So this distinction, though understandable to some degree, isn't exactly helpful. It's also very questionable when we get into the idea of governmental kind of medicine or even HMOs or things like that, these kind of governing things. So if you have health care through anything, either the government or a private corporation, and the corporation has the right to determine whether something is ordinary or extraordinary, then if something could totally be cheap, totally common, totally easy to do, but since it's not in your area, they could say, ooh, I am sorry, you are covered by health insurance. However, you live in Tennessee, and all of that thing that you need is in the state of Oregon. So unfortunately, that's extraordinary, and because it's extraordinary, we have the right to deny you. Check. So we need a better distinction than those two. So the next one, we go, okay, fine, that's not good. Let's go with the acts of commission and acts of omission. You might be familiar with these terms when it comes to sins. What is the distinction between commission and omission? Must do but don't. Great. Omission is what we don't do, whether we ought to or not. Commission is something we do, actually pursue, whether we should or not. So, this distinction shifts the focus between withholding treatment or giving treatment. This shifts the focus from the patient to the provider. And they go, well, what's right with giving or withholding care? You go, okay, well, here's what it is. We should give people things but not withhold things, or we should withhold things but not give people things. And there's this kind of weird interchange that goes on where it's like, well, what makes the determination in this case? So the idea is this. Commission is doing something to the patient in order to alter the course of their life. So that we actually actively do to the patient. So if I have respiratory failure, if I cannot breathe, then commission in this case would be like taking a pillow and putting it over my face. That is an act of commission. That would be wrong. It could also be something like, that would be right, that's a commission against somebody, like stopping their heart in order to restart it or work on it and start it again. It's an act against the patient, towards them. Then omission would just be avoiding doing something. I see something that needs to be done or at least could possibly be done and go, nope, I'm not going to do that thing. So it could be good or bad and that's the problem with this. Decisions aren't simplistic as, should we do this or not do this? We might do something with the wrong motives or do the wrong thing to somebody. Or do the wrong thing by getting them to accept care. Oh, you should totally do this, talking them into something that they would, they're kind of like, eh, I don't exactly know about that. Or we might do the opposite. Then there's times that appear that we're actually doing the right thing. Let's say that this is a thing, you're a nurse, you're working on an intensive care unit and there's a person who is at the very end of your unit who is very, very sick and is at the very last stages of their life and you've spent a few days with this patient. And that patient, that person, that patient, that patient, that patient, has spent a few days with this patient. And that patient has, is not really happy with the life they're living. And that person codes, which means that their heart stops beating. And you are the only nurse on shift. And it's down there. Okay? The reason this category is not real helpful is that you can walk towards the room. Right? And if you want to save that person, what's going to happen with your movement going towards that room? You're going to go quick, right? But let's say that you're like, this person is sad. Like this, I have made the determination that their life is not worth living. Then what am I going to do? Yeah, walk slow, trip. Oh, I was trying to get there, but I just couldn't get there. And then, you know, did the chest compress, couldn't bring him back. Shoot, didn't get it. This kind of stuff is the stuff that nurses and doctors face all the time. Some writers say this. Commission and omission seem to be the ends of a spectrum rather than either or categories of action. There are clear acts of commission, such as treating pneumonia with antibiotics or killing a patient. There are clear acts of omission, such as allowing a person to die of infection by electing not to treat. In between are actions that are harder to classify as commissions or omissions. Not really a helpful category. Sounds good to begin with maybe, but doesn't really help. The last one we'll cover this morning is a prominent one, but as we'll see, also kind of unhelpful, which is the distinction between withdrawing and withholding. So if, let's do a little dictionary work. What does it mean to withhold something from somebody? To have something that you don't give. Good. What is withdrawing? Taking something away that they already have. Great. So in the idea of medicine, this is either not giving somebody a treatment or some kind of medication, and withdrawing is taking back the medication treatment that you started. The idea here is that while it might be permissible to withhold a treatment from a patient, you should never withdraw something from a patient. And this sounds pretty good. If... You should never withdraw. Now you have the question about whether you should start it or not, but once you start it, the idea is that if you withdraw it, you're responsible for the death. So this is the common thing with pulling the plug. You should have the option of whether or not to put the plug in the wall, but once you put that thing in the wall, then you can't pull it out. Interestingly, this is not only true of human beings. It is also true of the way that human beings view robots that appear to have consciousness. In a study at MIT, there was this robot that didn't even look very human. It kind of looked like a torso, but it was just all gray and kind of had a head on it. And this woman, who wrote this fantastic article called Robots Should Be Treated as Slaves, I think that's what it is, catchy title, really good article. She is a roboticist at MIT. And she had this robot in her lab and they were working with it. And these people would come in who had no idea about anything about robotics. And they would see this thing, and you could interact with this thing. This thing had very kind of primitive artificial intelligence. It was both learning, and you could kind of speak to it, it would speak back to you. And it didn't even look human, but people said, what's the backup for this thing? And this professor was like, what are you talking about? He's like, well, what if the power goes out? If the power goes out, you kill the robot. This woman's like, it's a robot. It's like a toaster. It's just, I don't know what you're talking about. They're like, no, you're responsible for this thing. You created this thing. And if you pull the plug, then you killed it. It's not only the way we view robots, we view humans in exactly the same kind of way. If you plug it in, don't pull it out. Now, this is not the time and place to deal with the 1549 problems that exist with viewing robots as humans. But, it makes it clear that we make this distinction between withdrawing and withholding all the time. The reality is if we withdraw treatment, we're not killing the person. The disease or the sickness kills the person. Why is it unhelpful to hold this distinction in our minds? If we have this idea that we can withhold something, but once we start something, we've got to go all the way, then what might that do to us as those who are either deciding care or helping somebody else decide care, before the care even, like, the care is just mentioned. It's like, hey, here's something we could do. Why would you reject it? Exactly. You say, okay, so you might, and that might be the right play. Now, nobody knows the future, and nobody wants anybody to be in a coma for 10 years, unrehabilitatable coma, right, a permanent vegetative state. Nobody wants to actually give their affirmation to do that to a human being. Nobody purposefully puts somebody in a permanent vegetative state. But, if you think that's even a possibility, which it is on some of these things, and you think, and we can never withdraw care, then you will, at times, not go through with something that you ought to go through with, because you're like, no, because we can't withdraw. Once we put one foot over the start line, we have to run this whole race until it ends. The reality is, no, there's times to withdraw, and withdrawing is fine under certain conditions, because withdrawing is not killing the person. Withdrawing is letting the thing that is killing them kill them. Do its work. Is that easy to accept? No. It's like semi-easy to accept here in some kind of philosophical, theoretical level, but once you're there with your hand on the metaphorical plug, or switch, it becomes a whole lot more difficult, because you're going to feel responsible. You are an embodied creature. Your physical actions have repercussions on your brain and your soul. We all know this. If you hit your thumb with a hammer, it does not just physically hurt, right, it sends your brain thinking all kinds of craziness, and if your brain is all kinds of messed up, oftentimes your body hurts. If you flip that switch, you are going to say, if I had not flipped the switch, he or she would have still been alive. Possibly. But since I flipped it, I'm the cause. But you're not the cause. You're the cause of removing the thing that is sustaining them. Because they're not sustaining themselves. Without that thing... Yep. That's very true that there is a... it's easier to accept with... withholding treatment than it is withdrawing. It's easier to say, it's easier to go and say, hey, listen, Brian, I think that you shouldn't do this, and here's why. As hard as that would be to say, especially in Brian's case, because I love Brian, it would be much harder to say, Brian, I think you should give up on this treatment. Right? But, there is not, morally, any distinction between those two things. One of them is right, and one of them is wrong. So, we've now created a fence. Right? A kind of heavy fence. Maybe a semi-depressing fence. We go, okay, we can't make these distinctions this way. How ought we to think about these things? I want to think about these things, but I have to think about these things, not only for my own sake, for the sake of my family, but for the sake of the world, for the sake of those around me. So, next week what we'll do is a bit more positive. We'll say, okay, what are some ways we ought to think about accepting or foregoing treatment at the end of our lives? Let's pray. We thank you for this time to think, and pray that as we learn how to think well about these complicated issues, that you give us real wisdom, not only to make determinations for ourselves, but help others make good decisions at the end of their lives, thinking hard about not only what we do, but why we do it. In Jesus' name we pray. Amen.