Euthanasia and Economics: A Doctor's Formative Experience

She weighed, I supposed, about 65 pounds. All of her limbs were withered and fixed into what is commonly called a fetal position. She was only in her early sixties. As a hospital resident doctor I had been called down to the emergency department to see her. She had been referred in from a nearby nursing home where she had been a long-time resident. It seems that the catheter that drained her bladder had become caught somehow during the process of routine removal for changing. It was my duty to discover a way to remove it.

She was a victim of a rare, incurable disease that causes the brain gradually to deteriorate over a period of years, usually beginning in middle age and always fatal. The judgment and intellect diminish along with the personality and control over the body. She lost control of bladder and bowel. She had not uttered a word in several years. Nor moved much. Nor seemed to understand. Nor swallowed food. She had been fed by a plastic nasogastric tube. Even now it protruded from her nose with the capped end taped to her skin.

I will never forget her. It was one of those experiences that I regard as formative in my personal medical ethic. The Word of God should determine what is right and wrong. Yet experience serves to bring the issues to my attention and allows a focus on the Scripture. The Bible instructs my experience. I am in the world. The Bible helps me be not of the world.

I discussed her plight with a urologist. He recommended a procedure from freeing the stuck catheter. It was the least painful we could think of. But it was not without pain. As I carried out the procedure, I discovered that she could still understand pain. She could grimace. At least, that is how I interpreted the contorted expression on her hollow face behind the tube and tape.

Her life had intrinsic value because she was human. She was formed in the image of God. I knew that the image of God did not refer to her physical appearance, whether or not it was marred by the consequences of Adam's sin. Yet was she still alive because we valued her or because we value our pretended omnipotence in the world? The technology that had preserved her physical existence is all commonplace nursing skill today. Special air mattresses do not qualify as extraordinary care. Nor does the practice of turning and positioning her frequently to prevent bedsores. Nor do catheters, nor plastic nasogastric tubes.

Yet plastic itself is so new my father recalls it as a novelty in college chemistry. Balanced liquid nutritional formulas were new when I was a baby. I remember easily the development of several types of air mattresses. Because we can, we muss. Because it is not extraordinary, we do it. Because someone else can be made to pay for it, we aren't even forced to think about is Scripturally. Even then her care was costing $18,000 a year. Had she lived another generation, she would have died when she was no longer able to swallow. Would she have wanted it this way? I never knew. There were no living wills then. I wish there weren't now. No family member evidenced interest or awareness. Opposition was rising at that time to the horror of abortion and its close relative euthanasia. At last evangelical Christians were becoming vocal against these evils. With interest heightened by this index experience and bolstered by numerous like ones since then, I have read our journals, newsletters, and publications. There is a persistent blind side in the anti-euthanasia effort. On this blind side are two errors.

One error is a failure to consider money. We are acting as if we are omnipotent when we pretend that we have the resources to provide what has come to be considered ordinary care. Those who would actively kill a sufferer are sinfully "playing God." Also "playing God" are those who believe that even sacrificial giving will satisfy the technological idols we serve, hoping to receive from them a prolonged material existence. The other error is that we overlook simple kindness of the Golden Rule variety. Would I have wanted to be treated as this patient was, even if no one had to be extorted to pay for it? No. Despite the simplicity of a nasogastric tube, I see it as no kindness as all, as prolonging death. As a human being with intrinsic value, the image-bearer of God, she had a right to expect of us bread. We gave her instead a stone.


Originally published in The Presbyterian Journal, February 12, 1986

Extending Life Expectancy?

I don’t think it’s been shown that the medical profession has had anything positive to do with extended life expectancies in the United States. It’s a definitional matter. It’s an epistemological matter -- how do you know what you know. You start with presuppositions about your view of a human being: a human being is a person conceived. The medical profession, alone, is accountable for a decrease in average life expectancy. From around fifty years around the turn of the century in this country, to around forty-five years today -- probably having passed through a time of greater life expectancy in the mid-forties to early sixties, after which abortion became commonplace. Definitional issues aside, for those people who were allowed to make it to birth, there has been a very substantial increase in life expectancy, which might in part be due to some of the things we do in medicine. It was just done at too high a cost, as we took the resources of those who were not allowed to live and diverted them into many things, one of which was vast medical establishment that now exists.


Excerpt from an interview with Dr. Terrell

Facts vs. Wisdom

Doctors are concerned about keeping up with the literature, which is absurd on its face. There are millions of articles published in English alone relevant to medicine every year. If you are so aware that you could hone them down to one percent of what is published, you would have a daily reading load so heavy that you could never keep up. We have confused data with understanding, and the acquisition of massed of so called facts with wisdom. It is particularly telling that the fear of the Lord is the beginning of wisdom. Medical schools never mention the Lord in any positive contexts, whatever. We have grown away from the wisdom that was, perhaps, once there in medicine. Once we dropped the integrating capacity of Scripture, the data no longer makes any sense.


Excerpt from an interview with Dr. Terrell

Good Ends and Good Means

Our duty is to discover His will and to do it and to let Him take care of the outcomes. He is trustworthy.

Americans are characterized by a “can do” attitude. We are performance oriented. While there are many advantages to this there are also characteristic faults. We are prone to seek control beyond our rightful sphere, to take over from someone else [by unjust means]... Don’t like the employer? Just sue him. Don’t like your neighbor’s trashy yard? Get a zoning ordinance passed. Don’t like the way your acquaintance is raising her child? Anonymously report her for child abuse. Don’t think people should use echinacea for their ailments? Use the FDA to have it prohibited.

One characteristic all of these approaches use is their ends-justify-the-means assumption. God wants us to seek good ends. He also wants us to use good means. Respecting His division of authority is basic.


Excerpt from "Trusting God or Trusting Ourselves"

Germ Theory and the Spirit

[The germ theory] is a powerful concept. Great things have been accomplished in medicine by application of this theory. Ask today what the cause of pulmonary tuberculosis is, and nearly every physician will answer, “Mycobacterium TB” or one of the other Mycobacteriaceae. More than just for infectious disease, the germ theory is typical of a set of models which posit a material cause for each disease.

Common to these models is the idea that each disease is caused by an unbidden, alien, and usually unseen agent which invades a person against his will. The job of medicine is to find the alien and cut it out surgically or poison it out medically. Preventive medicine is supposed to lock out the alien substance or to lock it up harmlessly -- be it cholesterol, elevated blood glucose, uric acid, or a developing nest of malignant cells. The patient's job is rather passive in all of this. The patient is basically to hold still while the doctor identifies and destroys the invader. The whole idea of prevention or therapy is to change as little of the person as possible. Only the invader needs to be destroyed. The person's attitudes, beliefs, motives, loyalties, or character are largely incidental to the process.

The germ theory has worked!

One and a half centuries later, we have become victims of our success in exploiting these models of disease which feature a "physical causative agent" that comes in willy-nilly on a gene or a germ. Thus planted and matured, this model of physical causation of disease has borne such fruit that people are trying to grow it well outside of its natural range.

Physical causation for presenting complaints of patients has been transplanted to problems which do not have a physical cause, though they may have a physical consequence in the body. In addition, though multifactorial models for disease are now in ascendance, all of the multitude of factors examined are physical factors. The spirit of the suffering person is neglected as a factor, let alone as a key factor. The idea of physical agency for medical complaints has pushed the spirit of mankind out of its proper claim.

I wish to maintain that the spirit of mankind is actually the primary factor in determining health or sickness in the United States, and that the "basic science," as it were, of spiritual matters is Biblical theology. It follows then that Medicine should be functioning from a biblical framework that makes the natural science methodology subsidiary to theology.


Excerpt from "Physician and Pastor: Co-Laborers"

Average Human Life Expectancy

Average human life expectancy is calculated by dividing the number of people in a given generation into all the years lived by that generation. Textbooks and journal articles today take as axiomatic that the unborn do not count when determining the divisor. They count all people born alive instead of all people conceived. When the fate of the unborn was unalterable, it was a reasonable and convenient shortcut to omit the unborn. Today it is a profound deceit. The tacit presupposition that the unborn are not persons has a marked effect upon what is “truth.” …The commonly held belief that life expectancy is increasing in the U.S. is rendered utterly false when the personhood of the unborn is considered.


Excerpt from "Average Life Expectancy, 'What Is Truth?'"

The Importance of Theology

All of Scripture applies to all of life. Theology is not something to be held between our ears, but something that permeates our lives. There is no area of life to which Scripture does not speak (2 Tim. 3:15-17). The Christian reformation extended to every area of life. As we have retreated from the breadth of Scripture to a theology that is only personal, we have seen the forces of evil rise to pummel God's world. The earth is the Lord's and the fulness thereof. We need to have answers for those who ask what they suppose are rhetorical questions or unanswerable questions.

Spiritual Medical Care

The fact that human beings are a folding together of body and spirit makes it important to consider the influence of the spirit upon illness and treatment. Medical care is intrinsically a spiritual activity. What one believes in one's spirit – about what is true, about the nature of the physical world, about how and why illness comes, and so on – will influence the choice of an approach to healing. The ill person, then, will want to select a practitioner whose spiritual orientation and beliefs are most in accord with his own, if possible.


Excerpt from "Freedom to Contract"

The Manual of Instruction

“No temptation has overtaken you except such as is common to man; but God is faithful, who will not allow you to be tempted beyond what you are able, but with the temptation will also make the way of escape, that you may be able to bear it” (1 Cor. 10:13). The word “test” serves as well as “temptation.” God provides ethical tests for us, and in them shows us Himself, the sufficiency of His Word, and shows us ourselves and our need of Him.

We are often lazy, and expect Him to show us some escape hatch experientially, as we read in accounts of people like Corrie ten Boom or others who have been sorely tested and delivered. Surely, He can do that. It is, though, His Word that is our manual of instruction.


Excerpt from "Trusting God or Trusting Ourselves"

Happy Pluralism?

A few native Americans include hallucinogens in their worship. Child sacrifice has frequently been a part of many religions. Temple prostitution is another frequent part, and may soon be making a comeback. Some believe in mercy-killing. Some polls (which are always suspect to me) indicate that a bare majority of Americans already believe in euthanasia. Birth control by any method, including abortifacient methods, is practiced by huge numbers. For the very few thoughtful ones in this group, the issue of abortion is often handled by religious concepts as to when the soul enters the developing human being, or when personhood begins.

We are awash in religious beliefs and the practices which stem from them. They are not at all compatible. Yet, we pretend that we can all live together in a happy pluralism. We cannot. It is absurd.


Excerpt from "Trusting God or Trusting Ourselves"

Fighting Infection

Being exposed to a microbe is clearly not all that is required to become infected. Being ready to receive the infection is the other side. Have you slept well? Have you eaten well? Are your relationships with other people in good condition? Have you done something needful for someone who cannot do for himself?

Psalm 41:1-3 says, “Blessed is he who considers the poor, the Lord will deliver him in time of trouble. The Lord will preserve him and keep him alive, And he will be blessed on the earth; You will not deliver him to the will of his enemies. The Lord will strengthen him on his bed of illness; You will sustain him on his sickbed.”


Excerpt from "Pharmacy and Medical Interventions"

Chiseling Out a Christian Culture

Culture is religion acted out, not merely an ethically neutral set of tastes in diet, dress, and dance.

If revival starts with the church, one thing we could do from our side would be to inculcate amongst ourselves an understanding of what Christian culture would look like. That way, we would be less apt to follow the pied pipers whose analyses of this or that problem are superficial at best, if not badly wrong. We might be able here and there to work out our salvation chipping away at the monstrous incubus on our land. Ultimately, only God can revive and deliver us, but I believe He expects us to have some knowledge in our head and a chisel in our hand.


Excerpt from a personal letter

A Person, Not a "Risk"

1 Corinthians 3:16-17 says, “Do you not know that you are the temple of God and that the Spirit of God dwells in you? If anyone defiles the temple of God, God will destroy him. For the temple of God is holy, which temple you are.” Later in 1 Corinthians, we are reminded that we are “not [our] own” and that we are “bought at a price” (1 Corinthians 6:19-20). In the book of the Revelation, we are told that there is a judgment of all.

A managed care organization may regard its subscribers as a number, an account, or some other kind of cipher, but we know them as persons with faces, who have certain habits (like showing up drunk or two minutes before closing time, or trying to get one child's medicine on another child's Medicaid). To the insurer, they are simply “a risk” which can be managed by the averaging power of large numbers in a policy-holding group. No one in Insurance Command Central is answerable before God for the health of the insurance policyholders. Those of us who know the patient can remind the patients of their personal responsibility. When the occasion permits, which in these days is, I think, rather rare, we should remind our patients.


Excerpt from "Pharmacy and Medical Interventions"

Medicine Serves People

Medical care has been misconstrued as the treatment of diseases by drugs, surgery, and other means. More properly, it is the treatment of persons who may have diseases, using available means. There is a huge difference.

The persons we serve have a spirit. That spirit is intimately connected to their body and the ailments of those bodies. Only personal contact by nurses, pharmacists, doctors, and others can effectively touch that spirit and its resources. We serve persons, and we use bags of chemicals as part of the means. We do not serve bags of chemicals.


Excerpts from "Pharmacy and Medical Interventions"

Confusing Data with Wisdom

[One way] Americans deal with the different standards dilemma is to confuse data with wisdom. We heap up information. Computers help. Estimates are that there are six million articles annually published in English alone which relate to medicine. We do computer searches. We find out how much it costs. What the risks are. What the various treatments are. These are statements of what is. We will return to them, for they are important in making ethical decisions. However, ethics is about what ought to be, or what ought not to be. Data is about what is, or what is not. Even stacked exceedingly high and heated, a pile of “is” statements will not convert to an “ought” statement. Empirical statements do not transform under pressure and heat to normative statements.


Excerpt from "Counseling Persons with Questions on Medical Ethics"

Narrow-Minded Empiricism

Now, one of my “oughts.” We ought to pay more attention to the empiric data than we do. As I have tried to do this, I have discovered that the empiric data is often thin, subject to various interpretations, and varying. The consensus as to the proper treatment of peptic ulcer disease, of acute myocardial infarction, and many other things have changed drastically since I entered medicine. We call these changes “advances” but sometimes you get to see the indicator needle swing not 180 degrees, but 360 degrees. What is more, our empiric information, even when it is accurate, sometimes expresses a narrow-minded or one-sided view of reality. The way we think of the causes of diseases in medicine betrays that we are very prone to be materialistic reductionists. We seek those causes which are tangible and visible and which are reduced to their smallest elements, such as biochemistry.

As example, what causes gonorrhea? We are taught in medical school that gonorrhea is caused by Neisseria gonorrhea, a gram negative coccus. The answer is only partial and, if allowed to stand in that form, leads into a narrowness. Most commonly, sexual intercourse is also involved. More than that, it is normally required that the sexual intercourse be that in which at least one of the partners has had intercourse with one or more others who had the germ. The coccus is a sine qua non for the disease, but other features are also required: (1) Sexual intercourse. (2) Sexual partners in that intercourse who have had intercourse with others. In fact, though the germ appears to be rather readily infectious, for the disease to continue its propagation among humans requires that sexual intercourse be considerably afield from monogamy.

Without these additional causal features, gonorrhea might actually disappear even without treatment as the infected persons died out without passing it on. Throughout my lifetime – I am about as old as penicillin – there has never been a time when we did not have a chemotherapeutic agent effective against Neisseria gonorrhea. Throughout my lifetime, however, the prevalence of Neisseria gonorrhea has varied and often has been much higher than when I was a child. Thus, the view that Neisseria gonorrhea causes the disease is incomplete. It doesn't work by itself. It is, dare I say it, narrow-minded. In addition to the bacterium is also required that sufficient numbers of the population believe that it is appropriate to engage frequently in non-monogamous sexual intercourse, and who act on that belief.

Medical ethics has been bound down by an inflexible, narrow-minded habit of viewing problems in their most materialistic terms. We feel comfortable dealing with bacteria in our patients' genital tracts, but not with the belief systems in their minds. Excuses are offered, such as, “You don't really think that people are going to suddenly become monogamous, do you? That's impractical.”

Though that is supposed to be an unanswerable rhetorical question, I submit that it is eminently answerable. First of all, it misrepresents the broader viewpoint. No, people won't “suddenly” do much of anything, as a whole. Secondly, if antibiotics have failed to perfectly eradicate gonorrhea, certainly parallel efforts working on the belief system needn't be expected to produce perfect results. Finally, I remember when the belief systems made a difference. In regard, therefore, to causes of disease, consider what causes heart disease, emphysema, AIDS, alcoholism, trauma. Do we think of the causes narrowly? Do we think of fried foods, cigarettes, the HIV particle, ethanol, or motor vehicles and firearms? If so, why? Even if we do not regard ourselves in medicine as capable of making a difference in the larger conceptualizations, do we obstruct others in society who are willing to take that approach?


Excerpt from "Counseling Persons with Questions on Medical Ethics"

Teasing Out Relevant Medical Information

One of the matters we need to know in counseling persons with medical ethical questions is the relevant medical information. This information is our unique contribution in helping people make ethical decisions. At some risk to being caught up in the example, I will proceed to illustrate this with an example. The example I chose is screening for prostate cancer, a hot topic in medicine now. I mentioned earlier as an ethical matter what to do when a 75 year old man without urinary symptoms asks about screening for prostate disease as he heard on the radio. I chose the example because I have faced the question often enough. This is not a baboon liver sort of issue. Further, it is one in which the relevant medical information is key.

I happen to be convinced that screening for prostate cancer in asymptomatic 75 year old men with current tools of PSA, digital rectal exam, ultrasound, and biopsy, or any combination thereof, ought not to be done. There are perhaps urologists or others who want to argue. I love to argue, but I do not wish to let one example capture the whole. I grant that there is another view of the data. The point is that this is an ethical question because it seeks an “ought” answer. The patient asks, “Ought I to have the screening?” And the doctor asks, “Ought I to recommend and do the screening?” Of course, there are additional implied “oughts” in the question: “I ought to seek to extend my life and my health if I can” is one of these. If the doctor and the patient are agreed on this implied “ought” about life and health, then the ethical matter hinges on the empiric information. Does screening of asymptomatic American men aged 75 years improve their health or longevity?

I suggest to you that a number of the conundrums of medical ethics, particularly those that are grouped under “distributive justice” – who gets what when resources are limited – can be reduced in size by attention to the empirical information – physicians, doctors, insurance, hospitals, drugs, nursing, and so forth. Many articles and talks today agonize over how to distribute “scarce medical resources.” I am repeatedly drawn to inquire as to the actual effectiveness of the resources. Medicine is not as solidly based in unequivocal scientific empiricism as we like to think. Much is done by consensus – we think so, we hope so, it seems so, we've usually done it this way, it is considered good practice to...


Excerpt from "Counseling Persons with Questions on Medical Ethics"

Prioritizing Risks and Benefits

As finite beings who do not know everything, we need to help our patients know relative risks. Life is risk. Health care decisions are often decisions of prioritization. No path is risk-free. We should not so focus upon the most fearful risk and back away from it without looking behind us to see what risks we are backing into. For a Christian, good stewardship means making the most of the resources we have to further the kingdom of God. That means making risk/benefit estimates.


Excerpt from "Counseling Persons with Questions on Medical Ethics"

Mechanisms vs. Empirical Information

We have a tendency to substitute the mechanisms we have learned for outcome data. Pharmaceutical detail people major in mechanisms.

Pharmaceutical rep.: “This new medicine – Lipid-lo – scours atheromas at their base, substituting a slick, non-stick Teflon layer while the displaced lipids are carried by the ultra low density lipoproteins to the liver, where they are recycled along with aluminum cans into bone matrix that reduces osteoporosis.”

Doctor: “If my patients take Lipid-lo, is there evidence that their all-cause mortality or morbidity will fall?”

Pharmaceutical rep.: “This study in Stockholm last year, where they've used Lipid-lo for 1000 years, shows that middle-aged men had 22% fewer cardiac events than a control group that did not take the drug.”

Doctor: “I said all-cause. Did the Lipid-lo group have more hepatitis, or cataracts, or renal stones, or such?”

Pharmaceutical rep.: “I have another study here from Ohio in which the cardiac output during acute M.I.'s fell 33% less in the treated group than in the untreated group.”

Doctor: “Wonderful! But, did the treated group on the whole live better or live longer than the untreated group?”

Pharmaceutical rep: “It comes in convenient dose form shaped like a pretzel. See, you can break it in several points to get the right dose without having to switch to a new prescription.”

It's as if we were talking past each other. Mechanism is offered in place of evidence of outcome. Mechanisms are wonderful mnemonic devices, but things that stand to reason do not always stand to evidence.

What has this to do with making ethical decisions? When communicating with our patients, adding our unique input, we should as often as possible speak in terms of net outcome as based upon evidence. In medicine we are prone to focus on numerators.


Excerpt from "Counseling Persons with Questions on Medical Ethics"

Numerator Medicine: Putting Back the Denominators

The infant who comes to the ER badly damaged by being shaken hard by a relative weighs in so heavily with us that we give scant thought to the actual risk. Our state has a program against shaken baby syndrome that is, I believe, ethically ill-conceived.

Now, I am not in favor of shaking babies! But the zeal of those who are out to reduce the damage from this practice has led them to publish a brochure recommending, among other things, that small children not be dandled on an adult's knee! Perhaps somewhere there is a case report or two of a child who had brain damage accurately traced to dandling. I doubt it. But, anything can be dangerous! Children drown in toilets. They fall down back steps. They pick up copperheads in the back yard. What is the net effect of dandling? Are there no good effects from the interaction between toddler and adult? I'm guilty. I've done it with our own children. I plan to be guilty if we have grandchildren. Are there no downside effects from further eroding the confidence of parents to take care of, provide for, to nurture their own children? What is the net effect? To know that you have to slide a denominator beneath the numerator. All children injured by dandling over all children dandled. The fraction must be infinitesimally small. Further, from this small fraction must be subtracted whatever diffuse but definite benefits there are in dandling.

When we are trying to provide medical information to our patients so that they can make an ethical decision, we need to be mindful of the skew our own viewpoint sometimes takes. We don't think normally, sometimes, especially when we are estimating very small numbers – the risk that a given 60 year old woman has a cervical cancer, that a breast lump in a 14 year old girl is a cancer, that an intraocular pressure of 24 represents glaucoma in a 55 year old man. And so on. Are we merchants of fear?

As finite beings who do not know everything, we need to help our patients know relative risks. Life is risk. Health care decisions are often decisions of prioritization. No path is risk-free. We should not so focus upon the most fearful risk and back away from it without looking behind us to see what risks we are backing into. For a Christian, good stewardship means making the most of the resources we have to further the kingdom of God. That means making risk/benefit estimates.


Excerpt from "Counseling Persons with Questions on Medical Ethics"