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Chapter Six: Quality
of Life vs. Sanctity of Life
Joe Brady was drunk the night he crashed his car at 80 mph into
the large Oak tree in front of the high school. Now, ten days later,
in the Intensive Care Unit at Bridgeport Memorial Hospital, he was
still on the ventilator. He was not clinically brain dead. In a
few more days he would be able to be weaned off the ventilator.
He almost certainly would live. However, it was unlikely that he
would ever leave the nursing home where he would soon be sent.
He had never completed advanced directives, and his family was
all gone.
Drs. Brown and Jenkins discussed what to do next.
"He certainly will have no quality of life in the nursing
home, even if he does regain some ground," said Dr. Brown.
"I think that given the fact that he will have such a poor
quality of life, we should take him off the ventilator today, allowing
him to die peacefully. If we hesitate, and he goes into persistent
vegetative state, we will all be sorry."
"I agree," said Dr. Jenkins. "Let's just let him
go peacefully."
It was obvious that Melinda Tompkins was never going to smile,
talk, or interact socially again. She required frequent turning,
constant care, and thrice-daily tube feedings just to keep on breathing.
Her eyes opened from time to time, but she did not look directly
at faces or follow activities in the room. It had been six months
since she was transferred to the long-term care facility, and she
had never once said a word or obeyed any single command.
"She is just a burden on society," said Lucinda Hardy,
RN, to Debby Rak, the Health Care Tech. "Someone should put
her out of her misery."
"I don't know," said Debby. "She isn't really in
any pain, and I think we should let God decide when it's time for
someone to die."
"You and your religious nonsense. If you had to pay her bills
yourself, I doubt that you would be so high-minded. Did you know
it costs $500/day to keep her in that bed? What a waste of tax-payer
money."
Tim Johnson had shot himself in the head with a pistol. At least
that is probably what happened. No one had seen him do it, and he
had not been particularly depressed. He lay now, in the Intensive
Care Unit, clinically not brain dead, but never likely again to
talk, walk, think, or eat on his own. His family members had converged
on the hospital, and unanimously were demanding that he be removed
from the ventilator.
He had not completed a Living Will, or Health Care Power of Attorney,
and he was no in imminent danger of dying if he was carried safely
through the next few days.
Were the doctors completely certain that Tim would never function
independently? No one can be absolutely certain, but they felt quite
confident of their predictions.
Given the poor quality of life that Tim would likely experience
the family demanded discontinuation of all life-prolonging measures.
After a bedside Ethics Consultation the wishes of the family were
acceded to. Five hours later, off the ventilator and blood pressure
maintaining medications, Tim expired.
What is "quality of life"? This fairly nebulous term
applies to situations in which decisions about withholding or withdrawing
care are made based on the likely low levels of self-awareness,
reasoning, communication and activity that the patient will have
and the low probability of improvement. Quality of life decisions
are usually not made by the person in question, but by their physicians,
their families, or at times, the courts. Thus, there is inherently
an element of uncertainty and guesswork involved. There are a number
of reports of people who were seriously injured, made only limited
recovery, but when they reached their final new baseline, seemed
to be relatively happy. If they had been asked to predict what the
response to their new life would be, families and doctors would
have underestimated what the patients would rate their happiness
and adjustment to be. Stated another way, the observers would think
that the patients would have a low quality of life, but the patients
themselves would rate their quality of life fairly high.
This concept may also be employed in health care rationing discussions.
"After all, we shouldn't waste any more money on this person
because their quality of life will be so low, anyway." Utilitarianism,
with it goal of providing "the most good for the most number
of people" would espouse this type of decision-making.
Another concern in thinking along these lines is: "Whose definition
of quality do we use?" This was the way that Nazi Germany rationalized
killing mentally ill and handicapped patients. They essentially
maintained that the quality of life that these people led was not
worth saving. It would be an act of mercy to kill them. Eventually,
it became almost an obligation to the remainder of the Aryan race
to dispose of these subhuman elements. Eventually the Nazis killed
millions of Jews and Gypsies for similar reasons. These undesirables
were polluting the overall quality of life for the great Aryan race.
"Sanctity of life" advocates usually find themselves
on the opposite end of a choice/free will spectrum from quality
of life proponents. Quality supporters usually also support abortion
on demand and a patient's "right to die." Sanctity supporters
usually seek to support the patient regardless of likely outcome.
The extreme sanctity position is that everything possible must be
done for every patient regardless of expense in time, money or personal
sacrifice. This position is called "vitalism" (supporters
are called vitalists), and very few Christian bioethicists would
hold to this.
Even among sanctity of life advocates, for instance, many would
support removing feeding tubes from patients in persistent vegetative
state, if certain conditions apply. Scott Rae, in Moral Choices,
see below, suggests that under certain conditions removal of the
feeding tube is justifiable for a patient in persistent vegetative
state. If 1) the patient cannot absorb nutrients, 2) feeding is
a burden greater than a benefit, 3) there is no reasonable hope
of benefit or 4) if written advance directives dictate, removal
may be considered.
Finally, on a metaphysical level, what is the purpose of our lives?
Is it only to be happy, or is it primarily to glorify God and serve
him in whatever means he puts at our disposal? If we answer the
former, then we are hedonists, humanists, or utilitarians. If we
answer the latter, then we align ourselves with the great Christian
creeds of the ages.
God is eternal and sacred, so his life is sacred. We are fallen
creatures, and our time-locked lives are a gift from God. Our lives
are sacred because God has made us in his image, sacred. The phrase
"sanctity of life" reminds us that life is God's precious
gift and cannot be toyed with, or wasted. This gift of life that
he has given others, likewise, cannot be exploited. God's laws break
down primarily into two commands: 1) to love God, and 2) to love
others. This phrase is employed to emphasize the great respect that
we are to show for all human life including the newly conceived
up to the aged and infirm. No lack of intelligence, creativity,
or beauty on the part of the humans in question should diminish
the deep respect that we owe these persons simply because they are
God's creations, made in his image.
What does the Bible have to say about quality of life and sanctity
of life? Let's look and see.
Scripture and Discussion Questions
Job 2:9,10; 42:12-17
Psalm 22:1-8
Daniel 3:16-18
Matthew 5:3-12; 28:20
Mark 5:35-43
Luke 7:11-16
1 Corinthians 13:13
Philippians 1:19-25
1) What was Job's quality of life after he lost everything? What
became of Job?
2) Jesus had a poor quality of life in many ways, yet he brought
salvation to the whole world through his suffering? Have you witnessed
redemptive suffering?
3) Shadrach, Meshach, and Abednego placed their lives and their
futures completely in God's hands. He honored their faith. Have
you been faced with a situation where you had to choose between
trusting in the face of uncertainty or taking things into your own
hands? Were you able to say: as in Daniel 3:18 that even if God
did not choose to save you in the way you thought best that you
would continue to serve him? How does any of this fit into the issue
of quality of life?
4) What place do the beatitudes have to do in a quality of life
discussion? What does Matthew 28:20 impinge on this discussion?
5) In Mark 5, Jesus chose to heal the little girl. He does not always
choose to heal, and sometimes his chosen servants suffer the most,
as Paul did. How can you trust a God who does not always answer
your prayers in the way you see best? Perhaps a member of your class
might share how God ministered to them through a situation where
he did not answer prayer they way they would have liked.
6) When Jesus resurrected the widow's son the people said, "God
has come to help his people." Relate an event where God did
not immediately grant your prayer request, yet worked events out
to his glory and your good. What does that have to do with quality
of life or sanctity of life?
7) 1 Corinthians 13:13 ranks hope as one of the three cardinal virtues.
We often expound on faith and love, but do not often talk about
hope. Are you hopeful? What do you put your hope in? How is hope
different than faith?
8) Philippians 1:19-25 was written from prison. What quality of
life do you think that Paul had, by human standards? A wasted life?
See also Acts 9:15,16.
9) The decision made in the Joe Brady vignette is made many times
a day throughout this country. Is this wrong? Should doctors make
these decisions at the bedside or should special committees be set
up to deal with these questions? Are there other alternatives?
10) Do we as citizens have a right to make these complicated life
maintenance issues based on financial concerns? Do we have a right
to ignore financial concerns?
11) Some Christians never ask for God's healing for physical ailments.
In other congregations if a person has any physical ailment it is
felt to reflect a lack of faith on the person's part. What is the
Biblical position on healing and miracles today? How will your answer
to this question impact your position on strategic bioethical questions?
Comments
1) Medical futility, to be discussed further in chapter nine, has
an important bearing on the finances of long-term care. If we could
accurately predict when further intervention is truly futile, it
would simplify decision-making. At present, this is not really possible.
2) Some Christian thinkers talk about the redemptive merit of suffering.
God remains in control, and we remain in subjection to his will.
This might prompt some animated discussion in your group.
3) The "quality of life" argument raises the specter of
possible future "obligation to die". If one cannot demonstrate
than one has a high quality of life (after a severe stroke, after
severe burns or injuries, etc.) then perhaps one has the obligation
to die so that valuable resources may be shifted to those who have
a good life quality-or so the argument goes. I believe this is absolutely
wrong.
4) The phrase "Imago Dei" implies that our worth is based
on the fact that we are made in God's image, and that it is not
based on our abilities, talents or potential. This runs directly
counter to the basic tenets of utilitarianism.
5) Job is a complicated, fascinating book, and it underscores the
fact that God does not always make his thoughts or intentions clear
to us. Not knowing the exact reason something is happening often
serves to either pull us toward God or push us away from Him, depending
on our response to the uncertainty.
6) Some secular thinkers state that Faith and Reason are mutually
exclusive. I would contend, however, that rationalists begin all
their syllogisms with several steps of faith. These are: 1) that
there really are some answers as to how the universe began, what
is the meaning of life, etc., and 2) that their finite reasoning
is capable of discerning those answers without the help of God.
7) Evolutionary theory impinges directly on the "Quality vs.
Sanctity" discussion. "Natural selection" and "survival
of the fittest" as applied to social evolution are inherently
anti-scriptural. The idea of a soul is unnecessary and insupportable
in this model.
8) In almost every state at present, the Ethics Consultation carries
no binding authority. Many consultations focus on intra-family communications
or communications between the medical team and the family. In my
experience, most consultations are not particularly dramatic or
fascinating, but may be helpful in sorting out complicated situations.
PRAYER REQUESTS: As you close today's
lesson together, pray that God will speak to you about the way that
you are using your own life. Are you hoarding it to preserve your
quality of life, or are you acknowledging your life as a gift from
a holy God, and as a sacred trust? Pray that God will remind you
frequently of his love and gifts to you.
For Further Reading:
Much of the background for this chapter comes from Dr. John F. Kilner,
Life on the Line-Ethics, Aging, Ending Patients' Lives, and Allocating
Vital Resources (Grand Rapids, Michigan: Eerdmans Publishing Company,
1992). Dr. Kilner is Director of The Center of Bioethics and Human
Dignity, in Bannockburn, Illinois. A truly compassionate, Christian
intellectual, he is an author whose works any Christian bioethicist
should know well. His treatment of allocation of resources is exceptional.
Scott B. Rae, Moral Choices-An Introduction to Ethics (Grand Rapids,
Michigan: Zondervan Publishing, 1995). See page 179 for a discussion
of removing feeding tubes from patients in persistent vegetative
states.
See chapter three in Paul Ramsey's The Patient as Person (New Haven,
Connecticut: Yale University Press, 1970). Dr. Ramsey presents a
thoughtful discussion on caring for the dying patient. This may
be available through inter-library loan if your library does not
carry this classic work.
Jean Bethke Elshtain, Who Are We? -Critical Reflections and Hopeful
Possibilities (Grand Rapids, Michigan: William B. Eerdmans Publishing
Company, 2000). Dr. Elshtain is a fascinatingly insightful social
critic, with strong Christian roots, who is a professor at University
of Chicago. In Chapter two she discusses a pervasive consumerist-commodifiable
ideology in America. This has obvious implications in "quality
of life" discussions.
James Dobson, Solid Answers (Wheaton, Illinois: Tyndale Publishers,
1998). Dr. James Dobson is revered in many Christian homes as "America's
foremost family counselor." In this 575-page book, Dr.Dobson
answers all manner of child-rearing, marriage, and general family
questions. Chapter twenty-four is entitled "The Sanctity of
Life."
Tom L. Beauchamp and James F. Childress, Principles of Biomedical
Ethics, 4th ed., (New York: Oxford University Press, 1994). To many
secular bioethicists, this is considered the "bible" of
bioethical discourse. It contains numerous references to the "quality
of life" discussion.
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