Ethics at the end of life: The ultimate ethical issue is whether we wait for death

This is the third in a four-part series on ethics at the end of life.

The ultimate ethical issue at the end of life is whether we wait for death or instead hasten it. A massive and sometimes confusing vocabulary in ethics, law and health care has developed around this distinction. Let me see if I can simplify it.

Modern living conditions in advanced societies have extended the average human lifespan considerably, as I have noted. Diseases and conditions that once would have killed people have proved beatable. People are living far longer. But eventually minds and bodies wear out and death comes to everyone.

 

In my experience, the condition/diagnosis/treatment paradigm rules to the end in modern health care. Doctors look for what is “wrong” with the person/patient, come up with a diagnosis and offer treatment options. What modern people gradually have discovered is that after a while these treatments may no longer be worth the trouble. I would go further and say that after a while condition/diagnosis/treatment no longer always feels like the right paradigm.

Here is a person who is very old and their body is wearing out. Their condition is bodily breakdown or system shutdown due to extreme old age. There is no treatment for extreme old age. In such cases, it is sometimes best to discontinue various largely futile treatments and shift to a posture of helping the person prepare to die. The patient might die a bit sooner because, say, their cancer is no longer being treated with chemotherapy. But they were going to die soon anyway, and the treatment is causing more suffering than it is preventing.

This decision to discontinue treatment when more could be attempted used to be called “passive euthanasia.” I am now convinced that this is most certainly not a helpful term to use. Perhaps the old-fashioned phrase “letting nature take its course” remains the simplest and most accurate description.

“Perhaps the old-fashioned phrase ‘letting nature take its course’ remains the simplest and most accurate description.”

The decision no longer to attempt to intervene with high-end medicine and technology often is the best one and is in most cases not morally objectionable at all. It recognizes that death comes to us all. Stopping the fight against this or that diagnosed condition often is a step in the direction of dignity, humanity and an easing of suffering.

So let’s say we let nature take its course and the person begins to move toward death. In most circumstances, this process takes a while. Even an ill or extremely aged old body does not give up immediately. There is a dying process. It can take months, weeks or days. While details and timing vary, these last weeks or days are always difficult and at times awful, both for the dying person and for the family members accompanying them.

The ancient Jewish and Christian traditions have forbidden any hastening of this process because of the belief that God does not permit us to be the ones to end a human life. I will say more about this later, but for now I want to note the remarkable restraint this tradition creates. A person we love is dying in our presence. Their mind and body are shutting down. They lose interest in eating. Eventually they lose interest in drinking. Their body begins to change markedly and disturbingly. They can experience times of great distress and agitation. Sometimes mental or physical pain can become acute. For family, there are moments of great sadness, fear and maybe even horror. The last week or two can seem like it takes months.

Although everyone is suffering, although there is little or no quality of life remaining for the dying person, although they become completely unable to defend themselves or even express an opinion, what the rest of us decide to do is … basically, nothing. We keep vigil. We wait. We pray. We rub their backs. We sing to them. We stay up nights. We wait some more. With a pill or a shot or a hand over the mouth and nose they could be gone. But we do not do that. We wait still further. Finally, when they die, on their own, and only then, it is over.

“Active euthanasia” is one term that has been given for refusing to wait — for actively hastening death at the end of life. When active euthanasia is what the patient desires, it is sometimes called “voluntary active euthanasia” or “assisted suicide.” “Physician-assisted suicide” is the term for when a doctor helps someone hasten death, if death is sought and the state permits it. If what the person dies of is whatever we did to intervene and hasten death, we are in the zone of assisted suicide.

“Our human task, we have believed, is to bear the dying through that last dark night, to accompany them until they take their last breath without us doing anything to hasten it.”

Now that some of our societies have begun to abandon it, the remarkable nature of our former (and for many of us, our current) moral restraint becomes clearer. We have believed that it is not right for any human being to intervene to bring death to a dying person. Our human task, we have believed, is to bear the dying through that last dark night, to accompany them until they take their last breath without us doing anything to hasten it.

It is this restraint that is now under question or has been abandoned in law and/or ethics, in certain localities.

Where I write, in the state of Georgia, in the United States, citizens have no decision to make on the matter, because actively hastening the death of a dying person is simply treated as murder. But in other places, including the Netherlands, and several U.S. states, this legal norm has been abandoned.

Whether that should happen is the ultimate end-of-life ethical issue. I believe the embrace of active euthanasia is a great mistake. But it takes a bit more Christian ethics to show you why I believe this. That will be the focus of my last post in this series.

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