Assisted Suicide and the Ailments of Culture

Assisted suicide, or what is called “medical assistance in dying (MAID)” in Canada, is no new topic in our cultural. During my childhood, the name “Jack Kevorkian” became a byword and a punchline due to his advocacy for medical professionals helping their patients die instead of helping them live.

To those immersed in the flood of modernity with its emphasis on the radical autonomy of the individual, it is only logical that someone should be permitted or even encouraged to end their life in a clinical, sanitary manner. Why create a mess or a scene of horror for a loved one to find when you can end your existence with a slow wave of drowsiness wafting over you from the silent dripping of a potent fluid in a shapeless plastic bag?

Such an end is no more than what US Supreme Court Justice Kennedy argued for in the infamous Planned Parenthood v. Casey decision in 1992:

“At the heart of liberty is the right to define one's own concept of existence, of meaning, of the universe, and of the mystery of human life.”

That philosophy was, until the recent Supreme Court decision, sufficient to permit the killing of a child in the womb. It is a reflection of an entire cultural ethos that echoes that famous hymn of hell: “I Did it My Way.”

A recent ad from Canadian retailer La Maison Simons, or Simons, presents assisted suicide as a heroic, beautiful, and self-fulfilling way to die. Were the subject not so macabre, it would be a lovely video to watch.

(Note that the ad, originally published on October 24, 2022, has been pulled by the retailer due to negative reaction.)

For the Christian, of course, life is sacred. Whether in the womb or in the last moments of natural life, there is goodness and beauty in life. David taught us this is Psalm 139:16 while speaking to God:

“Your eyes saw my unformed substance;
in your book were written, every one of them,
the days that were formed for me,
when as yet there was none of them.”

 So, for the believer in Christ, of course intentionally ending one’s life is sin. For those of us who recognize that God’s laws are universal, there is no question, then, that assisted suicide is a sign of a corrupt society.  

But how dare we argue against the non-Christian’s right to day at the hour of his choosing? Is this not an example of “forcing our religion” on others? Or, what if this is really a big problem that will create social injustices and it is simply because of our knowledge of the goodness of God that we are able to see its horror and where it will inevitably lead? 

It is not too hard to see right now that the assisted suicide train is running away on the tracks. In Canada, since 2016, there have been over 31,664 reported deaths through MAIDs with 10,000 of them in 2021. This amounts to approximately 3% of all deaths. 

The current debate in Canada is whether mental illnesses, like depression, should be considered a justifiable reason to request the state to terminate the requestor.  

In the discussion offered in the report to the Canadian Parliament, the authors seem to recognize how dangerous making this option available to  those suffering from mentally ill. However, they also seem to shrug, noting that the original language of the statute allows assisted suicide for “that illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable.”  

This is “the right to define one's own concept of existence, of meaning, of the universe, and of the mystery of human life.” It is the right to die. If you don’t like the conditions under which your pain can be alleviated, then you have the right for the state to kill you. 

It does not take much to see how this right to die can quickly become the easy way out. How it can become a convenient way to avoid the hassles of a system built to make more expensive treatments hard to get. It can be an option so that “inconvenient” people who rely on care and accommodation from others can be “conveniently” encouraged to ease the burdens of others. It takes little imagination how the “beauty,” as the Simons ad calls it, could be a way to end a period of sorrow or struggle that might have made the person or their neighbor a little better as a person. That convenience may remove a whole lot of beauty from the world. 

No man is an island,
Entire of itself.
Each is a piece of the continent,
A part of the main.
If a clod be washed away by the sea,
Europe is the less.
As well as if a promontory were.
As well as if a manor of thine own
Or of thine friend's were.
Each man's death diminishes me,
For I am involved in mankind.
Therefore, send not to know
For whom the bell tolls,
It tolls for thee.
-          John Donne

On Our Moral Duty to Wear Masks

During recent weeks, world events have driven people to ask important questions about religious liberty, the role of the state, the nature of the common good, and the balance between individual freedoms and duties. As we’ve all sat in our homes with minimal chance to venture out, there have been gigabytes of data invested in the writing and reading of thoughts about the present, the future, epidemiology, and our longing for the delivery of our most recent online purchases.

One of the more recent questions that has arisen as many states and localities look forward to lifting their restrictions is: Should we wear masks in enclosed public spaces?

Unfortunately, for some, this has been turned into a political question related to a sense of submission and control, but at its heart, it is a question of neighbor love and concern for life. It is that angle—the concern for the preservation of life—that I will examine, ignoring the tangled web of frustration, argumentation, and misrepresentation.

Simply put, at the present time we have a moral duty to properly wear masks in enclosed public spaces.

Efficacy of Masks

Masks are worn because they help to slow the spread of viruses due to coughing, sneezing, speaking, and breathing from the nose and mouth. Essentially, even homemade masks help filter out the virus particulates that may be carried by our breath.

According to the CDC’s website,

It is critical to emphasize that maintaining 6-feet social distancing remains important to slowing the spread of the virus.  CDC is additionally advising the use of simple cloth face coverings to slow the spread of the virus and help people who may have the virus and do not know it from transmitting it to others.  Cloth face coverings fashioned from household items or made at home from common materials at low cost can be used as an additional, voluntary public health measure.

There was confusion early on in the pandemic, particularly as people tried to acquire necessary medical supplies and sought to use masks to protect themselves, which led to contrary guidance.

Confusion has been increased because the World Health Organization, which has to attempt to cross cultural barriers and a wide range of socio-economic conditions, is ambivalent on wearing masks to limit the spread of COVID-19. Most of their cautions have to do with the misuse of masks (e.g., repeatedly touching them to adjust them), wearing soiled masks that cannot be cleaned, or that wearing a mask would give a false sense of security leading to people not observing other significant precautions. Given that the WHO recommendations have to somehow support possible solutions in majority world countries as well as highly industrialized countries, it is not surprising there are a range of competing concerns that may be largely contextually driven.

It also does not help that there are intentional efforts to spread misinformation, to divide the nation, and to make simple, empirical decisions seem to be politically motivated. There are so many people writing about this issue that it is entirely possible to continue to search until we find an opinion we like and then point to that as decisive. Our best bet, though it will certainly be imperfect, is to go with the officials appointed by our government to do this research on our behalf and make recommendations. We should, unless it causes us to sin, obey authorities placed over us and use the best wisdom we can about less clear decisions.

Through all of this, we should remember that cloth masks, or simple surgical masks, are not particularly effective at preventing getting the infection. In fact, if you wear mask incorrectly (e.g., are constantly adjusting it, or think it functions as a shield for germs and don’t take normal precautions), wearing a mask may increase your likelihood of picking up germs.

Masks in public, as proposed and sometimes mandated during the current pandemic, are not primarily about protecting yourself. They are intended to prevent being a source of the infection. COVID-19 is unlike other common respiratory diseases in that it has, in some cases, a relatively lengthy asymptomatic period in which a person can also be contagious. There is a long period of time where we may be infected and contagious and have no idea, which makes COVID-19 different than many other respiratory diseases.

The moral duty in the case, is not simply to wear a mask, but to do so responsibly while maintaining other appropriate hygienic precautions, like frequent handwashing and maintaining personal space. We do this for the good of others, not (primarily) to prevent getting it ourselves.

Obedience to Authority

If a legitimate authority mandates that we wear masks, we should wear them properly if we are able. Rom 13:1-7 is fairly clear that we ought to submit to government authorities (or store owners, when on their property, or church leaders, when in their sphere of influence). If you are in a locality that requires masks, then you really don’t need to read the rest of this long article, because it is your moral duty to wear a mask properly, as long as you are able, in those situations mandated by the legitimate authority.

There are reams of explanation by Christians from many ages of Church History explaining that we need not obey authorities if it requires us to violate our conscience. However, apart from really odd reasoning (wearing protective gear obscures the image of God? If so, what do clothes do and what should we do with that?), belief that personal comfort is an absolute good, or some sort of belief that somehow not wearing a mask is subverting a conspiracy for social control, I have not seen much that argues that protecting the lives of others violates conscience.

An obvious caveat to this is that some people do feel an inordinate sense of anxiety due to some significant trauma if they wear a mask. That isn’t most people. But our duty is to ensure we obey authority and not to enforce the rules on others.

Risks of Infection

The likelihood of getting any virus is dependent on the concentration and duration of our exposure to those particles and the fighting ability of our immune system. Assuming equally healthy people, the person who is exposed to the greater number of virus particles for the longest time is more likely to get sick than someone with a lower exposure.

This is why many of the recommendations center on eliminating virus particles (e.g., by washing hands and sanitizing surfaces) and diluting the concentration (e.g., 6 feet distance, occupancy limits, etc.). There is also a time factor in the equation, so that reducing the time we spend in enclosed spaces reduces our risk of getting or spreading the disease, barring excess exertion that makes us breathe especially hard.

These are all probabilistic factors that we do not yet fully understand the exact values of, but reducing exposure is a critical means of lowering the chance the disease is transmitted.

No sane person wants to get the disease and we should take reasonable precautions to avoid it.

However, we also have a duty as Christians to minimize the potential that we spread the disease. Wearing a mask is primarily about preventing the spread of COVID-19.

This is particularly important since current estimates indicate that about half of the people who have the disease remain asymptomatic, there is a lag between becoming contagious and feeling symptoms even in bad cases, and asymptomatic people are capable of spreading the disease. In other words, we can feel perfectly fine and be spreading COVID-19.

Risk of the Disease

It is not clear at this point exactly how deadly COVID-19 is. Everyone admits that the death rates have been skewed upward because of the limited availability of the tests (especially early on when only those very ill could get the tests) and the number of asymptomatic people who are never tested.

However, COVID-19 tends to affect vulnerable populations more significantly. The elderly and those with underlying medical conditions often fare poorly. These are the sorts of people that our society tends to value less, but who Christians should be particularly ready to protect.

Even relatively healthy and youthful individuals who get the disease have described it as being severe. Experiences vary, often depending on the degree of exposure and the immune system’s response. In the most severe cases, people can require ventilators to supplement the body’s natural respiratory function.

It was concern over the availability of ventilators that initially led to the lockdowns in many states and cities.

Some areas, especially those that are populated most densely, have seen significant spread of COVID-19. Other areas, especially more rural parts of the country, have seen few cases.

This has fueled frustration in some less affected areas, which have faced strict restrictions with little visible impact. Those frustrations are increasing as low-density areas are being treated like high-density areas in a way that seems unfair and is damaging to the economy. There is some validity in the frustration; many of the lockdown measures were imposed broadly when narrower targeting would have been sufficient. (I am very thankful not to be one of the people trying to make these decisions right now.)

Presently, the restrictions on travel and commerce are helping to stop the transmission of the disease. However, the increasing frustration and significant economic harm being caused by the restrictions are pushing decision makers to lift those restrictions.

This is exactly the point of time when the tendency will be to relax the protective measures like wearing masks and maintaining personal distance. This is also exactly the point in time when those measures will be most important.

In the current condition, having stayed in contact with our families or very small clusters of friends, we have essentially proved that we have clusters of people who are no longer infected with COVID-19. All to the good.

However, when we begin to more freely associate and travel increases, we will be back to square one, unless we continue some of the basic precautions like maintaining physical distance from one another, washing hands frequently, and wearing masks to protect others.

There is no guarantee that we can prevent from getting the disease. We should protect our health reasonably, but as Christians we should be particularly concerned about protecting the health and lives of others. Our continued adherence to the recommendations of the CDC and other recommendations and regulations of our state and local authorities is part of our moral duty to protect others.

Especially those of us who come in contact with a broader public should be much more careful in preventing our spreading the disease unknowingly and inadvertently. This is exactly the reason properly wearing a mask in enclosed, public spaces is a moral duty right now.

Duty to be Cautious with Life

Most Christians are familiar with the 6th commandment, which prohibits murder. (Ex 20:13)

Contrary to much of the recent online discourse, accidentally spreading COVID-19 to someone who later dies is not murder. Neither is desiring to responsibly engage in economic activity and expression of disdain for healthcare workers or for the vulnerable populations around us.

But Christians have a duty to protect life beyond avoiding maliciously killing others. Christians also have a duty to be careful of life. Humans, even the ones we don’t like, are all made in God’s image and are precious to him.

As John Frame writes in his Medical Ethics,

The general principle of respect for human life also forbids any kind of physical harm (Exod. 22:12–36). God even forbids his people to put others in danger of such harm. (I believe that this is part of what God had in mind by legislating “cities of refuge” in the Old Testament [Num. 35:22-28; Deut. 19:4ff.].) Accidental killing is a crime, because we ought to be supremely careful with human life. . . . The moral obligation to be supremely careful with human life and not to take it accidentally is the fundamental principle of medical ethics: primum non nocere––“first, do no harm.”

He later refers to this as the “doctrine of carefulness,” which I think is an apt description of an obligation to avoid even the careless harm to others.

The doctrine of carefulness is the reason why we follow OSHA regulations at the worksite. It is the reason why we drive at a reasonable speed when there are kids playing soccer on the side of the road, even if we have to go slower than the posted speed limit.

The doctrine of carefulness is the primary driver behind wearing masks properly under the current conditions in enclosed, public spaces.

When we wear a mask, we are protecting the lives and health of others. The worker in the store has to stay inside the enclosed, recirculating building. The other members of our church are breathing in the air we have exhaled. Based on the CDC explanation, mask wearing minimizes their risk, even if it does not significantly protect the mask-wearer.

My Risk or Their Risk

The person who is receiving the risk is a critical element of this argument. In other words, am I putting myself at risk or another person?

If I choose to go skydiving or rock climbing I am taking risk upon myself that is unnecessary. Within certain parameters (i.e., we have an obligation not to be foolhardy to the point of suicidal risk) that is permissible. I can take risk upon myself.

Thus, for me to care for an infected individual is morally permissible, even if I don’t have all of the preferred protective gear. I should be careful, but I assume that risk.

I do not have the right to force that risk on other people, however, according to the doctrine of carefulness.

If I choose not to wear a mask, at this point in the pandemic, I may have been infected and I may therefore be pushing risk on other people that is unnecessary. That is unjust and immoral.

Obviously, it may be that I have been isolated for several weeks and finally returning to the grocery store. It may be that in that situation I have next to no potential to have the infection to spread to others. In that case, if there is no authoritative requirement (the store does not require it and governmental orders have been dropped) to wear a mask, then I am not bound to.

Most of us, however, will be out and about on a regular basis in the coming weeks as the restrictions are lifted. COVID-19 will inevitably spread more rapidly for a period of time after normal social and economic activities are restored. As we go back to stores and back to work, even on an intermittent basis, we will no longer be sure that we are “clean and free” of COVID-19. At that point, even if we believe we do not have the disease because we feel fine, we should choose to wear a mask properly in enclosed, public spaces out of love for our neighbor, to protect his or her life. We have no right to put our neighbor at risk any more than necessary.

There is, I think, in many circles a false sense of security and minimization of the real risk of COVID-19 because the drastic actions taken to reduce the spread have worked. Many people, therefore, do not know someone directly who has suffered from it and have not seen how dreadful it is. By the account of those who are seeing the work of the disease, it is significant and potentially deadly.

Particular Duties of Christians

Christians should likely be among the most cautious of people regarding this infection. Apart from sports, churches are often among of the largest gatherings of people in our communities. We come together a few times a week after we have been separated and gone out into the world, to various businesses and places of work.

Churches, therefore, are likely to be among the main ways that the disease will be spread. Not only do we gather and scatter, but we also often sing, which seems to be a particularly effective way of spreading the disease. Shouting and singing both encourage deeper breathing and, because of the extra force to make the sounds, tend to aerosolize the particulates more, which increases the likelihood that they spread.

Therefore, once we return to gathered worship (may the day come soon), especially inside, we are among the most likely to spread the disease and become infected. As a result, we have a greater chance of imparting risk to those we come in contact with. We should choose, therefore, to bear the mild inconvenience of wearing a mask to protect the lives of our neighbors.

Let us be known as the people who value life even over comfort and personal freedom.

Reasonable steps may include, and I think should include, choosing to wear a mask properly in enclosed, public spaces (beyond church) even after the CDC recommendation has been lifted or the local ordinances are dropped.

Masks and Christian Liberty

Some may argue that the stronger brother (mask wearer) should bear with the weaker brother (non-mask wearer) in this regard, when it comes to social interactions. In other words, I should be able to have the liberty to choose not to wear a mask if I don’t want to. That argument has the actual pattern reversed.

First, we have a duty to obey the authorities of those placed over us unless it causes us to sin. If there is a mandate to wear a mask, then we should wear one if able. Wearing a mask is not sin, even if we chafe at the restriction. If the leadership of a local congregation chooses to require a mask, then we should voluntarily do so.

However, if others in the congregation ask us to wear a mask, we ought to agree to it, even if we don’t like it. We should yield to them as the weaker brother, in this case.

As Paul describes eating meat sacrificed to idols in 1 Cor 8, it is our obligation to yield our rights to others. In this case, we ought to yield our perceived right not to wear a mask to those who feel that a mask is necessary for safety. Aside from the risk we are imparting on the other individual, our refusal to wear a mask is likely to force others to violate their conscience by not attending church. As Paul writes, “But take care that this right of yours does not somehow become a stumbling block to the weak.” (v. 9)

The meat eater must bear with the abstainer, not the other way around. In this case, the bolder action is to avoid the mask, therefore it is the mask abstainer that should yield.

On the other hand, if the congregation agrees not to wear a mask, then they should not look down on those that choose to avoid gathered worship until they feel comfortable. We should not attempt to force people to violate their conscience, even through social pressure, which is Paul’s point.

We have no right to expect others to choose the same level of risk that we accept for ourselves or others. We have no right to expect someone to violate their conscience by risking the spread of the disease. Those that choose to accept the risk should do so voluntarily and be prepared to bear whatever consequence results, but it should be mutually accepted.

Masks and Absolute Morals

One obvious question that arises from this discussion is whether the duty to wear a mask is absolute. How is it that we now have a duty to wear masks, but in January people would have thought us strange for wearing one? Has God’s truth changed? (After all, Scripture says nothing about COVID-19, etc.)

The answer is that absolute truth applied to a changing circumstance leads to a different action.

Sex is not sinful in and of itself. However, consenting sex outside of marriage is sinful. The circumstances are part of the moral calculus.

We have a duty to protect life. When our child is bleeding out in our back seat, that may lead us to violate the speed limit. When there are children playing soccer near the road, that may lead us to go well under the posted speed limit. The duty is the same, but how we live it out changes.

At the present time, the risk—especially the unknown risk—of COVID-19 is such that properly wearing a mask in enclosed, public spaces is morally warranted.

There will be a day at some point in the future that that will no longer be the case. As Christians, demonstrating love for neighbor, we should be among the more cautious when it comes to life. It does us little credit when people who claim the name of Christ demand autonomous personal freedoms without consideration for the vulnerable. We should be willing to sacrifice our comfort and convenience for the sake of the health and lives of others.

The moral absolute here is the duty to be careful with life. That does not mean absolute prevention of risk, but it does mean that we should work to minimize it, especially during a time of relative crisis like this.

We won’t know when the exact moment that it was no longer necessary to wear a mask until some time after it comes. To err on the side of caution is the morally prudent course of action.

Masks as a Historical Practice

Somehow, obscured in the politicization of this issue, people seem to be missing the fact that donning a mask has been a consistent practice recommended for visiting immunocompromised people for years. Perhaps I’m just unaware, but I’ve never heard or read anyone who objected to protecting the life of their child during cancer treatments by wearing a mask.

The duty to wear a mask was always conditioned upon the circumstance. The efficacy of masks has been assumed when dealing with visiting cancer patients, but suddenly it is being questioned now that the request is being made outside the sick ward.

The most reasonable arguments for this are that people aren’t going to wear the masks right, and will assume that the mask keeps everyone totally safe. Therefore, we shouldn’t wear masks.

People can be stubborn and ignorant, but repeated communication should help convince people that physical distance, hygiene, and proper mask wearing are three distinct (but related) measures to reduce spread of COVID-19.

Inability to Wear a Mask

If for some reason someone cannot wear a mask, then they should not wear a mask.

Churches should, within reason, work to accommodate those who cannot have a mask on. However, it may be that, since our buildings were not constructed for a respiratory pandemic, that accommodation may include being treated differently than those who can wear a mask. Different conditions may warrant different treatment.

People that cannot wear a mask can fulfill their duty to protect others through hygiene, maximal isolation, and maintaining distance as rigorously as possible.

We should do our best to bear with those who, for whatever reason, cannot take the same precautions for our health. This may include ensuring those individuals do not have to come in contact with infected individuals by running their errands, etc.

The simple fact that some cannot wear a mask should not prevent us as individuals from wearing masks or congregations from requiring them of everyone who is able. The goal is to minimize risk as much as reasonable, not to pretend we can entirely eliminate it.

At the same time, people who can wear a mask, but don’t want to ought to wear a mask. “It makes me feel hot and fogs my glasses” are not moral arguments against wearing a mask. (Trust me, I’ve worn a mask for an extended period of time during this and it’s no fun.)

Conclusion

Obviously, this is an ever-changing situation. If, for whatever reason, it becomes clear that properly wearing a mask in an enclosed, public space actually infects more people we should not do it. Our duty is to be cautious with life, not to wear a particular article of clothing.

When the CDC recommendations are relaxed, we should consider our own risk of being infected and be cautious about reducing our efforts to put our neighbor at risk. Leaders of churches should be especially cautious, as they will be setting the rules that will protect or endanger their congregations and the local communities. As I noted, churches are among some of the most high-risk activities that exist in our communities when it comes to communicable, respiratory diseases. It’s one thing to threaten someone with the common cold, it’s another thing to put them at risk of COVID-19. And, by putting those that attend at risk, we also put our communities at risk because of the particularly insidious nature of the disease.

We have no obligation to police our neighbor’s Facebook feed to see if they are wearing a mask. Our obligation is to ensure we are not spreading the disease, not to ensure others are not doing so. We should take appropriate care of our own health and lives, which may include avoiding corporate worship if the congregation refuses to take reasonable precautions. However, our goal should not be to shame or divide the congregation, but to reflect a consistent concern for life in a responsible, spiritually mature way.

At the end of the day, we will all give an account to God for our moral choices. Those that are in Christ will be covered by his blood, but our goal should be, as much as reasonable, to fulfill our duties as outlined in Scripture as much as possible for God’s glory. In this case, that requires us to take caution with the lives of our neighbors, which presently includes properly wearing masks in enclosed, public places.

Between Life and Death - A Review

Every birthday I have to remind myself there are only two options: Getting old or dying. Each year my mortality becomes a little more real as the physical symptoms of age and decay overtake me and as more people that I know experience medical treatments for major trauma or age-related organ failure.

Other than the drama of television and movies, my first glimpse into the world of the ICU came as a young naval officer, when one of my sailors died due to complications from a surgery. He was in one of the top hospitals in the nation and they couldn’t prevent the problem. That forced me to realize there are limits to the ability of medical professions and available technology to preserve or repair life.

Seeing that formerly jovial, proud sailor wired and tubed in the hospital bed was jarring. I was certainly not prepared to see a 34-year-old (which seemed old at the time) inert and unconscious. Thankfully, I was not part of the decision about future medical intervention, because I was entirely unprepared.

I was, however, in the room when the ventilator was removed at the doctor’s recommendation and at the families’ request, which was supported by the documents he had left behind. He was functionally brain dead, so the only thing keeping him alive were the machines forcing his body to keep working. Once the ventilator was removed, the end came peacefully and swiftly. It seemed merciful, but at the same time left me with questions about whether removing organ supporting medical interventions was, indeed, moral.

Such end of life decisions are difficult for several reasons. First, we do not always understand what the function of specific medical interventions are. Which ones offer remedial help and which ones simply sustain animal functions so the body’s other processes can continue? Second, non-medical personnel have little frame of reference for whether a particular condition is likely to be recoverable. What are the odds that any intervention, no matter how expensive and traumatic, are going to be successful? Third, we often have little idea how damaging the attempt to fix one problem will be and what the likelihood of complications will be. Will a heroic attempt to fix one problem likely doom the patient to major problems later? Fourth, too often we have failed to consider end of life care, even for those who are reasonably approaching the end of life. It is understandable for a family to have no guidance for end of life medical care for a teen or someone in their twenties or thirties. However, by the eighth or ninth decade of life, there is little reason for the individual and their family not to have already discussed options and made some decisions.

Summary

Kathryn Butler’s book, Between Life and Death: A Gospel-Centered Guide to End-Of-Life Medical Care, is an extremely helpful volume in learning about various critical medical treatments, which can help make the cost/benefit analysis for choosing to continue with interventions. She also carefully sorts through the biblical data to consider whether an ethic of life, which is demanded by Scripture, entails pursuing every medical treatment possible no matter the cost, the low likelihood of success, or the trauma to the patient. Butler, a trauma and critical-care surgeon, has worked at several significant medical facilities and brings her experience and expertise to bear in a compassionate manner in this book.

The book begins by considering the place of death in the human experience. It is unnatural, in that it is a result of the fall, but it is a normal expectation for humans that walk the earth. She also roots her ethic in the authority of Scripture, which reassures the reader that she is beginning from Scripture and interpreting medical technology through that lens, rather than the reverse.

In the second section of the book, Butler offers chapters on resuscitation for cardiac arrest, and intensive care treatments such as mechanical ventilation, cardiovascular support, artificially administered nutrition, dialysis, and brain injury support. The key message here is that whether one of these treatments is warranted is really based on whether it is likely to be a temporary support while the body recuperates or whether it is merely prolonging the inevitable. The medically accurate data in these chapters helps inform the conversations that Butler outlines in the third section of the book.

In part three of the volume, Butler provides an outline of what is constituted by palliative care and hospice, how that is different from physician-assisted suicide, the importance of advance care planning, and the role of individuals designated to make proxy decisions. After the conclusion, Butler offers several appendices that include summaries of organ supporting measures, a sample advance directive, and some Scripture passages that offer comfort for those making these decisions.

Analysis

Between Life and Death is an important book. It was written at an accessible level both theologically and medically. It helpful translates some difficult medical terminology and sometimes confusing ethical language that can make an otherwise painful decision unbearable.

Butler does very well dealing with the difference between killing and letting die. There is a pervasive myth among many American Christians that unless we are doing absolutely everything to sustain life for as long as possible, we are “giving up on” or “killing” the patient. Butler shows that many of these support measures are bringing their own additional trauma, prolonging the inevitable for a short time, and actually increasing suffering. Ceasing supposedly heroic medical interventions is not killing an individual, it is merely allowing the process of dying to take its course. Butler’s book helps readers develop the wisdom to understand the counsel of physicians and make compassionate, Christ-honoring choices.

If this book is revised in the future, it would benefit from a deeper discussion on the nature of and purpose of suffering. The topic is explored somewhat, but Butler’s expertise is really on the technical side of the discussion, so the development of a theology of suffering (which is very important in making these decisions) is a bit thin.

Conclusion

Between Life and Death is the single best book on this topic that I have encountered. It is pastoral, technically accurate, and scripturally framed.

This is a book that belongs in the library of every pastor. Not only that, but it should be read, underlined, and outlined by elders and deacons as they prepare for making hospital visits, offering counsel, and seeking to comfort the sorrowful. This is the sort of book that a senior’s group at the local church would greatly benefit from discussing as they prepare for inevitable decisions. The time to read Butler’s book is not when the beeps and whistles of the ICU are surrounding a patient, but rather months or even years before any such condition is highly likely.

Between Life and Death: A Gospel-Centered Guide to End-of-Life Medical Care

By Kathryn Butler

Buy on Amazon

NOTE: I received a gratis copy of this volume from the publisher with no expectation of a positive review.