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Good evening. Let everybody get settled. Everybody is settled. Let's go.

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My name is Louie Donaldson, and I teach New Testament here at the seminary. And it is my pleasure this evening to introduce Dr. James Childress. who is Kyle Professor of Religious Studies and Professor of Medical Education at the University of Virginia, and is our 2001 E.C.

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Westerfeld Lecturer. As Professor Garcia noted this morning, Dr. Childress is a crucial and powerful voice in the growing field of biotechnology and ethics. And we saw this morning why his voice is so respected

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and why his writings are so influential. While telling us stories of people involved in reproductive technologies, we touched on wonderfully complex questions. What does it mean to be human? What is the proper role of nature, of the human imagination, of passivity, of manipulation?

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How do we weigh one good against another, one evil against another? Does God love submissive people or aggressive people? Does God live in natural processes or in human reason and human desire? In all of this, Dr.

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Childress offered a clear, honest, proving, insightful and moral voice. If, in Dr. Childress's words, we need communities of moral discourse, then Dr.

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Childress himself can help us be such. I give you Dr. James Childress and the second 2001 Westerfeld lecture entitled Life's Endings. Dr.

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Childress. Thank you very much for the introduction. And thank you very much for appearing this evening. I must say, I'm impressed by your stamina and endurance.

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You have had a full day, and it's understandable if you fall asleep tonight. Good genes, okay. Life's endings. Let me sketch a personal, professional, and social context for the remarks I'll make this evening.

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The personal context. In August 1994, my first wife of close to 36 years died following a year and a half long battle with non-Hodgkin's lymphoma, surgery, chemotherapy, remission, quick relapse, more massive chemotherapy, radiation therapy, bone marrow transplant, and even quicker relapse and death from hepatic encephalopathy. We'd been in Boston for the bone marrow transplant. The University of Virginia's unit was down during that period.

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She'd received the transplant at Dana-Farber, and we returned to Charlottesville when it became clear that she would die in a short period. She had gotten to know our grandchildren in Boston. We didn't choose Boston because of the grandchildren, but it turned out to be quite fortuitous. Back in Charlottesville, hospice played a very important role.

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in helping her, helping me, helping other members of the family during the few weeks she had left. Her dying was continuous with her living, and she continued to smile and think first about others. But it was also made easier by the care she received. That's part of the context for my reflections this evening.

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Another part of my context is my professional life, which involves me in the academic study of ethics, especially biomedical ethics. During my wife's battle with cancer, one of my colleagues from another institution asked if all my work in biomedical ethics had been helpful. And I responded, not a damn bit. Now that was, by the way, that kind of response was appropriate for those of you who know that the questioner was Stanley Hauerwas, and it was quite appropriate to respond that way.

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But that was an exaggeration. It did help in some ways, but the contribution of ethics as a critical reflection on morality is a limited one. Ethicists bring to the discussion not so much answers as familiarity with traditions of reflection, distinctions, categories, norms, et cetera. And expecting more than this

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can lead to frustration. That's probably what led one wag to say, if all the ethicists in the world were laid end to end, it would be a good thing. The third Part of the context for these remarks is the remarkable set of changes in dying over the last 50 years, over the last part, last half of the 20th century.

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Over 80% of the two to two and a half million people who die each year in the United States die in institutions such as hospitals and nursing homes. That figure is only 50% at mid-century. People live longer and die mainly from chronic degenerative diseases, often diagnosed two or three years earlier.

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Not only is the process of dying longer, but dying often occurs part by part, bit by bit, frequently leaving patients incompetent to express their wishes. Technologies administered by strangers can prolong dying, often at fantastic cost. It's no wonder that the process of dying seems to be feared by many more than death itself, even in a pitatively secular age that may have little confidence in what will come after this life.

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The words of Kent and Shakespeare's King Lear come to mind. Vex not his ghost, oh let him pass, He hates him that would upon the wrath of this tough world stretch him out longer. This image of stretching people out longer in the dying process is one that rings too true for many people.

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Now, these facts need a face. And we can see that face in the following case, a case that Dr. David Hilficker, a remarkably sensitive writer in medicine, Casey reports in the New England Journal of Medicine.

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He reports being called at 3 A.m. by the nurse at the nursing home where Mrs. T, an 83-year-old woman, had been confined since her stroke three years earlier. Mrs.

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T is now bedridden and aphasic, unable to communicate, weighs only 69 pounds, has decubitus ulcers on her back and hip. But Dr. Hilficker recalls her condition before her stroke, her dislike and distrust of doctors and hospitals, her staunch pride and independence despite her severe scoliosis, her wry grin every time he suggested hospitalization for some problem.

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While talking to the nurse over the telephone and deciding what he should do, he also recalls admitting her to the hospital after her stroke. one side completely paralyzed, globally aphasic, incontinent, and reduced to helplessness. And he crawls aggressively treating the pneumonia that developed, providing intravenous antibiotics despite her apparent desire to die. He rationalized that she was depressed and would get over it.

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Now the nurse reports that she has a fever, 103.5, hasn't been eating much the last few days, and has a little cough. Dr. Hillficker decides that he should not wait until the morning, and he goes to the nursing home to examine Mrs. T, who peers at him from behind her blank face.

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His tentative diagnosis is pneumonia, and he asks the nurse to call the technician out of bed for a chest x-ray and also orders a urine culture. As Dr. Hillficker and the nurse discuss the case, they note that Mrs. T's only friend in the nursing home, who probably knows better than anyone else what Mrs.

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T would want, has said that she hopes there wouldn't be any heroics if Mrs. T. got sick again.

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But the only relative, a distant niece who lives far away, had called to request that everything possible be done for Rant. And Dr. Hilficker reflects there in the middle of the night. I quote a paragraph from his essay.

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I considered doing everything possible for Mrs. T, transferred to a hospital, intravenous lines for hydration antibiotics, thorough laboratory and x-ray evaluation, twice daily rounds to make sure she's recovering, more toxic antibiotics, even transferred to a regional hospital. None of it is unreasonable. And another night, I might just choose such a course.

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But tonight, my human sympathies lie with Mrs. T and what I perceive as her desire to die. In any event, I decide against the heroics. But I can't just do nothing either.

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My training and background are too strong. I do not allow myself to be consistent and just go home. I'm still quoting. Compromising and ultimately making a decision that makes no medical or ethical sense at all.

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I write orders instructing the staff to administer liquid penicillin to encourage fluid intake, and to make an appointment with my office so that I can re-examine Mrs. T in 36 hours. The statistics I presented, and also the case,

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raised for us an important question, and that is, what counts as good dying? What counts as a good death? Now, in a pluralistic society, we may have as many conceptions of a good death as we do of a good life. In the Middle Ages, a good death involved time to prepare for the judgment day, to repent of one's sins, and to set things right.

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And there were set ways to die, the art of dying. Now, for many, a good death is quick and easy. Roy Porter, a prolific historian of medicine and the author of The Greatest Benefit to Mankind, A Medical History of Humanity, is fascinated, as the book title would suggest, by health, but also by death.

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He calls ours an age of anxiety about death, But he's not sure whether this anxiety is really the fear of oblivion or whether it's the fear of having a bad death. And he notes that in the past there was a theater about dying, and you stage managed your illness and your death. You prepared to die and had your speech ready.

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One of his favorites comes from the deathbed words of Oscar Wilde, who reportedly said, My wallpaper and I are having a duel to the death. One of us has to go. Well, Porter says that ideally he would like to die while gardening.

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And he would like to be quick, but not so quick as to deny him the chance to utter a final von mott. I quite like the idea of being conscious of dying, but actually in the middle of doing something at the time, rather than going through a long process. But when death is delayed, when dying is drawn out, patients often go through stages, as Elisabeth Kubler-Ross taught us, denial, anger, bargaining, depression, acceptance.

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And the notion of stages of dying, of responses to dying, that was an illuminating metaphor. But some of Elizabeth Kubleross's followers converted these descriptive, metaphorical stages into prescriptive steps for dying and tried to get patients to die properly by passing through the four negative steps to the final and high stage of positive acceptance. But as ethicist Larry Churchill notes, to put the dying into stages is to control them. is to deny them the needed opportunity to tell us what dying means to them.

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Persons should both die and understand their dying in the manner they deem most appropriate, as long as the rights and welfare of others are not significantly abridged. Only the dying can determine the meaning of their lives and deaths. Caregivers should approach the dying not in terms of rigid stages, but in terms of metaphors of drama, narrative, stories, within which people locate the meaning of their lives and their deaths.

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For example, Flannery O'Connor, the great short story writer, novelist, who suffered from lupus for several years before her death, located her life within the Christian story. Hence, recalling Jesus' life and death, she could say in the year she died, I haven't suffered much to speak of. Now, there are important Christian convictions that relate to our conceptions of a good death and a good life. And some of these have significant bearings on how we may act to end life.

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Which of life's endings, especially if humanly chosen, would be acceptable? Now, part of the context, theological context for these reflections, obviously starts with God's covenantal actions, beginning with creation of human beings in His own image. A conviction that has important implications for our decisions about life and death. In Evangelium Vitae of the Gospel of Life, Pope John Paul II stresses that in the biblical narrative, the difference between man and other creatures

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is shown by the fact that only the creation of man is presented as a result of a special decision on the part of God to establish a particular and specific bond with the Creator. The life which God offers to man is a gift by which God shares something of Himself with His creature. And the biblical account back of that, of course, is then God said, Let us make man in our image, and after our likeness, let them have dominion. So God created man in his own image, and the image of God he created him, male and female he created them.

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And God blessed them, and God said to them, passage I quoted earlier, be fruitful and multiply, and so forth. Now the image of God has been interpreted in various ways. Reason, free will, spiritual capacities, including the capacity for self-transcendence, but major strands of Christianity view the human person as an animated body or embodied soul or spirit, and as relational rather than atomistic.

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No doubt, beliefs about the creation of human beings in God's image have some overlap or converge at points with secular views of autonomy and respect for autonomy. But Christianity stresses both embodiment and relationality in a way that prevents easy identification with secular views of autonomy that seem to emphasize almost exclusively human will. For example, one Protestant theologian criticizes modern secular views of autonomy for holding that when it comes to life and death,

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Each individual is a modern sovereign over his or her own existence. Of course, he continues, The Christian community would judge unacceptable such a view of human autonomy, in part because that view declares that individuals own their own bodies and have unlimited dispositional authority over them. And by contrast to that modern secular view, again, there's overlap with the Christian view. Christianity holds that divine ownership and dispositional authority set the context for human trusteeship and stewardship.

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Now, the passage from Genesis indicates that scriptural directions for human agents to image or to obey God do include human dominion, a matter of trusteeship or stewardship, rather than unlimited control. This divine authorization of human dominion, which presupposes that humans are in but distinguished from the rest of nature, is critically important in debates about human responsibility in developing and using biomedical technologies to extend human life, to enhance the quality of life, and to meet various human needs and desires. There are further implications. One is that human agents created in God's image have a negative obligation to refrain from killing themselves or others who are also created in God's image.

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This obligation is stated not only in the Decalogue, thou shalt not kill, but also in the covenant with Noah after the flood. Whoever sheds the blood of man, by man shall his blood be shed, for God made man in his own image. The phrase sanctity of life often appears in modern discussions, but it's not a biblical phrase. And there is considerable debate about its appropriateness in contemporary discussions.

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But it may provide one way, if properly understood, to identify and express the intrinsic value of human life as an implication of God's creation. Nevertheless, human life does not have an absolute value in mainstream Christianity. For example, martyrdom is permitted, even encouraged in some contexts.

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Killing in war and in self-defense is usually accepted. Capital punishment is sometimes permitted. And for our purposes, letting terminally ill patients die is accepted under some circumstances, by the major Christian traditions.

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In addition to the obligation not to kill and this connection with creation in God's image, there are positive obligations to neighbors, neighbor love being obviously a major example. And that idea of neighbor love, the norm of neighbor love, could support, for example, assistance in suicide or a voluntary act of euthanasia if they are morally acceptable. Now, part of the debate, modern debate, concerns not only whether death is in a person's best interest and hence may be prayed for, but whether death may ever be brought about by direct killing rather than merely letting die. Now, a couple of other points relating to the theological themes.

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Creation in God's image could provide a positive warrant for playing God, at least in a fitting way. But we use the phrase playing God negatively, for the most part. We criticize physicians, healthcare professionals, and others who play God by usurping God's sovereignty and power over life and death, for example, by ending life.

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However, we sometimes also inappropriately play God by extending the dying process. And then we deny human finitude and mortality, make an idol out of mere biological life, and so forth. We'll consider how these lines are drawn and limits are set, at least how they've been traditionally drawn and set in a moment. One other point about

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the religious arguments that frequently appear against suicide and active euthanasia. They tend to draw on metaphors and analogies, usually between ordinary human relationships and activities on the one hand, and relationships between God and human life on the other. And many of these metaphors and analogies are central in Christian debates about suicide, They involve, as Margaret Pouse-Batten has noted, property relationships, personal role relationships, and some combination of those.

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For example, property relationships. A life is a loan or a trust from God, or life is God's temple, or God's handiwork, or image. If we move to the personal and or role relationships, human beings are God's children, sentinels, servants, trustees, et cetera. Now, if we think about life as a gift from God, then it involves both sorts of metaphors, property and personal or role relationships.

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Hence, the obligation to protect life, taking this framework, including one's own, grows out of God's gracious gift of life. And according to the gospel of life, again, man's life comes from God. It is his gift, his image, an imprint, a sharing in his breath of life.

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God, therefore, is the sole Lord of this life. Man cannot do with it what he wills or as he wills. The sacredness of life has its foundation in God and his creative activity, for God made man in his own image. Now,

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Debates about euthanasia and assisted suicide in the Christian context often probe these metaphors and analogies. Are there limits to what the recipient may do with a gift? If the gift is faulty, for example, and if, take an instance of that, there are serious genetic defects that show up in midlife, Huntington's chorea, for instance, May the gift be returned or destroyed?

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Or is the gift, which may involve considerable suffering on the recipient's part, then viewed as a way for God to test or to educate the recipient? So central in this discussion then is the evaluation of human suffering, whether it's valued positively, merely tolerated, or always opposed. Back in the mid-70s, when Dr. Henry Pitney Van Dusen, former president of Union Theological Seminary, and his wife jointly committed suicide, the presbytery of New York City had a pastoral letter that concluded, it is clear that for some Christians, as a last resort in the gravest of situations,

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suicide may be an act of their Christian conscience. In his Theocentric Ethics, James Gustafson takes a similar view. He holds that suicide is always a tragic moral choice. It is sometimes a misguided choice, but it can be, I believe, a conscientious choice.

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Life is a gift, and to be received with gratitude, but if life becomes an unbearable burden, There is reason for enmity toward God. Now, over Gustavson's views, we have Evangelical Darryl Amundson, who argues that Christian attitudes and responses to suffering and dying must be molded by the reality that their Creator and Sovereign will cause all things to work together for their good, and that the Lord has called them into a fellowship of His suffering, in which they are sustained by dependence upon Him.

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Hence, for Christians to take their lives in order to escape from the trials and testings ordained by Him would be a failure of love and a breach of trust. For Gustafson, such a view is naively anthropocentric because it assumes that God's activity will always, at least in the long run, promote individual well-being. Now, those convictions, and there are obviously many others that could be brought into the picture, particularly having to do with the views relating to life after death. But if we take the ones that we've discussed this evening,

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Those views, particularly what I might call the majority views, and Gustafson would fall in the minority camp if we look at the Christian tradition over time, those majority views have been expressed in various ways, in societal norms, distinctions, and categories that have, until recently, fairly reliably governed our decision-making regarding death and dying. Now, Christianity is not the only source of these norms, but it's certainly one important source. And these norms basically express the view that given all that we can say about the sanctity of life, the sacredness of life, there is no obligation to do everything possible. Back to the language of the case.

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Now, a strong consensus, again in part influenced by Christianity, developed around several standards of decision-making. And I want to talk about three of those and deal in particular with the challenges to the third. One has to do with direct and indirect actions in ending life. Second has to do with some categories that help us identify the circumstances

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under which a refusal of life-sustaining treatment would not be considered suicide, or withholding or withdrawing treatment would not be considered homicide. And the traditional language for those distinctions is ordinary, extraordinary, and I'll show in a moment why those, I think, are mistaken. And then the last distinction, the one that is being most seriously challenged, is the distinction between killing and letting die. because the argument for physician-assisted suicide or for active euthanasia calls into question the adequacy of that distinction to deal with all the important real-life cases.

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So there's a rough consensus, or there has been a rough consensus, about these three distinctions and the standards that reflect these distinctions. First, a distinction between indirectly hastening death by medications intended to relieve pain and suffering and discomfort. That has been acceptable. It has been acceptable and remains acceptable to use medications to provide the kind of treatment to the patient, to relieve the patient's pain, suffering, and discomfort, even if it is foreseen.

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by the professionals and the family members involved, that death will be hastened as a result. By contrast, what has been ruled out is directly killing the patient in order to relieve pain and suffering and discomfort. That would be the more efficient way, but that has been traditionally rejected. Now, this distinction, which again has played an important role in Christian reflections,

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has an existence outside of the Christian community as well. And it's reflected in a variety of professional codes and judgments, and it's reflected in various court decisions as well. So directly killing patients to achieve these ends is considered ethically unacceptable, but indirectly hastening death by medications intended to achieve the ends of relief of pain, suffering, and discomfort.

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That can be justified. So that's one set of distinctions, and the major challenge is that set doesn't take us very far. It deals, or helps us deal with,