Reflect on the analysis of the sin of suicide and, thus, euthanasia from the topic readings. Do you agree? Why or why not? Refer to the lecture and topic readings in your response.  Ethical Issues at the End of Life Euthanasia and Physician-Assisted Suicide Definitions The word euthanasia comes from the Greek meaning "good (eu) death (thanatos)." Everyone desires a good death, an end to life that is both peaceful and without prolonged suffering. That is not the issue. What is at issue is the increasingly popular view that a good death must include the option, or even obligation, of taking one’s own life or having someone assist in doing so. Euthanasia has come to mean intentionally causing or hastening a patient’s death for generally good ends such as the relief of suffering and pain. Active euthanasia is when some action is performed, such as the administration of lethal doses of drugs, that intentionally and directly leads to a patient’s death. Passive euthanasia refers to a situation when medical treatments that are readily available, nonburdensome, and clearly would enable a nonterminal patient to live significantly longer are withheld with the direct intent of ending a patient’s life or hastening their death. A more useful expression for passive euthanasia is intentionally fatal withholding because it distinguishes the lethal intention of withholding useless or excessively burdensome treatment when death is imminent even with treatment. Euthanasia can be voluntary, involuntary, or nonvoluntary. Euthanasia is voluntary when a patient requests that someone end his or her life and that request is honored, involuntary when a patient explicitly refuses to have his or her life ended and their request is not honored, and nonvoluntary when a patient’s life is intentionally ended and the patient’s wishes are unknown or unobtainable. Physician-assisted suicide (PAS), also referred to as physician aid-in-dying or physician-assisted death, is a special case of voluntary euthanasia with the assistance or supervision of a physician to end a patient’s life, usually by providing access to or making available a lethal dose of medication, instructions, and advice on how to use it. In PAS, the patient is the active agent who may or may not take those drugs or may do so at a time of his or her own choosing (American Nurses Association, 2019). Physicians use their expertise to enable a patient’s suicide. In active euthanasia, someone other than the patient is the active agent. It is common in medical ethics discussions to distinguish PAS from euthanasia, but this may be a distinction without much of a difference. A physician participating in PAS is still morally culpable as an agent or accomplice in a suicide. The Distinction Between Accepting and Precipitating Death There is an important ethical difference between intentionally ending a life and accepting the end of life. It should be self-evident that there is a medical and ethical difference between refusing a heart transplant and deliberately ingesting a lethal dose of sleeping pills. To precipitate death is to deliberately introduce a "new lethal pathophysiological state" (Sulmasy, Finlay, Fitzgerald, Foley, Payne, & Siegler, 2018, p. 1396) with the direct intention of ending a patient’s life or hastening their death. To accept death is to either refuse or withdraw medical interventions that impede the progression of a preexisting lethal pathophysiological condition because, in the patient’s or physician’s judgment, a treatment has become too burdensome or is not providing any proven medical benefit. The difference between accepting and precipitating death is not merely semantic. A refusal of or request for cessation of life-prolonging treatment is not ethically or legally considered a request for euthanasia, but an acceptance of death and acquiescence to the natural process of dying. While some moral theorists may equate these two and view them as morally indistinguishable because they both have the same outcome, namely the shortening of the patient’s life, the distinction is still relative and important in medical, ethical, and legal decisions. In the case of Quill v. Vacco (1994), the U.S. Supreme Court rejected a claim of the Second Circuit Court of Appeals that ending or refusing life-sustaining treatment "is nothing more or less than assisted suicide" (p. 729). The unanimous court decision noted that "when a patient refuses life-sustaining medical treatment, he dies from an under-lying fatal disease or pathology; but if a patient ingests lethal medication prescribed by a physician, he is killed by that medication" (Quill v. Vacco, 1994, p. 729). Suicide is morally and legally distinct from the acceptance of death by acknowledging the limitations of medicine. Fundamental Worldview Differences Supporters of euthanasia and PAS are typically sincere and compassionate, desiring to be beneficent and respectful of the dignity of suffering persons. However, these attitudes toward respect for human dignity and compassion, and the difference in meaning these attitudes reflect, illustrate the differences between a Christian worldview and a secular worldview with regard to dignity, human suffering, and what a good death entails. For the secular-minded person, to end suffering by means of ending the life of the sufferer is a rational act of compassion. Conversely, for the Christian, suffering is to be relieved to the extent possible within the boundaries and principles reflected in the biblical worldview and God’s directives to not kill an innocent person (Exodus 20:13; Deuteronomy 5:17; Jeremiah 7:9; Matthew 5:21; 19:18; Mark 10:19; Luke 18:20; Romans 13:9; James 2:11). The words used for kill in both the Old and New Testaments mean "to murder" (Exodus 21:12–14; Leviticus 24:17–21; Numbers 35:16–31; Deuteronomy 19:4–13). The biblical worldview understands that intentional hastening of death for any reason is a distortion of the idea of a good death. In the Old Testament Book of Judges, a soldier by the name of Abimelech suffers a skull fracture when a woman drops a millstone on his head during the siege of a fortified tower. Assuming his injury is mortal, he asks his armor-bearer to kill him so that he would not suffer the "indignity" of being killed by a woman (Judges 9:52–55). In another example, Israel’s King Saul attempts to commit suicide by falling on his spear when surrounded in battle. After his unsuccessful attempt, Saul implores another to put him out of his misery and kill him (1 Samuel 31:1–10). These two examples are reminiscent of the two main arguments for PAS and euthanasia, to avoid a loss of dignity at the end of life and a compassionate relief from suffering. Both actions are condemned in the biblical narrative. It is a failure to faithfully acknowledge the sovereignty of God over life, death, and even suffering at the end of life. According to the Bible, it is God who determines (Job 14:5), ordains (Psalm 139:16), and appoints (Hebrews 9:27) all the days of life and the time of death. To request euthanasia or PAS is to abandon one’s stewardship over God’s gift of life (1 Corinthians 6:19–20). For the secular thinker, human dignity is centered on the ability to autonomously control the timing and manner of one’s death. For the Christian, human dignity is based on being created in the image of God, a dignity conferred on each human being by his or her Creator. Organizational and Legal Positions During the past decade, there has been an increasing interest by states to legalize PAS. While PAS is not a constitutional right according to the U.S. Supreme Court, states may choose to legalize the practice. As of 2019, PAS is legal in California, Colorado, Oregon, Montana, Vermont, Washington, and the Distinct of Columbia. Most referenda to legalize PAS are defeated. In 2017, referendums were voted down in 27 states, but new referendums appear each year across the U.S. Both New Mexico and New York courts have ruled that there is no constitutional right to PAS in those states. Professional medical and nursing societies have historically prohibited or opposed PAS. The American Medical Association (AMA), the American College of Physicians (ACP), and the World Medical Association (WMA) have all recently reaffirmed their positions opposing euthanasia and PAS. The AMA House of Delegates voted in their 2019 annual meeting to oppose PAS as "fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious risks" (White, 2019). In doing so, the AMA reasserted the fundamental role of the physician as healer and commitment to the Hippocratic principle to do no harm. The ACP published a position paper opposing legalization of PAS in 2017, calling for improvements in the care of dying patients, including increased awareness and improvement in hospice and palliative care (Sulmasy & Mueller, 2017). The WMA reaffirmed its position at its 2015 council session in Oslo, Norway: Physician-assisted suicide, like euthanasia, is unethical and must be condemned by the medical profession. Where the assistance of the physician is intentionally and deliberately directed at enabling an individual to end his or her own life, the physician acts unethically. However, the right to decline medical treatment is a basic right of the patient and the physician does not act unethically even if respecting such a wish results in the death of the patient. (WMA, 2017) The American Nurses Association (ANA) states that, "Euthanasia is inconsistent with the core commitments of the nursing profession and profoundly violates public trust…Nurses are ethically prohibited from administering medical aid in dying medications" (ANA, 2019, pp. 1–2). Other organizations that officially oppose euthanasia and PAS include the British Medical Association (Jaques, 2012), the National Hospice and Palliative Care Organization (NHPCO, 2005), and the Christian Medical and Dental Associations (CMDA, 2018). Recent developments in public and professional attitudes toward euthanasia and PAS may indicate an erosion of this opposition to PAS, as support for these positions is coming from organization membership. In 2016, members of the AMA and the WMA sought to revise their organization’s opposition to PAS, calling on their organizations to take a neutral stance on PAS and provide advice to health care professionals who participate in PAS in jurisdictions where it is legal (Frye & Youngner, 2016). Sulmasy et al., (2018) warned that by shifting to a neutral position, these organizations are in fact no longer neutral. "To change from opposition to neutrality represents a substantive shift in a professional, ethical, and political position, declaring a policy no longer morally unacceptable; the political effect is to give it a green light. Logically, neutrality implies, ‘We are not opposed.’" (Sulmasy et al., 2018, p. 1395). This was evident when, in 2015, the California Medical Society endorsed a neutral position on PAS, and the next day’s headlines announced, "California Physicians End Opposition to Aid-in-Dying Bill" (McGeevy, 2015, p. B4; Kheriaty, 2019). Is PAS Justified by Arguments for Autonomy, Freedom, and Dignity? The most prominent argument used to justify PAS is the argument for autonomy. Autonomy over the control of one’s life and the supremacy of private judgment have become the equivalent of moral absolutes in modern culture. To be autonomous is to have control and freedom to decide what is most valuable and meaningful in one’s life, and this has been extended to having mastery over one’s death, whether to be killed or assisted in suicide, so long as it is voluntary. It has been shown that in Oregon, those who received lethal prescriptions exhibited uncommon personality types fixated on issues of control (Oldham, Dobscha, Goy, & Ganzini, 2011). Proponents of PAS insist that upholding a patient’s control and freedom over the timing and means of a patient’s death is considered a right, and physicians have a duty to satisfy that right. Loss of autonomy is equivalent to a loss of human dignity. To accept a health care provider’s role in PAS is to respect and maintain the dignity of the dying patient. Autonomy, however, is not a fundamental or overriding principle in isolation from other principles of ethics in medicine and society. While respect for patient autonomy has prima facie priority in most clinical situations, and it must be weighed against other principles of medical ethics such as beneficence, nonmaleficence, and justice. Autonomy is not the isolated exercise of will that can demand anything a person wants to the exclusion of others, higher moral principles, or the goals of medicine and society (Kekewich, 2014). If upholding a patient’s control and freedom by acquiescing to any request, physicians and health care professionals become mere functionaries or technicians. If autonomy always trumps other ethical principles, there would be no principled barriers to withhold or deny any treatments requested by a patient. The ability to decline some patient requests for the good of the patient or the good of society is a requirement of medical professionalism and ethics (Sulmasy & Mueller, 2017). Legalization of PAS also has societal implications. If loss of dignity and autonomy, meaning one has lost control and is dependent on others, is used to justify PAS, what does this say about those in society who are already heavily dependent on others? This is why certain undervalued groups in society, such as the elderly and disabled, oppose legalizing PAS because it sends the implicit message that dependent persons have no dignity and are better off dead (McDermott, 2010; Koenig, Wildman-Hanlon, & Schmader, 1996). This is not just a theoretical concern. With an aging population and health care resources becoming increasingly expensive, aging and dependent patients may be pressured or coerced into choosing PAS (Hanson, 2018) or denied payment for expensive treatments in favor of PAS (Richardson, 2017). As discussed earlier in this chapter, human dignity is based on being created in the image of God, which is universal and inviolable. All humans possess dignity as special creatures of God, not because society attributes dignity to them. God chose to send his only Son to die for all human beings, "the whole world" (John 3:16). How can such beings for whom God loved and sacrificed so much lose their God-given dignity? Loss of control over one’s life and death cannot be a source of dignity, and the goal of maintaining complete autonomy in this life is a total illusion (Ecclesiastes 6:10,12). Only God has complete providential control over our life and death. According to a Christian worldview, the arguments for freedom and autonomy given by proponents of euthanasia and PAS present a distorted view of human freedom, denying the gift and stewardship of life given by God. This form of supreme autonomy and freedom also rejects God’s providential control of and purpose for each person’s life. According to Pellegrino (1996), the modern notion of autonomy and freedom, assumes that the only purpose of human life is freedom from all discomfort and pursuit of each individual’s notion of "quality" of life. It denies any idea of solidarity or community in which each person’s life has its special meaning regardless of how demeaned it may seem to the beholder…it denies that our lives, however difficult, may be instruments in God’s hand to shape the lives of those among whom we reside. (p. 109) The supreme act of freedom, according to the Bible, is the sacrifice of oneself for others and yielding one’s freedom to God’s purposes. In the Garden of Gethsemane, Jesus yielded his will to that of his Father’s (Mark 14:36; cf. Matthew 26:39–46). Yielding one’s freedom to God’s will and purpose, as the ultimate source of true freedom, is the ultimate act of all true human freedom. Is PAS Justified by Arguments for Compassion? The emotionally driven argument that PAS and euthanasia are ultimately acts of compassion and mercy is very appealing to many, as it should be. Christians share this concern for the sufferings of others, looking to Jesus’ whole life as one filled with compassionate and merciful acts, especially for the sick and dying. Compassion means “to suffer with,” and because suffering is a universal human experience, when one feels the suffering of another, that person is compelled to relieve it. Proponents of PAS differ, however, on the moral status of compassion as compared to the Christian worldview. For many proponents of PAS, the emotion or feeling of compassion justifies whatever means are necessary to end a patient’s suffering, and not doing so is considered cruel or even evil. For Christians, compassion means something different. While being a laudable emotion and motivation, compassion is not a moral principle by itself or a justification for any action deemed as compassionate. "Compassion cannot justify intrinsically immoral acts like usurping God’s sovereignty over human life. Compassion should accompany moral acts, but it does not justify them" (Pellegrino, 1996, p. 110). Like all other emotions, such as rage and fear, compassion must be expressed within ethical and moral boundaries. A Christian’s compassion for others is grounded in God’s love for the world as founded in Christ’s life, death, and resurrection. Without this supreme example of love, compassion is wrenched from its moral roots and has nothing to guide it. Is PAS Justified by Arguments for the Relief of Pain and Suffering? Relief of pain and suffering is a central component of medical and nursing care, and the relief of end-of-life pain and suffering is a major rhetorical theme of many arguments in favor of euthanasia and PAS. For advocates of PAS, suffering is a meaningless and unmitigated evil, and to escape suffering is both moral and merciful. Many proponents of PAS view the modern culture of medicine, with its emphasis on curing, to be complicit in end-of-life pain and suffering (Karsoho, Rishman, Wright, & Macdonald, 2016). Modern medicine is viewed solely as a life-prolonging enterprise composed of paternalistic and death-denying physicians. Moreover, many proponents view palliative care to have limited ability to relieve suffering at the end of life and, in some instances, to even produce suffering (Karsoho et al., 2016). This perception supports the view that one has only two choices: a gruesome and painful death in the hands of mainstream medicine or a peaceful end to pain and suffering through medical-assisted death. This is a false dichotomy. Progress in hospice and palliative care, symptom and pain control, and increased awareness and availability of end-of-life comfort measures does not support this view. It is not necessary for anyone to die in pain, and it is ethically acceptable to refuse burdensome life-sustaining therapies such as CPR, ventilators, a feeding tube, or dialysis when the burdens outweigh the benefits. Evidence shows that those who request PAS where it is legal do so for reasons other than fear of unrelieved pain and symptoms at the end of life. The predominant reasons include loss of autonomy and dignity or the fear of dependence and being a burden to others (Suarez-Almazor, Newman, Hanson, & Bruera, 2002) and not a fear of pain and suffering. There is a difference between pain and suffering. Pain is the objective unpleasant physical sensation mediated by nerves and the brain that signals something is wrong in the body. Suffering is the subjective way that pain is interpreted and the thoughts, judgments, beliefs, and meaning one gives to pain. All objective pain is accompanied by some form of subjective interpretation and meaning, but suffering is not always associated with physical pain, especially at the end of life. Studies show that patients requesting PAS have higher levels of depression, hopelessness, and dismissive attachment behaviors characterized by independence and self-reliance with limited social support (Smith et al., 2015). All these factors contribute to suffering. One of the strongest predictors of requests for PAS was a low level of spirituality, defined as a sense of meaning, peace, and purpose in life, as well as the relationship between the patient’s illness, faith, and spiritual beliefs (Smith et al., 2015). Without a belief in some purpose to life beyond its outward material pleasures and goods, in a meaningless world of illness, pain, and suffering, it can be easy to accept the alternative nothingness of death over purposeless suffering, even if that suffering is painless. Euthanasia and PAS requests are rare when a patient’s physical, social, emotional, and spiritual needs are addressed. The Christian worldview gives meaning and purpose to suffering. Suffering and death are ultimately the result of sin, and it is through the suffering and death of Jesus that the meaning and purpose of a believer’s own suffering and death is transformed. By faith, Christians are united to Christ in his own sufferings, but also united in his own resurrected and eternal life. There may be no explicit answer to why someone is suffering in a particular situation, and the reality of pain and suffering can never be minimalized. But God has promised that the sufferings of this world can bring spiritual growth, focus one away from this world and onto the next, and bear witness to God’s faithfulness in a fallen world (Romans 5:3; James 1:2–4). Suffering and pain is temporary, "preparing for us an eternal weight of glory beyond all comparison" (2 Corinthians 4:17). For the Christian believer, suffering has been redeemed through Christ’s own suffering. By faith, a Christian can look forward to a life after death in fellowship and peace with God where there is "no more death or mourning or crying or pain" (Revelation 21:4). Care for the whole person, a biopsychosocial and spiritual being, entails caring for all aspects of a patient’s suffering, not just physical pain and symptom relief. End-of-life care must also address the psychological aspects of depression and hopelessness, and the societal aspects, which include a lack of social support and the fear of losing independence. All caregivers, especially Christian caregivers, should be particularly aware of spiritual causes of suffering and involve appropriate pastoral care and counseling when appropriate. Good medical care, addressing the whole person, can give patients substantial control over their dying without the need for them to request the precipitation of their own death. Is PAS Justified by the Argument that There Is No Difference Between PAS and Providing Pain-Relieving Medications that May Hasten or Contribute to Their Death? Justifying PAS by arguing that providing pain-relieving drugs is no different from PAS is a common argument put forth by its proponents, but there is a real and important difference between PAS and end-of-life palliative pain relief. Sometimes administering pain-relieving drugs can inadvertently hasten a patient’s death as a side-effect. According to a well-accepted principle of medical ethics, referred to as the principle of double effect, it is morally permissible to cause harm as an unintended, yet foreseeable, side effect in order to bring about a good effect (Berger, 2013). This principle was developed in the Catholic Christian tradition and dates to the 13th century teachings of Thomas Aquinas in his work Summa Theologica. The principle states that when an action has two foreseeable effects, one good (pain relief) and one bad (hastening death), it is morally permissible under the following five conditions: The act itself is good or at least morally neutral (e.g., giving medications to relieve pain). The good effect is intended, not the bad effect (e.g., causing or hastening the death of the patient). The good effect is not brought about by means of the bad effect (e.g., relief of pain is not brought about by or dependent on hastening the patient’s death). There are no alternatives to the good effect that would be safer. There is a proportionately grave reason (e.g., intense pain) for risking the bad effect (e.g., side-effects of the drug that may cause respiratory or hemodynamic depression). In the case of PAS, the difference lies in the intent and purpose of providing a medication. The direct means of the patient’s death is a lethal dose of medication. In other words, the means of pain relief is the intended death of the patient. In terms of palliative pain relief, the intent of administering pain-relieving medications is solely for patients’ comfort, not their death. Even though it may be a foreseen possibility, hastening a patient’s death is not the intent of treatment. Even given these arguments, there is increasing evidence that adequate pain relief at the end of life is not associated with hastening death (Mette & Onwuteaka-Phillipsen, 2008). Should Health Care Professionals be Obligated to Participate in PAS? In a word, "No." First, euthanasia and PAS undermine the goals and meaning of medicine (Sulmasy & Mueller, 2017), which is to heal or at least to provide comfort and care. Facilitating suicide is not a healing act, nor is it comfort and care. Symptom relief can provide healing and care, and withholding or withdrawing burdensome or futile treatments acknowledges the limits of medicine and healing, but one cannot claim that healing in any way involves assisting patients in ending their lives. PAS and euthanasia disrupt the patient-physician relationship. "For whenever physicians use their knowledge and skills for ends other than the promotion of health and healing, medicine is corrupted—indeed, is no longer medicine" (Kheriaty, 2019, p. 33). The Hippocratic pledge to not kill is a minimal condition of trust within a patient-physician and other health care professionals’ relationship. Despite the medical culture’s shift away from any forms of perceived medical paternalism, patients remain vulnerable in their disease and illness, and health care professionals continue, by way of increasing specialized knowledge in health care science, to hold great power over a patient’s life and health. Patients need to trust health care professionals, in whose knowledge and skills they depend. "When the doctor is licensed to provide lethal drugs, patients could be inadvertently steered towards assisted suicide, especially those with low self-esteem or who are viewed negatively as weak, dependent, unproductive, unattractive, costly, and unworthy of the efforts of others." (Sulmasy et al., 2018). Even in jurisdictions where PAS is legal, under no circumstances should health care professionals be encouraged or coerced to participate in hastening the death of their patients or participating in PAS. Whereas the state can legitimately limit health care professionals from certain actions, the state does not have the legitimate authority to force health care professionals to commit, assist in, or accommodate actions they believe to be morally wrong, even when their moral objections are based on religious beliefs (CMDA, 2018; U.S. Department of Health and Human Services, n.d.) Brain Death, Coma, and Permanent Vegetative State Brain death, coma, and permanent vegetative state (PVS) are very different conditions that are sometimes equated by the general public. Brain death, as outlined above, is the irreversible cessation of all brain functions, including the brain stem, and is equivalent to clinical death. Coma, on the other hand, refers to severe depression of cerebral function with a loss of consciousness resembling sleep. Coma is a pathological state and physiologically distinct from sleep. When a person is asleep, the brain continues to function with highly organized and complex electrical activity that maintains bodily homeostasis and autonomic functions. With stimulation, sleep can easily be reversed to a state of alertness. Coma is a state of slowing and depression of electrical brain activity and cannot be reversed by stimulation. Coma implies a neurological injury to both cerebral hemispheres or the brain stem caused by either structural injury (e.g., trauma, hemorrhage, ischemia) or metabolic injury (e.g., drug overdose, lack of oxygen). Despite the erroneous title of the Report of the Ad Hoc Committee (1968), which equated brain death criteria with irreversible coma, patients in a coma, even persistent of irreversible coma, are considered alive and do not meet the criteria for brain death. Brain activity can be variable, and there can be some signs of response to external stimuli. In these cases, it can be difficult to assess whether a patient is aware of their environment or not. The vegetative state refers to a unique disorder that is the “least understood and most ethically troublesome condition in modern medicine” (Owen et al., 2006, p. 1402). A vegetative state is a descriptive term evidenced by severe cortical dysfunction, usually emerging after severe coma, and sometimes erroneously referred to as brain death. Patients in a vegetative state exhibit a form of wakefulness (e.g., eye-opening), normal sleep cycles, reflex movements (e.g., gagging, sucking, withdrawing, grabbing, and grimace or laugh) without appearing to be aware of themselves and their environment. They are unable to interact with others, speak, or respond to commands; however, recent functional MRI studies in PVS patients indicate that at least some patients may be more aware of their environment than originally thought. Evidence suggests that patients may retain the ability to understand someone speaking to them and respond to them through inner brain activity, rather than through speech and movement (Owen et al., 2006). PVS is a diagnostic term used when this state, after repeated clinical examinations, has continued for a prolonged period. Permanent vegetative state is a prognostic term used when there is no reasonable probability of improvement. These patients do not meet the criteria for brain death. While it is common in both lay and medical literature to refer to such individuals with severe cortical dysfunction as vegetative, health care professionals must be careful to not dehumanize their patients, whether through language, actions, or attitudes. Very little is known about the mysteries of consciousness and awareness, which are for the most part subjective experiences and difficult to study by empirical and objective measures. Patients in PVS are not dead, may have more awareness than originally thought, and should not be viewed or treated as less than human (i.e., vegetables). All patients, regardless of their diagnosis, condition, or ultimate prognosis, should be treated with dignity and respect. Termination of Life Support and Withdrawal of Artificial Nutrition and Hydration Modern health care has made available a host of technologies that can support and prolong life. But whether these life-supporting technologies should be used in certain circumstances or are consistent with a patient’s goals of care, values, and beliefs is not a question medical science alone can answer. All patients have a right to refuse any medical treatment, whether it be directly or according to an advance directive. As stated above, honoring a patient’s wishes for nontreatment or withdrawal of treatment is not the same as euthanasia or PAS. When natural death is inevitable, options to withhold or withdraw treatment are always a consideration. Technology should not be used merely to prolong the dying process when death is imminent. According to the writer of Ecclesiastes, there is “a time to die” (Ecclesiastes 3:2). A decision to withdraw medical treatments that are no longer effective is a form of beneficence or prevention of further harm. Withdrawal of ineffective or overly burdensome treatments does not mean that care should be withdrawn. When there is nothing more that can medically be done for the patient in terms of cure, the goals of medicine should shift to comfort and care. For the Christian believer, death is a conquered enemy, but that does not mean that death always needs to be resisted. Being stewards of one’s earthly life is an important good to be pursued, for sure, but it is not the most important good a Christian can pursue. Christians’ highest or ultimate good is their inner spiritual fellowship with God and a destined eternal life and fellowship with God in the future. A Christian view of the sanctity of life should not be equated with the pursuit of physical life and longevity at all costs. There is a time when it is good to acknowledge