Advance Directives and Living Wills

The following is an excerpt of a brochure, "The Sanctity of Human Life: A Time To Live, A Time To Die: Advance Directives and Living Wills," published by the Christian Life Commission, now the Ethics & Religious Liberty Commission of the Southern Baptist Convention. It is available at www.erlc.org.

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What is a living will?

A "living will" is a type of health care document known as an "Advance Medical Directive." An advance directive is a generic term for a form or document which expresses your preferences regarding medical treatments to be implemented in the event you are physically and mentally unable to make medical care decisions for yourself. That is, an Advance Medical Directive is a method of letting others know your wishes about treatment if you are unable to communicate those wishes at the time. There are several varieties of medical directives, including living wills, durable powers of attorney for health care, values inventories, etc. A "living will" is a specific kind of directive which is "restricted to rejecting life-sustaining medical interventions, usually, although not exclusively, when a person is terminally ill." Living wills have been in existence for over 20 years. Nursing homes and senior citizens’ centers have been supervising living will signings for several years.

Developing medical technologies, publicity about euthanasia and doctor-assisted suicide, and recent legislation have focused greater attention on living wills. On December 1, 1991, the Patient Self-Determination Act became federal law. This law requires personnel at all hospitals, nursing homes and hospices receiving Medicare and Medicaid reimbursement to advise patients upon admission of their right to accept or refuse medical treatments and to execute an Advance Medical Directive. These medical personnel must (1) document whether patients have directives, (2) implement medical directive policies and (3) educate their staffs and communities about medical directives.

While a living will may sound harmless and even desirable, there is the very real potential for future abuses. Before filling out a living will, be certain that you fully understand how much power and responsibility you are giving an attending physician.

What biblical principles apply to living wills?

No matter what the issue or technology, the Christian must always ask the question, "What does the Lord say? Are there precepts, principles or examples in the Bible that help us understand our Heavenly Father’s will on the matter?" While it is true that living wills are not mentioned in the Bible, it is not therefore true that the Bible has nothing to say about them. The Bible has much to say about life and death.

First, the Scripture says that human beings are made in the image of God, and He has invested our lives with sacred value (Gen. 1:26-27). Scholars disagree over the precise ingredients that make up the image of God in humanity, but at least one thing is clear: Human beings have a value and a unique place above all other forms of life on the earth. "The sanctity or sacredness of human life is a biblical doctrine that must be considered in any application of the Bible to medicine or science.

Second, the Bible teaches that God Himself is the giver and taker of human life. He is sovereign over human life. As Paul puts it in Romans 14:7-8: "For none of us liveth to himself, and no man dieth to himself. For whether we live, we live unto the Lord; and whether we die, we die unto the Lord: whether we live therefore, or die, we are the Lord’s." Whatever we decide about end-of-life issues, we must understand that we do not possess ultimate authority over life and death.

Third, the Bible everywhere condemns unjust killing. In fact, God clearly declares capital punishment for anyone, who with premeditation, unjustly kills another person (Gen. 9:6). There is no warrant in Scripture for active euthanasia or the intentional killing of another person because his or her condition appears terminal.

Fourth, Christians have the assurance of eternal life and the promise of the resurrection and must not be enslaved by the fear of death (Heb. 2:14-15). We have been set free from the fear of death through Christ, who conquered death for us.

Fifth, while suicide is not "the unpardonable sin," the Bible nowhere condones or speaks approvingly of suicide (1 Chr. 10:4, 13; Matt. 27:3-5; 2 Sam. 17:23; 1 Kings 16:18-19). Whatever you decide about end-of-life issues, suicide or active self-killing is not a biblical option.

Doctors, other care givers and family members want to know the wishes of their patient and loved one when the time of death is near. What are some of the problems with living wills?

1. The standard living will documents refer only to the termination of treatment. Most living wills only allow you to designate that you want certain medical treatments withheld or withdrawn, and "that (you) be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide (you) with comfortable care or to alleviate pain."

Some standard forms only allow you to say whether or not you want nutrition and fluids and whether or not you wish to donate your organs for transplantation. The desire to donate your organs at death is a very personal decision and one that you should make freely and without coercion. And the decision to discontinue food and water is a very complex and critical issue in medicine. First, the provision of food and water is the most basic of care and cannot be characterized as an "extraordinary measure."

Second, to cause a person to starve to death intentionally is unjust active killing, which is prohibited in the Bible. Third, euthanasia contradicts the role of the physician as healer. "The doctor’s role is healing, not to be the suspected purveyor of death."

The Christian Medical and Dental Society has declared, . . . we believe that physicians, other health professionals, and health care facilities should initiate and continue nutritional support and hydration when their patients cannot feed themselves. We are concerned that demented, severely retarded, and comatose individuals are increasingly viewed as "useless mouths" (we reject this dehumanizing phrase). Rather than encouraging physicians to withhold or withdraw such patients’ food and water, we encourage physicians to respond to God’s call for improved physical, social, financial, and spiritual support of all vulnerable human beings.

Furthermore, the [ERLC] has gone on record as officially opposing "any designation of food and/or water as ‘extraordinary’ medical care for some patients." An appropriate Advance Medical Directive should at least allow you both to specify the medical treatments you want maintained and the ones you might want discontinued.

2. Living wills may not be specific enough. Even the best of the approved living wills do not allow for sufficient options or details regarding treatment. The decision to discontinue food and water is a very complex and critical issue in medicine.

3. Living wills are vague. Phrases like "life-sustaining procedures," "treatments that prolong the process of dying," and "there is no reasonable expectation of recovery from extreme physical or mental inability" are very common in living will forms. Other phrases and words like "imminent death" and "artificially prolong the dying process" are highly problematic and impossible to define with precision. Their meaning and application will differ from case to case and will probably differ even over the course of one patient’s illness.

4. Living wills do not adapt to a patient’s condition. A physician and patient are in a covenant relationship which demands consultation and negotiation. The physician promises to provide certain treatments under certain conditions, and the patient promises to comply under certain conditions. Living wills usually do not allow for negotiation and revision of treatment decisions.

What are the alternatives to a living will?

1. Talk with your family about your values and wishes. Though the law is being tested at this point, it is still the case that most physicians will consult with and seek to honor the wishes of a patient’s next of kin regarding medical treatment. At least one other person in your family (preferably several) should know what you think about life and death and what you want done or not done if you are near death.

2. Execute a Durable Power of Attorney for Health Care.13 This medical directive enables you to name a trusted relative or friend to make your medical decisions when you cannot do so for yourself. This includes your right to refuse treatment you would not want. The Durable Power of Attorney for Health Care allows you to designate someone as your "attorney in fact," and empowers him or her to make health care decisions for you. Your "attorney in fact" does not have to be an attorney or doctor. He or she may be a spouse, relative, friend, neighbor or fellow church member. You should choose someone (1) who knows you well and shares your Christian values, (2) with whom you have discussed your wishes and (3) who is willing and able to serve as a decision-maker in what could be a very stressful time. Your local hospital administrator or attorney should be able to secure a Durable Power of Attorney for Health Care for you to review and explain it to you. If there is anything you don’t understand in the document, you should ask for the assistance of a competent attorney.

3. If you are uncomfortable placing life-and-death decision-making on the shoulders of a loved one, or if you have no one who may serve as your attorney in fact, you may wish to sign a "Will to Live." The Will to Live differs from standard living wills in its strong presumption in favor of life. That is, the Will to Live instructs your physician(s) to do what is necessary to preserve your life "without discrimination based on (your) age or physical or mental disability or the ‘quality’ of (your) life" and rejects "any action or omission that is intended to cause or hasten death." The Will to Live designates food and water as basic necessities and allows you to specify treatments you would want withheld or withdrawn under certain circumstances. The document also defines "imminent death" as, when "a reasonably prudent physician, knowledgeable about the case and the treatment possibilities with respect to the medical conditions involved, would judge that I will live only a week or less even if lifesaving treatment or care is provided to me . . ." Very simply, the Will to Live is a pro-life, antieuthanasia alternative to a living will.