Living Wills

by Andrew Kerr

The following notes form the minimally-edited substance of one of the lectures I gave at the RPTS last week: they're certainly not definitive or the last word on the subject - no doubt there will be those whose own thoughts on the subject are more mature or developed (all constructive feedback will be appreciated).

I guess my target audience is those who have considered the matter to be simply "black and white": what I am really attempting to do is to give you pause to think about some of the matters that Christians need to consider when thinking about the appropriateness or need to make a living will (subsequently abbreviated to LW).

My rudimentary framework for approaching any ethical questions is to ask what contribution do the following areas make to the ethics of the subject under consideration, with the first criterion overarching and dominant (but since most of these bioethical topics are not dealt with explicitly in the Bible, it will be necessary to take other implicit factors into account).

  1. Scripture (Normatively, Contextually and Personally Considered - this structure is implicit in the applications of Covenant Law in Exodus 21-23 which fleshes out the Decalogue in various practical situations).
  2. Nature (General Revelation, Natural Law, Conscience, Commonsense etc..)
  3. Law (for the powers that be are ordained of God)
  4. Virtue (chiefly the Christian Triad of faith, hope and love, but extending to other graces which are to be cultivated throughout life to take stress out of crisis situations or decisions - like patience, bravery, contentment etc..)
  5. Kingship (Jesus as glorified God-Man is Meditorial King who rules both cosmos & church as Agent of Creation and Redemption - our Lord therefore has a double claim upon all our words, thoughts and deeds [and bioethics], as Maker and Saviour).

And so for the lecture notes (gleaned from various sources & resources)....

Bioethics – Lecture 07C
Living Wills & DNRs

Introduction

Organ donation, informed consent, patient autonomy, litigation culture, life support & DNR orders have led to Living Wills (LWs) in recent decades - these are being used to give legal guidance to end-of-life carers & decision-makers.

Definition

LWs (also called advance directives or healthcare directives), are legal documents that outline an individual's preferences & instructions regarding medical treatment & care: they are implemented in the event that the subject becomes unable to communicate their wishes due to illness or incapacitation. LWs guide healthcare providers, family members, & medical decision-makers, about someone’s end-of-life care preferences.

Uses

  1. Medical Treatment Preferences: individuals can specify types of medical treatments they do or do not want to receive in various situations - such situations include resuscitation, ventilation, dialysis & tube-feeding.
  2. End-of-Life Care: they can outline end-of-life preferences including palliative or hospice care in the final stages of a terminal illness.
  3. Organ Donation: they may include instructions about organ & tissue donation to be used in transplantation or for research purposes.
  4. Religious & Spiritual Beliefs: they can guide medical decisions in alignment with the faith values of the subject.
  5. Pain Management: individuals can express preferences for pain management & comfort measures to be taken in order to ensure that healthcare providers address their pain & symptoms effectively.
  6. Family & Loved Ones: they can provide guidance on who should be involved in medical decision-making & who should be notified about an individual's condition. They can also specify whether family members or a designated healthcare proxy should make decisions on the individual's behalf.
  7. Quality of Life Considerations: some allow individuals to indicate the level of impairment or loss of cognitive function at which the person would no longer wish to receive certain therapies.
  8. Personal Values & Preferences: they can state preferences regarding care settings (e.g., home vs. hospital), cultural considerations, & other factors that influence medical decision-making.
  9. Avoiding Family Conflict: they can help dissipate tensions among family members who may have differing opinions about the most desirable medical steps to take in a given situation.
  10. Legal Protection: they provide legal documentation of an individual's wishes, helping to ensure that their preferences are respected even if they are unable to communicate them directly.

Scripture

The concept of a will, or a last will & testament, is an unquestioned part of the culture of the Ancient Near Eastern biblical world. Wills were used to pass on an inheritance, or to dispose of family property to an heir, or other beneficiaries: however, they could only be put into effect at the point of death. Wills are mentioned in many places & they include the portion of the inheritance to which a person was entitled – the concept of a "will" is mentioned in Genesis, Psalms, Gospels, Epistles & Hebrews. It may well be that testamentary disposition is mentioned in Hebrews, but certainly Christ is regarded as the heir of all things, and this will is put into effect by the death of the Cross (in fulfilment of the terms of the Covenant of Grace). There is also some evidence of LWs made out by Word of mouth, and not necessarily by document, at the end of the lives of Joseph and Jesus – the bones of the former are to be brought up to the land in 400 years (according to the Promise), & this is given as a pledge of the Gospel; while in the latter case, Mary is given into the safe-keeping of John, while the disciple will now have Mary as his adopted mother - both are to take place in the event of the death of Christ. What needs to be carefully noted is that wills living, or not, are used either for personal property to be distributed later, or for the body or bond to be disposed or maintained in the event of death – the modern contemporary LW is different in this sense that it effectively disposes of the life of the person before the point of death: the LW, in some sense, and under certain circumstances, may be the means of killing or permitting the individual under consideration to die. The prayer of Christ in Gethsemane did not exalt His own perfect will – He was Most High & Most Wise who was able to account for every eventuality, whereas we cannot (this is a significant difference).

Nature

It is natural to want to faithfully honour the wishes of the deceased. Conscience may be troubled that a person, by their LW, is effectively instructing those who have the responsibility to preserve life to sanction the taking of life – many will feel uncomfortable at being forced to do something they have no wish to be involved in. For example, a doctor might be concerned about the emotional impact organ harvesting procedures will have upon a grieving family - & he may not wish to be bound by the LW. Why should we be bound by the wishes of another living person to whom we have no relational obligation or connection? Or a nurse might feel that she wishes to save the life of the individual and not allow them to die. There is something in conscience that may also dictate that perhaps a person may not have considered carefully all the repercussions of their decision - in such a circumstance we would be reluctant to prioritize personal autonomy at the expense of professional judgment. Nature also teaches us that only God has absolute undelegated authority to make decisions about life & death - as all His created life is sacred – it is not, therefore, in our gift to order the time or manner of our own, or someone else's, demise.

Virtue

Faith will seek to please God in every way & not ask another person to commit a morally-unsound act. Faith will also trust in the God of providence to place decisions in the hands of relatives we respect. Faith will be prepared to suffer according to the will of God, particularly if a circumstance arises which is prolonged and painful (though steps will be taken to alleviate distress in a fallen world by using the gifts distributed by the common grace of Christ). Faith will trust that God knows best - contentment & submission to the will of our Lord prevent us from being overly-concerned about trying to stage-manage every aspect of our lives. Love will be concerned to do nothing to tread on the conscience of a relative or to offend their Christian convictions on any matter - it will be slow to add to the grief of friends: equally, love for God will seek to honour all of the will of God above our own will – grace from Christ can pray in pain nevertheless let not my will, but Your will, be done. Wisdom is careful not to hasten death, grasps potential for abuse in sinful human nature, & thus fears giving permission under future cultural or regulatory change that might open a door unwittingly for Physician-Assisted Suicide (PAS) or euthanasia. Wisdom tries to account for all potential personal or circumstantial change or consequence – Gospel profession must not countenance PAS. Wisdom knows that in pandemics bed pressure can lead to unwarranted, or even callous, DNR (Do Not Resuscitate) orders, from exhausted staff (who should know better). Wisdom is careful not to bind or wound consciences of relatives or doctors, but considers potential family friction that will lead to later regret, guilt & stumbling. Courage avoids the cowardice of an easy escape DNR order. Wisdom understands the Dutch experience (there is massive risk of mission creep & non-consensual PAS).

Law

LWs have been in force for years on both sides of the Atlantic – but enforcement & implementation may vary locally (at least in the United States - UK readers should consult the Law as it currently stands in their own jurisdiction) . Where LWs & God's Will conflict, God must be obeyed by relatives and carers (the virtue of courage & patience will assist) - Scripture is our only infallible rule, guide & compass in matters of faith & ethics. Consulting a legal expert, & communicating with professionals & loved ones, is crucial for creating & implementing an LW.

Kingship

All needed faith, hope, love, courage, wisdom, trust, patience & contentment is found at the throne of God through union with the glorified Christ. We must honour the Laws of the Cosmic Heir, realize that our body belongs to Him & only King Jesus has the right to take life & dispose of our remains. We proclaim His lordship by making loving arrangements which prove we are His. We will tidy up our affairs in an orderly, dignified, way that adorns our profession.