6-5-2016 Bioethics Part 60

The speaker begins by praying for understanding and the ability to apply what they have learned. They discuss the decision to accept or forego medical treatment and highlight unhelpful ways of thinking about the decision. They introduce the distinctions between ordinary versus extraordinary treatment, commission versus omission, and withdrawing versus withholding treatment. They argue that these distinctions are not sufficient for making the decision. The speaker then introduces the distinction between active killing and letting die. They emphasize that everyone will eventually die and that letting people die should be seen as an act of care. They discuss the uncertainty of predicting when someone will die and the possibility of choosing to die sooner than would otherwise be possible. The speaker emphasizes the importance of intending the right thing and intending it for the right reason when making decisions about treatment. They argue that aiming at death or choosing to forego treatm Okay, well let's pray that we thank you for today and for each other and pray that as we once again think about the end of our lives that we would think well and that we would use what we learned today not only to better understand and help other people but that it too would shape our living each and every day of our lives in Jesus name we pray amen. Last week we covered under the umbrella of accepting or foregoing treatment a number of unhelpful ways of thinking about whether to make that decision. Primarily thinking about this decision in the context of essentially when to just say no when to stop. We saw that it is not as much as we ought to be opposed to medical killing it is not necessary that you live as long as possible. That sense that is deeply ingrained in American medical practice and in the hearts and minds of many American people will and has led us to do many terrible and awful things to those who are suffering just to keep them alive. But as we think about whether we should accept treatment or just say no we saw that there is a number of ways to make that determination that aren't really helpful. The first way that we talked about was ordinary versus extraordinary. So ordinary treatment is what you're forced to receive that we should at least expect or demand you to receive and we should expect you to actually then say yes to those things like you only have an option if there are those things this is just in this category distinction. Extraordinary things would be what? Out of the norm. Yeah, great. So out of the norm. So it could be it's expensive it could be that it's not super readily available it could be that it is not ordinarily practiced maybe it's not the safest procedure. The problem is though with that kind of category distinction while it might sound good is that something could be very cheap very accessible but not very safe but probably going to work we could say oh sorry not going to do that or somebody like an HMO could say that they weren't going to do that. There's also the second category was commission versus omission what is commission? Doing something so acting towards somebody what is omission? Yeah, okay so being passive withholding something and we could say okay well this is the way we ought to think about whether to accept or forgo treatment we should think about doing something against somebody or not doing something against somebody but the reality is that rarely is it ever that black and white. The third one we looked at in closing was withdrawing versus withholding which is essentially this idea that like we can withhold a treatment from somebody that's fine but we can never withdraw a treatment from someone. So we use the example of plugging in an artificial respirator so you can say as a patient or as like the person who is speaking for the patient under medical power of attorney no do not plug that machine in he she would not desire it or I do not desire it that's fine but once that machine is plugged in and the idea is that if you pull that plug you kill them you're the one killing them which is not true. It is the disease or the sickness or the incredible trauma they have done to their body that will kill them not the artificial respirator. So if we saw that those are kind of things we can think about but not exactly the ways to determine this how ought we to at least begin to think about accepting or foregoing treatment and the helpful distinction that I want to lay before us today is the distinction between active killing and letting die. Active killing and letting die. Each and every one of you in case you were not knowing this this morning each and every one of you is going to die some of you are going to die rather soon that's not a prophecy by the way it's just a blanket statement some of you are going to die later the soon does not mean like tomorrow it means in relation to everybody else right there will be a handful of people here who are dead sooner rather than later just the way it's going to be. So because each and every one of us is going to die the idea of letting people die should be viewed as an act of giving care to people it is as it were the last act of giving care letting somebody die. If dying is what everybody does let's just get a real firm grasp on that then letting people die is what everybody in here is going to have to do at some point. You will have to let everybody die whether you want to or not. So letting die should be both seen as a care receiver and caregivers as the last act of care it's what we do it's the last thing that we can do for somebody. The question when it comes to people dying is not if right what would be the question when that's right and also how. So as we've seen as much as we ought to be opposed to medical killing it doesn't obligate us to keep people alive as long as possible because you could say when doesn't matter we just keep them alive and alive and alive and alive and alive and then we lose that's not a really good way of looking at things because then we're always losing and it's some kind of battle instead we have to look at this as letting people die. In some cases it might be the best the most loving and indeed the most Christian thing to refuse treatment and to die sooner than would otherwise be possible. Now do we know especially when it comes to people at the end of their lives exactly when they're going to die no nobody in here knows when anybody's going to die when the doctor says you have two months to live does the doctor know that you have two months to live? No the doctor has a general idea you've got about two months to live people go oh yeah well I told that to my grandma and my grandma lived for four years that's fine the doctor isn't like oh shoot right it appears to the doctor at the time with the best abilities that he had to determine yes you have two months to live and you know what doctors are occasionally close to being right right they're not and they're not like tricking you right they're not like just messing with people they are just giving the best kind of judgment that they can sometimes they have more reason to believe something or less reason however we very well might choose to die sooner than would otherwise be possible because the reason I say that isn't because I know the date of everybody's death or you know the date of your own death but it very well could be that there is a medical treatment presented to you that could possibly sustain your life for a defined period of time roughly could be six weeks could be six years and you make the determination no I'm not going to go there now could very well be that that medical procedure or that medication would end your life the next day right that's always possible or something else would happen to you and you die the next day sooner than would otherwise be possible is just this idea that if I do this there's the possibility of longer life if I do not do this there's a very real possibility of shorter life choosing shorter life is not always wrong how though do we make this decision there's two things we're going to go over this morning that will help us make these decisions first one is intending the right thing and the second one is intending the right thing for the right reason so intending the right thing again to return to our kind of axiom for the section here we are always aiming at providing or receiving care okay so if I am a caregiver it is my job to give care to this person even if it is letting them die and if I am receiving care then I am to accept the care even if the care I receive is to forego treatment and die sooner than would otherwise be possible if we give or receive or withhold treatment in order that we die faster then we're aiming at the wrong thing right so if I'm aiming at dying I go you know thing presented to me I go no you know what I want to die then you're aiming at the wrong thing and you should ask more questions if you decide to forego something in order to die then there is no distinction between your decision and an act of medical killing okay so if you think that it's okay for people to just go you know what I'm done living I just want to die then you ought to believe that people should have the right to either kill themselves or have other people help them out along the way the outcome of a decision of two different people who make the same determination could be exactly the same but the way they got to that outcome could mean all the difference in the world let's take two people we've done this often here's person a person a is a person dying of kidney failure okay they are in incredible amounts of pain and have to receive dialysis on a regular basis to cleanse their body of the waste that their kidneys would otherwise remove this person over here is sick of it they're tired of it and they say you know what get this I am done receiving this treatment I just want to die and they go off the treatment okay this person B, person B is a young person dying of kidney failure has to receive dialysis at the same time in the same place is person A right it is super annoying and they're commiserating about the annoyingness of getting dialysis just just like if you really want to get you know really concerned about your kidneys or whatever just look up on YouTube like what dialysis is and what people have to go through to do it this person goes you know what I've been struggling with this for a long time this is extremely painful and it is it is only prolonging my life and my prognosis for multiple people is exactly the same thing I am going to do this till the day that I die and I would rather spend the time that I have not doing dialysis I would rather spend it with my family or with my church or whatever and if it if I if I go I go what is the outcome of both person A and person B? Death. It could be that both people die at exactly the same time on exactly the same day right your your approach to giving up dialysis doesn't mean that one person is going to live longer than the other you're probably both going to go out around the same time if you have the same exact condition the same exact gravity you're going to go around the same time but the reality is that while the outcome of both cases is death how the person makes the decision morally makes a lot of difference you and I are social creatures we've seen this all the way through bioethics and the way that you make these determinations has an effect on other people okay has a real big effect on the way that you see other people and receive things from other people so you have to take into account whether you like it or not how your actions are going to affect other people no matter how big or how small this is one way that you and I love our neighbors when you get ready to say I am giving up on medical treatment and I am going to then kind of take what comes you are saying something profound to everybody around you that thing could be very good or very bad because giving up on the treatment does not necessarily just end in good or bad it might be one might be the other but the reality is that you are going to have an effect on other people and to say which is easy to do at the end of life this is my life I'm the one suffering I'm just going to do whatever I want to do is exactly the way that it sounds coming out of my mouth straight-up selfish now you could say like but nobody else is dying that's cool but as a Christian in particular you do not have the right to only think about yourself it is no longer I who live but Christ who lives in me I am inherently part of the living temple being constructed which is the very dwelling place for God it is the body of Christ and therefore I am not allowed to just say this is what I want for me at any point in my life especially when it comes to something like foregoing treatment or receiving treatment because people will learn from you you can let's apply it to something very pertinent to this congregation okay this has nothing to do with dying but has equally to do with this idea of your decisions affecting other people your marriage needs to be a good marriage for a number of reasons number one you need to help me out right if your marriage is a good marriage you'll be helping me out okay why would you be helping me out lots answers to this question I'm let's say that I this comes as an answer for both member and pastor of this congregation okay why are you helping me out you take less of my time all right that's super like pragmatic and like cold but it's totally true all right what else okay I'll have more joy that's right as a pastor yeah all right good that was good though you started it something yeah look up that verse I will have more joy how as a member or as a pastor both exactly you better believe it as a member how would that come across because it might come across differently right generally or like can you just answer this question for yourself like if there's a good marriage in this church how would you have joy encourage with it as possible amen that's right hey somebody's getting it all right and there's a pastor it might be a little shifted why yeah maybe I'm teaching maybe somebody's paying attention to the words coming out of my mouth maybe now that's not inherently true right but I'm definitely gonna read it that way saying all the encouragement I can get so I'll be like man all right this is great thank God for that marriage okay it will also be helpful for me particularly the pastor because your marriage being decent will mean that other people have hope in their marriage so that it all be a kind of like you know concentric circle of goodness and hopefully while it is not perfect and will make every marriage great if your marriage is great it can only do good for the congregation and the world if your marriage is good and you know what the exact inverse of that is also true if you have a terrible marriage and you are not working on it right some people just have terrible marriages right like everybody marries the wrong person that's totally true right nobody marries the right person but the people who are working on it are at least a sign of hope but the people who don't care and have a terrible marriage and just bomb are a very real reason for people that believe in Jesus okay there's something that comes up premarital counseling okay your terrible marriage means that people have good reason to not believe in Jesus welcome to it now apply that to the end of your life every single thing that applies to marriage also applies to the way that you die everything so if you just go me me me my I'm gonna I'm done living I don't suffer anymore I'm out of here okay that will have an effect on every single person in here some ways very small some very large effect but the way that you live your life inevitably impacts every other person around you small ways big ways there's no way to determine exactly how it will end up but being social creatures you cannot help but affect the people around you and in making these kinds of decisions you must consider what it means to love your neighbor what is true and difficult is that we might end up making with a bad outcome if we aim at the right thing okay bad outcome if we aim at the right thing end of life palliative care is full of this so let's take an example of this you might receive a large dose of morphine to relieve pain that ends up killing you right that could totally happen happens a lot people receive increasing amounts of morphine to get rid of their pain and at some point it just stops their ability to do the very basic things that they are able to do your aim is what is important though the goal of what you are trying to get to is the key not the goal of where you actually end up I might sound like hyper relativism like nothing really matters right it's just like how you feel about something that's not true in every case in this case it is absolutely true this is something known as the principle of double effect and shortly defined it's something like this we may give or receive care that we know might be bad if our primary intention is to do something good okay so in your decision to give or forego or receive care you could say we're talking with the doctor and the doctor is like hey here's the thing we can do this procedure now this procedure is extremely dangerous and this procedure could end up in you dying there is like only a 10% chance of you living through this procedure is that procedure inherently wrong to pursue no absolutely not now if you go I got 10% chance of getting out of this thing you know what that means I got a 90% chance of dying that would be great let's do this thing hope I die doc I hope I never see you again hope that this ends miserably for you but it'll be great for me then it would be a wrong decision however if you go at 10% because all these other factors that we're going to talk about in a minute those other factors that help you determine it you could do something with a good intent that could have terrible consequences and the thing in and of itself isn't necessarily wrong to do so we need to intend the right thing second though we need to intend the right thing for the right reason this is where things get a little complicated because these distinctions are moral they are very hard to judge because we're essentially judging is somebody making the right decision for the right reason now that sounds super judgmental right like let's just throw that one on the table and as Americans who believe in like really strong autonomy and like individual rights then it kind of grinds against our sense of at least American this if not humanity that like other people would at least ask the question of whether we're making the right decisions for the right reasons but we have to ask these questions because seeking to love our neighbor means not letting them just do whatever the heck they want if you believe that loving your neighbor is letting them do whatever they want then you have to be completely accepting of everything every single human being does that's insane right nobody believes that people who believe that are crazy people right you cannot accept everything everybody does nor should you there has to be a limit on something but when people say oh but I'm making this decision it's perfectly appropriate to go yeah but why some think that this is this category is so hard to determine that it's useless I disagree strongly but it is difficult it demands something from us when it comes to gauging another person what does it demand from me when it comes like you're the one making the decision I know you what does it demand of me to make the determination of whether you are making this the right decision and you're making the right decision for the right reason knowing the person that's right what is it what does it take to know a person time what else engaging that's right both of those are key okay you spend a lot of time with people and never actually get to know them that's by the way most of your human relationships right let's be honest so it is very easy to spend time with people without ever getting to know them and you cannot get to know somebody you can't engage somebody if you don't spend time with them both of those things have to be present most of us are pretty good at judging people right out of the gate right like you give me three minutes in your presence and I pretty much think I have you pegged I'm almost always wrong but we are very quick to judge other people it's what we do as human beings we must get to know people this doesn't mean that our decisions will ever be easy but as we cut out one avenue in our brains of trying to help people think through these things if we cut out the avenue of medical killing then all of a sudden these decisions become at least manageable some guys writing about this say this in this murky world the distinction between active killing and letting die offers one bright line a line that keeps us from being killers ourselves fidelity to the life we care for requires that we not set ourselves up resolutely against it perversely trying to help it by erasing it altogether caregiving that truly cares will not annihilate the beneficiary so caregiving can never be you know what let's just take you out that's not actually caregiving and so as we talk to people we can say okay that's not caregiving caregiving is receiving care it's kind of implied the word so what does that look like and why are you doing what you're doing and it's here that we return to the virtues at the near the end of a very long study on bioethics this is where we can really help people as they aim at the right thing in receiving treatment or letting themselves die what is most important is the way that they're approaching these decisions so we're going to do a little role-playing okay we've spent so much time here that you guys ought to just crush this one out of the park okay so we're going to take two virtues in turn and you're going to help me think through how these play into this I think you would agree with me that it takes courage to forego or withdraw treatment knowing that death might be the outcome or receive some kind of treatment that has a high probability of going wrong so how does courage play first of all how do we determine whether somebody has courage what does this courage look like particularly in the context of being a Christian and how do we help somebody think through this okay so first of all we need to understand kind of the general broad context of what's going on great that's true for everything good place to begin now we understand what it is they're facing right now what yes right and so that's that is that is true on this objective level like this courage especially like who Christ is for us how do I determine if the other person is believing that at the moment yeah well it is it easy to get somebody to talk about whether or not they're making the right decision for the right reason whether they have courage is it easy to call somebody else it's like currently dying and say actually you have no courage right you should never do it that way by the way but like at the end of the day like say that would that ever be easy no like let me just be very clear that it is easy to let people die anyway they want because you're not doing that is also unloving okay right okay great yeah great so yeah so we have this idea that it courage would mean that we have more in a sense we have more fear of God than we do have fear of man how the heck would we have fear of man when it comes to either receiving or foregoing treatment at the end of our lives expectation who's that okay so whether they will respond rightly right expectations who's the day okay great yeah every single person who's not dying now let's let's think of some categories in particular and define those things but what would be a category of the everybody who would have expectations okay church great church neighbors family let's take those three what kind of expectations might they have okay oh so you're actually there from that see now you've never been the fear thing on the other side you're flipping it's fine because that actually exists too right you got fear like I don't know if this person who's who's suffering and dying is actually gonna listen to what I have to say that's true but in the person who's actually suffering and dying has the fear of these people the expectations they're putting on us and the expectation broadly and generally United States is what's the person going to do when faced with an option at the end of their lives they're gonna try and live as long as possible right the fear of man could come in in the sense of like oh if I say no I'm gonna have to explain this to everybody I might as well just go ahead and do it right I don't let everybody down which gets to a very important point when it comes to helping people decide to receive or for care at the end of their lives the burden of receiving and giving care is on the person dying and not on you right just embrace that one like eat drink of that one deeply okay if it dies die now there is a sense in which CS Lewis is right like if I lose a friend and all my other relationships are affected too but very often what happens is those who are not dying burden people who are dying to receive treatment because they don't want to deal with somebody else dying that's you being selfish and just trying to keep somebody else alive it's one of the most sick and disgusting things we do as human beings it's understandable because helping somebody receive care which could be foregoing care at the end of their lives is very hard you're letting them go you're essentially like saying yeah okay I get it however this is this is something that comes into play in the church context and something like this getting married way too few of us speak about the joys of not getting married and as a result everybody who's ever grown up in church assumes that what I have to do is get married right singleness is definitely not an option everybody's either gonna think I'm gay or something and I'm just I can't do that or think I'm just a weirdo I have to get married because having kids will complete me which is a total lie they won't love you guys so we we burden people with living up to our expectations it's also true in death and it is a miserable thing we make people do things or at least give the people the impression which means that it behooves us who are speaking to those who are dying and tell them what if the assumption is going to be if you will already have every single person is going to have to some degree some greater some less this fear of man thing then as we approach people in the end what do we have to say knowing that the kind of general broad consensus in the world is you have to receive treatment yeah now we're not telling people like you know you just give up and die like how would you do that you're doing those opening up the possible avenue of foregoing treatment at the end of their lives right for a better purpose trying to instill in them courage to make a wise and sober decision instead of just well everybody would want me to do X therefore I will do X yeah exactly it also comes to like especially we've seen this before doctors are the high priests of our civil religion they can fix us they can make us perfect they are the gods of our society so when the doctor comes in and goes you need to do this and a doctor should never do that but doctors often do it is one of the major problems in health care today then what we see is people go I don't want I'm fearing the doctor the doctor says I have to do this thing I can't tell the doctor no like the doctor went to school for a long time super smart wearing the white jacket I got to do what the doctor says and courage finding this courage in Christ will lead people to make better decisions will mean that people make the right decision every time no not at all if there is exactly an objectively right decision but fear is a motivator for all kinds of things but not a good one it is a terrible one so we help people work through whether they are making these kinds of decisions on the basis of courage rooted in Christ or not let's think about a second one constancy okay what is constancy being consistent yes stick with itness okay consistency consistency you and I find it extraordinarily easy to reject the gospel and the implications of it when we are faced with trying circumstances right when everything is golden it's easy to be a Christian right I love Jesus Jesus blessing me I you should believe in Jesus look at everything around me right then you get like just a little bit of a flu and you're like God why aren't you listening to me I'm so miserable right I don't know if I believe this anymore now imagine waking up with something that's like the flu times a thousand every single day of your life you know it's never going away okay there's a world everybody wants to live in and a world more more people will live in as a result of medical technology how does constancy play into this idea of accepting or foregoing treatment at the end of your life no for the person making this decision yeah which way which way would it not play in yeah right good all right so yeah so the first thing is you ought to trust in Christ because whether or not you have cancer Jesus is who Jesus is so the constancy aspect is like cancer doesn't change that all right and it's going to seem like it changes that which is why you have to help people see like well what is the gospel we might very well forego treatment because we know that our Redeemer lives and that we live with him therefore it's like you know what I'm done done I'm joyfully done I am going to joyfully live out the end of my life in relative comfort surrounded by people that love me instead of being stuck by tubes in a beeping room surrounded by nobody yes exactly yes absolutely again outcomes are not going to look any different than a person who is either denying the gospel or doesn't believe in the gospel at all and goes you know what I'm done with this garbage right forget this I hate all these tubes I hate medicine I'm done the outcome is going to be exactly the same there's no trusting in Christ there there's just so it's gonna look the same which means that the person dying must do what in order to prove their constancy there you go you cannot be a faithful witness to Christ at the end of your life by simply foregoing treatment atheists do it all the time so the Buddhists Sikhs Jews everybody else so do a lot of Christians and a lot of Christians do it for exactly the wrong reasons the most powerful opportunity you may have in your life to speak forth the good news of the gospel of Jesus Christ is as you are dying fighting through pain right everybody's like I want to be a witness for Jesus great get cancer it was a paper that don't waste your cancer all right somebody good line great line don't waste your cancer right you could easily do a great job of being a witness for Jesus not by you know selling everything you have moved in the middle of Africa that would work too it could also just mean being a super faithful human being at your job and you know being a faithful member of church to the day you die that's also totally effective a great way would be yeah I'm done and here's why I'm done it could be that you forego treatment for the sake of your neighbor right only limited amount of beds and you go you know what I'm I know where I'm going okay there's these other people who might not believe the same thing I do or in more need or more treatable or whatever I'm done I'm done it could be this kind of thing we're like you know what I would rather be with my family than this so in my constant I'm gonna decide to live shorter than what otherwise be possible it could be a financial thing remember you will spend statistically half of your health care dollars in the last six months of your life as an American you could say you know what there's a perfectly appropriate Christian thing taking that money is in my kind of consumption of the world immoral it's it's not going to prolong my life for a significant period of time it's gonna give me another couple weeks and it's gonna cost $100,000 I don't even have to pay that like health care is gonna pay that which means everybody else has to pay for it you know what I'm not gonna do that I'm not gonna do that it doesn't mean that every Christian gives upon life is that what that means not at all it means that you must consider at least the possibility of maybe this is just my time right the reality is as we've kind of winding down of this long study of bioethics we're going to talk in the coming weeks about what we should do with bodies once they're dead and then we're gonna go into the Heidelberg Catechism but a little different than bioethics what we have seen is that there are way lots of gray areas there's not a lot of black and whites when it comes to this stuff what matters is that we seek to avoid being judgmental and just say I wouldn't have done that I wouldn't have done that because here's the thing you don't have to do that when you die the question though isn't whether you would have done that or not it's why did that person do that seeking to help and love the other person always the decisions we make have tons of internal and external factors so is a hundred dollar experimental treatment that could extend your life moral or immoral really depends on the circumstances if your child is going to be born to your wife and you might possibly see that child being born as a result of living for six weeks longer maybe it's the best decision you've ever made in your life and maybe if you're a old person who really has nothing waiting for them six weeks from now and it's just like maybe this could happen for six weeks it's going to be really painful and miserable and cost a whole bunch of money it could be that you go you know what that I'm just not going to do that it could be internal things it could be all kinds of situations that come up that make one make a decision go one way and one decision go the other way and it doesn't just come down to some very simple facts of whether things are right or wrong it really comes down to a whole list of things and in order to help people we must know them we must aim for the right thing for the right reason and if we do that and if we think about that today then we will live much better lives because as we've seen throughout this whole thing you cannot die well if you do not prepare for it why the heck did we spend a year and a half studying bioethics because each and every one of you is going to die that's why and as a result of that we all have to think hard about what it means to die and what it means to live well as we're alive because the time for discipleship is not when you call me trying to determine whether to pull the plug or not I will be of some help but I will not be of much help if you do not work on the pursuit of the virtues today so I would encourage you strongly to get to know people to get to know the God that you worship in order that you might be conformed in the image of Christ and become literally the best human you could possibly be in order to be of the best service to those around you and the best service to yourself as you live always towards death let's pray now we thank you for the reality of death it is on the one hand an incredible curse that we wish did not exist and at the other hand that really puts everything into perspective we pray that as we consider the last days of our life that we would live today well seek to do so pray that in living well our neighbors would be comforted by the truths that are both expressed in our lives and expressed by our lips we pray that you would make us into virtuous people in order that we would faithfully serve you every day of our lives in Jesus name we pray amen