Living Wills and the Will to Live

How Christian faith can guide us through the new legal quandaries surrounding health care and dying.

As of late last year, every American entering a federally funded hospital, nursing home, or hospice had to face the unsettling question, “Do you have a living will?” A new law requires these institutions to tell incoming patients of their right to some form of “advance directive,” a document that specifies treatment preferences should one become incapacitated by a potentially fatal illness. What special questions do such documents raise in the light of Christian faith and practice? A theologian responds below. Accompanying articles offer a Christian physician’s counsel, followed by cautions from an anti-euthanasia advocate.

It is the ultimate statistic, wrote George Bernard Shaw—one out of one dies. We should hardly need to be reminded. Yet death catches us unawares. We don’t expect anyone to die, least of all me. It goes right back to Adam and Eve. What did the serpent say? “You will not surely die.” And they lapped it up. The illusion that they could sin and yet live forever proved irresistible. Only when someone we know dies do most of us wake up, briefly, to the truth.

The illusion has never been stronger than it is today. A century back our old people died at home, and so did some of our children. For the Victorians, the great unmentionable was sex, not death; with us it has been reversed. Part of the devastating significance of AIDS has been to remind us forcibly—all of us—of our mortality. Thou shah surely die.

Understanding this helps explain why we have been caught off guard by the mounting debate about death in the wider community—“living wills,” suicide machines, and Derek Humphry’s best-selling suicide manual, Final Exit. How should we make up our minds?

We need to start with death itself and then work backward. Indeed, as Christians we need to rekindle a theological and devotional interest in death itself—not to make us morbid, but to return us to the realism of Scripture in a society that has delusions of immortality. Only a solidly scriptural view will let us negotiate the sometimes difficult medical choices that confront us.

Is Death The Final Victor?

The most important thing the Bible says about death is also the oddest: Jesus abolished it. By breaking free from its grip and rising from the grave, he pioneered the way for all of us who believe. Of course, we still die; in that sense death seems yet to be not just the last enemy, but the final victor. But Jesus has broken the power of death by destroying its finality. It is just one stage on the path to resurrection. The dominion of death is over—it no longer rules our future, and it need not rule our present.

C. G. Jung, pioneer of psychoanalysis, once said that no one can live at peace if he knows that his house will one day collapse around his head. The knowledge that death will finally destroy us all is hard to live with. Yet, for us, death is the gate to an immortal life. Christ is risen, so we shall rise, and our broken mortal bodies shall be raised up like his glorious body.

We need to reflect on that because the world we live in has almost squeezed out our Christian hope and condemned us to the values and the fears of those who have no hope. Being “worldly” is not all luxury and self-gratification. It is hopelessness and death. We have to keep learning the hopes and fears of the world to come. That is what Christian living is all about, and if it doesn’t make a difference when we stand face-to-face with death and dying—when will it?

But there is another side to death. An old Christian image is that of the cold waters of the Jordan, to be crossed at last as we finally reach the Promised Land. In fact, the Bible tells us that the riverbed dried up for the Israelites (Josh. 3), but the image of crossing a river is still a potent image. We cannot quite shrug off the fact of death, for death, as the wages of sin, is still with us. That is why, in the shortest and most poignant verse in the Bible, “Jesus wept” at his friend’s grave (John 11:35). This little statement should be enough to dispel, once and for all, the naïve notion that Christian funerals should be “fun.” Resurrection hope shines into the night, but on this side of death the darkness lingers.

So if we feel a certain ambivalence in Christian attitudes to death we should hardly be surprised. While death is not the end—it is, in a sense, only the beginning (“school is over,” wrote C. S. Lewis, “the holidays have begun”), yet Jesus wept. The grave is also the fruit of sin, an obscene irruption into human experience, severing plans and relationships asunder. Death is the last enemy indeed. It is no more irrational than unfaithful for Christians to grieve, though our grief is freed from the bitterness of those who have no hope.

The Web Of Medical Issues

In the light of this perspective on life and death, what of medicine, and the complex web of clinical, ethical, and legal decisions surrounding it? Healthcare advances have enabled us to live longer and cut infant mortality to a rarity at the same time they have presented us with choices from which our grandparents were spared. High-tech hospital care has proved both bane and blessing. Do we want the best medical skills in the world when we secretly fear they may be used to draw out the dying process, holding us on a rack of suffering when we should be left alone to die and experience all God has in store for us after this life?

We feel we need protection from that kind of medicine. Concern over such issues may explain why the voters of Washington State almost became the first people in the world to have the legal right to be killed by their doctor (CT, Dec. 16, 1991, p. 50). But euthanasia can never be the answer for the Christian.

The “living will” (one form of advance directive) seems to offer an alternative, letting the patient decide beforehand how he or she wants to be treated when he or she is no longer in a position to say. The Patient Self-Determination Act (which went into effect December 1 last year) offers major congressional encouragement to the living-will movement by insisting that every time we are admitted to health-care facilities that receive federal funds we are to be asked whether we have one. The principal motive, of course, is saving money, as death is cheap and medical care toward the end of life can be costly. The theory is that living wills are more likely to say “No, thank you” than “Yes, please” to life-sustaining treatment. But there are ethical issues to be addressed. What do Christians have to say?

We find in Scripture four key principles about life and death that help guide us through the medical complexities:

1. Human dignity comes from God, since human life reflects the very life of God. We are created in the image of God, so our dignity and God’s are hinged together. “Whoever sheds the blood of man, by man shall his blood be shed: for God made man in his own image” (Gen. 9:6). God’s lordship over life and death leads us to say, with Job, “The Lord gave, and the Lord has taken away; blessed be the name of the Lord” (Job 1:21).

2. All human life has equal dignity. That is plain enough in Genesis 1:26–27: “And God said, Let us make man in our image, after our likeness … male and female he created them.” Women and men bear equal dignity, and so do people of all races and ages and conditions: wherever there is humankind there are human beings who bear the dignity of God. This has devastating implications for sexism, racism, ageism—and for subtle and subversive notions of “quality of life.” However incapacitated, mentally disabled, chronically sick, or dependent human beings may be, they bear that dignity and have an equal claim on us.

3. Thou shalt not kill. That commandment sums up many things, and certainly includes both homicide and suicide—the killing of others and of oneself. Euthanasia, of course, can be “voluntary,” in which case it is consensual homicide—partly suicide and yet wholly homicide at one and the same time. And killing can be by omission. We can stop feeding patients who are dependent on us, like the mentally retarded or sick, and they will die. When Arthur Hugh Clough, the English poet of the last century, wrote his famous lines, “Thou shalt not kill, but needst not strive / Officiously to keep alive,” he was poking fun at this particular attempt to get around the teaching of the commandment. We are indeed obliged to strive, officiously or not, to maintain the bodily functions of those in our care (whether the “our” is that of a family, a hospital, the health-care professions, or the wider community).

4. Love your neighbor. What if the sickness is unto death? What of the chronic sick, who face years of illness that cannot be cured? These situations are very common, and the appropriate medical and Christian response has been one of “palliative care”—treating symptoms and making the patient comfortable. Drug therapies and other aspects of terminal and chronic care have made major advances in recent years, and the hospice movement—which had origins as a Christian response to the needs of the dying—blazed a trail in new standards of expertise and commitment. We have no wish to draw out the dying process once it is advanced and irreversible. It has always been good medicine to let people die when their time has come.

The Crisis In Medical Values

The real problem is that life-saving technologies have come at the very worst time. They are developing at a time when there is little or no agreement on what constitutes the life the technology is supposed to save. The Judeo-Christian consensus on matters of life and death is breaking down, and our culture does not have another to put in its place. Instead, the emphasis is on “patient autonomy”—letting the patient choose. Discussions about bioethics now take place in a society where values are no longer shared and each patient must make his or her own ethical choices. Patient autonomy has great appeal at a time when the alternative seems to be letting someone else make our decisions for us. Yet its popularity underlines the significance of the breakup of the consensus. Soon the right of each of us to hold our own values will be the only value we all share. That, of course, is the death of society, for a society is a community of shared values and vision.

The devastating effects of this new “society” are being felt more in medicine, perhaps, than anywhere else. Until recently, it was medicine that symbolized much of what was best about our common values. A generation ago we still largely shared the medical values associated with the name of Hippocrates, the greatest physician of the ancient world, whose opposition to abortion and euthanasia, and whose concern always to put the patient first, led the early Christians to adopt Hippocratic medicine as their own. That tradition of humane, sanctity-of-life medicine has come to us down the centuries, and only in our own generation has it begun to fall apart.

So Christians are in a difficult place. What we really want to do is to set the clock back and return to a society that once held our values in common. That may seem a foolish wish, but if we remember the consensus society once held, we may find help in facing the practical choices with which we are confronted today.

Is the living will a further step down the road to euthanasia? That is certainly how euthanasia advocates have seen it. Is it simply speeding the fragmentation of our medical values? Or do we see it as a means of carving out an island of Judeo-Christian values and witnessing to the old ethical norms that are fast being lost by our community? The anguish of our decision is that it is all three of these. If we finally decide to sign a directive, we must make very sure it partakes of Hippocratic and Christian medical standards. We have no wish to let in euthanasia by the back door, no wish to take the advice of Job’s wife, the patron saint of euthanasia, to “curse God and die” (Job 2:9) when disease and incapacity take their toll. The Lord gave, and it is for the Lord to take away.

We also need to learn anew the art of dying well—in this culture terrified of its mortality, and terrified even more of the dying process. We need to give the lie to the curious belief that only in a combination of suicide and homicide can we die “with dignity.” We need no hemlock; we regard life too highly. And we walk death’s valley without fear. We look to the resurrection and the life of the world to come. Such a perspective will guide us and make a world of difference when we face the hard choices.

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