I have completed my Bachelor's of Commerce and Chartered Accountancy ('CA'). I have over 9 years’ experience as an internal auditor and tax consultant. I have worked across various industries like shipping, banking, hospitality, manufacturing and I understand their business operations in depth. During these days I like to spend my time experimenting with my cooking skill, gardening and relaxing. As a CA, I am technically self-sufficient, but nowadays CA’s services are no longer restricted to traditional areas of practice. I expect to enhance my leadership, people management, negotiation and interpersonal skills. These skills in turn will help me achieve my long-term goals. . 26 Death, Dying, and Grief By Paul J. Hoehner If we ask about religion in America, you can see the conclusion which I must draw. The God whom Americans worship as the final and absolute reality is the power of death. Here I do not use the term god to designate the divinity revealed in Jesus Christ. I use the word in a more open way, to name what a people believe to be the final, the ultimate reality which controls their lives. Many Americans (notwithstanding their dedicated commitments to the ethics of success and resistance) still believe that death is the ultimate reality that will finally and permanently determine their existence. (McGill, 1987, p. 18) When the perishable puts on the imperishable, and the mortal puts on immortality, then shall come to pass the saying that is written: "Death is swallowed up in victory." "Oh death, where is your victory? O death, where is your sting?" The sting of death is sin, and the power of sin is the law. But thanks be to God, who gives us the victory through our Lord Jesus Christ. (1 Corinthians 15:54–57, English Standard Version) Essential Questions · How does a Christian worldview, especially the Christian doctrine of Christ’s death and resurrection, give new meaning to death? What affect does this have on health care? · What is the difference between cardiopulmonary, whole-brain, and higher brain criteria of death? What worldview assumptions inform the definitions behind each of these criteria for death? What are the clinical tests used to confirm the criteria for whole-brain death? · What should the Christian response be to euthanasia, physician-assisted suicide, and withholding and withdrawing life-supportive therapy? · That are the stages of grief, and how can knowledge of these stages assist a health care professional in counseling the dying and their families? · What does it mean to die well according to a Christian worldview? Introduction · · The subject of death and dying can be an emotional and distressing topic, especially for health care workers who witness daily the existence of human mortality, trained as they are to use every means that medical science can offer to push back against this inevitable and unavoidable constraint of earthly existence. In this chapter, five aspects of death and dying will be presen ...

1. I have completed my Bachelor's of Commerce and Chartered
Accountancy ('CA').
I have over 9 years’ experience as an internal auditor and tax
consultant. I have worked across various industries like
shipping, banking, hospitality, manufacturing and I understand
their business operations in depth.
During these days I like to spend my time experimenting with
my cooking skill, gardening and relaxing.
As a CA, I am technically self-sufficient, but nowadays CA’s
services are no longer restricted to traditional areas of practice.
I expect to enhance my leadership, people management,
negotiation and interpersonal skills. These skills in turn will
help me achieve my long-term goals.
.
26
Death, Dying, and Grief By Paul J. Hoehner
If we ask about religion in America, you can see the conclusion
which I must draw. The God whom Americans worship as the
final and absolute reality is the power of death. Here I do not
use the term god to designate the divinity revealed in Jesus
Christ. I use the word in a more open way, to name what a
people believe to be the final, the ultimate reality which
controls their lives. Many Americans (notwithstanding their
dedicated commitments to the ethics of success and resistance)
still believe that death is the ultimate reality that will finally
and permanently determine their existence. (McGill, 1987, p.
18)
When the perishable puts on the imperishable, and the mortal
puts on immortality, then shall come to pass the saying that is
written: "Death is swallowed up in victory." "Oh death, where is

2. your victory? O death, where is your sting?" The sting of death
is sin, and the power of sin is the law. But thanks be to God,
who gives us the victory through our Lord Jesus Christ. (1
Corinthians 15:54–57, English Standard Version)
Essential Questions
· How does a Christian worldview, especially the Christian
doctrine of Christ’s death and resurrection, give new meaning to
death? What affect does this have on health care?
· What is the difference between cardiopulmonary, whole-brain,
and higher brain criteria of death? What worldview assumptions
inform the definitions behind each of these criteria for death?
What are the clinical tests used to confirm the criteria for
whole-brain death?
· What should the Christian response be to euthanasia,
physician-assisted suicide, and withholding and withdrawing
life-supportive therapy?
· That are the stages of grief, and how can knowledge of these
stages assist a health care professional in counseling the dying
and their families?
· What does it mean to die well according to a Christian
worldview?
Introduction
·
·
The subject of death and dying can be an emotional and
distressing topic, especially for health care workers who witness
daily the existence of human mortality, trained as they are to
use every means that medical science can offer to push back
against this inevitable and unavoidable constraint of earthly
existence. In this chapter, five aspects of death and dying will
be presented. First, the Christian biblical worldview perspective
of the meaning of death and dying will be reviewed. Death is
not merely a physical phenomenon but has meaning in all
cultures and religions that transcends the merely biological. For
the Christian believer, death is given its ultimate meaning in
terms of Christ’s own suffering, death, and resurrection.

3. Next, the definition of death will be addressed. While death
may seem like an obvious concept, especially for the general
public, defining death in an era of advanced life-support
technologies and vital-organ-transplantation surgery can be
problematic and raises a host of ethical questions. Third, ethical
issues at the end-of-life, such as euthanasia, physician-assisted
suicide (PAS), and withdrawing or withholding life-supporting
therapy will be examined from a Christian worldview. Fourth,
the stages of grieving as outlined in Kübler-Ross’s (2014)
book, On Death and Dying, will be presented as an aid for
health care workers to understand, evaluate, and counsel
grieving patients, their families, and loved ones when facing
impending death and separation. The final section will explore
how a Christian’s hope in the resurrection provides a context
for learning to die well and prepare for the final chapter of
one’s life with meaning and purpose.
Worldview and the Meaning of Death
·
Despite the great strides to alleviate pain and prolong life in
even the most serious of illnesses, the death of the body remains
one of the central, universal, and inevitable outcomes of life. "It
is appointed for men to die once" (Hebrews 9:27, English
Standard Version). From a purely biological and worldview,
death is essentially reduced to nothing more than organic life
returning to an inorganic state. As Sigmund Freud (1961) said,
"Everything living dies…becomes inorganic once again” (p.
32). Even the concept of personhood, when assimilated into this
materialistic paradigm, is merely an expressive part of this
living organism that does not survive the death of that
organism. Seneca (trans. 1900), a first century Roman stoic
philosopher expressed this nihilistic view of death and human
mortality in his treatise Of Consolation, To Marcia:
Death is a release from and an end of all pains: beyond it our
sufferings cannot extend: it restores us to the peaceful rest in
which we lay before we were born. If anyone pities the dead, he
ought also to pity those who have not been born. Death is

4. neither a good nor a bad thing, for that alone which is
something can be a good or a bad thing: but that which is
nothing, and reduces all things to nothing, does not hand us
over to either fortune, because good and bad require some
material to work upon. Fortune cannot take ahold of that which
Nature has let go, nor can a man be unhappy if he is nothing (p.
9.5).
This ultimately pessimistic, if not cynical, view of death
remains a part of much of modern rationalistic and materialistic
culture and contributes directly to contemporary and seemingly
conflicting attitudes toward death, including denial, fear and
foreboding, helplessness and hopelessness, heroic acquiescence,
and ultimately, attempts to autonomously master and control the
timing and means of the end of one’s own existence (Smith,
Harvath, Goy, & Ganzini, 2015).
This meaninglessness of death can be a source of anxiety about
the value, meaning, and purpose of life itself. Science and
reason can reveal only so much of general physical truths, but
they cannot provide or become a source of value, meaning, or
purpose. Everyone rightly values their individual existence,
freedom, and ability to make rational choices in their daily
lives. But in a seemingly meaningless and irrational universe,
how can one do so unless one defines or creates his or her own
meaning and values in life? This outlook on life, that one must
create one’s own meaning and value in a meaningless and
valueless world, has become very influential in modern culture
and secular ethics, especially medical ethics. It is easy to see
how autonomy then becomes the central and controlling value
for an individual and in ethical decision-making. By contrast,
the Christian worldview recognizes the truth of a transcendent
source of value, meaning, and purpose in life and death.
This nothingness of death, which is the logical conclusion of
many who hold to a naturalist or physicalist worldview, is not
affirmed by most human cultures and societies throughout
history. Death has always had meaning that transcended the
merely biological, even while being coexistent with the

5. biological. Beliefs in an individual essence or soul that survives
the death of the individual organism or body in some form
persists across all cultures, from the most primitive of peoples
to the most sophisticated of religions. Any full concept of the
meaning of human death must include both the physical and
scientific perspective coupled with a philosophical or religious
understanding. In other words, death is given its fullest meaning
only through a consistent worldview lens. Differing worldviews
on the meaning of death and, consequently, life itself are the
root case for many of the current ethical debates surrounding
death, including issues such as abortion, capital punishment,
euthanasia, and organ transplantation.
In a pluralistic culture, the existence of differing worldviews
can often result in simultaneous and sometimes contradictory
attitudes toward death. There can be both a defensive denial of
death, and at the same time a desire to master it or at least
control its disrupting effects on social life (Parsons, 1971; Lidz,
1995). Consider how different worldview attitudes toward
death, including both denial and mastery, are reflected in many
of the attitudes and practices of modern culture, many of which
are good and certainly worth pursuing, such as restricting
cigarette smoking in public, health food, physical fitness,
firearm control, and environmental movements.
The never-ending quest for eternal youth and avoidance of signs
of aging (e.g., the proliferation of beauty aids and treatments
for baldness and impotence) may reflect a type of pushback to
the signs of an impending and imminent dying process.
Institutions, such as public health services, insurance, and
estate and retirement planning are designed to deal with and
manage the practical aspects of death. Funeral and mourning
customs designed to support the survivors of loved ones in
overcoming grief and guilt, can be viewed as attempts to
mitigate the social effects of death by returning them to normal
participation in society as soon as possible. This is not to
disparage any of these practices, only to point out how a
culture’s worldviews on the meaning, or meaninglessness, of

6. death is reflected in many day-to-day practices.
Death is both unavoidable and, in many ways, uncontrollable.
To deny one’s own mortality does not make it less of a reality.
Attempting to control the uncontrollable is illusory and
ultimately self-deceiving. Medicine, when viewed solely as a
project aimed toward controlling life and defeating death, can
become complicit in this denial of one’s own mortality and
desire to be in control of the uncontrollable. According to
Shuman and Volck (2006), the project by which the medical
industry has become the chief mediator over the power of death
is in many respects a religious one. By religious, they do not
mean something akin to belonging to an organized church or
religious group, but rather pertaining to those objects of
affection around which people’s lives are centered.
According to Lash (1996), by this definition, everyone is
religious because all "have their hearts set somewhere, hold
something sacred, worship at some shrine” (p. 21). Although the
human heart rarely settles on a single object, modern culture’s
objects of devotion certainly include "beliefs and practices
protective of…things we are too terrified to mention, or of
instincts, prejudices and convictions lying at the very heart of
who and how we take ourselves and other things to be" (Lash,
1996, p. 20). In today’s materialistic culture, this would
certainly include the care, comfort, and longevity of one’s body.
Death, as a foreigner and a stranger to life, holds great power
over the human condition. Pain, suffering, grief, and physical
death become the ultimate powers over us that must be
conquered through an almost religious devotion to scientific
medicine and the priesthood of the medical and health care
profession. Much of the ethics of modern health care centers on
defeating the powers of things such as pain, suffering, grief,
and ultimately death itself as the highest good. According to
Shuman and Volck (2006), health care professionals in our
modern culture represent godlike power:
This is not because these people think of themselves more
highly than they ought, but because of the social significance

7. we give to the power they represent. This is how the fallen
powers function; they cooperate with the disordered appetites of
those who use and depend upon them, allowing us to see them
not as God’s instruments, but as gods, period. To a significant
extent, they are successful because they promise to deliver us
(while God appears unwilling or incapable) from the evil of
certain contingencies. (p. 38)
According to many secular worldviews, health, or at least the
pursuit to be free from all pain, suffering, grief, and ultimately
death, becomes the highest good and the ultimate goal that
determines one’s values, priorities, and ethics.
In contrast, the Christian worldview does not leave one alone in
a meaningless, valueless, and purposeless universe to create
meaning, value, and purpose in life and death simply out of thin
air. Rather, it looks to Jesus as both the author of life (Acts
3:15) and conqueror of death (2 Timothy 1:10) to find the true
meaning, deliverance, and hope in the face of the present human
condition. Ultimately, Christian believers do not live with an
illusion of autonomy in a meaningless world, but rather live
with the comfort and assurance that they have been "bought
with a price" and called to "glorify God" in their bodies (1
Corinthians 6:20). This is what ultimately gives a Christian
believer true meaning, value, and purpose.
The Heidelberg Catechism, written almost 500 years ago,
remains one of the most cherished explanations of the historic
Christian faith. The first question of the catechism is, "What is
your only comfort in life and in death?" The answer begins,
"That I am not my own, but belong—body and soul, in life and
in death—to my faithful Savior Jesus Christ" and continues to
affirm that "all things must work together for my salvation.
Because I belong to him, Christ, by his Holy Spirit, assures me
of eternal life and makes me wholeheartedly willing and ready
from now on to live for him."
To seek relief from pain, suffering, grief, and to aid the dying
in this fallen world are good and wonderful things to be
pursued, as they reflect God’s own love, care, and mercy for his

8. creation. Christians, in particular, are called to pursue these
things to the best of their ability as part of the good and
gracious gifts of God’s goodness in creation. But these things
are not the highest good to be pursued. According to the Bible,
the highest good is to love and serve God. All earthly goods are
subordinate to and are to be used to glorify and serve God. Even
the real, but subordinate goods of medicine and medical
technologies, after the fall, are tainted by sin and in need of
redemption, that is to serve God in the ways God intended.
According to Mohrman (1995), a physician and theologian,
Health can never be anything other than a secondary good. God
is our absolute good; health is an instrumental, subordinate
good, important only insofar as it enables us to be the joyful,
whole persons God has created us to be and to perform the
service to our neighbors that God calls us to perform. Any
pursuit of health that subverts either of these obligations of joy
and loving service is the pursuit of a false god. Health is to be
sought in and for God, not instead of God. (pp. 15–16)
A Christian believer understands that God cares for all
humanity as part of his good creation, and they need not be
anxious or fearful in health, sickness, or death as long as they
seek first to serve God (Matthew 6:25–33). The biblical
perspective on suffering, death, and hope in an eternal
resurrected life molds a Christian believer’s outlook on life,
gives meaning and value to their trials and ordeals in life, and
transforms the way they make decisions about many end-of-life
issues.
Biblical Reflections on Death and Dying
·
Death is not a natural part of life. It is not, as some
professionals in different disciplines might suggest, a part of
the natural cycle of birth, death, and rebirth as another
individual is born to carry on a species. This well-meaning, but
mistaken sentiment implies that death is as natural as life—
something to be readily accepted and perchance to control as
best as possible. According to the Bible, and in contrast to

9. materialistic and naturalist accounts, death, while certainly a
present universal reality, is not a "natural” part of God’s
original good creation but was a result of human sin and
rebellion. It is truly a familiar stranger to this world (Romans
5:12).
Illness, Disease, and Death as an Effect of the Fall
According to the biblical narrative, both spiritual and physical
death are ultimately the result of sin. In the opening chapters of
the book of Genesis, the origins of sin and death are traced to
God’s command to Adam and Eve, human beings created in his
own image, to not eat of the Tree of the Knowledge of Good and
Evil, for "in the day that you eat of it you shall surely die"
(Genesis 2:17). This was not an arbitrary command and
punishment by a capricious God, but a condition and outward
expression of love and faithful obedience. The gracious reward
for this faithful obedience was eternal life and the punishment
for disobedience was eternal death. This covenant, or agreement
and promise, that God established with Adam and Eve can never
be broken. God is faithful to his promises even if fallen men
and woman are not (Deuteronomy 7:9; 2 Timothy 2:13). God’s
promises are a sure thing.
Physical death is certainly meant here, but not exclusively.
Adam and Eve did not physically die immediately upon
disobeying God by eating from the Tree, but much later. The
death that immediately overcame them was of a spiritual nature,
a separation and breaking of Shalom with God through their
disobedience, even as their physical death would be a future
certainty. Death, while indeed physical, has a religious and
ethical significance, in which the life, in its broadest context,
both spiritual and physical, of all human beings is dependent on
faithful obedience to their Creator. Both physical death and
spiritual death are the penalty and consequence of sin and the
universal lot of all mankind because all have sinned (Genesis
2:17; Ezekiel 18:4, 20; Romans 5:12; 6:23; 7:13; Ephesians
2:1,5).
This religious and ethical nature of death is not only clearly

10. expressed in the opening narrative of Genesis, but also is the
fundamental and underlying theme of the whole of the Christian
Bible and a central theme of the biblical message of salvation.
Death, in its broadest context, is the humanity’s separation from
their Creator as the source of both physical and spiritual life,
with sin being the cause of this separation. The Bible is not as
concerned with the physical and scientific contrast between life
and death, although it does include this, as it is with the moral
and spiritual difference between those who are spiritually alive
by way of their fear of the Lord and those who are spiritually
dead in their sin. Just as physical death is to be unresponsive
and alienated from the realm of the living, spiritual death is to
be alienated from God, resulting in a lack of responsiveness to
the living God and even hostility to God. Because of the dual
nature of human beings as body and spirit, the physical and
spiritual concepts of life and death are intimately interwoven in
this same duality.
As outlined in Chapter 3, the fall has universal and even cosmic
implications (Genesis 3:17–19; Romans 8:19–21). Not only
physical death, but pain, suffering, and illness are all effects of
the fall and not part of God’s original design. Sin results in
consequences that affect the mind, body, and spirit of each
human being. While certain illnesses and suffering are direct
consequences of one’s choices, such as physical effects and
illness caused by lack of exercise, excessive alcohol and/or
illicit drug use, and smoking, the Bible does not link individual
sins directly to specific illnesses or diseases (John 9:1–3). This
is not inconsistent with the biblical concept that all suffering,
pain, and illness in this present post-fall world, including death,
is a general punishment for and has its ultimate origins in sin.
Sinfulness is the general condition of all mankind; all are guilty
before God. All men and women are sinners by nature and by
their own acts of rebellion against their Creator God. Sickness,
pain, suffering, and ultimately death are all the result of this
rebellious and sinful nature.
The Death and Resurrection of Jesus Christ

11. The life, death, and resurrection of Jesus is the central event of
the biblical narrative. It is the culmination of the Old Testament
covenants, promises, and prophecies and the foundation of the
gospel, or good news, that is proclaimed in the New Testament.
The event of God taking on flesh and dwelling among us, the
incarnation, is proclaimed clearly throughout the New
Testament (Luke 1:35; Philippians 2:5–7). This was God’s own
answer to the dilemma and tragedy of sin in the world. Because
God is both holy and just, he cannot simply overlook sin, allow
sinful beings in his presence, or accept them into his holy
kingdom. Sin must be punished, and justice upheld. But God is
also loving and merciful.
Beginning immediately after the sin in the Garden of Eden, God
promised to send a savior, a messiah, to break the hold that sin
had on the world and to redeem a people for himself (Titus
2:11–14). A sacrificial lamb was needed, a substitute that would
take on the guilt and punishment of sin that mankind deserved
and atone for the sins of the world. This substitute needed to be
perfect and blameless, not deserving of the guilt and
punishment that he would voluntarily bear for the sake of God’s
beloved people. Because "all have sinned and fall short" of
God’s holy law (Romans 3:23), this substitute needed to be God
himself, taking on human nature. This is the mystery of the
incarnation: The God-man Jesus Christ. Christ, a title Christians
use to refer to Jesus, comes from a Greek translation of the
Hebrew word for messiah, which means "the anointed one," and
refers to the one who was promised throughout the Old
Testament to come and redeem God’s people. Jesus the Christ is
the only perfect and sinless Lamb of God sufficient to atone for
the sins of all mankind. Probably the clearest statement of the
atonement is found in the Old Testament prophecy of Isaiah:
But he was pierced for our transgressions; he was crushed for
our iniquities; upon him was the chastisement that brought us
peace, and with his wounds we are healed. All we like sheep
have gone astray; we have turned—everyone—to his own way;
and the Lord has laid on him the iniquity of us all…he was cut

12. off out of the land of the living…Yet is was the will of the Lord
to crush him; he has put him to grief; when his soul makes an
offering for guilt. (Isaiah 53:5–10)
Jesus Christ, the innocent and blameless Son of God, took upon
himself the sins of the world when he was unjustly executed on
a Roman cross, a cruel and torturous experience that was
prophesied almost a millennium earlier by Israel’s King David
in Psalm 22. This would have been simply another meaningless
execution if it were not for Jesus’s subsequent resurrection from
the dead that witnessed to the sufficiency of his sacrifice and
his power over sin and death (1 Corinthians 15:14). That Jesus’s
death indeed paid the full penalty for the guilt of his people’s
sins, for all those who put their trust in him, is attested by the
resurrection. The prophet Isaiah goes on to say that Jesus, the
Messiah, will "see his offspring; he shall prolong his days; the
will of the Lord shall prosper in his hand" and "make many to
be accounted righteous, and he shall bear their iniquities"
(Isaiah 53:10–11).
Jesus’s death and resurrection from the dead made a way of
salvation, putting an end to the guilt and punishment for sin
every human being deserves, and ending the estrangement and
separation that sin brought between God and mankind. Because
of this, death itself becomes a conquered enemy for all those
who have also died in Christ. The phrase in Christ is used
frequently in the New Testament when referring to those who
have placed their "hope in Christ" (Ephesians 1:12), making
Christ the object of their faith. Good works or living a good life
cannot bring about a right relationship with God, as is the case
in virtually every other religion. The way to God is not, as
believed by so many other religions, about living in a certain
way, praying certain prayers, or following certain rituals or
customs. Sin is too much an indelible part of human nature and
a part of everyone’s life. No one can be good enough. The good
news that Jesus brings is not merely good advice on what needs
to be done, but an announcement that by trusting in what he has
already accomplished, fully and completely, one can obtain

13. salvation, peace with God, and share in his resurrected li fe. The
Apostle Paul succinctly and clearly summarizes this message
when he says that, "by grace [God’s unconditional love and
undeserved mercy] you have been saved through faith. And this
is not your own doing; it is the gift of God, not a result of
works” (Ephesians 2:8–10).
Death as a Conquered Enemy
How is death considered in the Bible to be a conquered enemy
when, in fact, all men and women, Christians included,
eventually die? The answer lies in what was said at the
beginning of this section regarding the connection between
spiritual death, physical death, and sin. The Bible, especially
the New Testament, does not reflect on death as a purely
biological phenomenon, nor is this the central concern. Living
under the guilt of sin, which separates one from the God who is
the source of life, is living in death. Death is a power that
dominates the life of a sinner and to that extent is talked about
in the Bible as a present reality. As the Apostle Paul says, "The
sting of death is sin, and the power of sin is the law” (1
Corinthians 15:56). "‘Spiritual’ death and ‘physical’ death,
inextricably bound up together, constitute the reality of a life in
sin” (Schmithals, 1980, p. 436). To reiterate, both spiritual
death and physical death are the consequences and penalty for
sin and are the universal lot of all mankind because all have
sinned.
Those, however, who live in Christ, meaning those who place
their hope in the finished work of Christ and not their own good
works, can experience the present reality and certainty of
eternal life and communion with God. This allows the Apostle
Paul to exclaim in a joyous rhetorical outburst, "Oh death,
where is your victory? O death, where is your sting?" (1
Corinthians 15:55). Physical and biological death remains, even
for those in Christ through faith. But the meaning and
significance of physical suffering, pain, and biological death
now takes on new meaning, new significance, and new
consequences within this new life (Romans 6:4) in Christ.

14. Through faith, believers are mysteriously united with Jesus in
both his sufferings and death, as he assumes the believer’s sin
and guilt in his own death, and in his resurrection (Romans 6:4,
2 Corinthians 4:14). Death is no longer a punishment for sin,
but a means whereby believers put off a perishable, mortal flesh
and put on an imperishable, eternal, and spiritual body at the
resurrection.
Eternal life is a present reality that Jesus explains, "Truly, truly,
I say to you, whoever hears my word and believes him who sent
me has eternal life. He does not come into judgment, but has
passed from death to life" (John 5:24); however, this present
eternal spiritual life still awaits a future redemption of the
body—a new spiritual body. This is the already and not yet
tension of faith that is present in the biblical view of salvation.
The Gospel of John in the New Testament records several
miracles Jesus performed that display his power over nature,
sin, and sickness. The climax of these miracles is Jesus’s
demonstration of his total victory over death in his raising of
Lazarus from the dead (John 11:1–46). Jesus announces to those
who witnessed the event, "I am the resurrection, and the life.
Whoever believes in me, though he die, yet shall he live" (John
11:25). James Montgomery Boice (1985), in his commentary on
John, explains the significance of this miracle and Jesus’s
claim:
The miracle shows that Jesus is the source of eternal life, that it
may be enjoyed here and now, and that the same power which
assures it now will also, after the death of the body, raise the
dead to a new and better existence beyond. (p. 353)
John’s Gospel points to the raising of Lazarus as a sign that
proclaimed Jesus’s power over life and death. It was an event
that led many who witnessed it and heard about it to put their
faith and hope in Jesus.
Future Resurrected Life
Human death is not the complete annihilation of the person
leading to nothingness. According to the Bible, all those who
die in Christ will be resurrected and given new spiritual bodies

15. when Jesus Christ returns. A spiritual body, according to the
Bible, is not some form of eternal disembodied existence like
the popular cartoon view of winged cherubs forever playing
harps on a heavenly cloud. This is a form of an ancient Greek
philosophy called Gnosticism. Gnosticism teaches that human
beings consist of a dualism of soul (i.e., the real person) and
body (i.e., the prison of the soul). The goal of Gnosticism is to
escape the body through death so that the authentic person can
finally be free and live forever. This is not biblical Christianity.
As discussed in previous chapters, the Bible speaks of human
beings as a duality, or a unity of body and soul (e.g., ensouled
bodies or embodied souls).
For those in Christ, physical death is a conquered enemy, and
comfort is found in the fact that to be "away from the body" is
to be "at home with the Lord" (2 Corinthians 5:8). Nevertheless,
the ultimate hope of a Christian believer is not a disembodied
spirit existence, but a resurrected bodily life. Biological or
physical death of the body does imply a death of this body/soul
unity and is not inconsistent with the concept of an intermediate
state of the soul between physical death and the resurrection.
The Bible does allude to the souls or spirits of the deceased
existing after death and before the resurrection (Luke 16:23–25,
28; 2 Peter 2:9). The Bible assures Christian believers that
death leads them immediately into the presence of God. But this
state of existence is temporary, incomplete, and provisional —a
human being is not totally a human being apart from the body
(Luke 20:35–38; John 11:25–26; 1 Corinthians 15:52–53; 1
Thessalonians 4:16).
The Bible also distinguishes between living in the flesh and
living in the spirit. This is a distinction between a life under the
domination of sin and in rebellion from God in which a person
trusts in his or her own works, and a life trusting by faith in
Jesus and his righteousness. The spiritual resurrected body is
not a ghostly disembodied existence, but a renewed bodily
creation uncorrupted by sin and its consequences. It is a life
that continues to experience relationships with many of the

16. things and people enjoyed during this life, but on a much
grander scale. It is not to be less than human, but more.
Reflecting on the nature of the resurrection, C. S. Lewis (1996)
understood that, "To enter heaven is to become more human
than you ever succeeded in being on earth"(pp. 127–128). In his
letter to the Corinthian Church, the Apostle Paul stretches the
imagination as he attempts to explain the mystery of the
resurrection and the nature of the resurrected spiritual body
with metaphors drawn from agriculture, comparative anatomy,
and even astronomy:
What you sow does not come to life unless it dies. And what
you sow is not the body that is to be, but a bare kernel, perhaps
of wheat or of some other grain. But God gives it a body as he
has chosen, and to each kind of seed its own body.
For not all flesh is the same, but there is one kind for humans,
another for animals, another for birds, and another for fish.
There are heavenly bodies and earthly bodies, but the glory of
the heavenly is of one kind, and the glory of the earthly is of
another. There is one glory of the sun, and another glory of the
moon, and another glory of the stars; for star differs from star
in glory.
So is it with the resurrection of the dead. What is sown is
perishable; what is raised is imperishable. It is sown in
dishonor; it is raised in glory. It is sown in weakness; it is
raised in power. It is sown a natural body; it is raised a spiritual
body. If there is a natural body, there is also a spiritual body.
Thus, it is written, "The first man Adam became a living being";
the last Adam became a life-giving spirit.
But it is not the spiritual that is first but the natural, and then
the spiritual. The first man was from the earth, a man of dust;
the second man is from heaven. As was the man of dust, so also
are those who are of the dust, and as is the man of heaven, so
also are those who are of heaven. Just as we have borne the
image of the man of dust, we shall also bear the image of the
man of heaven. I tell you this, brothers: flesh and blood cannot
inherit the kingdom of God, nor does the perishable inherit the

17. imperishable.
Behold! I tell you a mystery. We shall not all sleep, but we
shall all be changed, in a moment, in the twinkling of an eye, at
the last trumpet. For the trumpet will sound, and the dead will
be raised imperishable, and we shall be changed. For this
perishable body must put on the imperishable, and this mortal
body must put on immortality. When the perishable puts on the
imperishable, and the mortal puts on immortality, then shall
come to pass the saying that is written: "Death is swallowed up
in victory." (1 Corinthians 15:36–55)
A Christian believer’s hope is not in an unrecognizable
disembodied existence, nor in an immeasurably long life on a
perishable planet with a body constantly fighting against the
ravages of illness and disease, the contingencies of nature, and
the evils of a culture in rebellion from God. Rather it is a new
creation and new life in perfect peace and communion with
God, free of pain, suffering, and death.
Human Value and Dignity
·
A central concept in the ethics of many end-of-life issues is the
dignity and value afforded to each and every human being. It
has been a fundamental theme of this text that, according to the
Christian worldview, every human being is made in the image
of God and possesses innate dignity and worth regardless of
race, ethnicity, socioeconomic status, stage of development, or
mental/physical functional capacity. This dignity and value are
given by God and are therefore inviolable.
The term human dignity has become an important and powerful
rhetorical instrument that is thrown about carelessly in many of
the debates surrounding end-of-life issues such as euthanasia,
physician-assisted suicide, and the treatment of individuals in
so-called permanent or persistent vegetative state. The term
itself is not foundational because it can mean different things to
different people depending on how it is used and how it is
defined. Because human dignity is not always clearly defined in
contemporary medical ethics discussions, it can be used by both

18. sides of many discussions to support different positions. This
lack of definition and subsequent confusion contributes to much
of the polarization surrounding many bioethics issues. A clear
understanding of how this term is defined and used to support
varying positions is vital to mapping the contours of many of
the current debates on end-of-life issues, especially within a
secular culture.
In his 1996 encyclical letter, Evangelium vitae, Pope John Paul
II affirmed, explained, and defended the Catholic Church’s pro-
life stance against abortion, physician-assisted suicide, and
euthanasia. In this pronouncement, he maintained the core
belief that "society as a whole must respect, defend, and
promote the dignity of every human person, at every moment
and in every condition of that person’s life" (John Paul II, 1995,
n. 81). During the same decade that Evangelium vitae was
published, the Swiss organizationDignitas was established.
Dignitas was founded to promote euthanasia and the right of
persons to choose the manner and timing of their own death as
well as provide individuals with the means to do so. Their motto
was "to live with dignity, to die with dignity."
How can the Catholic Church and the organization Dignitas,
both with completely different beliefs and practices, appeal to
the same concept of human dignity to support their positions? It
is obvious that the term human dignity is being used differently
and to represent very different ideas. When John Paul II used
the term, he was referring to a specific theological concept,
namely, the image of God that all human beings possess. On the
other hand, Dignitas’s motto was meant to convey the idea that
the rational autonomy of every individual was central to their
dignity as a human being. Autonomy, in this case, is understood
as individual self-rule, without any controlling interference or
limitations.
Autonomy
While the differences can be subtle, it is important to
distinguish this use of the term autonomy from what is meant by
the principle of respect for patient autonomy as one of the

19. principles of medical ethics. The philosophical
term autonomy that is implied in Dignitas’s motto and exhibited
in their ethical position is much broader, comprehensive, and
absolute than the term autonomy as used by Beauchamp and
Childress in their book Principles of Medical Ethics.
On the broader understanding of autonomy presupposed by
Dignitas, without the right to self-determination, specifically
the ability to control the time and manner of one’s death, one
was not truly autonomous and, therefore, deprived of dignity.
One author has suggested that Dignitas’s motto should read, "To
live with autonomy, to die with autonomy" (Genuis, 2016, p. 8).
James Griffin (2002) succinctly summarized this view of dignity
when he said that, "autonomy is a major part of rational agency,
and rational agency constitutes what philosophers have often
called, with unnecessary obscurity, the ‘dignity’ of the person"
(p. 131).
Because of the way the term dignity has come to simply mask
an appeal to more fundamental concepts such as autonomy
without adding any significant content, some contemporary
bioethics scholars have referred to the term dignity as "stupid"
(Pinker, 2008, p. 28) or as a "useless concept" that "can be
eliminated without any loss of content" (Macklin, 2003, pp.
1419–1420). Despite the ambiguities of definition, the problem
is not with the term dignity itself. Dignity provides a language
for discussion about what makes a human being worthy of honor
and respect, a concept that is essential to any discussion of
medical ethics. The question is, what it is about human beings
that makes them worthy of honor and respect—that which
provides for, and is foundational to, their dignity? Is that which
makes human beings worthy of honor and respect contingent
and relative depending on certain characteristics or i s it
something that is absolute and inviolable?
According to the Christian narrative, human value and worth is
based on the more fundamental concept of being created in the
image of God, a concept that has been central to many of the
arguments in this text. Human life has incalculable value

20. because it is created, upheld, and sustained in spite of sin,
redeemed by God, and is ultimately destined for eternal
communion and glory with God.
The Christian tradition also speaks in more theologically
grounded terms when it talks about the sanctity of human life
rather than dignity. The word sanctity comes from the
Latin sanctus, which is usually translated as “holy.” In the
Bible, holiness, which can sometimes mean righteousness or
perfect goodness, has the deeper connotation of being set apart
for a special or sacred use. Human life is sacred because all
human beings have been set apart from the rest of creation by
their Creator. They have been given special purpose and a
special relationship with their Creator. This special sacredness
is what makes sin so disruptive and so deserving of God’s
judgment. This sacredness, because it is given by God, confers a
transcendent or alien dignity that is absolute and inviolable. It
is absolute because it does not depend on any arbitrary
characteristic that a human being may or may not possess, gain,
or lose. It is inviolable because it is not relative or dependent
on the changing utilitarian needs of society or the majority.
The Christian concept of the dignity of all human life provides
the rationale and guidance for the Christian health care
professional’s calling, the call to care for human health. It also
forms the underlying justification for the Christian response to
many of the ethical controversies surrounding end-of-life
issues, including physician-assisted suicide, euthanasia,
termination of life support, counseling those who are facing
their own death or the death of a loved one, and preparing
oneself to die well in Christ. Even the medical definition of
death, and the controversies surrounding brain death and organ
donation, depend on a view of human worth and dignity
dependent on the biblical concept of being created in the image
of God.
Death in the 21st Century
Medical Technology and the Shifting Definitions
·

21. Before the advent of modern life-support technologies that
artificially support ventilation and circulation, death was a
relatively simple concept, easily diagnosed by the absence of a
beating heart and breathing. It was also a unitary phenomenon.
When any single vital-organ system ceased to function (e.g.,
respiration, circulation, or brain), the other systems quickly
stopped as well. The absence of pulse, respiration, and
movement were simple and reliable empirical indicators that
death had occurred. This classical definition needed to be
reevaluated, as the traditional criteria for determining death lost
its meaning in an age of advanced cardiopulmonary supportive
technologies that can mechanically support some vital
functions, such as ventilation and circulation, in the absence of
others, such as brain function. The concept of brain death as a
fundamental definition of death was derived from the idea that
circulation and respiration are vital functions because they
ultimately support brain function. Cardiopulmonary definitions
of death are valid and sufficient only insofar as they lead
inevitably to the irreversible loss of brain function; however,
they are not necessary for defining death in the presence of
artificially supported respiration and circulation.
The ability to successfully transplant vital organs, such as the
heart and lungs, also raises questions about death and when it is
appropriate to remove vital organs from a donor. The dead
donor rule states that the removal of vital life-sustaining organs
should never be from a living patient, which equates with
actively contributing to a patient’s death (i.e., active euthanasia
or physician-assisted suicide), and has been an important and
central requirement of transplantation legality and ethics
(Robertson, 1999). While the concept of brain death certainly
improved the development and advancement of vital-organ
transplantation, this alternative definition and criteria for death
developed independently of the developments in transplantation
and was not developed solely to benefit transplantation
(Machado, Korein, Ferrer, Portela, de la C Garcia, & Manero,
2007).

22. Despite the philosophical and medical controversies involving
the definition of death that are still being raised in the advent of
further medical and surgical advances, death should remain a
nontechnical term that can be used broadly and correctly by the
general public. The definition of death and its timing should not
rely on arbitrary social conventions or utility. Death is
fundamentally an irreversible biological phenomenon that is an
event and not a process (Kass, 1971). "Physicians should be
able to determine that death has occurred at some specific time,
at least in retrospect, and be able to distinguish a living
organism from a dead organism with reasonable reliability"
(Bernat, 1998, p. 16), while also recognizing that a precise
determination, given the nature of progressive multisystem
organ failure in the modern hospital environment, may be
technically limited and recognized only in retrospect. The Bible
also clearly distinguishes physical life and death. Death is not a
process, and there is no transitional physical state of being
intermediary between life and death (2 Corinthians 5:8;
Philippians 1:23, 24).
Logical Distinctions and Practical Implications
As stated at the beginning of this chapter, the meaning and
significance of biological death is determined by broader
worldview questions. Even the actual definition of biological
death is not a purely medical or scientific question, and
advancements in medical technology do not change these
fundamental definitions, although they may influence the
criteria for this definition and the empirical tests that are
available. While this may seem surprising, it is important to
recognize the philosophical and theological issues that are
raised by any definition of death. One way to do this is to
recognize distinctions between a definition of death, the
criterion applied to this definition, and the empirical tests that
examine and test for the specific criteria. These three aspects
must be carefully distinguished and not confused.
Death: Definition, Criteria, and Testing
Many of the ethical and legal problems raised by the medical

23. profession’s seeming inability to adequately define a given
point at which death occurs demands an analysis of the
conceptual levels of the term death that are involved. Almost
anyone can readily tell the difference between a living being
and a corpse; however, deciding the exact essence of life, as
opposed to death, from a scientific or medical context becomes
problematic, especially in the face of modern advances in life -
support technology. Life support is sometimes a misnomer,
because in many cases life is not being supported. A person can
be brain dead while technology artificially supports organ
functions. To say life support is only supporting vital signs is
also a misnomer in many cases because vital means necessary
for life, and in the irreversible absence of whole brain function,
things like blood pressure, pulse, and respiration are not
contributing to life at this point and by this definition. Words
can contribute a great deal to patient and lay person confusion.
An essential concept, or definition, must include a simple and
clear formula that is neither too broad or too general for its
application. Secondly, the criteria for application are those
standards by which one applies the essential concept to an
individual situation. Finally, how does one tell if the criteria
apply? This involves empirical tests, observational or
experimental, that may change as medical science advances.
An example of the application of these conceptual levels is as
follows. Suppose one defines death as the loss of personality or
consciousness. The essential concept in this case is simply
irretrievable cessation of personality or irretrievable loss of
consciousness. But what is personality? What is consciousness?
One must be able to establish criteria for personality (e.g., the
ability to feel, be aware of one’s environment and surroundings,
act, reason). How is this tested? What kind of experiments or
observations are necessary to assess the presence of personality
or consciousness in an individual? Consciousness itself is
particularly problematic because every empirical test currently
known can only test for the outward effects of or expression of
consciousness, not individual consciousness itself.

24. On the other hand, suppose one defines death as the loss of any
essential function of the biological organism. To provide
criteria for application, one must first define what is meant by
essential functions. Typically, this has been defined as an
irreversible, by any known technique, cessation of respiration,
circulation, and any central neural function. Finally, one must
apply the empirical tests to assess if respiration has indeed
stopped: circulation is gone and reflexes are absent. From this
framework, one can understand that the Harvard Ad Hoc
Committee proposal drafted in the 1970s was not a definition of
death, nor was it strictly a criterion for death, rather, it speaks
of irreversible coma. The Harvard Committee’s proposal is
merely a list of empirical tests for determination of an implied
criteria to which there is no definition (Report of the Ad Hoc
Committee, 1968).
It is important to understand that science can only provide us
with adequate empirical tests for established criteria, and these
will change as science advances. Criteria are based on both
philosophical and scientific concepts. Because there is both a
scientific as well as philosophical aspect, criteria are also
subject to change as the science advances; however, a definition
of death is a purely philosophical concept. When science
purports to provide a definition of death, it becomes scientism.
The criteria and the empirical clinical tests for those criteria for
different definitions of death discussed in the following section
are summarized in Table 4.1.
Table 4.1
Definitions, Criteria, and Clinical Tests for Death
Definition
Criteria
Clinical Tests
Permanent (irreversible) loss of any essential function of the
organism as a whole
Cardiopulmonary or Circulatory
Permanent cessation of respiration and circulation which leads

25. directly to whole brain death
· No pulse or blood pressure (circulation)
· No respiratory efforts
Whole Brain
Permanent cessation of all brain functions including the
cerebral cortex and brain stem
· No brain stem reflexes
· No responsiveness or voluntary movements
· No respiratory efforts
Permanent loss of what is essential to the nature of being human
(i.e., personhood)
Higher Brain (Neocortical)
Permanent cessation of all or essential neocortical functions
· Lack consciousness or cognitive (mental) function
· No responsiveness
· No voluntary movements
Whole Brain Criteria of Death
·
·
Death can and should be defined from a purely biological
perspective. This statement does not contradict what was said
before but is derived from a philosophical and theological view
of what it means to be a human being. This view acknowledges
that a human being is a single entity consisting of both a
material body and an immaterial soul. It is a duality of body and
soul together and not two separate parts. Hence the biological
death of the organism, the material body, is sufficient to mark
the death of the whole human being. Louis Berkhof (2011), a
Christian theologian, describes this complex twofold unity of
human beings:
Every act of man is seen as an act of the whole man. It is not
the soul but man that sins; it is not the body but man that dies;
and it is not merely the soul, but man, body and soul, that is

26. redeemed by Christ. (p. 192)
Together the physical and spiritual aspects of human beings
bear the single image of God and constitute the single essential
nature of human life. So, the question remains: What is the
biological definition of organismic death?
To define death as merely the cessation of life is tautologous
(i.e., saying the same thing with no added meaning). Defining
death as the soul leaving the body, as expressed in some popular
religious expressions, is unhelpful because it does not permit
any measurable criterion, is not consistent with the body-soul
unity of human beings, and, even if it did, cannot provide a
useful and measurable criterion for death. To the lay person,
death is simply when a person takes his or her last breath or
when their heartbeat has permanently stopped; however, this is
not a definition of death, but a recognition of when death has
occurred. Neither can death be defined more technically as the
cessation of all physiological functions of the body. It is well
known that certain tissue groups, such as hair and nails,
continue to grow for days after a person has died. Certain cells
can be removed from a dead organism and kept alive in tissue
cultures for decades.
The answer to what defines the death of an organism is
contained in the word organism. Death is the permanent
cessation of the function of the "organism as a whole" (Bernat,
1998, p. 17). Organism as a whole does not mean the whole
organism or the sum of its individual parts, but rather i t refers
to those functions of integration and control that contribute to
the unity of the organism (i.e., the critical organizing functions)
(Bernat, 1999; Condic & Condic, 2005). Death can then be
defined as that point in time when there is permanent and
irreversible cessation of the critical functions of the organism
as a whole. These functions include:
1. the vital functions of the spontaneous breathing and
autonomic control of the circulation,
2. the integrating functions that assure homeostasis of the
organism, and

27. 3. consciousness.
This definition of death has the advantage of being
unambiguous and can be applied to other higher animals. It also
accords with a natural understanding of what it means to be
dead across most cultures. The whole brain criteria, except for a
minority of Roman Catholic and Orthodox Jewish positions, is
compatible with the belief systems of the three major Western
religions, Christianity, Islam, and Judaism (Veith et al., 1977).
The Christian Medical and Dental Associations accept the brain
death definition as the "Christian View of Physical Death" in
their official position statements (Christian Medical and Dental
Associations, 2018).
With this definition in mind, the most appropriate criterion for
its application is the irreversible cessation of the clinical
functions of the entire brain. The word clinical is important
because it distinguishes systemic integrated functioning from
mere physiologic activity (President’s Commission, 1981). It
also refers to those functions that can be easily observed and
measured by bedside physical examination. This criterion does
not mean that every single neuron of the brain must be dead in
the same way that the death of every single myocardial cell is
not required for the determination of circulatory death. All that
is required is irreversible global neuronal death sufficient to
end the critical functioning of the organism as a whole. The
presence of residual spontaneous electroencephalogram (EEG)
signals, which can represent the isolated, purposeless, and
random activity of a few surviving neurons, does not indicate
systematic integrative functioning of the brain as a whole and
should not be a sole indicator that a patient is not brain dead.
Permanent cessation of the whole brain includes the brain
hemispheres, diencephalon, and brain stem. These three parts of
the brain are vital for controlling respiration and circulation
(brain stem), the critical integration of bodily functions (brain
stem and hypothalamus), and consciousness (the wakefulness
component of consciousness is provided by the brain stem and
the awareness component of consciousness is provided by the

28. thalamus and cerebral cortex). The whole brain definition of
death requires a higher brain and brain stem criterion as neither
is sufficient on its own. Neuroendocrine function may be
present despite irreversible cessation of cerebral hemisphere
and brain stem functions (Nair-Collins, Northrup, & Olcese,
2016), but is not inconsistent with the whole brain definition of
death (Russell, Epstein, Greer, Kirschen, Rubin, & Lewis,
2019). Using a thermodynamic model, Korien (1978) argued
that the brain is the critical and irreplaceable system of the
organism without which the organism can no longer oppose
entropy. When this entropy opposing system ceases to function,
despite other systems being supported by artificial means, the
function of the organism as a whole ceases, and the organism is,
by definition, dead.
In 1968, the 22nd World Medical Assembly published a
statement on human death, referred to as the Sydney
Declaration. From a clinical viewpoint, the Sydney
Declaration maintained that death "lies not in the preservation
of isolated cells but in the fate of a person" (Gilder, 1968, p.
493). In the same year, the Report of the Ad Hoc Committee of
the Harvard Medical School to Examine the Definition of Brain
Death published in the Journal of the American Medical
Association a landmark article establishing neurological criteria
for brain death (Report of the Ad Hoc Committee, 1968).
Although widely accepted, the report generated several
subsequent studies and criteria that only served to complicate
the actual diagnosis of brain death. In 1981, after suggestions
from the American Bar Association, the American Medical
Association, the National Conference of Commissioners on
Uniform State Laws, and the President’s Commission for the
Study of Ethical Problems in Medicine and Biomedical and
Behavior Research, the Uniform Determination of Death Act
(UDDA) was published to establish a uniform definition of
death by "accepted medical standards" (UDDA, 1981, p. 7) that
would be "clear and socially accepted" (Russell et al., 2019, p.
228). The UDDA is a nonbinding statutory text that was meant

29. to serve as a guide for state lawmakers to emulate. The
definition of death by neurologic criteria as outlined in the
UDDA is currently accepted as legal death throughout the
United States and the District of Columbia. It is not only
relevant for medical purposes, such as determining when a
patient can be an organ donor, but also has implications for
various legal situations, such as criminal cases, tort action,
estate law, and life insurance.
The current standards for clinical tests to determine brain death
in adult and pediatric patients, accepted by the majority of the
U.S. medical profession, were published in the 2010 "Evidence-
Based Guideline Update: Determining Brain Death in Adults"
(Wijdicks, Verelas, Gronseth, & Greer, 2010) and the 2011
"Guidelines for the Determination of brain death in infants and
children" (Nakagawa, Shwal, Mathur, Mysore, & the Committee
for Determination of Brain Death in Infants and Children,
2012). According to Wijdicks et al., (2010), the clinical
guidelines for adults are:
· Clinical Evaluation (Prerequisites)
· Rule out reversible causes
· Absence of metabolic or endocrine disorders
· Hypothermia
· Shock
· Depressant drugs
· Neuromuscular blockade
· Establish diagnosis (irreversible and proximate cause of coma)
· Clinical prerequisites
· Normal core temperature (>36° C)
· Normal systolic blood pressure ( 100 mm Hg) with or without
vasopressor support
· Neurologic examination (a single examination is sufficient in
most of the United States)
· Irreversible coma
· No motor response to painful stimuli in all four extremities
(excluding spinal mediated reflexes)
· Absence of decorticate or decerebrate posturing

30. · Absent cortical and brain stem reflexes
· No pupillary response to light; pupils remain fixed or dilated
(4-9 mm)
· No ocular movements to oculocephalic testing and
oculovestibular reflex testing (doll’s eye reflex and cold caloric
response)
· No corneal or eyelid response to touch
· No facial muscle movement to painful stimuli
· No gag, cough, or swallowing response to posterior
pharyngeal stimulation (e.g., esophageal and pharyngeal
suctioning)
· Apnea Testing
· Prerequisites
· Absence or reversal of muscle relaxants or respiratory
depressants
· Preoxygenation (PaOs > 200 mm Hg)
· No evidence of prior COs retention (COPD, severe obesity)
· Initial normocapnia (PaCOs 35-45 mm Hg)
· Ventilator frequency to 10 breaths per minute; positive end-
expiratory pressure (PEEP) to 5 cm H2O
· Testing
· Passive oxygenation and disconnection from ventilator
· 8-10 minutes of apnea; PaCO2 > 60 mmHg (or 20 mm Hg
increase above baseline)
· Respiration is defined as abdominal or chest excursions and
may include brief gasps. This represents a negative test. If
respiratory movements are absent, this represents a positive test
and supports the clinical diagnosis of brain death.
· Patients with severe COPD may not be able to safely undergo
apnea testing
· Hemodynamic instability constitutes an indeterminate test
· Ancillary tests
· EEG, cerebral angiography, transcranial doppler
ultrasonography, cerebral nuclear scan, MRI
· To be used only if clinical examination cannot be fully
performed or if apnea testing is inconclusive or aborted

31. As of 2010, there have been no reported cases in adults of
neurologic recovery after a clinical diagnosis of brain death
according to the AAN practice parameters (Wijdicks et al.,
2010). Despite this, there remains a significant need for
education regarding the clinical tests used to determine brain
death among both the general public and health care
professionals within all specialties. A 2014 study, for instance,
showed that a group of neurologists and neurosurgeons were
only able to correctly answer 54% of questions on a standard
test related to the intricacies of brain death determination
(MacDougall, Robinson, Kappus, Sudikoff, & Greer, 2014).
The concept of brain death can be difficult for families because
the patient looks alive. They are warm and have a pulse and
blood pressure. Their chests are moving even though this
movement is provided by ventilator. Counseling and education
are very important at this stage, but it is also very important to
remember that there are not two different definitions of death,
of which brain death is a special category. Brain death is
equivalent to circulatory death. There is no distinction between
being dead and brain dead. This also can be a cause of great
confusion with families and certain religious cultures. Under
brain death criteria, to be brain dead is to be dead by definition,
and one cannot say that a patient is brain dead, but not really
deceased. Health care professionals and hospitals are under no
obligation to care for deceased persons.
Physicians are ethically justified to unilaterally discontinue
treatment for patients declared dead by neurological criteria just
as they would if a patient had died from cardiopulmonary
criteria; however, these decisions should be sympathetic and
respectful of the social, moral, cultural, and religious
considerations of family and loved ones who may not
understand the accepted medical standards or hold to different
standards. Requests of family members, loved ones, or
surrogates to maintain life-support measures for a patient who
meets brain death criteria should be treated with understanding
and appropriate counseling. Such requests must be according to

32. the values of the patient, if that can be reasonably determined,
and not according to those of surrogate decision-makers. The
decision to discontinue artificial ventilatory support should
come only after full discussion with the family, clergy if
available, and possibly with the assistance of a hospi tal ethics
committee.
Beliefs about death can vary not only between, but within
religious traditions and cultures, and there still exists some
disagreements even within strict religious orthodoxies (Veith et
al., 1977). The question becomes, "Should individuals be
allowed to choose their own definition of death based on
religious or philosophical convictions?" Only New Jersey has
codified this accommodation in its state law: "The death of an
individual shall not be declared upon the basis of neurological
criteria…when the…physician…has reason to believe…that
such a declaration would violate the personal religious beliefs
of the individual (New Jersey Declaration of Death Act,1991,
§5).
In California and New York, one must provide reasonable
accommodation to objections. What is meant by reasonable
accommodation is left up to individual institutions (Lewis,
2018)? In Illinois, a patient’s religious beliefs must be
considered when determining the time of death (Lewis, 2018).
The American Academy of Neurology (AAN) acknowledges a
need to respect cultural and religious perspectives; however, the
AAN also recognizes the potential harms for accepting a
multitude of different definitions of death in a society that
would create medical, social, and legal confusion and
difficulties. Potential harms to the patient and/or family can
include "mistreatment of the newly dead, deprivation of dignity,
provision of false hope with resultant distrust, prolongation of
the grieving process, undermining of the professional
responsibility of the physician to achieve a timely and accurate
diagnosis, and an anticipated societal harm arising from a
negotiated and inconsistent standard of death" (Russell et al.,
2019, p. 4). The question is how much variation in the

33. definition of death and its declaration can be tolerated in a
single society?
Higher Brain Criteria of Death
·
·
Alternate definitions of death have been proposed that are based
on the loss of higher brain functions rather than the whole
brain. These definitions are based on philosophical definitions
of terms, such as personhood, and rely on a distinction between
being a person and being a human being. According to higher
brain definitions of death, it is the loss of personhood, however
that is defined, that determines whether a human being is alive
or dead, whether it is ethical to remove life-supporting
measures, or even if vital organs can be removed for donation.
Proponents of higher brain, or neocortical, criteria of death
limit the definition of personhood to human beings whose
cognitive functioning is intact, meaning that they are
"conscious” and “sentient" (Lizza, 1993, p. 363). An
individual’s moral standing within the human community ends
"when it is reasonable to deduce that there has been a break-
down of the link between bodily integrity and mental and social
capacity" (Veatch, 1981, p. 245) or "the loss of integration of
bodily and mental function" (Veatch, 2005, p. 353). "The
principle is simple. It relies on qualitative considerations: when,
and only when, there is the capacity for organic (bodily) and
mental function present together in a singly human entity is
there a living human being" (Veatch, 2000, p. 111).
For Veatch (2000), consciousness and cognition define that
which is essential to the nature of man. Veatch (2000) at times
appeals to classical Judeo-Christian notions of the integration of
mind and body, but these views are more representative of
neoplatonic dualism than the biblical view of man as a single
body-soul duality. Contrary to higher brain criteria, a human
being is a "sacredness in the natural biological order. He is a
person who within the ambience of the flesh claims our care. He
is an embodied soul or an ensouled body" (Ramsey, 2002, p.

34. xlvi).
When specific capacities or abilities define one as worthy of
respect and dignity, the decisions of which capacities or
abilities are necessary can become arbitrary and subject to mere
social utility. This is not just a theoretical concern, as is evident
in an article in the Annals of Internal Medicine that proposed
that medical care, including artificial nutrition and hydration,
can be unilaterally withdrawn and organs harvested from
persons who have lost the potential for cognitive functioning.
The authors’ rationale was ultimately economic, concerned
primarily with "the appropriate use of social resources" (Halevy
& Brody, 1993). As medical care becomes more expensive, and
resources become more limited with an expanding and aging
population, there will be an increased temptation to
depersonalize individuals and groups, to exclude through
redefinition, for the purpose of social needs (Hoehner, 2018).
Higher brain criteria entail serious slippery slope issues when
the criteria for death becomes confused or indistinct. One could
easily make the argument that if patients in persistent vegetative
states are to be considered dead, then patients with severe forms
of dementia may reach a stage whereby they similarly lack
"experiential and social integrative functions" (Veatch, 1975, p.
28.
Higher brain criteria of death are not univocal and do not apply
to other animals of high intelligence because they were intended
solely for Homo sapiens. These criteria do not entail what
society has traditionally meant by death. Would society condone
burying or cremating spontaneously breathing patients in a
persistent vegetative state who would be classified as dead by
certain higher brain criteria? "The fact that higher brain
proponents generally favor stopping their breathing and
heartbeat prior to burial shows that implicitly they too regard
such patients as alive" (Bernat, 1998, p. 17). Indeed, higher
brain criteria of death are a radical redefinition of death and
rely on an unbiblical view of the nature of human life. Death is
fundamentally a biological phenomenon applicable only to an

35. organism. The concept of personhood (i.e., higher brain
definitions) is a psychosocial or spiritual concept. Personhood
cannot die except metaphorically (Bernat, 1998).
Cardiopulmonary Criteria of Death
·
·
Despite acceptance by most medical professionals, the whole
brain criteria for death remains controversial (Shewmon, 2001;
Veatch, 2005; Verheijde, Rady, & McGregor, 2009). Because of
perceived difficulties with whole brain criteria, alternative
definitions of death have been proposed that go beyond brain
death and focus on total body somatic integration, which is the
structural disruption of all the essential functions of the whole
organism, including respiration, circulation, and the entire
brain. Proponents of this view cite specific individual cases
whereby patients declared dead by whole brain criteria retained
many of the body’s normal systematic physiological functions
for weeks and even months. Obviously, this definition and
associated criteria would drastically decrease the availabi lity of
viable organs for transplantation. Further research and future
technologies may compel a change in the criterion associated
with the fundamental definition of death as the cessation of the
function of the organism as a whole.
These alternative concepts remain a minority opinion, but,
along with cultural and religious challenges, they have fostered
some resistance to whole brain definitions of death in deference
to traditional cardiopulmonary criteria, which is the permanent
cessation of respiration and circulation. The language of the
UDDA does give the impression that there are two distinct
definitions of death, one by brain death criteria and another by
cardiopulmonary criteria; however, the conceptual argument
behind the UDDA is that there is a single conceptual definition
of death, which is the permanent cessation of all brain
functions. In the absence of effective circulation, the brain will
inevitably and permanently cease to function (whole brain
criteria).

36. Organ Donation after Circulatory Death
·
·
The success and progress of vital-organ-transplant surgery and
immunology has resulted in a demand for life-saving organs that
far exceeds the available supply of donors. Most organs are
obtained from heart-beating cadaver donors (HBCDs), or brain-
dead donors, because their hearts are beating at the time of
surgical procurement. Because of the increasing demand for
organs, alternative sources and protocols have been devised to
procure organs from patients who do not meet whole-brain-
death criteria, but do meet cardiopulmonary or circulatory
criteria (the terms essentially mean the same thing and are
interchangeable).
In the 1990s, the University of Pittsburgh Medical Center
developed a protocol to procure organs from patients when they
or their families decided to withdraw artificial life support
(UPMC, 1993). These patients are referred to as non-heart
beating cadaver donors (NHBCDs) because, at the time of organ
procurement, they have been declared dead by circulatory
criteria. For instance, a donor candidate would be one with a
terminal or end-stage disease but does not meet brain-death
criteria and consents for, or has a written advance/surrogate
consent for, withdrawal of life-sustaining medical treatment or
ventilatory support. Under various protocols, life support would
be discontinued in the operating room with the expectation that
a natural death by circulatory criteria would soon follow and
subsequent organ procurement could proceed according to the
dead-donor rule. These protocols are referred to as donation
after circulatory death (DCD).
DCD protocols, which are now widespread, remain
controversial. Central to the ethical evaluation of DCD are the
tests for circulatory death being employed. According to
circulatory criteria, heart function must be irreversibly absent
resulting in no blood circulation. The question revolves around
the definition of irreversible and the minimal period of

37. observation required to assure irreversibility. In other words,
does the term irreversible mean cannot be reversed under any
circumstances no matter what intervention is done, or does it
mean will not reverse under existing circumstances, as when no
further intervention is intended. When a heart stops beating and
circulation ceases, there is a minimal, but inexact interval of
time when it is possible for the heart to be restarted, which is
why CPR and ACLS algorithms work. In the case of DCD,
irreversibility takes on this second meaning as no further
intervention to resuscitate the patient is intended or desired. It
is not a question of whether the circulatory function can be
resumed, as there remains the possibility that it can, but
whether it will be, given the intention to not attempt any form
of resuscitation.
Complicating this discussion is the possibility of
autoresuscitation of the heart, in which the heart spontaneously
resumes function following a cardiac arrest that occurs without
pharmacologic or mechanical assistance or attempts at
resuscitation. This has been reported to occur within a range of
seconds to minutes of asystole. In a retrospective study of 73
controlled DCD patients, there was no occurrence of
autoresuscitation after a 5-minute period of asystole (Sheth,
Nutter, Stein, Scalea, & Bernat, 2012). Five minutes appears to
be a safe limit after which autoresuscitation does not occur and
is the period of time recommended by the Institute of Medicine
(IOM) for determining death by cardiovascular criteria in the
setting of DCD (Driscoll, 2012). After a 5-minute period of
asystole, irreversibility can be ascertained, death declared, and
vital organs removed in accordance with the dead-donor rule.
Despite the IOM’s recommendations, there remains no
universally recognized standard, and various organ procurement
centers have DCD protocols with mandatory observation periods
ranging from 2-10 minutes. The dilemma is that with shorter
periods of time, irreversibility cannot be assured, and patients
may not, in fact, be dead by circulatory criteria. Longer
observation periods increase the ischemic time of the donor

38. organs, which increases their chance of being damaged. The 5-
minute period appears to be a reasonable compromise between
reducing organ ischemic time and assuring circulatory criteria
are met.
Organ procurement after DCD presents many ethical challenges
and potential for abuse, especially with societal and medical
institutional pressures to increase the pool of organ donors.
Christian ethicists and organizations have taken a generally
positive but cautious stance, supporting the ethical practice of
DCD to enable the altruistic act of organ donation while at the
same time having grave concerns about the implementation of
DCD protocols in actual practice (Driscoll, 2012; CMDA,
2018). Using DCD as a means of euthanasia and physician-
assisted suicide is ethically unacceptable. It would also be
morally problematic to broaden DCD donor criteria to include
autonomously consenting and cognitively intact patients who
are not imminently dying but may, for example, suffer from
irreversible neuromuscular disease and paralysis, along with
those who are not terminal yet suffer from a perceived poor
quality of life.
The dead-donor rule, as a fundamental moral principle, should
not be abandoned or compromised merely to increase the supply
of organs for transplantation. While it is ethically permissible to
employ either whole-brain-death criteria or cardiopulmonary
criteria, they should be applied consistently and without
compromise to increase organ procurement. In the case of
circulatory arrest, a minimum of 5 minutes of postarrest
observation should be observed to assure irreversibility in
accordance with the definition of cardiopulmonary death.
There are several other moral principles that apply not only to
DCD, but to all organ donors (HBCDs and NHBCDs). These
include prohibiting any procedures, such as pharmacologic
agents or placement of vascular cannulas, prior to a declaration
of death that would cause the patient distress or discomfort,
which has the preservation of donor organ viability as the sole
purpose. Furthermore, interventions that only maintain or

39. improve the quality of donor organs cannot be the proximate
cause of the death of the donor.
A patient’s end-of-life care and treatment decisions should also
be free from external pressure for organ donation. Discussions
of whether to remove life-sustaining medical treatment or
ventilator support should be made independently of decisions
for organ donation. In the same manner, organ-procurement
organizations should refrain from contacting the patient or the
patient’s surrogate or family until that decision has been made.
Prior to withdrawal of life-support therapies, consent for
donation can be withdrawn at any time. Quality palliative
care and spiritual care should be provided during the dying
process, along with support of the family and loved ones.
Health care professionals who have moral objections to DCD
protocols should not be coerced into participating but should be
allowed the freedom to be excused without the threat of reprisal
or condemnation.
Ethical Issues at the End of Life
Euthanasia and Physician-Assisted Suicide
Definitions
·
·
The word euthanasia comes from the Greek meaning "good (eu)
death (thanatos)." Everyone desires a good death, an end to life
that is both peaceful and without prolonged suffering. That is
not the issue. What is at issue is the increasingly popular view
that a good death must include the option, or even obligation, of
taking one’s own life or having someone assist in doing so.
Euthanasia has come to mean intentionally causing or hastening
a patient’s death for generally good ends such as the relief of
suffering and pain. Active euthanasia is when some action is
performed, such as the administration of lethal doses of drugs,
that intentionally and directly leads to a patient’s death. Passive
euthanasia refers to a situation when medical treatments that are
readily available, nonburdensome, and clearly would enable a
nonterminal patient to live significantly longer are withheld

40. with the direct intent of ending a patient’s life or hastening
their death.
A more useful expression for passive euthanasia is intentionally
fatal withholding because it distinguishes the lethal intention of
withholding useless or excessively burdensome treatment when
death is imminent even with treatment. Euthanasia can be
voluntary, involuntary, or nonvoluntary. Euthanasia is voluntary
when a patient requests that someone end his or her life and that
request is honored, involuntary when a patient explicitly refuses
to have his or her life ended and their request is not honored,
and nonvoluntary when a patient’s life is intentionally ended
and the patient’s wishes are unknown or unobtainable.
Physician-assisted suicide (PAS), also referred to as physician
aid-in-dying or physician-assisted death, is a special case
of voluntary euthanasia with the assistance or supervision of a
physician to end a patient’s life, usually by providing access to
or making available a lethal dose of medication, instructions,
and advice on how to use it. In PAS, the patient is the active
agent who may or may not take those drugs or may do so at a
time of his or her own choosing (American Nurses Association,
2019). Physicians use their expertise to enable a patient’s
suicide. In active euthanasia, someone other than the patient is
the active agent. It is common in medical ethics discussions to
distinguish PAS from euthanasia, but this may be a distinction
without much of a difference. A physician participating in PAS
is still morally culpable as an agent or accomplice in a suicide.
The Distinction Between Accepting and Precipitating Death
There is an important ethical difference between intentionally
ending a life and accepting the end of life. It should be self-
evident that there is a medical and ethical difference between
refusing a heart transplant and deliberately ingesting a lethal
dose of sleeping pills. To precipitate death is to deliberately
introduce a "new lethal pathophysiological state" (Sulmasy,
Finlay, Fitzgerald, Foley, Payne, & Siegler, 2018, p. 1396) with
the direct intention of ending a patient’s life or hastening their
death. To accept death is to either refuse or withdraw medical

41. interventions that impede the progression of a preexisting lethal
pathophysiological condition because, in the patient’s or
physician’s judgment, a treatment has become too burdensome
or is not providing any proven medical benefit.
The difference between accepting and precipitating death is not
merely semantic. A refusal of or request for cessation of life -
prolonging treatment is not ethically or legally considered a
request for euthanasia, but an acceptance of death and
acquiescence to the natural process of dying. While some moral
theorists may equate these two and view them as morally
indistinguishable because they both have the same outcome,
namely the shortening of the patient’s life, the distinction is
still relative and important in medical, ethical, and legal
decisions. In the case of Quill v. Vacco (1994), the U.S.
Supreme Court rejected a claim of the Second Circuit Court of
Appeals that ending or refusing life-sustaining treatment "is
nothing more or less than assisted suicide" (p. 729). The
unanimous court decision noted that "when a patient refuses
life-sustaining medical treatment, he dies from an under-lying
fatal disease or pathology; but if a patient ingests lethal
medication prescribed by a physician, he is killed by that
medication" (Quill v. Vacco, 1994, p. 729). Suicide is morally
and legally distinct from the acceptance of death by
acknowledging the limitations of medicine.
Fundamental Worldview Differences
Supporters of euthanasia and PAS are typically sincere and
compassionate, desiring to be beneficent and respectful of the
dignity of suffering persons. However, these attitudes toward
respect for human dignity and compassion, and the difference in
meaning these attitudes reflect, illustrate the differences
between a Christian worldview and a secular worldview with
regard to dignity, human suffering, and what a good death
entails. For the secular-minded person, to end suffering by
means of ending the life of the sufferer is a rational act of
compassion. Conversely, for the Christian, suffering is to be
relieved to the extent possible within the boundaries and

42. principles reflected in the biblical worldview and God’s
directives to not kill an innocent person (Exodus 20:13;
Deuteronomy 5:17; Jeremiah 7:9; Matthew 5:21; 19:18; Mark
10:19; Luke 18:20; Romans 13:9; James 2:11). The words used
for kill in both the Old and New Testaments mean "to murder"
(Exodus 21:12–14; Leviticus 24:17–21; Numbers 35:16–31;
Deuteronomy 19:4–13).
The biblical worldview understands that intentional hastening of
death for any reason is a distortion of the idea of a good death.
In the Old Testament Book of Judges, a soldier by the name of
Abimelech suffers a skull fracture when a woman drops a
millstone on his head during the siege of a fortified tower.
Assuming his injury is mortal, he asks his armor-bearer to kill
him so that he would not suffer the "indignity" of being killed
by a woman (Judges 9:52–55). In another example, Israel’s
King Saul attempts to commit suicide by falling on his spear
when surrounded in battle. After his unsuccessful attempt, Saul
implores another to put him out of his misery and kill him (1
Samuel 31:1–10). These two examples are reminiscent of the
two main arguments for PAS and euthanasia, to avoid a loss of
dignity at the end of life and a compassionate relief from
suffering.
Both actions are condemned in the biblical narrative. It is a
failure to faithfully acknowledge the sovereignty of God over
life, death, and even suffering at the end of life. According to
the Bible, it is God who determines (Job 14:5), ordains (Psalm
139:16), and appoints (Hebrews 9:27) all the days of life and
the time of death. To request euthanasia or PAS is to abandon
one’s stewardship over God’s gift of life (1 Corinthians 6:19–
20). For the secular thinker, human dignity is centered on the
ability to autonomously control the timing and manner of one’s
death. For the Christian, human dignity is based on being
created in the image of God, a dignity conferred on each human
being by his or her Creator.
Organizational and Legal Positions
·

43. ·
During the past decade, there has been an increasing interest by
states to legalize PAS. While PAS is not a constitutional right
according to the U.S. Supreme Court, states may choose to
legalize the practice. As of 2019, PAS is legal in California,
Colorado, Oregon, Montana, Vermont, Washington, and the
Distinct of Columbia. Most referenda to legalize PAS are
defeated. In 2017, referendums were voted down in 27 states,
but new referendums appear each year across the U.S. Both New
Mexico and New York courts have ruled that there is no
constitutional right to PAS in those states.
Professional medical and nursing societies have historically
prohibited or opposed PAS. The American Medical Association
(AMA), the American College of Physicians (ACP), and the
World Medical Association (WMA) have all recently reaffirmed
their positions opposing euthanasia and PAS. The AMA House
of Delegates voted in their 2019 annual meeting to oppose PAS
as "fundamentally incompatible with the physician’s role as
healer, would be difficult or impossible to control, and would
pose serious risks" (White, 2019). In doing so, the AMA
reasserted the fundamental role of the physician as healer and
commitment to the Hippocratic principle to do no harm. The
ACP published a position paper opposing legalization of PAS in
2017, calling for improvements in the care of dying patients,
including increased awareness and improvement in hospice and
palliative care (Sulmasy & Mueller, 2017). The WMA
reaffirmed its position at its 2015 council session in Oslo,
Norway:
Physician-assisted suicide, like euthanasia, is unethical and
must be condemned by the medical profession. Where the
assistance of the physician is intentionally and deliberately
directed at enabling an individual to end his or her own life, the
physician acts unethically. However, the right to decline
medical treatment is a basic right of the patient and the
physician does not act unethically even if respecting such a
wish results in the death of the patient. (WMA, 2017)

44. The American Nurses Association (ANA) states that,
"Euthanasia is inconsistent with the core commitments of the
nursing profession and profoundly violates public trust…Nurses
are ethically prohibited from administering medical aid in dying
medications" (ANA, 2019, pp. 1–2). Other organizations that
officially oppose euthanasia and PAS include the British
Medical Association (Jaques, 2012), the National Hospice and
Palliative Care Organization (NHPCO, 2005), and the Christian
Medical and Dental Associations (CMDA, 2018).
Recent developments in public and professional attitudes toward
euthanasia and PAS may indicate an erosion of this opposition
to PAS, as support for these positions is coming from
organization membership. In 2016, members of the AMA and
the WMA sought to revise their organization’s opposition to
PAS, calling on their organizations to take a neutral stance on
PAS and provide advice to health care professionals who
participate in PAS in jurisdictions where it is legal (Frye &
Youngner, 2016). Sulmasy et al., (2018) warned that by shifting
to a neutral position, these organizations are in fact no longer
neutral. "To change from opposition to neutrality represents a
substantive shift in a professional, ethical, and political
position, declaring a policy no longer morally unacceptable; the
political effect is to give it a green light. Logically, neutrality
implies, ‘We are not opposed.’" (Sulmasy et al., 2018, p. 1395).
This was evident when, in 2015, the California Medical Society
endorsed a neutral position on PAS, and the next day’s
headlines announced, "California Physicians End Opposition to
Aid-in-Dying Bill" (McGeevy, 2015, p. B4; Kheriaty, 2019).
Is PAS Justified by Arguments for Autonomy, Freedom, and
Dignity?
·
·
The most prominent argument used to justify PAS is the
argument for autonomy. Autonomy over the control of one’s life
and the supremacy of private judgment have become the
equivalent of moral absolutes in modern culture. To be

45. autonomous is to have control and freedom to decide what is
most valuable and meaningful in one’s life, and this has been
extended to having mastery over one’s death, whether to be
killed or assisted in suicide, so long as it is voluntary. It has
been shown that in Oregon, those who received lethal
prescriptions exhibited uncommon personality types fixated on
issues of control (Oldham, Dobscha, Goy, & Ganzini, 2011).
Proponents of PAS insist that upholding a patient’s control and
freedom over the timing and means of a patient’s death is
considered a right, and physicians have a duty to satisfy that
right. Loss of autonomy is equivalent to a loss of human
dignity. To accept a health care provider’s role in PAS is to
respect and maintain the dignity of the dying patient.
Autonomy, however, is not a fundamental or overriding
principle in isolation from other principles of ethics in medicine
and society. While respect for patient autonomy has prima facie
priority in most clinical situations, and it must be weighed
against other principles of medical ethics such as beneficence,
nonmaleficence, and justice. Autonomy is not the isolated
exercise of will that can demand anything a person wants to the
exclusion of others, higher moral principles, or the goals of
medicine and society (Kekewich, 2014). If upholding a patient’s
control and freedom by acquiescing to any request, physicians
and health care professionals become mere functionaries or
technicians. If autonomy always trumps other ethical principles,
there would be no principled barriers to withhold or deny any
treatments requested by a patient. The ability to decline some
patient requests for the good of the patient or the good of
society is a requirement of medical professionalism and ethics
(Sulmasy & Mueller, 2017).
Legalization of PAS also has societal implications. If loss of
dignity and autonomy, meaning one has lost control and is
dependent on others, is used to justify PAS, what does this say
about those in society who are already heavily dependent on
others? This is why certain undervalued groups in society, such
as the elderly and disabled, oppose legalizing PAS because it

46. sends the implicit message that dependent persons have no
dignity and are better off dead (McDermott, 2010; Koenig,
Wildman-Hanlon, & Schmader, 1996). This is not just a
theoretical concern. With an aging population and health care
resources becoming increasingly expensive, aging and
dependent patients may be pressured or coerced into choosing
PAS (Hanson, 2018) or denied payment for expensive
treatments in favor of PAS (Richardson, 2017). As discussed
earlier in this chapter, human dignity is based on being created
in the image of God, which is universal and inviolable. All
humans possess dignity as special creatures of God, not because
society attributes dignity to them. God chose to send his only
Son to die for all human beings, "the whole world" (John 3:16).
How can such beings for whom God loved and sacrificed so
much lose their God-given dignity? Loss of control over one’s
life and death cannot be a source of dignity, and the goal of
maintaining complete autonomy in this life is a total illusion
(Ecclesiastes 6:10,12). Only God has complete providential
control over our life and death.
According to a Christian worldview, the arguments for freedom
and autonomy given by proponents of euthanasia and
PASpresent a distorted view of human freedom, denying the gift
and stewardship of life given by God. This form of supreme
autonomy and freedom also rejects God’s providential control
of and purpose for each person’s life. According to Pellegrino
(1996), the modern notion of autonomy and freedom,
assumes that the only purpose of human life is freedom from all
discomfort and pursuit of each individual’s notion of "quality"
of life. It denies any idea of solidarity or community in which
each person’s life has its special meaning regardless of how
demeaned it may seem to the beholder…it denies that our lives,
however difficult, may be instruments in God’s hand to shape
the lives of those among whom we reside. (p. 109)
The supreme act of freedom, according to the Bible, is the
sacrifice of oneself for others and yielding one’s freedom to
God’s purposes. In the Garden of Gethsemane, Jesus yielded his

47. will to that of his Father’s (Mark 14:36; cf. Matthew 26:39–46).
Yielding one’s freedom to God’s will and purpose, as the
ultimate source of true freedom, is the ultimate act of all true
human freedom.
Is PAS Justified by Arguments for Compassion?
·
·
The emotionally driven argument that PAS and euthanasia are
ultimately acts of compassion and mercy is very appealing to
many, as it should be. Christians share this concern for the
sufferings of others, looking to Jesus’ whole life as one fille d
with compassionate and merciful acts, especially for the sick
and dying. Compassion means “to suffer with,” and because
suffering is a universal human experience, when one feels the
suffering of another, that person is compelled to relieve it.
Proponents of PAS differ, however, on the moral status of
compassion as compared to the Christian worldview. For many
proponents of PAS, the emotion or feeling of compassion
justifies whatever means are necessary to end a patient’s
suffering, and not doing so is considered cruel or even evil. For
Christians, compassion means something different. While being
a laudable emotion and motivation, compassion is not a moral
principle by itself or a justification for any action deemed as
compassionate. "Compassion cannot justify intrinsically
immoral acts like usurping God’s sovereignty over human life.
Compassion should accompany moral acts, but it does not
justify them" (Pellegrino, 1996, p. 110). Like all other
emotions, such as rage and fear, compassion must be expressed
within ethical and moral boundaries. A Christian’s compassion
for others is grounded in God’s love for the world as founded in
Christ’s life, death, and resurrection. Without this supreme
example of love, compassion is wrenched from its moral roots
and has nothing to guide it.
Is PAS Justified by Arguments for the Relief of Pain and
Suffering?
·

48. ·
Relief of pain and suffering is a central component of medical
and nursing care, and the relief of end-of-life pain and suffering
is a major rhetorical theme of many arguments in favor of
euthanasia and PAS. For advocates of PAS, suffering is a
meaningless and unmitigated evil, and to escape suffering is
both moral and merciful. Many proponents of PAS view the
modern culture of medicine, with its emphasis on curing, to be
complicit in end-of-life pain and suffering (Karsoho, Rishman,
Wright, & Macdonald, 2016). Modern medicine is viewed solely
as a life-prolonging enterprise composed of paternalistic and
death-denying physicians. Moreover, many proponents view
palliative care to have limited ability to relieve suffering at the
end of life and, in some instances, to even produce suffering
(Karsoho et al., 2016). This perception supports the view that
one has only two choices: a gruesome and painful death in the
hands of mainstream medicine or a peaceful end to pain and
suffering through medical-assisted death.
This is a false dichotomy. Progress in hospice and palliative
care, symptom and pain control, and increased awareness and
availability of end-of-life comfort measures does not support
this view. It is not necessary for anyone to die in pain, and it is
ethically acceptable to refuse burdensome life-
sustainingtherapies such as CPR, ventilators, a feeding tube, or
dialysis when the burdens outweigh the benefits. Evidence
shows that those who request PAS where it is legal do so for
reasons other than fear of unrelieved pain and symptoms at the
end of life. The predominant reasons include loss of autonomy
and dignity or the fear of dependence and being a burden to
others (Suarez-Almazor, Newman, Hanson, & Bruera, 2002) and
not a fear of pain and suffering.
There is a difference between pain and suffering. Pain is the
objective unpleasant physical sensation mediated by nerves and
the brain that signals something is wrong in the body. Suffering
is the subjective way that pain is interpreted and the thoughts,
judgments, beliefs, and meaning one gives to pain. All objective