How a 'spirituality of martyrdom' shapes a Christian approach to end of life care

Behind the legal push for physician-assisted suicide or euthanasia lies a real cultural confusion over end-of-life care, a fear of loss of autonomy and a fear of being a "burden" to loved ones. Travis Pickell, assistant professor of theology and ethics at George Fox University, is the author of "Burdened Agency: Christian Theology and End-of-Life Ethics," which addresses these concerns and discusses the current climate that has led to the increased legalization of physician-assisted suicide. He recently spoke with OSV News' Charlie Camosy about the principles underlying Christian opposition to euthanasia.

-- Charlie Camosy: Your new book with the University of Notre Dame Press, "Burdened Agency: Christian Theology and End of Life Ethics," is a bit unusual for an academic book in that it has appeared at exactly the right time to engage the culture on a very hot topic. What's your general sense of the state of the question when it comes to discussions of euthanasia and physician-assisted killing in the United States and Europe?

--Travis Pickell: Early critics of euthanasia and physician-assisted suicide often cited concerns about the dangers of a "slippery slope." In addition to opening up possibilities of abuse, they worried that legalizing these practices would erode existing moral norms against causing harm and would undermine medical practitioners' sense of professional identity and purpose.

As assisted suicide continues to be legalized in new states (in the U.S.) and new countries abroad (as the U.K seems well on its way to doing), and as the raw number of people dying by assisted suicide continues to increase where it is already legal, it seems that we are steadily sliding down the slope.

What is even more interesting (and troubling) to me is a second type of slippery slope that some early critics (like Daniel Sulmasy) pointed out: a "logical slippery slope." This one has to do with the logical tension between the supposed moral justifications of euthanasia and the existing restrictions we place on it.

For example, support for assisted suicide often appeals to a desire to minimize suffering (i.e., "compassion") and a commitment to respect for patient autonomy (i.e., "choices). But if "respect for autonomy" is truly morally important, then in what sense can we limit an individual's access to assisted suicide based on a requirement that the patient demonstrate a specific form of suffering (like "unrelenting and intractable physical suffering") or require a patient to have a terminal diagnosis?

Alternatively, if "compassion" is truly morally important, why should it be absolutely necessary for patients to demonstrate legal competence? Would it not be more compassionate to euthanize non-competent suffering patients, like some with advanced dementia, or never competent patients, like infants with "low quality of life" (as is legal under the Groningen Protocol in the Netherlands)? This is precisely what is happening now in Canada, as existing requirements (like a terminal diagnosis) have been stripped away, and qualifying conditions are being multiplied (including a proposal to allow for assisted suicide or euthanasia for all mental illnesses).

--Camosy: As you know, one of the main reasons people request physician-assisted killing is because, in some very real sense, they fear being a burden on others. Can you say more about this phenomenon?

--Pickell: This is exactly right. The slogan of "compassion and choices" suggests that physical or mental suffering at the end of the life is a primary motivation for people pursuing physician-assisted suicide, but statistics suggest a different story. In one study (out of Oregon in 2017), fewer than one-fourth of respondents cited "inadequate pain control or concern about it" as a primary motivation, while 56% named fear of being "a burden" and 90% named fear of a "loss of autonomy."

To me, this fact suggests three lines of reflection we ought to consider. First, on the surface level, it means that people are worried about the very real economic cost of end-of-life care. A stay (or more than one stay) in an ICU can be incredibly expensive. A sizable portion of our total health care spending occurs in the final weeks or days of patients' lives, with negligible impact on morbidity and mortality.

We have to consider whether our health care system is set up to care well for those who are vulnerable and those who are dying without leading to economic ruin for many people. This is a crucial question for public bioethics today.

Beyond that, however, there is also the question of what we mean by being a "burden?" Here we must reflect on the underlying cultural narratives that we all tend to live by -- narratives that associate "dignity" and worth with independence, ability and economic productivity. In my book, I suggest that these narratives are deeply embedded in our modern self-understanding, but they are deeply at odds with some core Christian convictions.

Finally, I think the concern with "being a burden" also relates to the difficulty of medical decision-making at the end of life. In my book, I discuss the notion of "burdened agency," the idea that we are now increasingly expected to make concrete choices about when and how we die, while simultaneously we live in a society that avoids death and that does not share very much in the way of cultural or religious guidance on how to die well. This can lead to an existentially fraught situation of fear and anxiety. I believe some people do not want to "burden" others with this kind of responsibility, though, as Gilbert Meilaender once pointed out, it is bearing one another's burdens that makes our relationships truly meaningful.

--Camosy: Folks need to read your book for the full answer, but can you begin to sketch out how Christian theology can help explain and respond to what is going on here?

--Pickell: In my book, I spend a lot of time excavating the underlying cultural assumptions behind our current end-of-life health care practices, especially assumptions about what it means to be a moral agent and what kind of agency is supposedly associated with a good and worthwhile life. To make a long story short, we tend to prioritize either rational autonomy or expressive individualism, two forms of agency that are primarily active, controlling and atomistic. And, to be sure, there are Christian thinkers who also emphasize these things. But, by and large, things look different when we explore the Christian theological tradition.

In Roman Catholic writings, for example, there is a consistent theme of trusting God in and through one's own dying, of "dying in the Lord." As theologians like Karl Rahner point out, this theme overlaps with Catholic teachings about martyrdom as faithful Christian witness, authenticating one's faith even to the point of death (a death, importantly, which is out of one's control).

So, I argue, that this theological tradition recommends a "spirituality of martyrdom," by which all Christians can see their dying as a form of witness to what it means to believe in God even unto death.

On the Protestant side, we might look to figures like Karl Barth or Stanley Hauerwas, both of whom emphasize the goodness of creaturely finitude and a cruciform and kenotic form of agency that is ultimately about learning to become "dispossessed," rather than being "independent."

Overall, I argue that Christian theology teaches us that we find our highest forms of flourishing in a form of submission and trust that is more "receptive" than active (or passive). Those formed and shaped into this form of agency may be in a better position to bear the burden of agency at the end of life without feeling they need to "take control" of their deaths in order to maintain dignity.

--Camosy: What are some practical ways readers can make sure their Christian theological values are reflected in their end of life treatment and care?

--Pickell: The philosopher Iris Murdoch once wrote, "At crucial moments of choice, most of the business of choosing is already over." While there are certainly things that we can do to advocate for affordable access to health care or just laws regarding assisted suicide and euthanasia, my own sense is that we also have to focus on question of formation.

Stanley Hauerwas once quipped that "we get the medicine we deserve." Christians, whose central practices (baptism and Eucharist) revolve around death and dying, should of all people be those who are comfortable talking about death and dying and facing it with trust.

Admittedly, as Justin Hawkins recently noted in his review of my book, empirically it does not seem that this is the case. Nevertheless, I believe (and argue in the book) that Christian practices are formative, and that God can and does help us to become more receptive (though I would not suggest that they do so "magically," but rather must be paired with good teaching and with a constant recognition of the forces of mal-formation that are all around us).

On the side of medical practitioners, we must recognize that the heart of medicine as a healing vocation is deeply contested, especially as medicine shifts from a Hippocratic (and Christian) understanding of the healer's art to a "provider or services model" that converts medical care into an economic and consumeristic exchange and empties it of its inherent telos. The question of formation, then, is crucially important in medical education if doctors and nurses and other health care workers are to avoid the dehumanization that often accompanies modern medicine.

For example, at George Fox University I teach a class called "Healthcare and the Integrated Life," in which students explore what it means to view health care as a Christian vocation, and what it means to become the kind of person who can sustain a commitment to that vocation over time (i.e., one who has developed virtues such as attention, compassion, courage, faith, hope and love). This is just one way that I hope to contribute (in the long run) to a more humane view of medicine, and to help create a context for dying well.